Coronary Artery Disease Flashcards
1
Q
Cardiovascular Disease
A
- leading cause of death in Canada
2
Q
Coronary Artery Disease
A
A type of blood vessel disorder that is included in the general category of atherosclerosis
3
Q
Progression of Atherosclerosis
A
- begins as soft deposits of fat that harden with age (hardening of arteries)
- Atheromas (fatty deposits) have a preference for the coronary arteries
4
Q
Synonyms for Coronary Artery Disease
A
- Arteriosclerotic heart disease (ASHD)
- Cardiovascular heart disease (CVHD)
- Ischemic heart disease (HD)
- Coronary heart disease (CHD)
5
Q
Major cause of CAD
A
- atherosclerosis
6
Q
Atherosclerosis
A
- focal deposits of cholesterol & lipid, primarily within the intimal wall of the artery resulting in reduced or obstructed blood flow
7
Q
Developmental stages of Atherosclerosis
A
- Fatty streaks (earliest lesion, possible reversible). lipid-filled smooth muscle cells
- Fibrous plaque (beginning of progressive changes) fatty streak covered with collagen
- Complicated lesion (continuous inflammation results in plaque instability, ulceration, and rupture and thrombus formation. total occlusion)
8
Q
Collateral circulation
A
normally some arterial anastomoses exist within coronary circulation
9
Q
Growth and extent of collateral circulation is attributed to two factors…
A
- inherited predisposition to develop new vessels (angiogenesis)
- presence of chronic ischemia
10
Q
Non-modifiable Risk Factors
A
- increased age
- sex (men>women until 65 years of age)
- ethnicity
- family history
- genetics
11
Q
Modifiable Risk factors (9)
A
- elevated serum lipids
- hypertension
- tobacco use
- obesity
- physical inactivity
- diabetes
- metabolic syndrom
- psychological stress
- homocysteine levels
12
Q
Metabolic Syndrome
A
- obesity
- BMI > 30 kg/m2
- Waist circumference > 102 cm in males and 88 cm in women
- HTN
- abnormal serum lipid levels
- elevated fasting glucose
13
Q
Health Promotion in CAD
A
- identification of people at high risk
14
Q
People at High Risk of CAD
A
- personal & family history
- Presence of cardiovascular symptoms
- Environmental patterns: eating habits, type of diet, activity
- Psychosocial history: smoking, alcohol, type A behaviours, recent stressful life events, sleeping, presence of anxiety or depression
- Attitudes and beliefs about health and illness
- Educational background
15
Q
Health-Promoting Behaviours: CAD
A
- physical fitness
- nutritional therapy (omega-3 fatty acids, choose plant-based fats vs saturated fats) (cholesterol lowering drug therapy - statins restrict lipoprotein production)
- anticoagulant therapy - apsirin/heparin - prevention of embolus formation & subsequent stroke or MI
16
Q
Chronic Stable Angina: Manifestation of CAD
- etiology and pathophysiology
A
- reversible
- myocardial ischemia = angina
- intermittent chest pain
- issue is either increased demand or decreased supply
- primary reason for insufficient blood flow is narrowing of coronary arteries by atherosclerosis
17
Q
At what percentage of occlusion will ischemia occur?
A
- 75% or more is stenosed (obstructed)
18
Q
Chronic Stable Angina (type of pain?)
