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Nursing 172 > Week 8: Chp 30: Coronary Artery Disease > Flashcards

Week 8: Chp 30: Coronary Artery Disease Flashcards

1
Q

When does Coronary Artery Disease Occur?

A

occurs when the blood vessels that deliver oxygen-rich blood to the heart muscle become obstructed or dysfunctional

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2
Q

Coronary Artery Disease is also known as?`

A

-coronary heart disease
-or ischemic heart disease
>most common cause of heart disease

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3
Q

Modifiable Risk Factors

A

amenable to intervention

  • cigarette smoking
  • high total cholesterol, high LDL level, low HDL levels and high triglycerides
  • hypertension
  • diabetes (hyperglycemia)
  • obesity, partially central obesity
  • sedentary lifestyle/ physical inactivity
  • stress
  • excessive alcohol consumption
  • hyperlipidemia (high level of fats)
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4
Q

Non-modifiable Risk Factors

A

not-amenable to intervention

  • gender
  • race
  • age older than 45 for men (increases with age)
  • genetics/ family history
  • being postmenopausal
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5
Q

What is Coronary Artery Disease? (pathophysiology)

A

CAD is characterized by the obstruction of blood flow within the coronary arteries

  • atherosclerosis, or plaque within the lumen of the vessel, is the principle cause of obstruction to blood flow
  • the arterial wall is made up of 3 layers and this is how CAD starts (from atherosclerosis starting in the tunica intima layer)
  • can be obstructive or non-obstructive
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6
Q

3 Layers of the arterial wall

A
  • tunica intima
  • tunica media
  • tunica adventitia
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7
Q

Layer of the arterial wall: Tunica intima

A
  • composed of endothelium and basement membrane
  • atherosclerosis begins with an injury to the endothelium that causes an inflammatory response
  • that inflammatory response initiates a series of specific cellular and molecular reactions that lead to the accumulation of atherosclerotic plaque
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8
Q

Formation of atherosclerosis starting in the tunica intima layer of the arterial wall; can result in CAD

A

atherosclerosis begins with an injury to the endothelium that causes an inflammatory response
-low-density lipoprotein (LDL) enters the tunica intima layer of the arterial wall and becomes trapped
-inside the tunica intima layer, the trapped LDL is modified through the process of oxidation
-once modified, the LDL attracts macrophages, which absorb the LDL to become foam cells; fatty streaks within the tunica intima are an accumulation of foam cells
-as the process continues, various components in the blood such as macrophages, calcium, and cholesterol, adhere to the injured part of the vessel forming plaque
-the plaque deposits increase in size over time, causing narrowing of the coronary arteries, which impedes oxygen rich blood flow to the heart
>when the heart muscle does not get enough oxygen and nutrients to meet its demands, myocardial ischemia results (pathology known as obstructive coronary artery disease)

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9
Q

When the heart muscle does not get enough oxygen and nutrients to meet its demands, what results?

A

myocardial ischemia (pathology known as obstructive coronary artery disease)

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10
Q

What is the principle cause to the obstruction of blood flow?

A

atherosclerosis (plaque; within the lumen of the vessel)

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11
Q

Most dangerous complication in the development of atherosclerosis?

A

potential plaque rupture

  • when this occurs, platelets aggregate on the ruptured plaque surface; the coagulation cascade is initiated, and thrombus formation is stimulated
  • this clotting further decreases or obstructs blood flow altogether, leading to unstable angina, myocardial infarction (MI), or sudden cardiac death
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12
Q

Nonobstructive coronary artery disease

A

do not have significant plaque that occludes the coronary arteries

  • ischemic symptoms are caused by reduced blood flow through the coronary microvascular system
  • the microvascular system is not able to dilate in response to the myocardial demand for oxygen or may have stenosis
  • have similar symptoms to obstructive coronary artery disease
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13
Q

When do Clinical Manifestations happen?

A

virtually silent until the artery is approximately 40% blocked by plaque in obstructive disease

  • ischemia develops when there is an imbalance between supply and demand of oxygen-rich blood to the heart tissue, resulting in insufficient oxygen to meet the demands of the myocardial tissue
  • infarction, or cell death, occurs when that imbalance is severe or prolonged which causes irreversible damage
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14
Q

What develops as a result of a imbalance between supply and demand of oxygen-rich blood to the heart tissue, resulting in insufficient oxygen to meet the demands of the myocardial tissue?

A

ischemia

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15
Q

What develops as a result of severe or prolonged imbalance between supply and demand of oxygen rich blood to the heart?

