Coronary Artery Disease CAD

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Coronary Artery Disease (CAD)

• Arteriosclerosis/Atherosclerosis
• Angina Pectoris
• Myocardial Infarction ( MI)

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Arteriosclerosis /Atherosclerosis

• Arteriosclerosis term describe conditions that
  afffect the arteries and may lead to occlusive
  cardiovascular disease lining of artery and
  arteriole walls become thickened and hardened and
  lose elasticity- hardening of the arteries
• Atherosclerosis a type of arteriosclerosis
  formation of plaques within arterial wall
• Both usually develop over a long period of time
  and usually occur together

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Patho Atherosclerosis

• Injury to inside lining of wall (endothelial)
• Results in inflammation and immune Rxs
• Lipids, platelets, other clotting factors
  accumulate and scar tissue replace some of the
  inside lining of the endothelial wall
• An early indication of injury is Fatty streaks or
  deposits A build-up is called Plaques which
  have irregular jagged edges that allow blood
  cells and other material to adhere to the inside
  lining of the artery. Over time becomes calcified
  and hardened (atherosclerosis) causing turbulence
  and stenosis occlusion - reduced blood flow

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Causes etiologic factors
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Arteriosclerosis/Atherosclerosis

• Clinical Findings
• No s/s till later in disease progression
• Possibly s/s dizziness or chest pain amb decrease
  blood supply to heart and brain
• Pallor, diminished or absent peripheral pulses,
  and delayed cappillary refill gt 3 seconds

• Pallor of nailbeds due to reduced blood flow to
  extremities, reddish-purplish color to
  extremities, loss of hair to extremities,
  thickened nails, skin temperature is cooler to
  touch extremities,
• Slow tissue healing

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Arteriosclerosis/Atherosclerosis

• Initial Diagnostics
• Cholesterol and Triglycerides increased
• Cholesterol gt200
• Low-density lipoproterins (LDL) elevated CAD
  risk factor

• High-density lipoproteins (HDL) good cholesterol
  and suggest a protective effect
• Hyperglycermia increases risk CAD
• High homocysteine levels or C-reactive proteins

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Arteriosclerosis/Atherosclerosis

• Later Radiologic studies if indicated
• Treatment Healthy lifestyle choices
• Low fat diet per AHA, stop smoking, exercise to
  increase collateral circulation and decrease
  cholesterol

• Medications
• Primarily Statin
• Lipitor, Zocor take drug a night!
• monitor liver enzymes
• Stop drug if s/s muscle weakness/pain skeletal
  muscle break down Rhabdomyolysis
• Niacin flushing

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Coronary Artery Disease (CAD)

• Term applied to obstructed blood flow through the
  coronary arteries to the heart muscle.
• Primary cause Atherosclerosis
• If blood flow reduction from CAD is severe and
  prolonged, Myocardial Infarction (MI) heart
  attack occurs, causing irreversible damage.

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Risk Factors CAD

• Modifiable
• Smoking, Obesity, Diet, Hypertension controlled,
  cholesterol Lipids, Stress, Blood sugar WNL,
  sedentary lifestyle, elevated homocysteine levels

• Non-Modifiable
• Heredity, ethnicity-with Afro-Americans with
  higher incidence
• Gender- males
• Age gt 50 yrs men and women after menopause

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CAD

• Surgical management
• Coronary Angiography Percutaneous
  Trans-luminal Coronary Angioplasty (PTCA)
• Catheter inserted via femoral or brachial and
  threaded up to coronary artery guided by
  fluroscopy. Dye injected to visualize vessels,
  coronary arteries for stenosis or obstruction or
  narrowing gt 50

• Balloon on end of the catheter is inflated and
  compresses plaque against wall of artery, thus
  restoring blood flow to the coronary artery
• Often, coronary artery mesh-wire -stents are
  inserted during PTCA

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CAD

• Coronary artery stents complications
  thrombosis often clients on anti-platlet drugs
  like Plavix, and or 81 mg ASA, or anticoagulants.
  Often Stents close off after months or years
• Cardiac catheterization often done before heart
  surgery ( more invasive), measures pressure heart
  chambers, coronary arteries, cardiac output, O-2
  sats, inject dye

