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NUR 254-Test 1 > Coronary Artery Disease > Flashcards

Coronary Artery Disease Flashcards

1
Q

Arteriosclerosis vs. Atherosclerosis

A

ARTERIOsclerosis: narrowing of artery

ATHEROsclerosis: narrowing d/t plaque build up;
–when this narrowing occurs in coronary arteries = CAD/CHD/ or heart disease

–when this narrowing occurs in peripheral vessels =
peripheral artery disease (PAD)

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2
Q

Patho of atherosclerosis

A

lipoproteins and fibrous tissue accumulate in arterial wall d/t injury/inflamm. or endothelial cells in arterial wall

  • -monocytes & lipids enter injured vessel&raquo_space;
  • -smooth muscle builds w/i vessel wall&raquo_space;
  • -fatty accumulations (streaks) develop&raquo_space;
  • -plaque enlarges and vessel narrows&raquo_space;
  • -blood flow decreases&raquo_space;
  • -plaque may RUPTURE and form THROMBUS, which could obstruct blood flow
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3
Q

CAD non-modifiable risk factors:

p. 1108

A

~age

  • -men >/= 45
  • -women >/= 55

~gender (men dx earlier than women)

~family hx of CAD (males dx before 55, female before 65)

~ Race (AA higher risk)

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4
Q

CAD modifiable risk factors:

p. 1108

A
  • hyperlipidemia (tx @ > 200)
      • high LDL & low HDL
  • smoking (vasoconstricts)
  • HTN
  • DM (have small vessels)
  • stress
  • kidney disease
  • Obesity / physical inactivity
  • atherogenic diet
  • oral contraceptives/HRT

** METABOLIC SYNDROME **

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5
Q

what is metabolic syndrome?

p. 1110

A

a group of metabolic risk factors that create a HIGH RISK CAD

  • –3 underlying causes: —
    1) overweight/obesity
    2) physical inactivity
    3) genetic factors

RISK FACTORS:

  • -large waistline
  • -high triglyceride level
  • -low HDL level
  • -HTN
  • -elevated fasting blood glucose
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6
Q

Preventing CAD

A

1) prevent occurrence of CAD
2) early detection & stopping progression of CAD

FOUR MAJOR AREAS:

  • ->control cholesterol
    • –fasting lipid profile q6wks after acute event
  • ->stop smoking
    • –nicotine replacement has same risks as tobacco
    • –bupropion (zyban) –antidepressant
  • ->manage HTN (repeatedly > 140/90)
    • –HTN damages vessels&raquo_space;causes inflamm & incr. atherosclerosis
  • ->control DM
    • –hyperglycemia fosters abnormal lipid levels, increased platelet aggregation, & altered RBC function&raquo_space;> leads to THROMBUS formation
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7
Q

Diet: SATURATED FATS (BAD)

A

biggest dietary cause of LDL

found in animal products
--butter
--milk
--cheese
--cream
--fatty meats
also found in coconut & palm oils
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8
Q

Diet: UNSATURATED FATS (GOOD)

A

help lower cholesterol if used to REPLACE SATURATED FATS; BUT they have a lot of calories (so limit them)

A) MONOunsaturated fats
—nuts, avocados, olive oil, canola oil

B) POLYunsaturated fats

  • –fish, safflower, sunflower, corn, soybean
    • -best = omega 3 fatty acids in fish and flaxseeds
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9
Q

Diet: COMPLEX CARBOHYDRATES (GOOD)

A

provide vitamins, minerals, and FIBER!!

  • breads
  • legumes
  • rice
  • pasta
  • starchy vegetables
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10
Q

Diet: SIMPLE CARBOHYDRATES (BAD)

A

broken down QUICKLY to be used as energy but lack vitamins, minerals, and fiber (empty calories)

–fruits, milk, milk products, cake, candy, refined sugars

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11
Q

Diet: PROTEIN

A

choose these low fat products:

  • -LEAN MEATS
  • -POULTRY w/o SKIN
  • -FISH
  • -DRIED BEANS
  • -low-fat / fat-free dairy
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12
Q

Physical Activity

A

regular, moderate exercise REDUCES TRIGLYCERIDES & INCREASES HDL

  • -** 30 min/day 5 - 6 days/week
  • -5 min warm up and cool down
  • -STOP IF any CP, unusual SOB, lightheadedness, or nausea (classic s/s of MI), or jaw pain
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13
Q

angina vs. ACS vs. MI

A

angina = ISCHEMIA (CP)

ACS = INJURY

MI = DEATH (cell)

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14
Q

Angina pectoris

“angina”

