CAD Flashcards
Basic Layers of the heart
Composed of three layers, the endocardium, myocardium, and the epicardium over which is laid a sac called the peri cardium. This sac is divided into visceral layer and parietal layer, and is sperated by the pericardial space which prevents friction
The heart is divided vertically by the
Septum
interatrial
septum divides
R and left atria
What divides the ventricles
Interventricular septu
4 Heart valves and their roles
The mitral and tricuspid
valves’ prevent the eversion of the leaflets into the atria during ventricular
contraction.
The pulmonic and aortic valves (also known
as semilunar valves) prevent blood from regurgitating into the
ventricles at the end of each ventricular contraction.
What is unique abt the myocardiums blood supply
It has it’s own, known as the coranary circulation
What is the dominnant pace maker node of the heart?
sinoatrial node
Atherosclerosis
characterized
by deposits of lipids within the intima of the artery. Endothelial
injury and inflammation play a central role in the development
of atherosclerosis.
Stages of development of atherosclerosis
(a) fatty streak, (b) fibrous plaque, and (c)
complicated lesion.
collateral circulation
Pre-existing small blood vessels (arterioles, capillaries) enlarge or adapt in response to increased demand due to obstruction.
New vessels may also form through angiogenesis (growth of new blood vessels).
Leading causes of death in Canada
CVD (Ischemic and CAD)
Stroke
Lung disease
Coronary circulation delivers blood to the
Myocardium
Two primary coronary arteries
Right Coronary Artery
Left main coronary artery
Coronary veins are resposnible for
delivering deoxygenated blood to the heart primarily via the coronary sinus
Left main coronary artery divides into
Circumflex Coronary artery
Left Anterior Descending Coronary Artery
Blood flows from the right atrium into
The right V and then into the pulmonary artery (DO2 Blood)
To the lungs
Blood returns from lungs to heart via
Pulmonary vein, entering left atrium, then left ventricle
Largest chamber of heart
Left Ventricle
Canadians of _____ descent are more at risk for CAD
South Asians
CAD deals with problems of
Blood supply to the heart, primarily relevant to the arteries
Primarily the RCA and the LMVs
Generally speaking, in most pts, anytime tissue is inadequately oxygenated, it will cause
Pain
The basic word of Atherosclerosis can be broken down to mean
Hardening of the arteries
The main cause of CAD
Atherosclerosis
What is the most dangerous stage of artherosclerosis
Third - complicated lesion
Describe the complicated lesion stage of athersclerosis
Continued inflammation can result in plawue instability, ulceration and tupture
Thrombus formation
Increased narrowing or total occlusion of lumen
Factors affecting collateral circulation
Inheritied predispositon for angiogenesis
Presence of CHRONIC ischemia
Collateral circulation can develop if
The development of atherosclerosis occurs slowly
New blood supply, not as strong and solid as the OG, however, they can continue to deliver adequate blood supply
CAD Risk factors
Increasing age
Gender (Women are generally less suspeciple until 65)
Ethnicity
Family history
Genetics
Familial hypercholeterolemia
Genetic predisposition for high cholesterol
Modifiable risk factors for CAD
Elevated serum lipids
HTN
Tobbaco useObesity
Physical inactiviy
Elevated fasting blood glucose
Contributing
DM
Metaboic syndrom
Psych states
Homocysteine
Obesity is
BMI >30kg/m2
Helath promotion for CAD
ID of people at risk
- Family/personal health hx
- Presence of VC symptoms
- Environmental Patterns: Eating habits type of diet, activity
Psychosocial history that increases peoples risk of CAD
Smoking, alcohol, type A behaviours, recent stressful life events, sleeping, presence of anxiety or depression
Attitudes/beliefs abt health/illness
Educational background
CAD health promotion BEHAVIOURS
Physical fitness
Nutritional therapy (Omega 3 fatty acids, better fats)
Cholesterol lowering drug therapy
Anticoagulant therapy - aspirin/heparin
Two different types of CAD
Chronic stable angina
Acute Coronary Syndrom
- Unstable angina
- NSTEMI
- STEMI
Acute coronary syndrome
The eterioation of plaque already formed in the arteries
Plaque becomes unstable causing blockages, thrombuses etc.