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Coronary Angiography PTCA

• Pre-op Signed informed consent
• Check for allergies to iodine, seafood,
  radiographic dyes
• Baseline VS, Assess knowledge of procedure
• Client may be awake 1-2 hrs and feel a hot
  flash and metallic taste when dye is inserted
• May feel a skipped beat or two, or rapid pulse

• Post-Op VS, monitor distal pulses, color,
  movement, sensation, temp, capp. Refill X 15 min
  for First hr, then q 30 min, next hr, then Q 4hr.
  On affected extremities
• HOB 30 degree, pressure over catheter insertion
  site, check bleeding over groin/ or wrist, use 5
  lb.sandbags, X 6 hrs. no flexion of
  extremity,Monitor ECG, any SOB or Chest Pain

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CAD

• Surgery A cardiac cath will determine if open
  heart surgery is indicated for severe s/s of CAD,
  chest pain or MIs
• Coronary Artery Bypass Graft (CABG)
• Read chpt. 23 that discusses this surgery
• and many of the diagnostics used in disorders
  of the cardiac system

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Angina Pectoris (chest pain)

• Symptom of ischemia
• Especially noted upon activity, (ex.) exercise,
  when the workload of the heart requires more
  oxygen. Normally, the coronary arteries dilate
  when more oxygen is needed for the heart muscle
  but in CAD, the coronary arteries cant dilate
  and ischemia and chest pain may occur- usually
  few minutes when activity is stopped. IF at rest,
  adequate blood supply to the myocardium is
  restored no lasting damage to the heart muscle,
  however, the opposite may occur too!

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S/S of Angina Pectoris

• Heaviness, Crushing
• Tightness or Vise-like in the center of the chest
• Pain may radiate up neck, jaw, and down back and
  arms espec. Left side
• Feeling of impending doom
• Some people feel no pain or discomfort, maybe
  only Indigestion

• During the episode of pain Pallor, SOB,
  diaphoretic
• Often activity or exercise may bring on the chest
  pain and it subsides when activity is stopped
• Give Nitrates/NTG
• Risk for MI and or Sudden Death

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Diagnostics ECG Stress test, other cardiac
diagnostics, coronary angiography

• Major TX Drugs
• Vasodilators/Nitrates
• NTG Sub-lingually
• Nitrostat-short acting
• Isordil- longer acting
• Nitro-Bid/paste-patch
• Tab or nitro spray
• Review NTG protocol on pg. 280-281
• Other drugs Calcium channel blockers beta
  blockers

• General Guidelines
• Monitor pulse and B/P before administering these
  drugs in Hospital
• Hold if B/P is less than 90 Systolic or Heart
  rate is lt 50bpm and call M.D.
• Review all cardiac drugs used for angina

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Pharmocological Tx for Angina

• Nitrates NTG s/e h/a, dizzy,postural
  hypotension, dec. B/P , tachycardia, flushing
• Drug of choice for acute chest pain. Take 1 SL q
  5 min up to 3 doses-if chest pain not relieved
  call 911.
• Carry NTG at all times, keep in sealed dark
  colored bottle (prevent light), good for only 6
  mos after opening.
• NitroPaste or ungt or Patch longer lasting
  nitrateapply 1-2 hairless area of the upper
  thorax/chest wall area in morning removed at
  bedtime to prevent tolerance to drug- so you get
  a 8-12 hr nitrate free period
• Isorbide dinitrate (Isordil)- more longer lasting
  nitrate
• Nitrates all act to maintain coronary artery
  vasodilation

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Pharmological Tx for Angina

• These drugs are slower acting and are
  in-effective in relieving acute chest pain!
• Often used conjunctionwith other vasodilators
  and beta blockers

• Calcium Channel Blockers
• Ca needed for excitability cardiac cells
  /contractions of myocardium
• Relax smooth muscle, decrease PVR (afterload) and
  decrease myocardial oxygen demands- Plus dilate
  main coronary arteries increasing oxygen supply
• Nifedipine (Procardia)
• Verapamil ( Calan)
• Diltiazem (Cardizem)

