Coronary Artery Disease, Angina, ACS

1. Coronary Artery Disease, Angina, ACS Lewis, ch 34 Concept 22.3, pp. 1360-1389 (exclude all info on MI and CABG)

2. Coronary Artery Disease • AKA: • CAD • Ischemic Heart Disease • Coronary Heart Disease (CHD) • Arteriosclerotic Heart Disease (AHD) • Arteriosclerotic Cardiovascular Disease (ASCVD)

3. Pathophysiology of CAD • Abnormal accumulation of lipids and fibrous tissues causes an atheroma (plaque). • Starts as a fatty streak, progresses to fibrous plaque, then to an ulcerated lesion with thrombus (clot) formation. • The vessel wall becomes inflamed and damaged, attracting platelets and WBCs. (complicated lesion)

4. Pathophysiology cont’d • The atheroma protrudes into the lumen of the vessel, obstructing blood flow (762) • Obstruction of blood flow causes lack of oxygen (ischemia) to the part of the cardiac muscle that is perfused by the affected artery, resulting in pain (angina). • If collateral circulation does not develop, permanent damage can occur.

5. Development of Collateral Circulation

6. Non-modifiable Risk Factors for CAD • Age (M > 40; F > 50) • Gender (M > F until menopause) • Family Hx • Race (WM > BM; BF > WF) • Major cause of death in both genders (763)

7. Modifiable Risk Factors for CAD • Hyperlipidemia*-high LDL and low HDL, high triglycerides (765) • C-reactive protein—1 mg/L; 3 is hi-risk • Elevated homocysteine >2.3 mg/L • Tobacco use > 1 ppd; twice as bad in women • Hypertension* > 140/90 • FBS > 110* • Obesity*—BMI > 30, central obesity

8. Modifiable Risk Factors cont’d • Atherogenic diet • Abnormal clotting • Inactivity • Oral contraceptives and HRT • Stress *Metabolic syndrome—underlying pathophysiology related to insulin resistance

9. Angina: Chronic, Stable • Predictable and manageable • Caused from CAD, but also anything that could increase the heart’s oxygen demand: • Exertion • Emotion • Eating big meal • Tobacco use • Stimulants (cocaine, thyrotoxicosis) • Irregular, fast heart rhythms • Anemia

10. Manifestations of Chronic Stable Angina • Caused by partial occlusion with atheroma • Squeezing, tightness, heaviness • Epigastric, midsternal, or retrosternal pain • May radiate to neck, jaw, arm, back • May have nausea, diaphoresis, dizziness

11. Chronic Stable Angina cont’d • Usually lasts 3-5 minutes • Responds to rest and nitrate therapy • Same each time • Usually follows pattern of activity-pain; rest-relief • T-wave inversion with episodes • Women and individuals with diabetes are frequently atypical with GI sx, fatigue, and back pain

12. Angina: Unstable (Acute Coronary Syndrome) • Blood flow is reduced, but not fully occluded. • Ischemia with or without significant injury to myocardial tissue. • Coronary vessel is damaged and inflamed. • Coronary artery spasms may occur (Prinzmetal’s angina). Pain is unpredictable. • Not an MI—that is death to the myocardial tissue (covered in NUR 213)

13. Manifestations of ACS • Usually caused from partial occlusion and coronary artery spasm • Substernal or epigastric pain • Radiates to neck, left shoulder, left arm, epigastric area • Pain is more severe and prolonged, increasing in frequency and severity; may occur at rest

14. Manifestations cont’d • Lasts 10-20 minutes • Dyspnea, tachycardia, pulsus alternans, pulse deficit • Gallop rhythm, murmur • Hyper or hypotension • Cool, pale skin • ECG changes—arrhythmias, ST depression, T wave inversion

15. ECG Changes with Angina

16. Manifestations cont’d • Negative or positive serum cardiac markers, increased lipids, elevated WBC • Positive stress test and thallium scans • CXR shows cardiac enlargement or pulmonary congestion • Echo shows abnormal wall motion • Positive coronary angiography

17. Diagnostics for CAD and Angina with Nursing Responsibilities • Lipid levels—should be fasting • Cardiac markers: • Troponin (protein released in response to injury) • Creatine kinase-Myocardial bands (CK-MB)—enzyme released in response to cardiac injury. Let patient know why blood is drawn often. • ECG—apply leads and ask pt to lie still

18. Diagnostics cont’d • Exercise stress test • Nuclear scan—IV access for nuclear med injected at a critical point in the stress test • Monitor ECG and VS; crash cart available; let pt know radioactivity is small.

19. Diagnostics cont’d • Left sided cardiac catheterization (diagnostic or interventional): • Preprocedure: • requires consent; IV access; mark pulse sites, let pt know sensations; assess allergies. • Postprocedure: • monitor VS & pulse sites, and for hemorrhage.

20. Nursing Diagnoses for CAD • Ineffective Tissue Perfusion • Acute Pain • Imbalanced Nutrition • Ineffective Health Maintenance • Ineffective Therapeutic Regimen Mgmt • Ineffective Coping • Fear

21. Nursing Management of CAD: Health Promotion • Diet—low sodium, low fat • Lose weight • Exercise—at least 30” of aerobic 5x wk • Stop tobacco products • Monitor and control blood sugar • Monitor BP and lipid levels • Reduce stress

22. Nursing Management cont’d • Monitor effects of and provide education for med therapy if indicated (see Cardiac Meds ppt): • Antilipidemics • Antiplatelets • Antidiabetics • Antihypertensives • Antianginals

23. Nursing Management of ACS • ICU or CCU admission 24-48h • Rest, O2, liquids • VS, pulse ox, telemetry, IV access • NTG q 5” x3 if BP ok or ASA; MS if needed • If markers are negative, but angina continues, HCP may order ASA, heparin, and/or Aggrestat • Percutaneous revascularization, atherectomy

24. Percutaneous Revascularization

25. Revascularization cont’d

26. Patient Education • S&S of CP • Avoid activities that cause CP • If pain occurs, stop activity and take NTG • If no relief, BP gets too low, or weakness, dizziness, or syncopy occurs, call 911 • Med therapy (self adm, storage, etc) • Preventative NTG tx • Control modifiable risk factors