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Coronary Artery Disease Occlusive Disorders

Coronary Artery Disease Occlusive Disorders. Angina Myocardial Infarction. Objectives. Describe occlusive disorders of the cardiovascular system. Explain the pathophysiology of common occlusive disorders. Describe nursing interventions in caring for clients with occlusive disorders.

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Coronary Artery Disease Occlusive Disorders

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  1. Coronary Artery DiseaseOcclusive Disorders Angina Myocardial Infarction

  2. Objectives • Describe occlusive disorders of the cardiovascular system. • Explain the pathophysiology of common occlusive disorders. • Describe nursing interventions in caring for clients with occlusive disorders.

  3. Arteriosclerosis vs. Atherosclerosis • Arteriosclerosis is a general term describing any hardening (and loss of elasticity) of medium or large arteries • Atherosclerosis is a hardening of an artery specifically due to plaque. Atherosclerosis is the most common form of arteriosclerosis.

  4. Coronary Artery Disease (CAD) • A narrowing or obstruction of one or more coronary arteries as a result of atherosclerosis • Decreases the blood flow and therefore the oxygen and nutritional supply to the heart muscle

  5. Coronary Artery Disease • Blood vessel narrowed by atherosclerosis

  6. Coronary Artery Disease When does it become a problem? • When enough occlusion occurs to the point where an inadequate blood supply to the myocardium occurs. The resulting effect on the myocardium is called ischemia. • Significant CAD is when the Left Main Artery is narrowed more than 50% or any other major branch is narrowed more than 70%.

  7. Coronary Arteries

  8. Coronary Arteries

  9. Coronary ArteriesCollateral Circulation • More than one artery that supplies an area of the myocardium with blood • When chronic ischemia is present (as in an older adult), additional collateral circulation develops

  10. Coronary Artery Disease Collateral Circulation

  11. Coronary Artery Disease • Complications • Hypertension • Angina • Dysrhythmias • Myocardial Infarction • Heart Failure • DEATH

  12. Coronary Artery Disease Blood clot in an atherosclerotic artery

  13. Angina • Angina = a spasmodic, cramplike, choking feeling • Pectoris = the breast or chest area • Angina Pectoris = paroxysmal (severe, usually episodic) thoracic pain and choking feeling caused by decreased oxygen to the myocardium

  14. Angina • May develop slowly or quickly • Signs and symptoms • Patient may describe as substernal pain, tightness/squeezing or heaviness on chest (mild to moderate) • May think it is heartburn • Pain may radiate to other sights: • Left Arm, Right Arm, Epigastric area, Neck, Jaw, Shoulders, or the Back Men and women often experience discomfort in different sites

  15. Angina: Data Collection • Subjective: Ask patient to describe Chest Pain (CP) in as much detail as possible. • Objective: Head to Toe Assessment Signs/symptoms of Decreased Cardiac Output

  16. Acute Management of Angina • Medications to control platelet aggregation • ASA (325mg (Four 81mg chewable ASA is preferable) • Medications to dilate coronary arteries • Nitroglycerin • Morphine • Medications to decrease heart workload • Beta Blockers • Propanolol • Metoprolol • Oxygen • 2-4 L/minute

  17. Nitroglycerin • Nitrates • Dilate Blood Vessels (brain, coronaries, peripherally) • Reduces preload to heart • Reduces afterload • Side Effects: Hypotension, headache • Routes: Sublingual, Oral, IV also includes Isosorbide nitrates

  18. Acute Management of Angina • Diagnostic Tests • EKG • CXR • Cardiac Enzymes, CBC, and BMP • Coronary Angiography • Echocardiogram

  19. Angina • Surgical Interventions • Coronary Artery Bypass Graft (CABG) – restore blood flow to the affected heart muscle area through grafts which bypass the occluded area • Graft sources: saphenous veins in the leg or internal mammary artery • PercutaneousTransluminal Coronary Angioplasty (PTCA) – widens the narrowing in the coronary artery without open heart surgery via a balloon inflation

  20. Angina • Surgical Interventions (cont.) • Stent Placement – expandable mesh-like structures designed to maintain vessel patency • Compresses the arterial walls and resists vasoconstriction • Thrombogenic – pt. must take anticoagulants (3+ mo.)

