Coronary Artery Disease

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Coronary Artery Disease
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Coronary Atherosclerosis

• definition- abnormal accumulation of lipids and
  fibrous tissue in the coronary arteries which
  results in decreased blood flow to myocardium
• Atheroma comprises the lumen of the
  vessel---clots may form and obstruct the lumen

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Clinical Manifestations

• a) narrowing-angina (ischemia)
• b) occlusion- AMI (necrosis)
• c) other
• -EKG changes
• - aneurysms
• -dysrhythmias
• d) sudden cardiac death

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Angina Pectoris

• definition-chest discomfort (pain) due to
  decreased blood flow resulting in atheroma or
  spasm
• decreased blood flow results in myocardial
  ischemia-nerve endings around cells send pain
  messages to brain
• usually transient chest pain (3-5), subsides
  when precipitating factor removed

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Types of Angina

• Unstable- referred to as preinfarction,Crescendo,u
  npredictable,or
• progressive (increase in frequency and
  duration)
• treated with ASA and Calcium Channel
  Blocking Agents

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Chronic, Stable Angina

• referred to as predictable and consistent
• occurs on exertion
• relieved with rest
• EKG changes-ST depression
• classic type of angina

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Nocturnal Angina

• referred to as Angina Decubiti
• occurs at night due to lying flat when the
  workload on the heart is increased (increased
  venous return or preload)
• relieved by standing or sitting

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Prinzmetals Angina

• usually spontaneous and accompanied by increased
  ST elevations on the EKG due to coronary artery
  spasm
• associated with risk of MI
• rare form of angina

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Factors Precipitating Angina

• a) physical exertion-increases workload of heart
  ( sex, exercise, raking leaves ,or lifting heavy
  objects)
• b) exposure to heat or cold resulting in
  vasoconstriction-elevated blood
  pressure-increased demands of body for oxygen

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Factors Precipitating Angina

• c) heavy meals-divert blood to GI tract (25of
  CO)
• d) strong emotions-increased release of
  catecholamines
• e) cigarette smoking
• f) sexual activity
• g) stimulants-coffee or cocaine
• h) circadian rhythm patterns-early a.m. after
  arising

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Description of Pain

• a) substernal-varies in intensity from discomfort
  to pressure to agonizing pain
• adjectives used to describe pain
• heavy feeling, pressure,weight
• oppressive or sharp
• tightness
• viselike

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Description of Pain

• crushing
• constricting
• squeezing
• suffocating
• burning
• indigestion

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Types of Pain

• b) deep-retrosternal
• c) localized but may radiate to
  neck,jaws,shoulder,inner aspects of either arm-
• usually subsides when cause removed
• relieved by nitrates and rest
• duration of pain -approximately 15 or less

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Diagnostic Tests

• a) EKG-changes occur only while having angina
• b) Stress tests results-look for changes in ST
  segments
• c) Thallium stress test-inject dye 1 minute
  before peak exercise, scan immediately and in 2-4
  hours. Look for cold spots indicating lack of
  Thallium uptake or lack of perfusion

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Diagnostic Tests

• d) Cardiac Catheterization-Angiography Looks
  at oxygen levels and pressure readings in heart
  chambers as well as blood flow through coronary
  arteries
• e) Chest X-Ray- Identifies enlarged heart,
  calcification,pulmonary congestion
• f) Lipids and Enzymes

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Diagnostic Tests

• g) PET-Positron Emission Tomography-
• non invasive test that identifies and
  
• quantifies ischemia and infarction
• h) Echocardiography

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Management of Angina

• Objective-decrease the discrepancy between the
  oxygen supply and demand
• - Rest-decrease the amount of oxygen needed
  by all tissues of body
• - Percutaneous Transluminal Coronary
  Angioplasty (PTCA)
• -Intracoronary Stints
• -Atherectomy

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Interventions for Angina

• Acute Attack - Pain assessment - quantify the
  pain using a 1-10 scale (1-least severe and
  10-most severe)
• Remember that cardiac pain is diffuse, deep and
  intense

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Acute Anginal Attack

• Provide oxygen at 2L/minute
• Take Vital Signs
• perform EKG - look for changes in ST segments
• Administer Nitrates or Analgesia
• semi-Fowlers position

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Nursing Interventions-Angina

• Prevent Pain
• -Avoid activities that cause pain
• - Change ADL schedules if pain in a.m.
• - Unhurried pace
• -Avoid causes

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Nursing Interventions- Angina

• Reduce Anxiety
• - Fear of Death is common
• - Stay with anxious client
• - Educate client for discharge

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Nursing Interventions- Angina

• Objectives of Client Education- Home Care
• - reduce frequency/ severity of attacks
• - delay disease progression
• - protect from complications
• - plan activities to minimize episodes
• - modify risk factors

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Medications To Treat Angina

• 1) Nitroglycerin-,decreases preload and
  afterload by dilating venous and arterial
  system,decreases venous return and arterial
  pressure
• a) works in 2-3 minutes
• b) dose-0.3-0.6 mg sl.x3 at 5-10 minute
• intervals
• c) effects last only 10-15 minute maximum
  

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Side Effects of Nitroglycerin

• Increased Heart Rate
• Orthostatic Hypotension
• Throbbing Headache
• Flushing of face
• Vertigo
• Tachycardia