A

infarction, or cell death

-can cause irreversible damage

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16
Q

Clinical Manifestations

A

Chest Pain (Angina); classified as stable or unstable

  • ischemia
  • infarction
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17
Q

Stable Angina

A

chest pain or discomfort that is associated with physical activity

  • linked to fixed plaque formations and is predictable
  • symptoms often alleviated with rest and/or medications
  • nitrates such as nitroglycerin that dilate the coronary arteries, improving oxygen rich blood flow to the heart, are usually prescribed for angina
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18
Q

How to usually treat Stable Angina?

A
  • symptoms alleviated with rest and/or medications
  • nitrates such as nitroglycerin that dilate the coronary arteries, improving oxygen rich blood flow to the heart, are usually prescribed
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19
Q

Unstable Angina

A

chest pain that can occur at rest

  • most concerning
  • identified as initial phase of acute coronary syndrome (ACS)
  • precursor to MI and should be treated as an emergency
  • usually prolonged and may not be relieved with medication or rest
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20
Q

Acute Coronary Syndrome (ACS)

A

a disorder caused by an acute decrease in blood flow through the coronaries to the myocardial tissue

  • unstable angina is the initial phase of ACS
  • primary complication of CAD
  • includes unstable angina and MI
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21
Q

What is a variation of Unstable Angina?

A

Prinzmetal’s (or variant) Angina

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22
Q

Prinzmetal’s (or variant) Angina

A

a variation of unstable angina

  • the blockage of blood flow in this disorder is caused by coronary artery spasm rather than plaque formation
  • occurs at rest and in clusters
  • normally occurs at night between midnight and 8 a.m.
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23
Q

Symptoms that may accompany Angina (chest pain)

A
  • angina may radiate to the left arm, back, neck, and jaw
  • chest pressure
  • shortness of breath or dyspnea
  • fatigue
  • nausea
  • vomiting
  • diaphoresis
  • weakness
  • syncope
  • and epigastric discomfort
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24
Q

Non-ischemic causes of chest pain (not associated by cardiac ischemia)

A

aortic dissection, pericarditis, gallbladder disease, pleuritic pain, pulmonary embolism, pneumonia, and gastroesophageal reflux disease

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25
Q

Diagnosis

A

diagnosis is made on the basis of clinical presentation and diagnostic findings

  • CAD is suspected only when the person presents with clinical symptoms (formation of plaque is a silent process)
  • timely recognition is essential
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26
Q

Diagnostic Tests

A
  • gold standard is coronary angiography
  • blood tests
  • electrocardiogram (ECG)
  • Exercise stress test
  • CT angiography, MRI, and stress imaging techniques
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27
Q

Gold standard for diagnosing CAD

A

Coronary Angiography

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28
Q

Coronary Angiography

A

gold standard for diagnosing CAD

  • a left-sided cardiac catheterization with the purpose of evaluating the coronary arteries for blockage
  • performed to determine the location of the plaque within the coronary circulation, the degree of occlusion and whether the area can be treated with percutaneous transluminal coronary angioplasty (PTCA)
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29
Q

Blood Tests Performed

A

assess for presence of risk factors for CAD

  • lipid profiles, inflammation, and coagulation studies
  • lipid profiles evaluate total cholesterol and triglyceride levels as well as LDL and HDL
  • Specific cardiac biomarkers are used to rule out MI; Creatinine Kinase (CK) or creatinine kinase-muscle/brain (CK-MB) and troponin levels rise when myocardial injury occurs and are used to identify when ischemia has led to tissue damage
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30
Q

What do lipid profiles evaluate?

A

total cholesterol, triglyceride levels, LDL, and HDL

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31
Q

What Specific biomarkers are used to rule out MI?

A

Creatine Kinase (CK), creatinine kinase- muscle/brain (CK-MB) and troponin levels

  • these levels rise when myocardial injury occurs and are used to identify when ischemia has led to tissue damage
  • because these markers do not immediately rise with chest pain, they are measured every 6 hours after admission to the hospital to evaluate chest pain (known as serial cardiac enzyme or biomarker testing)
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32
Q

Serial Cardiac Enzyme or Biomarker Testing

A

because MI markers such as Creatinine-kinase (CK), Creatinine kinase- muscle/brain (CK-MB), and troponin do not immediately rise with chest pain, they are measured every 6 hours after admission to the hospital to evaluate chest pain

33
Q

Diagnostic Test: Electrocardiogram (ECG)