Chronic stable angina
Reversible (temporary) myocardial ischemia = angina (chest pain); intermittent chest pain
Issue is either increased demand or decreased supply
Primary reason for insufficient blood flow is narrowing of coronary arteries by atherosclerosis
For ischemia to occur, the artery is usually 75% or more stenosed (obstructed)
Anytime someone expereinces angina for the first time we assume it is
Unstable and therefore a preciptating factor for an MI
Generally, chronic Angina is treated in a way
To relieve pain
Lie down
Nitro spray
(Temporary/reversible)
How is Angina determined to be stable?
Must be fully investigated
Angiogram, inspection, ID precipitating factors (Never occurs AT rest)
Which kind of angina can occur at rest
Unstable angina
How long does pain last in chronic stable angina
3-5 minutes
Is chronic angina predictable?
It can be, pts can know their pattern, and can take nitrospray to releave pain OR ahead of precipitating factor
Precipitating factors for chronic stable angina
Physical exertion, temperature extremes, strong emotions (SNS), conception of heavy metals, sexual activty, circadiem rythym patterns
Chronic stable angina is rarely
Sharp or stabbing
Normally “Chest tightness”
Most important thing to know abt Chronic stabnle angina
Predictable
Happened before, can be solved
Chronic Stable Angina management
Antiplatlets agents (ACE Inhibs/Antanginal thereapy)
Beta Blockers (Management of BP)
Cessation of smoking (Management of cholesterol
Diet and DM (Management)
Education and Exercise (Regular)
Flu vaccination (Flu can increase CV demand)
Other types of Angina
Silent Ischemia
(Associated with DM and ANS neuropathy)
- Might feel dizzy, nauseous, unwell
- Poorly managed T1 or T2
Nocturnal angina (Occurs at night, but not necessarily in recumbet position or during sleep)
- Can be more associated with chronic angina
Angina Decubitus
- Chest pain that occurs only while lying down
Silent Ischemia
Associated with DM and ANS neuropathy)
- Might feel dizzy, nauseous, unwell
- Poorly managed T1 or T2
Prinzmentals (Variant) Angina
Occurs at rest usually in response to spasm of major coronary artery
Seen in clients with hx of migraine headaches
Spasm may occur in absence of CAD
May be relieved by moderate exercise
ACS (Acute Coronary Syndrome) includes
Includes
Unstable Angina
NSTEMI
STEMI
Categorized differently because of different treatment
Time is muscle
Early intervention = reduced mortality
Any time chest pain or angina is experienced that is not KNOWN to be stable, it is investigated immediately
Unstable Angina (UA)
Chest pain that is
New
Occurs at rest or has a worsening pattern
Pain that is not sustained
Medical Emergency
Resulting from myocardial ischemia
Occur from acute Arterosclerosis plaque break down
Non ST Elevated MI
ST is part of electrocardiogram
Partial Thickness Blockage MI
Majority of MI’s Occur Secondary to a thrombus Formation
Takes 20 mins before cellular death starts to occur
5-6 hrs before full thickness of heart muscle becomes necrosed
Not considered a heart attack
Occlusion is not occuring through the full thickness of the heart muscle, therefore manifestations are less dramatic
The higher up the clot, the worse it is
What is ST in NSTEMI
ST is the graphed wave of heart beat on electrocardiogram
The electrocardiogram identifies the ST segment in the waveform as being NOT isoelectric - returns to the same line (which it should be)
ST segment elevation AFTER the
Can dead heart muscle rejuvinate?
No
Partial thickness or full thickness MIs occur secondary to
Thrombus formation/blood clots
What effects the speed of cellular death in the heart during an MI?
How large is the clot (Full/partial), where is the clot? (Higher up/more downstream = More damage)
What vessel is clotted (More major artery = More major results)
If there is.a block high in the left main coronary artery which part of the hert will be effected
Left Ventricle
Massive clinical symptoms
RCA supplies
Right Atrium
Right ventricle
Portion of posterior wall of left ventricle
AV Nodes
Bundle of His
LMCA
Left atrium
Left Ventricle
___ Give us an idea of the location of ischemia in chest pain
ECG
Chest pain tells us that a pt needs ____ immedialy
ECG
NSTEMI is a heart attack
True
Unstable angina is
Not a heart attack
Heart attack is defined as
Positive cardiac markers
ECG changes
Presence of cardiac blockages
Must have all three
NSTEMIs look the same as
Unstable angina symptoms
NSTEMI or unstable angina more severe?
