Chapter 33 CAD and Acute coronary syndrome Flashcards
is the most common type of CVD.
Coronary artery disease (CAD)
is a type of blood vessel disorder that we consider in the general category of atherosclerosis.
Coronary artery disease (CAD)
comes from 2 Greek words: athere, meaning “fatty mush,” and skleros, meaning “hard.”3
atherosclerosis
form in the coronary arteries, the disease is called CAD
atheromas (fatty deposits)
arteriosclerotic heart disease (ASHD), cardiovascular heart disease (CVHD), ischemic heart disease (IHD), coronary heart disease (CHD), are
other terms used to describe CAD.
tobacco use, hyperlipidemia, hypertension, toxins, diabetes, high homocysteine levels, and infection causing a local inflammatory response
Damage to the endothelial lining can result from
, a protein made by the liver, is a nonspecific marker of inflammation. CRP levels rise when there is systemic inflammation, such as rheumatoid arthritis or inflammatory bowel disease
C-reactive protein (CRP)
are (1) fatty streak, (2) fibrous plaque, and (3) complicated lesion.
The stages of development in atherosclerosis
the earliest lesions of atherosclerosis, are lipid-filled smooth muscle cells
Fatty streaks
stage is the beginning of progressive changes in the endothelium of the arterial wall. These changes can appear in the coronary arteries by age 30 and increase with age.
fibrous plaque
some arterial anastomoses or connections, called collateral circulation, exist within the
coronary circulation
(1) inherited predisposition to develop new blood vessels (angiogenesis) and (2) presence of chronic ischemia (poor blood flow).
Two factors contribute to the growth and extent of collateral circulation:
Frequency (how often), Intensity (how hard), Type (isotonic), and Time (how long). Everyone
FITT formula
Red meat, egg yolks, and whole milk products are \
major sources of saturated fat and cholesterol.
is the most potent statin currently available.
Rosuvastatin (Crestor)
work by aiding the removal of VLDLs. They are very effective for lowering triglycerides and increasing HDL levels.
fibric acid derivatives
muscle ache
myopathy
increase conversion of cholesterol to bile acids in the liver and decrease hepatic cholesterol
Bile-acid sequestrants
are a newer class of cholesterol-lowering drugs
PCSK9 inhibitors
selectively inhibits the absorption of dietary and biliary cholesterol across the intestinal wall
-patients with primary hypercholesterolemia
Ezetimibe (Zetia)
is recommended for people who have CAD.
Low-dose aspirin (81 mg)
is an option for people who are aspirin intolerant.
Clopidogrel (Plavix)
Aggressive treatment of hypertension and hyperlipidemia
helps stabilize plaques in the coronary arteries.
break down skeletal muscle
rhabdomyolysis
joint pain
Arthralgia
results from a decreased ability to sweat efficiently
Heat intolerance
on most days of the week as able
older adult should exercise a minimum of 30 minutes
, is the clinical manifestation of myocardial ischemia
Angina, or chest pain
When the demand for myocardial O2 exceeds the ability of the coronary arteries to supply the heart with O2,
myocardial ischemia occurs
is significant narrowing of 1 or more coronary arteries by atherosclerosis.
The most common reason for angina to develop
, the artery is usually blocked (stenosed) 70% or more (50% or more for the left main coronary artery).20
For ischemia to occur from an atherosclerotic plaque
refers to chest pain that occurs intermittently over a long period of time with a similar pattern of onset, duration, and intensity of symptoms.
Chronic stable angina
provoked by physical exertion, stress, or emotional upset
- a pressure, heaviness, or discomfort in the chest.
- described as a squeezing, heavy, tight, or suffocating sensation
- does not change with position or breathing.
cause of Chronic stable angina
substernally, it may radiate to other locations, including the jaw, neck, shoulders, and/or arms
-feeling of indigestion or a burning sensation in the epigastric region. The sensation may be felt between the shoulder blades
most angina pain occurs
including dyspnea, nausea, mid-epigastric discomfort, and/or fatigue. We refer to this as an angina equivalent.
women and older adults, report atypical symptoms of angina
only a few minutes
pain of chronic stable angina usually lasts for
when the precipitating factor is resolved (e.g., by resting, calming down, using sublingual nitroglycerin [SL NTG]) (
chronic angina subsides
ST segment depression and/or T wave inversion. ( changes represent inadequate supply of blood and O2 to the heart muscle)
With ischemia, the 12-lead ECG often shows
the isoelectric line should be flat
normal heart ECG
refers to ischemia that occurs in the absence of any subjective symptoms
Silent ischemia (diabetic)
This is likely due to diabetic neuropathy affecting the nerves that innervate the cardiovascular system.
Patients with diabetes have an increased prevalence of silent ischemia.
early morning
Circadian Rhythm Patterns occur
Coronary vasospasm
Prinzmetal’s angina
Treatment may include long-acting nitrates and/or calcium channel blockers
-occur at rest
Prinzmetal’s angina treatment
Myocardial ischemia from microvascular disease affecting the small, distal branches of coronary arteries
Microvascular angina
More common in women
• Triggered by activities of daily living (e.g., shopping, work) vs. physical exercise (exertion)
• Treatment may include nitroglycerin
Microvascular angina
Rupture of unstable plaque, exposing thrombogenic surface
- Occurs at rest or with minimal exertion
Unstable angina (last more than 10 mins)
is a rare form of angina that often occurs at rest and not with increased physical demand. It is sometimes seen in patients with a history of migraine headaches, Raynaud’s phenomenon, and heavy smoking.
Prinzmetal’s angina(variant angina)
usually due to spasm of a major coronary artery. Strong contraction (spasm) of smooth muscle in the coronary artery results from increased intracellular calcium.
Prinzmetal’s angina(variant angina) // cause pathophy
(not usually associated with an MI)
When spasm occurs, the patient has angina and transient ST segment elevation
significant CAD or coronary spasm of a major coronary artery
In microvascular angina, chest pain occurs in the absence of
MVD is often used interchangeably with the term
syndrome X
or develop into UA (unstable angina) or ACS.
Chronic stable angina can progress
1) relief of pain, (2) immediate and appropriate treatment, (3) preservation of heart muscle if an MI is suspected, (4) effective coping with illness-associated anxiety, (5) participation in a rehabilitation plan, and (6) reduction of risk factors.
The overall goals for a patient who presents with angina include
(1) position patient upright unless contraindicated and apply supplemental O2, (2) assess vital signs, (3) place patient on continuous ECG monitor, (4) obtain a 12-lead ECG, (5) provide prompt pain relief, first with NTG, followed by an IV opioid analgesic, if needed, (6) obtain cardiac biomarkers, (7) assess heart and breath sounds, and (8) obtain a chest x-ray. T
patient has angina, perform the following measures:
may indicate ischemia of a papillary muscle of the mitral valve, causing mitral regurgitation (the mitral valve does not close properly).
new systolic murmur heard during an angina attack