A

initial test when CAD is expected

  • during anginal episodes or symptoms of ACS, the ECG may show ST segment depression of greater than 0.5 mm or flat or inverted T waves that are indicative of ischemia
  • these changes turn to normal when chest pain is relieved
  • some patients with ischemia they may be electrically silent with an ECG appearing to be normal; serial ECGs may be done with cardiac biomarkers to rule out infarction
34
Q

Diagnosis: Exercise Stress Test

A

done when ECG and cardiac biomarkers appear normal

  • done to assess the function of the heart during exercise
  • alternatively for those who are unable to use a treadmill or stationary bike, pharmacological agents such as dobutamine can be used to increase HR, mimicking effects of exercise on the heart
  • stress echocardiogram can also be done
  • goal is to determine whether there is reduced oxygen-rich blood flow to the heart tissue during physical activity and to determine what parts of the heart are affected by decreased blood flow
35
Q

Stress Testing and Nuclear imaging

A

can be combined such as thallium and technetium studies, to further evaluate perfusion to the heart

36
Q

Treatment: Medications Goal

A

for CAD are often prescribed with the goals of stopping the aggregation of blood components to the injured endothelium, controlling factors that led to damage of the endothelium, N=and relieving symptoms

37
Q

Medications for patients with Stable Angina at low risk for ACS

A

-Aspirin and Nitroglycerin along with medications to reduce risk factors such as, anti-hypertensives, antidiabetic agents, and cholesterol lowering medication
>Aspirin prevents thrombus formation in the coronary artery
>Nitroglycerin, a vasodilator, is used to manage anginal episodes

38
Q

Aspirin

A

prevents thrombus formation in the coronary arteries

39
Q

Nitroglycerin

A

a vasodilator, is used to manage anginal episodes

  • can be administered as sublingual tabs, a spray or powder, intravenously, transdermal patches, ointment, or by mouth with extended-release (XR) tablets
  • during anginal episodes, sublingual and IV routes are preferred to restore blood flow promptly
  • BP should be monitored carefully do to adverse reactions of hypotension
  • headaches can also occur but treated with non-opioid analgesics like acetaminophen
40
Q

Treatment of ACS (acute coronary syndrome)

A

aspirin, supplemental oxygen, nitroglycerin, and morphine and can be referred by the acronym MONA
-beta blockers, additional anticoagulants, and possibly calcium channel blockers are also prescribed

41
Q

What can be given for Angina pain for patients not responsive to Nitroglycerin?

A

morphine, but its use can be associated with hypotension, nausea, and vomiting

42
Q

Safety Alert: NItroglycerin

A

effective treatment for Angina

  • be instructed to take this medication as prescribed, typically one tablet or spray under the tongue not to exceed 3 doses taken 5 minutes apart
  • if the symptom of angina is not relieved with three doses or if the pain worsens, they should be instructed to call emergency personnel
  • co-administration with sildenafil (Revatio, Viagra) increases risk of hypotension
43
Q

Treatment: Percutaneous transluminal coronary angioplasty (PTCA)

A

procedure most commonly performed to relieve symptoms caused by atherosclerotic changes in the coronary vessel

  • after the patient receives monitored anesthesia care (MAC), a catheter with a small balloon on its tip is advanced under fluoroscopy through a suitable artery (femoral or radial), to the area with atherosclerotic plaque
  • the balloon is inflated and deflated to open the lumen of the artery (patients may experience chest pain due to vessel occlusion)
  • once lumen is open, a stent may be advanced to the location to hold the artery open and maintain adequate blood flow; stent options include bare metal stents (BMS), drug-eluting stents (DES) to prevent clots, or the newer bioabsorbable stents
  • patients frequently return from the procedure with a vascular closure device such as a angioseal, applied to the access site to maintain hemostasis; allows early ambulation
44
Q

If no closure device is applied to the access site after percutaneous transluminal coronary angioplasty (PTCA), how long do patients need to be on bedrest until homeostasis is achieved?