NSTEMI
Cardiac death of some sort
STEMI
St Elevation MI
Full thickness blockage MI (Total occlusion of cardiac artery
Can have same symptoms as a NSTEMI, though usually more rapid onset and progression
People usually loock “shocky”
- Impending doom feeling
What is the treatment goal for STEMI
Angiogram in 90 minutes
Symptoms of STEMI depend on
Location of blockage
When pt complains of acute chest pain nurse response
Stat ECG
Thorough assessment
VS
Clinical manifestations of CAD
Midsternal
L Shoulder and down both arms
Neck and arms
Substernal radiating to neck and jaw
Substernal radiating down L arm
Epigastric
Epigastric radiating to neck, jaw, and arms
Intrascapularddd
Who often presents with atypical symptoms
Women
Assessment of Angina
Precipitating events
Quality of pain
Radiation of pain
Severity of pain
Timing
Acute Coronary Syndrome Nurisng assessment
Subjective Data
Health hx
Symptoms
Medication (Adherence?)
Objective Data
General - anxiety, fear, restlessness
Integumentary- cool, clammy, diaphoretic, pale/grey
CV- tachy/bradycardia, dysrhythmias, BP changes
GOals of care for all SCS
Dcrease demand for O2
They should rest
Decrease anxiety
Work of breathing (asthma)
Increase O2 supply/blood flow to cardiac arteries
O2 therapy
Nitroglycerin (Short or long acting)
Morphine *
When would we need to be careful about giving nitro?
Inferior MI
If we give Nitro it can be fatal (drops BP)_
What must be done BEFORE giving nitro (aside from in stable angina)
ECG
Diagnostic of CAD
12 lead ECG
Lab studies
- Urgently: serial troponin +ECG
- CBC, CP&, fasting lipids and glucose, LFTs, BNP, TSH
Chest X-ray
Echocardiogram
Exercise stress test
What is significant about the enxyme troponin?
It is a myocardial enzyme that is ONLY released if a cardiac muscle cell DIES
Serial troponins help us ____ what is happening with the heart
Trend
Echocardiagram
Ultrasound of the heart
For looking at valves + Chest wall movement
Exercise stress test is done for
Pts with normal tropnins and normal ECG
ECG leads with increased exertion, looking for ECG changes secondary to exertion
Exercise stress test is done urgently when?
If chest pain occurs that has never been experienced before\
Otherwise, it can occur wheenver is conveneient
Goal of Acute coronary syndrome
Preservation of heart muscle
Treatment of pain
Timely treatment
Acute nursing interventions ofr angina attack
Rest
Supplemental O2
VS with chest pain
Stat 12L ECG with new chest pain
Relieve pain promptly that does NOT show inferior MI
Auscultate heart sounds
Position clietn comfortably
What medications CONTRAINDICATES giving nitrate?
