Coronary Artery Disease Flashcards
Cardiovascular Disease
- leading cause of death in Canada
Coronary Artery Disease
A type of blood vessel disorder that is included in the general category of atherosclerosis
Progression of Atherosclerosis
- begins as soft deposits of fat that harden with age (hardening of arteries)
- Atheromas (fatty deposits) have a preference for the coronary arteries
Synonyms for Coronary Artery Disease
- Arteriosclerotic heart disease (ASHD)
- Cardiovascular heart disease (CVHD)
- Ischemic heart disease (HD)
- Coronary heart disease (CHD)
Major cause of CAD
- atherosclerosis
Atherosclerosis
- focal deposits of cholesterol & lipid, primarily within the intimal wall of the artery resulting in reduced or obstructed blood flow
Developmental stages of Atherosclerosis
- 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)
Collateral circulation
normally some arterial anastomoses exist within coronary circulation
Growth and extent of collateral circulation is attributed to two factors…
- inherited predisposition to develop new vessels (angiogenesis)
- presence of chronic ischemia
Non-modifiable Risk Factors
- increased age
- sex (men>women until 65 years of age)
- ethnicity
- family history
- genetics
Modifiable Risk factors (9)
- elevated serum lipids
- hypertension
- tobacco use
- obesity
- physical inactivity
- diabetes
- metabolic syndrom
- psychological stress
- homocysteine levels
Metabolic Syndrome
- obesity
- BMI > 30 kg/m2
- Waist circumference > 102 cm in males and 88 cm in women
- HTN
- abnormal serum lipid levels
- elevated fasting glucose
Health Promotion in CAD
- identification of people at high risk
People at High Risk of CAD
- 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
Health-Promoting Behaviours: CAD
- 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
Chronic Stable Angina: Manifestation of CAD
- etiology and pathophysiology
- 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
At what percentage of occlusion will ischemia occur?
- 75% or more is stenosed (obstructed)
Chronic Stable Angina (type of pain?)
- chest pain with the same pattern of onset, duration, and intensity of symptoms
Chronic Stable Angina characteristics
- 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
Precipitating Factors for Chronic Stable Angina
things that increase O2 demand, physical exertion, temperature extremes, strong emotion, consumption of heavy metals, tobacco use, sexual activity, circadian rhythm patterns
Collaborative Management (ABCDEF) of Chronic Stable Angina
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
Silent Ischemia
ischemia is asymptomatic
associated with diabetes mellitus
Nocturnal angina
occurs only at night but not necessarily in recumbent position or during sleep
Angina decubitus
chest pain that occurs only while lying down
usually relieved by standing or sitting down
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
Acute Coronary Syndrom (ACS)
- when myocardial ischemia is prolonged and not immediately reversible
- ACS is umbrella term, covers unstable angina, NSTEMI, STEMI
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
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
Symptoms of NSTEMI
- diaphoresis, crackles, SOB, increased HR
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
Symptoms of STEMI
- shocky
- tachycardic, nauseous, vomiting, crushing chest pain
- impending doom feeling
- generally look very unwell
Goal in STEMI
angiogram in 90 min (door to balloon time: 90 min)
ECG 10 min from onset of chest pain
ECG (electrocardiogram)
- electrical conduction in the heart
- electrical depolarization proceeds electrical conduction
- electrical abnormalities = mechanical abnormalities
- 12-lead
P-wave
little one that proceeds the QRS complex - atrial depolarization
QRS complex
ventricular depolarization
T-wave
repolarization of ventricles
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.
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
Assessment of Angina (PQRST)
P: precipitating events Q: quality of pain R: radiation of pain S: severity of pain T: timing
Subjective Data: CAD
- health history: hypertension, diabetes, smoking, obesity, history of stroke
- symptoms: ask questions. chest pain.
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
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
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.
Lab Studies for ACS
- serial troponins (urgent)
- CBC, CP7, fasting lipids and glucose, LFTs, BNPs, TSH
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
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
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
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
Discharge plan for those with ACS
Encourage cardiac rehabilitation
Encourage reduction of risk factors
Teach regarding medications
Beta-adrenergic blockers
- reduce workload of heart, decrease myocardial oxygen demand. slow heart rate and can drop BP
Calcium channel blockers
- dilate coronary arteries
- used if B-adrenergic blockers are poorly tolerated, contraindicated, or do not control anginal symptoms
- Reduce heart rate
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
Angiotensin converting enzyme inhibitors
- dilate blood vessels and decrease BP
- need to check BP before administering
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
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
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
Discharge Planning
- ambulatory and home care
- client teaching (CAD and angina, precipitating factors for angina, educate regarding energy preservation strategies, risk factor reduction, medications.
Unstable Angina/NSTEMI
- ECG
- Serial troponins
- Stress test
- Urgent angiogram/-plasty
STEMI treatment
- ECG
- serial troponins
- emergent angioplasty and stenting
Restoration of Blood Supply
- angioplasty
- stenting
- CABG
Angiogram
part of cardiac catheterization. A procedure that uses contrast dye and fluoroscopy to examine blockage in coronary arteries. A diagnostic piece
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.
Stenting
a small wire, mesh tube angioplasty is often combined with placement of stent. maintains patency.
CABG
- coronary artery bypass graft surgery
- not a cure. long-standing smoking patients or long-standing diabetics.
- uses arteria and veins for grafts
