Coronary Artery Disease

Question 1

What is Coronary Artery Disease?

Answer 1

• Conditions that affect the arteries that provide blood, oxygen, and nutrients to the myocardium.
• When the blood flow is partially or completely blocked, ischemia and/or infarction may occur.
• Most common cause is atherosclerosis (blocked artery)

Question 2

What can CAD cause?

Answer 2

• Angina
• Myocardial Infarction (Heart Attack)

Question 3

What is the difference between Angina and MI?

Answer 3

• Angina - ischemia
• Myocardial Infarction (heart attack) - ischemia that leads to tissue death or infarction

Question 4

Non-modifiable risk factors of CAD?

Answer 4

• Increasing age
• Genetic predisposition

Question 5

Modifiable risk factors of CAD?

Answer 5

• Lipid levels
• Elevated blood pressure levels
• Physical Inactivity
• Tobacco use
  
  • Tobacco decreases estrogen levels which increases risk for CAD (estrogen is cardioprotective)
• Obesity
  
  • BMI > 30
  • Waist circumference greater than 40 for men and 35 for women

Question 6

What are some modifiable risk factors (psychological) of CAD?

Answer 6

• Type A personalities
• Individuals with suppressed anger
• Acute and chronic stress
• Individuals who are caregivers
• Depression - elevated levels of catecholamines results in increased endothelial inflammation

Question 7

What is Angina?

Answer 7

• A clinical syndrome characterized by episodes of pain or feeling of pressure in the anterior chest.
• Cause is insufficient coronary blood flow, resulting in inadequate oxygen supply to the myocardium.
• This episode is temporary and occurs with an increased workload on the heart.

Question 8

What is Angina caused by?

Answer 8

Usually caused by atherosclerotic heart disease and almost invariably is associated with a significant obstruction of a major coronary artery.

Question 9

What are some factors that contribute to Anginal pain?

Answer 9

• Eating a heavy meal increases the blood flow to the mesenteric area for digestion, thus reducing the available blood supply to the heart.
• Stress or any emotion-provoking situation causing the release of adrenaline and increased blood pressure may accelerate the heart rate, increasing myocardial workload.
• Physical exertion can precipitate an attack by increasing oxygen demands.
• Exposure to cold can cause vasoconstriction and elevated BP with increased oxygen demand.

Question 10

What is Stable Angina?

Answer 10

• Occurs with moderate to prolonged exertion in a pattern that is familiar to the patient.
• The frequency, duration, and intensity of symptoms remain stable over the preceding months.
• Results in limitation of activity.
• Usually relieved with nitroglycerin or rest

Question 11

What is Unstable Angina?

Answer 11

• Chest pain or discomfort that occurs at rest or with exertion and causes marked limitation of activity.
• Increase in number and intensity.
• Pain may last longer than 15 minutes or poorly relieved by rest or NTG.

Question 12

Angina clinical manifestations?

Answer 12

• Pain - produced by ischemia of the heart muscle.
  
  • Precipitated by exertion or stress
• Pain varies from pressure in the upper chest to agonizing pain that is accompanied by severe apprehension and a feeling of impending death.
• The pain is usually felt in the upper chest behind the upper or middle third of the sternum.
• The pain is usually localized but may radiate to the neck, jaw, and inner aspects of the upper extremities.

Question 13

Other angina clinical manifestation?

Answer 13

• May complain of indigestion or burning sensation in the epigastric region or between the shoulder blades.
• An important characteristic of anginal pain is that is subsides when the precipitating cause is removed.

Question 14

Gerontologic considerations for Angina?

Answer 14

• The older adult may not exhibit the typical pain profile because of changes in neuroreceptors.
• Pain is often manifested in the older adult as weakness or fainting.
• Can also experience disorientation or confusion due to poor cardiac output.
• When exposed to cold temperatures, older adults may experience anginal symptoms more quickly than younger persons because have less subcutaneous fat to provide insulation.

Question 15

How is Angina diagnosed?

Answer 15

• Evaluating the clinical manifestations of pain and the patient’s history.
• Patient’s response to exertion or stress tested by EKG monitoring while exercise tolerance testing is done.

Question 16

What is the goal of Angina management?

Answer 16

• Decrease the oxygen demands of the myocardium
• Increase the oxygen supply

Question 17

What is the main drug for treating Angina? How does it work?

Answer 17

• Nitrates remain the mainstay for treating angina pectoris.
• Reduces myocardial oxygen use, which decreases ischemia and relieves anginal pain.
• Acts to dilate both the veins and the arteries and affects peripheral circulation.

Question 18

What are the types of Nitrates?

Answer 18

Short-acting:

• Nitroglycerin

Long-acting:

• Isosorbide dinitrate (Isordil)
  
  • Used to reduce the frequency of anginal attacks.

Question 19

Nitroglycerin tablets nursing considerations?

Answer 19

• Placed under the tongue (sublingually) or in the cheek (buccal pouch).
• The client is taught to avoid swallowing saliva until the NTG tablet is dissolved.
• Can drink 5ml of water, if necessary, to help tablet dissolve.
• Tablets can be crushed between the teeth to hasten absorption.
• In 5-minute increments, a total of three doses may be administered.

Question 20

How do you assess Nitroglycerin effectiveness?

Answer 20

• Pain relief should begin 1-2 minutes and should be alleviated in 3-5 minutes.
  
  • Effects last approximately 30-40 minutes
• After 5 minutes, recheck the patient’s pain intensity and vital signs.
• If the patient is experiencing some but not complete relief and vital signs remain stable, give another NTG tablet (or spray).

Question 21

What BP reading would require an intervention? What type of intervention is best?

Answer 21

systolic blood pressure is less than 100 mmHg or 25 mmHg lower than previous reading

• lower the head of the bed and notify a health care professional
  
  • this promotes blood flow

Question 22

What does if mean if there is no relief from Nitroglycerin?

Answer 22

Patient may be experiencing a myocardial infarction/heart attack.

Question 23

When can you take Nitroglycerin?

Answer 23

• Can be taken when experiencing chest pain
• Can be taken prophylactically before beginning an activity

Question 24

How is Nitroglycerin stored?

Answer 24

• Patient should carry the medication with them at all times.
• Nitroglycerin is very unstable and is kept in a securely capped dark glass bottle because it is sensitive to light.

Question 25

What to educate the patient about Nitroglycerin?

Answer 25

• NTG is inactivated by heat, moisture, light and time.
• If fresh, the patient will feel a burning/tingling sensation under the tongue and a feeling of fullness or throbbing in the head.
• The NTG supply should be renewed every 6 months (can lose potency)

Question 26

How to use Nitroglycerin Lingual Spray?

Answer 26

• NTG spray is available and absorbed quicker.
  
  • The spray should be directed on the tongue and not inhaled.
• Spray can be taken prophylactically before beginning an activity.

Question 27

How to use Nitroglycerin Ointment (Nitrobid)?

Answer 27

• 2% topical ointment that is dosed by the inch
• Placed on the upper body or arm
• Flat muscular area that is free from hair and scars
• Once absorbed it has a duration of action for 3-6 hours
• Should be wiped off to allow for a 10 to14-hour nitrate free interval.
  
  • To prevent nitrate tolerance

Question 28

Nitroglycerin side effects?

Answer 28

• Flushing
• Dizziness-caution patient to change positions slowly.
• Headache
• Hypotension/orthostatic hypotension
• Tachycardia

Question 29

What other meds can be used for long-term prevention of Angina?

Answer 29

• ACE Inhibitors
• Beta Blockers
• Calcium Channel Blockers