Viagra (Any medications ending in dil)
Which reduces preload to the heart
Could rsult in fatal hypotension
Broad interventions for acute coronary syndrom
Provide pain releif
Preserve myocardium
Maintain signs of efective cardiac perfusion
Procide immediate and ongoing treatment
Ensure a comprehensive d/c plan
Encouragereduciton of risk factors
Meications given if prompt myocardial surgery is not available
Aspirin
Takagreor
Heparin (reversilable)
Nitrates are (Action)
Vasodialator
Short-acting (SL/transL spray)
Transdermal (nitropatch)
Acute chest pain is generally dealt with wih
Short acting nitates
Chronic cardiomyoapthy or CAD
Long acting nitrate
Nitropatch everyday
To support optimal blood flow
Nursing considerations with nitrates
Monitor VS bw doses
No relief after 5 minutes, give it agian
People don’t take more than ___ sprays of nitro before calling 911 in the event of Angina
3
Beta Adrenergic Blockers
Reduce workload of heart, decrease myocardial oxygen demand
They also slow the HR and drop BP
- MUST monitor VS PRIOR to admin
Calcium channel blockers
Dilate coronary arteries
Used if B-adrenergic blockers are poorly tolerated, contraindicated, or do not control anginal symptoms
Monitor BP/HR prior to admin, looking for signs of heart failure
Prevent calcium entry into smooth muscle
Angiotensin Converting Enzyme Inhibitors (ACE inhibs)
Dilate BVs and decrease BP
Opiods - Morphine/Fentanyl
Reduce pain/may lower HR and reduce need for O2
Pain tells us something in regards to heart ischemia
Monitor RR, don’t give if RR <12
ASA/antilatlet agents
Monitor for GI bleeding
Ask abt stool (Melina), N/V (signs of pain)
Long term Aspirin use can cause this
Chronic Stable Angina and ACS D/C details
Precipitating factors,
Education regarding energy preservation strategies
Risk factor reduction
Medications (adherence)
Unstable Angina/NSTEMI VS STEMI
Both need ECG
Both need Serial Tropnins
Unstable/STEMI may need stress test
STEMI NEVER has a stress test
STEMI needs emergent angioplasty (90 minutes) and stenting
U/NSTEMI: Urgent angiogram/plasty, but NOT critical
Angioplasty
Reopens narroved BVs to increase blood flow
CABG
Coronary Artery Bipass Graphting
Heart surgery involving creating collateral circulation using less needed arterires
Angina in simple terms
Chest pain related to lack of tissue oxygenation
Chronic Stable Angina is it progressive?
The goal is to slow progression, often they do progress to unstable or STEMI
If condition is changing over time, this is an indication of more investigation needed
Key features of Chronic stable angina
Usually an exetrionn type pain
Avoidance of risk factors is critical
When myocardial ischemia is prolonged and not immediately reversible … what is it
Acute Coronary Syndrome (umbrella term)
Chest pain that is:
new in onset
occurs at rest, or
has a worsening pattern
unpredictable
Chest pain that isn’t sustained
What is it
Unstable Angina
Medical emergency
Who are the populations who expereince unique angina pain?
Women and diabetics
Quality of angina pain is investigated by
Precipitation factors
Quality
Radiating?
Severity
Timing
80% of MI occurs secondary to
Thrombus formation (Clot)
Inferior leads of ECG usually correlate with what part of the heart?
RCA and LCx
What is important to know abt MI in inferior
It affects preload
- The amount of blood available going into the heart
THEREFORE WE DO NOT GIVE NITRO OR MORPHINE BEFORE ECG
Should we have treponin circulating in the blood?
No
NSTEMI is a
Partial thickness. blockage MI
If the first test taken 20 minutes after chest pain, will treponins be present?
No, even with cardiac damage, therefore trends must continued to be tracked
Most serious occlusion in coronary vessel is called?
STEMI
Name the parts of the cardiac wave?
P wave, QRS complex (The big spike), T wave, the distance bw the spike and T wave is called the ST segment
Fasting Lipid Profile
Patients are NPO (except water) for 8 -10h before the test
Includes:
Cholesterol
Triglycerides
High density lipoproteins
Low density lipoproteins
Ratio of HDL to LDL
Important to assess AFTER emergent nSTEMI or STEMI care.
NOT an emergent diagnostic.
What does an ECG of stable angina look like
Minimal or no ST elevation
What are cardiac markers
Troponin
How to differentiate ACS
Begins with an ECG
Determines ST elevation (YorN)
Cardiac Markers tested (Y or N)
Reperfusion thereapy
Angiogram (Picture to see coronary artereries) and then
Angioplasty w/ stent (Surgery)
Angiogram
part of cardiac catheterization
A procedure that uses contrast dye and fluoroscopy to examine blockages in coronary arteries
Angioplasty
aka percutaneous coronary intervention (PCI)
Invasive treatment
Stenosis (narrowing) of coronary arteries are dilated with a balloon catheter
What type of treatment is CABG?
Palliative
When someone is expereincing a STEMI, what meds are given on the way to the cath lap
Heparin (Anticoagulant)
ASA chew