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Pharmacological TX for Angina

• Beta Blockers decrease workload heart block
  effects of epinepherine/nor-epi (vasoconstriction
  w/ inc heart rate and B/P) (Good drug dec. B/P)
• Works by decreasing myocardial oxygen demand
  secondary to decrease HR, contractibility, and
  B/P Cant use if Heart Failure
• Use cardio-selective beta blockers if asthma,
  COPD such as metoprolol (Lopressor) or atenolol
  (Tenormin) May prevent MI or stroke?
• Give with food check HR if lt50 hold drug

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Myocardial Infarction

• MI or heart attack results in the death of
  heart muscle
• Results from complete or partial blockage of the
  coronary artery which supply oxygen to the heart
  muscle
• Extent of the cardiac damage varies depending on
  the location and amount of blockage in the
  coronary artery, thus cardiac conduction, blood
  flow, and function is altered by an MI

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Myocardial Infarction

• Ischemic injury occurs over several hours before
  complete necrosis and infarction takes place.
• Ishcemic process affects sub-endocardial layer
  which is most sensitive to hypoxia
• Once necrosis takes place, the contractile
  function of heart muscle is lost. There is a zone
  of ischemia and injury around the necrotic area.
  If treatment is started within 1 hr after s/s
  often the area of ischemia with viable tissue can
  be re-build and maintain collateral circulation
• If prolonged ischemia- extend the damaged area

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Myocardial Infarction

• Area affected depends on the Coronary artery
  involved and extent of blockage
• Anterior interventricular branch of Left Coronary
  arteryfeeds anterior wall heart left ventricle
• Right Coronary artery (RCA) feeds the inferior
  wall heart and SA AV node may see serious
  conduction problems (dysrhythmias ?)
• Left Circumflex Coronary artery feeds lateral
  wall of heart and part of posterior wall
  primarily affecting the lateral part left
  ventricle

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Diagnostics MI

• Cardiac enzymes released enzymes into the
  bloodstream CK or CPK, LDH, however they are
  also found in other muscles and tissues so a more
  specific Iso-enzymes are analyzed
• CK-MB rise 4-6 hrpeak 12-24hrs, and return
  normal 48-72 hrs after injury heart
• Sometimes ( older value) look at LDH
• LDH- rises 8-12 hr peaks24-48normal 5-7 days
• (norm LDH-2 gt LDH-1) and after MI it reverses
  and and see ( LDH-1 gt LDH-2)

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MI review s/s

• DX ECG- ? changes ST segment/dysrhythmias
• serum cardiac troponin 1 or Thighly sensitive
  indicators of myocardial damage-released elevated
  protein levels 4-6 hr after damage to heart
  muscle, and peak 10-24 hrs, and remain elevated
  up to 7 days after injury
• Myoglobin- protein found in skeletal and
  cardiac muscle(not site specific like
  troponin)-elevate after 1-2hr, peaks 4-12 hr,
  return normal 18-24 hr

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Quick TX Time is Muscle

• POX, ABGs, Oxygen therapy ( 2L/NC) HOB
  elevated
• Morphine reduce pain, decrease anxiety, decrease
  PVR ( pre-load afterload), thus increasing
  blood supply and oxygen to the myocardium. Given
  IV push small doses
• Vasodilators NTG or via IV drip
• Thrombolytics Check PT/PTT/INR given to
  dissolve a blood clot lodged in artery/must be
  given within 6 hrs
• Bedrest, no caffeine, low NA diet, small frequent
  meals, (No heavy large meal), Cardiac Diet,
  BSC, stool softener prevent straining Valsalva
  maneuver dec. HR
• Complications Dysrythmias, Heart Failure,
  Extension MI

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Nursing Diagnoses

• Acute Pain R/T dec. coronary blood flow
• Decreased Cardiac Output (CO) R/T ischemia or
  infarction
• Activity Intolerance
• Anxiety R/T fear of the unknown
• Review care plans in med-surg book