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Nursing Implications Associated With Nitroglycerin

• Fresh supply every 6-9 months
• Take at earliest sign of pain or discomfort
• Keep in brown bottle and cool spot-it is volatile
  to air
• Sit or lie down when taking
• Remove cotton from bottle
• Does not always sting under tongue

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Nitrate Preparations

• Nitroglycerin sublingual-If no relief from 3
  pills taken 5 minutes apart-seek medical
  attention
• Long Acting Nitrates
• a) Topical Ointments-duration of effect
  
• is 4 hours so client needs 4-6
  applications a day
• Apply to arms, legs ,any unhairy body
  area

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Long Acting Nitrate Preparations

• DM preparation-long acting
• examples-Peritrate, Isordil -last 6-8 hours
• Nitrodiscs-apply in a.m., remove at h.s.to
  provide a nitrate free period
• Examples-Transderm NitroDur discs where
  drugs are continually
• released to skin absorption site

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Intravenous Nitroglycerin

• rationale-increase collateral blood flow to
  ischemic area, decrease myocardial oxygen demand
  by decreasing preload and decreasing afterload
• examples- Nitrol IV, Nitrostat IV, Nitrobid or
  Tridil IV

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Beta Blockers

• action-decrease myocardial oxygen consumption by
  blocking sympathetic impulses to heart, smooth
  muscle of bronchi and blood vessels. It lowers
  heart rate and blood pressure and decreases
  myocardial contractility

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Beta Blockers

• Common Drugs in Use
• - Inderal-80-320mg BID or QID
• - Atenolol (Tenormin)-50-100mg/day
• may take up to 200 mg/day
• -Metoprolol (Lopressor) -50-100mg/day
• may take up to 450mg/day

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Beta Blockers

• Timolol (Blocadren10 mg. BID or up to 100
• mg./day

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Side Effects of Beta Blockers

• Musculoskeletal Weakness
• Hypertension
• Bradycardia
• Depression
• Fatigue
• Sexual dysfunction

• Bronchospasm-watch clients with history of Asthma
  .COPD
• Hyperglycemia-watch for DM
• Weight gain

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Calcium Channel Blocking Agents

• Calcium influences cardiac contraction and
  electrical stimulation
• Action--dilates smooth muscle of coronary
  arteries thus, increasing oxygen supply,decreases
  systemic arterial pressure and decreases workload
  of LV (decreasing peripheral resistance)

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Calcium Channel Blocking Agents

• Effects-
• - Systemic vasodilatation with decreased
  systemic vascular resistance
• - Decreased myocardial contractility
• - Coronary vasodilatation

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Common Calcium Channel Blocking Agents

• Nifedipine (Procardia) -10-30 mg.q4-8 hours
• Verapamil (Isoptin, Calan)-60-80 mg. q8 hrs. po
  or IV
• Diltiazem (Cardizem) -60-90- mg. q8 hrs.po
• Nicarpine (Cardene) -

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Side Effects of Calcium Channel Blocking Agents

• Orthostatic Hypotension
• Bradycardia
• Flushing
• Headache
• Pedal Edema-Nifedipine
• Constipation- (Verapamil)

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Common Nursing Diagnoses-Angina

• a) Pain rel.to ischemia of myocardium
• b) Activity Intolerance rel. to fatigue or
  weakness
• c) Altered Health Maintenance rel to knowledge
  deficit
• d) Anxiety rel. to fear of cardiac disease,
  future sudden death

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Percutaneous Transluminal Coronary Angioplasty

• (PTCA)
• rationale- attempts to improve blood flow within
  the coronary artery by cracking the plaque or
  atheroma that is interfering with the circulation
  of blood to the heart
• Procedure is done in Cath Lab-cardiac
  catheterization documents stenosis

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PTCA

• Catheter equipped with an inflatable ballon tip
  is inserted into coronary artery and passed
  beyond lesion
• Ballon is inflated (3-4 seconds) and
  atherosclerotic plaque is compressed resulting in
  vasodilation
• Ballon is deflated
• Procedure may be repeated several times

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Advantages of PTCA

• Alternative to surgery
• Local anesthesia used
• Eliminates Thoracotomy Incision
• Client is ambulatory within 24 hours
• Hospital stay is 1-3 days not 5-7 days as with
  CABG procedure
• Rapid return to work-1week instead of 8weeks with
  CABG procedure

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Advancements with PTCA

• Use of more flexible guidewire/catheters
• Dilates stenosed CABG grafts
• Provide blood flow to distal myocardium during
  inflation

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Complications of PTCA

• Dissection of dilated artery
• Rupture of artery causing tamponade, ischemia,
  infarct, decreased CO,death
• Occlusion of vessel distal to catheter
• Coronary spasm from mechanical or chemical
  irritation from dye
• abrupt closure-24 hours
• Restenosis rates of 30 within 3-6 months

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Newer Treatments

• Radiation with Intravascular Stent
  Placements-expandable, meshlike structures to
  maintain vessel patency
• requires anticoagulants for 3 months
• Atherectomy-shave plaque using rotating blade
  when proximal or middle part of artery involved

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Newer Treatments for Angina

• Laser Angioplasty-A small laser on tip of
  catheter welds the area open or melts the
  plaque areas facilitating blood flow
• Is still a new technique and needs refinement