Week 6 Management of Patients with CAD Ch23 Flashcards
Abnormal accumulation of the lipid deposits and fibrous tissue within arterial walls and lumen
Atherosclerosis
In _____________________ ___________________ blockages and narrowing of the coronary vessels reduce blood flow to the myocardium
Coronary Atherosclerosis
Leading cause of death in the United States for all men and women of all racial and ethnic groups
Cardiovascular Disease
Most prevalent cardiovascular disease in adults
CAD
Pathophysiology of Atherosclerosis
- Endothelium, intima, media, adventitia
Injury response - Monocyte emigration
- Smooth muscle proliferation
- Fatty streak and lymphocyte
- Fibrofatty atheroma, collagen, lipid debris
Clinical manifestations of CAD include
Symptoms are caused by MI
Angina pectoris most common
other symptoms include: epigastric distress, pain that radiates to jaw or left arm, SOB, atypical symptoms in women
MI
HF
Sudden Cardiac Death
Non modifiable risk factors of CAD
Family History
Increasing age
Gender
Ethnicity
Hx premature menopause before 40
Primary hypercholesterolemia genetically elevated LDL
Name modifiable risk factors of CAD
Hyperlipidemia
Tobacco use
HTN
Diabetes
Metabolic Syndrome
Obesity
Physical Inactivity
CKD stage
How to prevent CAD?
Control Diabetes
Control cholesterol
Dietary measures
Physical activity
Medications
Cessation of tobacco use
Manage HTN
What are some cholesterol medications
-HMG-CoA or statins
- Nicotinic Acids
- Fibric Acids
Resins—Bile acid sequestrants
- Cholesterol absorption inhibitors
- Omega 3 acid ethyl esters
When ischemia is prolonged and not immediately reversible which what develops
ACS
- Either be partial or complete blockage
ACS encompasses what?
- Unstable Angina
- NSTEMI
- STEMI
What is the relationship between CAD, Chronic Stable Angina, and ACS
CAD—- Chronic stable angina —–Acute coronary syndrome
Acute coronary syndrome is broken up to two things
- Unstable angina
- NSTEMI
or 1. STEMI
Decreased blood flow in a coronary artery
Unstable Angina
Plaque ruptures and the clot completely occludes the artery
Ischemia and necrosis of tissue
MI
Other causes of MI include
Vasospasm
Rapid HR
Decreased O2 supply
Anything that can cause a profound imbalance between myocardia O2 supply and demand
MI
2 types of MI- NSTEMI or STEMI
Syndrome characterized by episodes or paroxysmal pain or pressure in the anterior chest caused by insufficient coronary blood flow
Angina Pectoris
Name the types of angina
Stable
Unstable
Intractable/ refractory
Variant (Prinzmetal)
Silent
Name Angina Precipitating Factors
Exertion
Temperature
Emotional Changes
Exercise or other physical exertion increases the HR and decreases the duration of diastole, which interferes with circulation to the coronary arteries
Exertion
Extremes increase the heart’s workload. Cold results in Vaso restriction, limiting the coronary blood flow. Heat causes peripheral vessels to dilate and blood to pool in the skin, again limiting coronary blood flow
Temperature
Strong emotions, such as anger or fear, stimulate the sympathetic nervous system and increase the pulse and the heart’s workload
Emotional Changes
This angina occurs when your heart is working harder and needs more oxygen that can be delivered through the narrowed arteries
Pain goes away when you rest or take nitroglycerin usually < 15 minutes
May continue without much change for years
Treatment and control
Stable Angina
Nitro SL
Extended Release Nitro
CC plus, BB
New in onset
Occurs at rest and longer than 15 min
Has worsening pattern may indicate deterioration of plaques
Unstable Angina
What angina is unpredictable and represents a medical emergency can lead to MI
Unstable Angina
Dx- No ECG changes or elevation of enzymes
Identified based on EKG, non ST segment elevation but still positive cardiac markers
NSTEMI
Management of UA/ NSTEMI for high risk
Coronary Arteriography - high risk strategy
Not high risk for UA and NSTEMI
Clopidogrel
Statin
ACEI
Outpatient Rx
Negative Stress tests from UA or NSTEMI
Consider alternative diagnosis
What is the nursing assessment for angina?
-Tightness, choking, or heavy sensation
- Frequently retrosternal and may radiate to neck, jaw, shoulders, back or arms
- Anxiety comes with pain
- Dyspnea, SOB, dizziness, nausea, vomiting
- The pain of typical angina subsides with rest or NTG
- Unstable angina
This is characterized by increased frequency and severity and is not relieved by rest or NTG. Requires medical intervention
Unstable Angina
Name Gerontologic considerations for CAD etc
Diminished pain transition that occurs with aging may affect presentation of symptoms
Silent CAD
Teach older adults to recognize their chest like pain ie weakness
- Pharm stress testing: cardiac cath
- Meds used cautiously
Tx of Angina/ CAD etc include
Tx to decrease myocardial oxygen and increase oxygen supply
Medications
Oxygen
Reduce and control risk factors
Reperfusion therapy may also be done
Medications for Angina/ CAD etc
Nitroglycerin
Beta adrenergic blocking agents
Calcium channel blockers
Antiplatelet and anticoag meds
- Aspirin
- Clopidogrel and ticlopidine
- Heparin
Glycoprotein IIB/ IIIa agents - Intergrilin and Reopro
Nitrates do what?