A

ischemic pain d/t precipitating factors (physical activity, stress/emotion, big meal, or exposure to cold)
causing INCREASED MYOCARDIAL O2 DEMAND, which results in INSUFFICIENT CORONARY BLOOD FLOW

ELDERLY MAY HAVE SILENT ISCHEMIA

DIABETICS MAY NOT HAVE PAIN D/T NEUROPATHY

Tx: sublingual NITROGLYCERIN (q5min x 3) to vasodilate arteries and improve perfusion
–s/efx: HA, VISON CHANGES, & DECR. BP

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15
Q

3 types of angina

A

1) STABLE *GOAL!!! to maintain coronary blood flow
- -most common & predictable (r/t activity & stressors)
- -relieved w/ REST & NITRATES

2) Prinzmetal / Variant
- -atypical; occurs unpredictably (unrelated to activity)
- -caused by coronary artery spasm

3) UN-STABLE (headed to ACS)
- -increases in frequency, severity, & duration
- -UNPREDICTABLE
- -occurs w/ DECR. level of activity / stress
- -may occur at rest
- -AT RISK FOR MI

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16
Q

Acute Coronary Syndrome (ACS)

“unstable angina”

A

blood flow is acutely reduced but not fully occluded

  • -myocardial cells are INJURED by the acute ischemia
  • -precipitated by plaque rupture, CA spasm, vessel obstruction by plaque, inflamm. of CA
  • **different from ANGINA b/c:
  • CP lasts longer (10 - 20 min)
  • may occur @ rest
  • pain is more severe (indicates INJURY…not ischemia)

other manifestations:

  • -dyspnea
  • -diaphoresis / cool skin / pallor
  • -tachycardia
  • -hypotension
  • -nausea / lightheaded
17
Q

Acute Myocardial Infarction

“MI”

A

blood flow to a portion of cardiac muscle is COMPLETELY BLOCKED&raquo_space; prolonged tissue ischemia & irreversible cell damage = INFARCTION / blockage
(CELL DEATH)…MUSCLE DOES NOT REGENERATE

  • -SUDDEN ONSET ; unrelated to exercise or rest
  • -SUBSTERNAL PAIN @ REST
    • may RADIATE (back/neck/jaw/arm/shoulder)
  • -pain = “crushing, pressure, squeezing, heavy”
  • -LAST > 20 MINS
  • -NOT relieved by nitroglycerin
18
Q

MI manifestations

A
  • dyspnea & SOB
  • -tachycardia / tachypnea
  • syncope (decreased BP)
  • N/V (** very indicative of MI **)
  • extreme weakness
  • diaphoresis
  • -cool, mottled skin / diminished peripheral pulses
  • -palpitations / dysrhythmias
  • denial / impending doom
  • incr. HR (b/c of myocardial O2 demand)
  • -CP is substernal/precordial (across chest)
  • -s/s of L-SIDED HF (dyspnea, fatigue, weak, crackles)
  • -decr. LOC
19
Q

MI Complications:
DYSRHYTHMIAS

p. 1112

A

–infarcted tissue effects electrical conduction&raquo_space; incr. risk for dysrhythmias

–PVCs MOST COMMON; may lead to VT or VF w/i 1h

–heart block or bradyarrhytmias

20
Q

MI Complications:

PUMP FAILURE & CARDIOGENIC SHOCK

A

HF –> CHF –> SHOCK

MI reduces contractility & ventricle wall compliance, LEADING TO PUMP FAILURE (HF)

–anterior MI = L-sided HF
(dyspnea, fatigue, weak, crackles)

–inferior MI = R-sided HF
(neck vein distention, peripheral edema)

Cardiogenic shock = IMPAIRED TISSUE PERFUSION d/t pump failure (LOW C.O.)

–occurs when myocardial mass decr. by > 40%

– * heart is UNABLE TO PUMP ENOUGH BLOOD to meet needs of body & maintain organ function; also have IMPAIRED CORONARY ARTERY PERFUSION

21
Q

MI Complications:

STRUCTURAL DEFECTS

A

necrotic muscle is REPLACED BY SCAR TISSUE
(thinner than ventricular muscle mass)

can result in:

  • -ventricular aneurysm (out-pouching of vent. wall)
  • -rupture of interventricular septum/papillary muscle
  • -myocardial rupture
22
Q

MI Complications:

PERICARDITIS

A

tissue necrosis prompts INFLAMMATORY RESPONSE
usually d/t VIRAL INFECTION
pericarditis = inflamm. of pericardial tissue around <3
–causes CP that is sharp / stabbing / aching
–pain is aggravated by movement or deep breathing
–may hear pericardial friction rub on auscultation