A
- chest pain with the same pattern of onset, duration, and intensity of symptoms
19
Q
Chronic Stable Angina characteristics
A
- pain usually lasts 3-5 min
- patient knows pattern of pain and will take Nitrospray (0.4 mg SL Q5 min 3x ahead of precipitating factor
- subsides when precipitating factor is relieved
- pain is constrictive, squeezing, heavy, choking
- Predictable
20
Q
Precipitating Factors for Chronic Stable Angina
A
things that increase O2 demand, physical exertion, temperature extremes, strong emotion, consumption of heavy metals, tobacco use, sexual activity, circadian rhythm patterns
21
Q
Collaborative Management (ABCDEF) of Chronic Stable Angina
A
A. antiplatelet, anti-anginal, ACE inhibitors
B. Beta-blockers, management of BP
C. Cigarette smoking, cessation, Management of cholesterol
D. Diet and diabetes
E. Education and exercise.
F. Flu vaccination
22
Q
Silent Ischemia
A
ischemia is asymptomatic
associated with diabetes mellitus
23
Q
Nocturnal angina
A
occurs only at night but not necessarily in recumbent position or during sleep
24
Q
Angina decubitus
A
chest pain that occurs only while lying down
usually relieved by standing or sitting down
25
Prinzmetal's angina
- occurs at rest usually in response to spasm of major coronary artery
- seen in clients with a history of migraine headaches and Raynauds phenomenon
- Spasm may occur in the absence of CAD
- May be relieved by moderate exercise
26
Acute Coronary Syndrom (ACS)
- when myocardial ischemia is prolonged and not immediately reversible
- ACS is umbrella term, covers unstable angina, NSTEMI, STEMI
27
Unstable Angina (UA)
- chest pain that is new in onset, occurs at rest, or has a worsening pattern
- chest pain isnt sustained. constitutes a medical emergency
chest pain results form myocardial ischemia
28
NSTEMI
(non-ST elevated MI)
- partial-thickness blockage MI - blockage of only part of the thickness of the heart muscle. Part of the heart can still be living and functional.
- Takes time to damage heart muscle
- 20 minutes before cell death
- takes 5-6 hr before the entire thickness of the heart muscle becomes necrosed
29
Symptoms of NSTEMI
- diaphoresis, crackles, SOB, increased HR
30
STEMI
- total occlusion of a cardiac artery
- full thickness blockage MI
- can have same symptoms as NSTEMI (more rapid onset and progression)
- Symptoms depend on the location of the blockage
31
Symptoms of STEMI
- shocky
- tachycardic, nauseous, vomiting, crushing chest pain
- impending doom feeling
- generally look very unwell
32
Goal in STEMI
angiogram in 90 min (door to balloon time: 90 min)
| ECG 10 min from onset of chest pain
33
ECG (electrocardiogram)
- electrical conduction in the heart
- electrical depolarization proceeds electrical conduction
- electrical abnormalities = mechanical abnormalities
- 12-lead
34
P-wave
little one that proceeds the QRS complex - atrial depolarization
35
QRS complex
ventricular depolarization
36
T-wave
repolarization of ventricles
37
ST segment
following QRS complex and before the T wave.
| - in STEMI, the ST segment does not return to isoelectric line. important when it happens in two or more vectors.
38
Clinical Manifestations of CAD
- midsternal left shoulder and down both arms
- neck and arms
- substernal radiating to neck and jaw
- substernal radiating down left arm
- epigastric
- epigastric radiating to neck, jaw, and arms
- intrascapular
- women - nausea, right shoulder or bilateral
39
Assessment of Angina (PQRST)
```
P: precipitating events
Q: quality of pain
R: radiation of pain
S: severity of pain
T: timing
```
40
Subjective Data: CAD
- health history: hypertension, diabetes, smoking, obesity, history of stroke
- symptoms: ask questions. chest pain.
41
Objective data:
General: anxiety, fear, restlessness
Integumentary: cool, clammy, diaphoretic, pale/gray
Cardiovascular: tachy/bradycardia/dysrhthmias, BP, changes, quality of pulses, listen to heart sounds, look for changes in baseline vitals, listen for crackles in lungs
42
Goals of Care for all ACS patients
- same as it was for stable angina patients
- decrease demand for oxygen
- increase oxygen supply/blood flow to the cardiac arteries. - deliver supplemental O2, keep SpO2 over 90%. 2L/min
43
ACS Diagnostic Studies
- 12-lead ECG - need to happen within 10 min of onset of chest pain.