Small does dilate veins
Higher doses dilate arteries
Lo dose of nitrate
Affects veins/ venous pooling decreases pre load- low doses decreases CO and BP
High doses of nitrates
Affects arteries
Decrease BP and afterload and decrease myocardial O2 damages
Route: SL, IV, patch, spray
Blocks beta adrenergic sympathetic stimulation to the heart
Beta antagonist
Decrease
-HR- neg dromotrope
-BP
- Force of contractility- neg. inotrope
Caution in pulmonary diseases asthma
Calcium Channel Blockers have negative what?
Inotropic effects
Calcium Channel Blockers decrease what?
SA and AV node= Decrease HR and strength of contraction
Cardiac workload
BP by relaxing the vessels
In return increase
- Coronary artery perfusion
myocardial O2 supply by dilating arterioles
Decreases myocardial O2 demands by decreasing ABP and workload of LV
What labs do you look for heparin?
PTT
therapeutic levels are 2-2.5 x> normal
Anti factor Xa 0.11-0.4
Use LMWH for
Unstable angina and NSTEMI
PTT
Bleeding precautions: IM or restrictive BP cuffs
Acute angina dose for ASA is
160mg- 325 mg load
Maintenance is 81mg-325mg prophylactic
Coupled with H2 Blockers or PPI for GI upset
Name calcium channel blocker
Amlodipine
Diltiazem
Used when BB are ineffective and can prevent or tx venospasms
What does ASA do?
Decrease platelet aggregation, reduces incidence of MI and death from CAD
Prevents formation of new clots
Heparin
Nursing Assessment for pt with Angina includes
Healt history
Symptoms and activities especially those that precede and precipitate attacks
Risk factors, lifestyle, and health promotion activities
Pt and family knowledge
Dx
Diagnoses for Angina Pectoris patients include
Risk for decreased cardiac tissue perfusion
Anxiety related to cardiac symptoms and possible death
Deficient knowledge about the underlying disease and methods for avoiding complications
Noncompliance, ineffective management of therapy regimen
Interventions for patient with angina
MONA
Reduce anxiety
Prevent pain
Educate patients about self care
Continuing care
Blocks platelet activation and efficacy is achieved over days
Clopidogrel
HIT risk is
Heparin for 3 months or UFH 5-15 days period
Patient has Angina what do you do?
Stop all activity and rest
Assess pt with VS, resp. distress, and assessment of pain. ECG
Administer medications as ordered by protocol usually NTG. Reassess pain and administer NTG up to 3 doses
2L O2 by nc
Nursing goals for patient with Angina Pectoris
Immediate and appropriate tx of angina (relief of pain/ sx)
Prevention of angina
Reduction of anxiety
Awareness of disease process
Understanding of care and adherence to program
Absence of complications
Nursing Intervention in preventing pain includes
Identify the level of pain from activities
Plan accordingly
Alternate
Educate
Collaborative problems include
ACS, MI, or both
Dysrhythmias and cardiac arrest
Heart Failure
Cardiogenic Shock
Nursing intervention for patient teaching
Balance activity with rest
Follow prescribed exercise regimen
Avoid extreme temperatures
Use resources for emotional support
Avoid OTC medications
Stop using tobacco
Diet low in fat and high in fiber
Nursing interventions to reduce anxiety include
Use a calm manner
Stress reduction techniques
Patient teaching
Address spiritual needs
Address both family and patient
Nursing Intervention for patient teaching continued
Carry NTG all times
Follow up with provider
Report increases of s/s to provider
Maintain normal BP and blood glucose levels
ACS and MI
Emergent situation
Characterized by an acute onset of myocardial ischemia that results in myocardial death if definitive interventions do not occur promptly
Terms used Coronary occlusion, heart attack, and MI. MI preferred
Result of sustained ischemia greater than 20 min, causing irreversible myocardial cell death (necrosis)
MI
Necrosis of entire MI takes about 4-6 hours
Reperfusion is less than 20min and is
Salvaged
Reperfusion is 2-4 hr and is
Partial salvage
Permanent occlusion is
Complete infarct
What is the pain like in MI?
Total occlusion
–anaerobic metabolism and lactic acid accumulation
—severe, immobilizing chest pain not relieved by rest, position change, or nitrate administration
Presenting symptoms of MI include
Pain or discomfort to the right or left sided chest with radiation to the shoulder, neck jaw or back as well as tightness around the chest
Atypical symptoms of MI include
Dyspnea
Nausea
Vertigo
Diaphoresis
Fatigue
Gender disparity women MI includes
Ear pain, back pain, neck pain, upper abd. pain
More easily missed in women
Increase chance in post menopausal women
What is silent ischemia?
Up to 80% of patients with MI are asymptomatic
Associated with DM and HTN
Confirmed by ECG changes