23
Q

MI treatment Goals

A

1) RELIEVE CP
2) reduce infarction (damage)–“time is muscle”
3) maintain cardiovascular stability
4) decrease workload (dobutamine; metoprolol)
5) prevent complications

R E P E R F U S I O N:
–PCTA (percutaneous transluminal coronary angioplasty)&raquo_space; cath. w/ balloon that goes through groin; inflate the balloon to push plaque aside and re-establish blood flow

–CABG (coronary artery bypass graft)

24
Q

Immediate MI treatment

A 
"MONA"
Morphine (d.o.c. for acute MI)
Oxygen (oxygenate circulating volume)
Nitroglycerine
Aspirin (ASA)--give 325mg of chewable aspirin
25
Q

ECG changes of ischemia vs. MI

A

ischemia:

  • -T wave INVERSION
  • -ST depression

MI:

  • -Q wave present
  • -ST ELEVATION
26
Q

CAD management: CHOLESTEROL LOWERING DRUGS

A 
IF diet &amp; exercise don't normalize levels...
Second line therapy =
*** CHOLESTEROL LOWERING DRUGS ***
1) STATINS
--lower LDL synthesis &amp; serum levels
--monitor liver enzymes

2) BILE ACID SEQUESTRANTS
–lower LDL by binding bile acids & reducing their reabsorption and cholesterol production in the liver
–watch for constipation/gastric distress
NAMES: “cholestyramine, colestipol, colesevelam”

3) NICOTOINIC ACID
–lowers total cholesterol, LDL, & triglyceride levels; raises HDL levels
–typically used in combo w/ STATINS
NAMES: “niacin”

4) FIBRIC ACID DERIVATIVES
–used to lower serum triglyceride levels (only have modest effect on LDL); used for very high triglyceride levels
–affect lipid regulation by blocking triglyceride synthesis
NAMES: “gemfibrozil, fenofibrate, clofibrate”

27
Q

Drugs for Angina: NITRATES

A

reduce myocardial O2 CONSUMPTION via arterial dilation&raquo_space; decreases ischemia&raquo_space; relieves pain

–used to treat acute angina attacks & prevent angina

  • **causes HYPOTENSION! ***
  • **high doses can decr. CO & BP ***
  • ** HA is COMMON***
  • can also cause nausea & dizziness*

Routes:
1) SL (tab or spray)–q 5 min; up to 3 tabs

2) TOPICAL (patch or ointment)–don’t get on your fingers! (causes HA & low BP); remove old patch before new one is applied

3) IV–titrate for s/s relief (to avoid hypotension)
* held if SBP is , 90 mmHg*

28
Q

Drugs for Angina: BETA-BLOCKERS

“-lols”

A

reduce myocardial O2 consumption by BLOCKING SNS stimulation
–prevent anginal attacks by reducing HR, BP, and CONDUCTION&raquo_space;
which decreases CP by decreasing ischemia

**contraindicated for pt with asthma or severe COPD b/c they can cause bronchospasm **

**HOLD IF: hypotension, HR < 50bpm, 2nd or 3rd degree heart block **

S/E: depression, fatigue, DECREASED LIBIDO, masks hypoglycemia

do NOT stop abruptly (wean off)

29
Q

Drugs for Angina: CALCIUM CHANNEL BLOCKERS

“verapamil, amlodipine, nifedipine, diltiazem”

A

–block Ca nodes in <3 so that only certain impulses can get through

–decrease SA & AV node conduction&raquo_space;
slows HR and DECR. STRENGTH of CTX,&raquo_space;
which decr. WORKLOAD of the <3 by decreasing myocardial O2 demand

–are also POTENT CORONARY VASODILATORS, which increases O2 supply

(high Ca = low ctx // low Ca = rigid muscles)

** act too slowly for acute angina&raquo_space;
USED for LONG-TERM PROPHYLAXIS **

***HOLD IF: bradycardia, heart block

***CAUTION w/ HF, dysrhythmias, or hypotension

30
Q

Drugs for Angina: ANTIPLATELET MEDS

“aspirin (ASA), clopidogrel (Plavix)”

A

given to prevent platelet aggregation (makes platelets slippery & interrupts platelet cascade)

NEITHER ARE GIVEN IN ACTIVE BLEEDING

  • **give ASA IMMEDIATELY AFTER ANGINA
  • -160 - 325mg dose
    • -routine dose = 81mg (baby ASA) - 325mg daily