- lab studies
- chest x-ray
- echocardiogram - more important in heart failure
- exercise stress test.
44
Lab Studies for ACS
- serial troponins (urgent)
| - CBC, CP7, fasting lipids and glucose, LFTs, BNPs, TSH
45
Troponin
cardiac cell monocytes has to be damaged, strained, or have died to release the enzyme - it is a specific cardiac marker.
- repeat test in 3 hr to capture the rise in troponin that may not be captured in the first test + ECG
46
Nursing Management of ACS
- relief of pain
- preservation of myocardium
- immediate and appropriate treatment
- effective patient coping and illness-associated anxiety
- prevention of further angina or MI by reducing risk factors
47
Acute interventions for angina attack
- REST
- Give supplemental oxygen is spO2 < 92% (due to risk for oxygen toxicity)
- Determine vital signs and do routinely
- Do a 12-lead ECG
- Provide prompt pain relief with a nitrate followed by an opioid analgesic if needed
- auscultate heart sounds
- position client comfortably
48
Broad interventions for ACS
- provide pain relief
- preserve myocardium (cardiac monitoring and diagnostics)
- maintain signs of effective cardiac perfusion
- provide immediate and ongoing treatment
- ensure comprehensive discharge plan
49
Discharge plan for those with ACS
Encourage cardiac rehabilitation
Encourage reduction of risk factors
Teach regarding medications
50
Beta-adrenergic blockers
- reduce workload of heart, decrease myocardial oxygen demand. slow heart rate and can drop BP
51
Calcium channel blockers
- dilate coronary arteries
- used if B-adrenergic blockers are poorly tolerated, contraindicated, or do not control anginal symptoms
- Reduce heart rate
52
Nitrates - first line of therapy for angina
- vasodilator
- short-acting nitrates - SL or TL (spray) nitroglycerin
- transdermal nitrates (nitropatch)
- Nursing considerations; lowers BP, and headache. monitor VS and give again after 5 min if doesn't help
53
Angiotensin converting enzyme inhibitors
- dilate blood vessels and decrease BP
| - need to check BP before administering
54
Opioids - morphine/fentanyl
- reduce pain
- may lower HR and reduce need for O2
- nursing consideration: monitor resp rate. do not five to patient with RR < 12
55
ASA/antiplatelet agents
- inhibits platelet aggregation
- is there blood in stool or vomit (GI bleed)
- chewable so if can be absorbed faster
- reduces platelet stickiness so the thrombus that forms at atherosclerotic plaque does not fully occlude artery
56
What to do if suspected MI
- order troponin to determine ACS or NSTEMI. tells degree of heart strain
- start IV incase they stop breathing and need Epi quickly
- left-arm because angiogram goes in rt arm
- five blood thinners
- if near cath lab, give ASA and heparin then communicate with hospital they are going to and send the ASAP
57
Discharge Planning
- ambulatory and home care
- client teaching (CAD and angina, precipitating factors for angina, educate regarding energy preservation strategies, risk factor reduction, medications.
58
Unstable Angina/NSTEMI
- ECG
- Serial troponins
- Stress test
- Urgent angiogram/-plasty
59
STEMI treatment
- ECG
- serial troponins
- emergent angioplasty and stenting
60
Restoration of Blood Supply
- angioplasty
- stenting
- CABG
61
Angiogram
part of cardiac catheterization. A procedure that uses contrast dye and fluoroscopy to examine blockage in coronary arteries. A diagnostic piece
62
Angioplasty
the balloon that is inflated to push the blockages out of the way. Temporary. inflation of the balloon right at the narrowing of the artery.
63
Stenting
a small wire, mesh tube angioplasty is often combined with placement of stent. maintains patency.
64
CABG
- coronary artery bypass graft surgery
- not a cure. long-standing smoking patients or long-standing diabetics.
- uses arteria and veins for grafts