A

6 to 8 hours

45
Q

Genetic Connections: Pharmacogenetics and Anticoagulants after PTCA

A

anticoagulants such as warfarin or clopidogrel are prescribed after percutaneous transluminal coronary angioplasty

  • patient responses to doses can vary greatly; some require low doses for therapeutic level while others require higher doses
  • Pharmacogenetics: study of how a persons genes affect responses to medications
    ex: some patients are fast metabolizers which increase risk of clotting and the need for higher or more frequent doses; slow metabolizers have a increased of bleeding and require lower or less frequent doses
46
Q

Medications for Coronary Artery Disease

A
  • Statins: reduce cholesterol and increase clearance of LDL from the blood
  • Beta Blockers: inhibits the sympathetic nervous system response to physical activity which decreases cardiac workload and oxygen consumption
  • Calcium channel blockers: lowers BP and increases blood flow to the coronaries, used when cant tolerate beta blockers, prevents coronary artery spasms in prinzmetals angina
  • Aspirin
  • Vasodilator: nitroglycerin
  • anticoagulants
  • ACE inhibitors and ARBS: reduced BP and decreases workload and oxygen demands; beneficial in patient with HTN, diabetes, renal disease, and HF
47
Q

More invasive surgical Treatment

A

Coronary Artery Bypass Grafting (CABG)

  • blockages in coronary arteries are bypassed using other arteries from the chest or arm or veins from the legs
  • patients undergo general anesthesia
  • large incision through sternum is made, and a cardiopulmonary bypass (CPB) is begun through large catheters in the vena cava or right atrium and aorta; a CPB provides continuous gas exchange and perfusion while the heart is stopped to provide a still, bloodless field for surgery.
  • then arteries or veins being used as bypasses are surgically attached to the diseased coronary artery, creating an alternate path for blood to flow around the blockage
  • sent to critical care unit for intensive monitoring and care
48
Q

Lifestyle Management

A
  • Diet and Physical activity
  • maintain a healthy body weight or BMI
  • smoking cessation
  • refraining from excessive alcohol use
  • cardiac rehabilitation
49
Q

Diet

A

low in saturated fat and sodium as well as high in fruits, whole grains, vegetables

50
Q

Cardiac Rehabilitation

A

supervised program of education, counseling, and supervised physical activity

  • begins before discharge and continues in outpatient setting
  • participation can improve morbidity and mortality, reduce angina episodes, and decrease rehospitalization
51
Q

Complications of CAD

A
  • acute coronary syndrome, which includes unstable angina and MI
  • dysrhythmias and HF
  • higher rates of adverse outcomes in women
52
Q

Nursing Management: Assessment of clinical manifestations

A

careful assessment of chest pain and other manifestations of CAD is required to identify those patients with CAD and those patients who have stable angina that may progress to ACS

  • clinical manifestations are the result of the imbalance of oxygen supply and demand to the myocardial tissue
  • epigastric discomfort
  • nausea and vomiting
  • diaphoresis
  • syncope
  • SOB
  • pain between shoulders/ jawline
53
Q

Nursing DIagnosis

A

-decreased tissue perfusion r/t inadequate blood flow secondary to the presence of plaque within the coronary arteries and microvascular dysfunction

54
Q

Nursing Interventions: Assessment

A
  • Vital Signs
  • Pain assessment using provoking factors, quality, region/radiation, severity, time (PQRST)
  • electrocardiogram and continuous cardiac monitoring
  • physical assessment
  • patient history
  • recreational drug use
  • depression screening
  • laboratory values; cardiac biomarkers troponin, CK/ CK-MB, creatinine, blood urea nitrogen, glycosylated hemoglobin (HgbA1c), lipid profiles
55
Q

Assessment: Vital Signs

A

tachycardia ad tachypnea can be manifestations of cardiac ischemia

  • hypertension is a CAD risk factor
  • Nitroglycerin and morphine administration can result in hypotension
56
Q

Assessment: Pain assessment utilizing provoking factors, quality, region/radiation, severity, time (PQRST)

A

angina can be non-specific in some patients; establishing location and quality can aid in the diagnosis of cardiac chest pain and disease progression
-headache can result from Nitroglycerin administration

57
Q

Assessment: Electrocardiogram and continuous cardiac monitoring

A

depressed ST segment or flat or inverted T waves are indicative of ischemia

  • ST elevations are indicative of acute injury
  • cardiac dysrhythmias may result from ischemia or infarction
58
Q

Assessment: Physical assessment

A

pallor, clamminess, nausea, vomiting, SOB, and diaphoresis may indicate cardiac ischemia
-Xanthomas (papules or nodules of the skin or mucous membranes that contain lipids) are associated with hypercholesterolemia

59
Q

Assessment: Patient History

A

evaluate CAD risk factors and anginal patterns

  • fatigue and weakness may be indicative of CAD
  • identify potential noncardiac causes of chest pain, such as GERD or respiratory disorders
60
Q

Assessment: Recreational Drug Use

A

illicit drug use (cocaine) can cause vasospasm, obstructing blood flow and causing symptoms that resemble CAD