–should take ASA even when taking TYLENOL

–use H2 blocker (famotidine-“Pepcid”) or
PPI (omeprazole-“Prilosec”/pantoprazole -“protonix”) if pt has GI UPSET or BLEEDING

  • -PLAVIX given in addition to ASA in pt w/ HIGH RISK FOR MI (synergistic effects)
  • -does not always work on Asian pts d/t lack of an enzyme
31
Q

DRUGS FOR MI: analgesics

1st goal = STOP PAIN

A

pain stimulates SNS&raquo_space; which increases HR and BP&raquo_space; which increases myocardial O2 demand

1) SL NTG 0.4mg (q 5min x 3)
* ask about SILDENAFIL (Viagra) before giving b/c the two can cause SIGNIFICANT DROP in BP*

2) if unrelieved by NTG (and for sedation)&raquo_space;
MORPHINE SULFATE (IV)
–initial dose: 4 - 8 mg
–small repeat doses: 2 - 4 mg q 5 min until pain gone
***watch for bradypnea & hypotension (decr resp. drive)

if pain is still unrelieved, inform MD b/c it may represent extension of infarct

32
Q

DRUGS FOR MI: fibrinolytics

“-ase”

A

“TREATS CLOTS”

dissolves clots & restores perfusion in MI or stroke

  • -tPA
  • -streptokinase
  • -urokinase
  • *best if given w/I 6 hours of ONSET** (fresh clots)
  • -limits infarct size & reduces <3 damage

*****CONTRAINDICATED: recent
FALL, SX, INTRACRANIAL BLEEDING, or GI BLEEDING

monitor for:

  • -bleeding
  • -cardiac rhythm changes (VT)
33
Q

DRUGS FOR MI: heparin & glycoprotein IIB/IIIa agents

(anticoagulants & antiplatelets)

do you know the bleeding precautions?

A

“PREVENT CLOTS”

anticoagulants prevent thrombi formation

HEPARIN

  • -IV bolus + continuous infusion
  • -titrated according to PTT (goal: 2-3x normal PTT)
  • -can use LMW heparin (Lovenox/enoxaparin) instead of regular heparin&raquo_space; NO PTT MONITORING NEEDED
  • **monitor for bleeding (BP & HR) ***
  • **place on BLEEDING PRECAUTIONS ***
  • **monitor for HIT in pt rec heparin for 5-15days or in the last 3 months

GLYCOPROTEIN AGENTS

  • -prevent platelet aggregation
  • -BLEEDING is MAJOR S/E to watch for
  • -“eptifibatide, tirofiban, abciximab”
  • -BLEEDING PRECAUTIONS:
    • longer pressure to puncture sites
    • no IM injections
    • avoid tissue injury (frequent automatic BP cuff)
    • soft bristle toothbrush
    • electric shaver
34
Q

DRUGS FOR MI: (others)

A

–Beta Blockers

–ACE inhibitors

–DOPAMINE (vasopressor):
vasoconstrict to increase BP with pump failure
(wont work if pt does not have sufficient volume)

STOOL SOFTENERS: prevent vagal response

35
Q

Clinical Therapy for MI

A
  • ICU + telemetry (12-lead & thorough CP questions)
  • frequent I/O & VS
  • bedrest for 12h (decr. myocardial O2 demand)
  • calm / quiet / limit visitors
  • liquid diet 4 - 12h
    (decr. gastric distention&raquo_space; blood goes to gut to digest food)

-no caffeine or very hot/cold foods (trigger dysrhythmias)

  • -SUPPLEMENTAL O2
    • given at onset of CP
    • 2 - 5 L/min
    • eval. effectiveness based on resp. Rate & rhythm
    • ** GOAL O2 sat = > 93% **
36
Q

Revascularization procedures (4)

A

1) Percutaneous Coronary revascularization (angioplasty)
- -stent + balloon on catheter inflated/expanded; balloon & cath removed but stent stays implanted in artery

2) Coronary Artery Bypass Graft (CABG)
- -vein or artery graft used as a bypass b/t AORTA & CORONARY ARTERY beyond obstruction
* **donor part (leg, arm, etc) will ALWAYS SWELL

3) Intra-Aortic Balloon Pump 1:1 pt*
- -temporary life-saving measure unitl O.R.
- -circulatory support device for cardiogenic shock
- -allows <3 to recover by decr workload and incr perfusion of coronary arteries
- -inflates during diastole (to support perfusion)
- -deflates during systole (so CO is unimpeded)

4) Ventricular Assistance Device (VAD)
- -* bridge for heart transplant *
- -take partial or complete control of cardiac function
- -augments contraction
- -provides “cardiac rest”

NUR 254-Test 1 (6 decks)

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