  21. Stable Angina • Onset usually during exertion or stress • Relieved with rest or nitro • Usually follows a specific pattern (predictable onset)

  22. Nursing Management of Patient with Angina Pectoris • Promoting comfort • Chest pain=an oxygen hungry heart • Promoting tissue perfusion • Promoting activity and rest • Promoting relief of anxiety and feeling of well-being • Patient and family education

  23. Acute Coronary Syndrome • Includes • Unstable Angina • Variant Angina • ST Elevation MI • Non ST Elevation MI

  24. Unstable Angina • Usually unpredictable onset (at rest or with less exertion) • May increase in occurrence, duration, and severity over time • Not relieved consistently by Nitroglycerin

  25. Variant Anginaaka Prinzmetal’s or Vasospastic Angina • Coronary Artery Spasm • May occur at rest and might last longer than classic angina • ST Elevation may appear on an EKG • Treated with Calcium Channel Blockers • Procardia, Diltiazem, Verapamil

  26. Myocardial Infarction • Necrosis of the myocardium due to atherosclerosis or embolism in the coronary arteries • AKA “heart attack” • Ability of cardiac muscle to contract and pump is impaired

  27. Myocardial Infarction (MI) • Abrupt lack of oxygenated blood flow to the myocardium, which results in myocardial necrosis if blood flow is not restored quickly • May be ST Elevation MI or Non-ST Elevation MI • Troponin I level >around 0.5

  28. Signs and Symptoms of MI • Similar to angina, but more intense pain, longer in duration • “silent MI” may occur with no initial symptoms • Patient may experience nausea, dizziness, DOE, weakness, pallor, ashen color, impending sense of doom

  29. Necrotic Heart Tissue can’t be seen

  30. Medical Management of MI Morphine Oxygen Nitrates Aspirin

  31. Treatment of MI • Once MI is apparent: • Heparin gtt may be started or Lovenox injections • Decision needs to be made how to treat: • Cath Lab (PCI) • PTCA • Coronary Stent Placement • Fibrinolytics (thrombolytics)

  32. Heparin • Heparin Sodium • Prevents Thrombin from being converted to Fibrinogen to Fibrin and forming a clot • Dosing is dependant on aPTT levels and the patient’s weight • Therapeutic Levels measured by activated partial thromboplastin time (aPTT) • Goal of heparin is to prolong the clotting timefrom 8-15 minutes to 15-20 minutes This is verified by an aPTT that is 1.5 to 2.5 times normal • Serum aPTT levels are drawn every 4-8 hours • Heparin gtt will be increased or decreased based off of aPTT levels * Antidote is Protamine Sulfate

  33. Lovenox • Low molecular weight heparin • aPTT levels do not need to be measured, as the effect of Lovenox is more predictable

  34. Nursing

  35. Heparin and Lovenox • Monitor for signs and symptoms of bleeding (including Hemoglobin and Hematocrit) • Lovenox is potentially nephrotoxic, adjustments in dosing should be considered for someone with renal impairment. Monitor BUN and Creatinine levels • Monitor Platelet count (Possible Heparin Induced Thrombocytopenia)

  36. Fibrinolytics(Incorrectly known as Thrombolytics) • Activates plasminogen, which generates plasmin • Plasmin breaks down clots • Must be started within 6 hours • Monitor for signs of bleeding • Coagulation Studies • Hypotension, Tachycardia • Neurological Changes • All excretions should be tested for blood

  37. Fibrinolytics • Should not be given if: • Recent CPR • Uncontrolled HTN • Signs of active internal bleeding • History of CVA • Hepatic or Renal Disease • Recent trauma or surgery • Known intracranial problems • AV malformations • Aneurysms

  38. Fibrinolytics • Once given and for the next 24-48 hours • Avoid injections and blood draws if possible • Hold direct pressure over puncture site for 20-30 minutes • Extreme caution when moving the patient • Bedrest • Electric Razors only *Antidote is Aminocaproic Acid (Amicar)

  39. Percutaneous Coronary InterventionBalloon Angioplasty, Stent Placement

  40. Post-Procedure • PLAVIX! ASA! • Clopidogrel! Acetylsalicylic Acid • Also includes Ticlopidine (Ticlid), Tirofiban (Aggrastat) • IV Meds • Abciximab (ReoPro) • Eptifibatide (Integrelin) • Antiplatelet medications- Inhibit aggregation of platelets • Indications- to prevent future MI and/or in-stent thrombosis • Side Effects- Bleeding/Bruising • Client Teaching- Do not stop taking oral medications unless instructed to do so by a cardiologist

  41. Post-MI Medications • ASA • Plavix • Beta- Blockers • Nitrates • Ace-Inhibitors

  42. Nursing Management of MI • Administration of medications to control pain, dilate coronary vessels, and to decrease the workload on the heart is paramount in preventing further injury • Patient needs to be on a cardiac monitor • Prevention of overexertion, including anything involving the valsalva maneuver • Education is a large component of post-MI recovery

  43. Prognosis ?

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