61
Q

Assessment: Laboratory Values: Cardiac Biomarkers

A

Troponin, Creatinine-kinase (CK), CK-MB
cardiac enzymes and troponin levels rise when the heart sustains an acute injury– can help differentiate between angina and MI pain

62
Q

Assessment: Laboratory Values: Creatinine, Blood Urea Nitrogen (BUN)

A

assess renal function

-the contrast dye used during heart catheterization is nephrotoxic

63
Q

Assessment: Laboratory Values: Glycosylated hemoglobin (HgbA1c)

A

hyperglycemia occurs with diabetes and is a risk factor for CAD

64
Q

Assessment: Laboratory Values: Lipid Profiles

A

Cholesterol, triglycerides, LDL, HDL

-assess for hyperlipidemia, a risk factor for CAD development (high level of fats)

65
Q

Nursing Interventions: Actions

A
  • administer oxygen to keep oxygen saturation greater than 93%
  • obtain ECG with the occurrence of chest pain
  • administer nitroglycerin as ordered
  • administer aspirin as ordered
  • administer morphine as ordered if nitroglycerin does not relieve pain
  • administer beta blockers/ calcium channel blockers as ordered
  • administer statin medications as ordered
66
Q

Nursing Interventions: Actions: administer oxygen to keep oxygen saturation greater than 93%

A

supplemental oxygen optimizes oxygen delivery to the myocardium
-cardiac dysrhythmias, especially tachycardia, and anxiety increase myocardial oxygen consumption

67
Q

Nursing Interventions: Actions: Obtain ECG with the occurrence of chest pain

A

evaluates new anginal episode for evidence of ischemia or injury
-in cases of acute chest pain, an ECG within 10 minutes is recommended

68
Q

Nursing Interventions: Actions: administer nitroglycerin as ordered

A

vasodilator; dilates the coronary arteries to improve flow to the heart and relieve pain

69
Q

Nursing Interventions: Actions: administer aspirin as ordered

A

prevents platelet aggregation

70
Q

Nursing Intervention: Actions: administer morphine as ordered if nitroglycerin does not relieve pain

A

minimizes pain and decreases the workload on the heart

-monitor for adverse effects of hypotension, nausea, vomiting, and respiratory depression

71
Q

Nursing Interventions: Actions: administer beta blockers/ calcium channel blockers as ordered

A

inhibit cardiac response to physical activity, decrease oxygen consumption; may consider holding prior to exercise test

72
Q

Nursing Interventions: Actions: administer statin medications as ordered

A

reduce cholesterol level and decrease the risk of increase plaque formation

73
Q

Actions After PCI

A
  • report and treat chest pain immediately (re-occlusion, vasospasm, or stenosis can result in ischemia)
  • administer additional anti-coagulants (prevents vessel occlusion by thrombus)
  • maintain fluids through catheterization sheaths if left in place (allows for immediate coronary access if return to cath lab is needed)
  • maintaining bedrest and compression devices at the catheter insertion site (promotes homeostasis and prevents bleeding)
74
Q

Teaching

A
  • medication regimen
  • angina management
  • bleeding precaution if on anticoagulants
  • risk factor reduction strategies: physical activity, blood pressure management, healthy diet/ weight loss, smoking cessation, decreased alcohol consumption, control of glucose
  • when to call providers or emergency service
  • encourage cardiac rehab for ACS patients after PCI or CABG
75
Q

Teaching: angina management

A

if angina occurs during activity (stable angina), stop activity and take dose of nitroglycerin

  • tabs can cause tingling or taste bitter when placed under the tongue
  • not to exceed three doses 5 minutes apart
  • caution about use of medication in the setting of lightheadedness or dizziness because this can be indicative of hypotension
76
Q

Teaching: bleeding precautions if on anticoagulants

A

avoiding activities that have a high injury or fall risk, using a soft toothbrush and electric razor, and using caution with sharp objects

77
Q

Teaching: When to call provider or emergency services

A

unrelieved chest pain— chest pain at rest requires early intervention
-for PCI patients; uncontrolled bleeding, swelling, redness, purulent discharge, nd pain at the insertion site or fever need prompt treatment

78
Q

Evaluating care outcomes

A
  • complying with prescribed medical therapy
  • maintaining a healthy diet
  • limiting alcohol
  • engaging in regular exercise
  • achieving desired activity levels and meeting self-care needs with minimal or no pain indicate achievement of care goals
  • important that patient understands the disease process, the medications used to treat it, and when to call 911

Nursing 172 (120 decks)

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