CORONARY ARTERY DISEASE

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CORONARY ARTERY DISEASE

• Nursing 422
• By Patricia Speaks, MSN, APRN-BC

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CORONARY ARTERY DISEASE (CAD)

• Also known as Coronary Heart Disease (CHD)
• Single largest killer in America
• AA and Hispanics women have higher CAD risk
  factors
• CAD risk factors HTN, smoking, high
  cholesterol, obesity, DM

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CAD PATHOPHYSIOLOGY

• Includes Angina, Acute Coronary syndrome (ACS)
• Affects the arteries that provide blood, oxygen
  and nutrients to the myocardium
• Obstructed blood flow through the coronary
  arteries will cause ischemia and/or infarction

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CAD PATHOPHYSIOLOGY CONTINUED

• Ischemia Insufficient oxygen supplied to meet
  the requirement of the myocardium
• Infarction Necrosis or cell death occurs when
  severe ischemia is prolonged and irreversible
  damage to tissue results

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ANGINA PECTORIS

• Temporary imbalance between the coronary
  arteries ability to supply oxygen and the
  cardiac muscles demand for oxygen
• Ischemia that occurs with angina is limited in
  duration and does not cause permanent damage of
  tissue
• Two types Stable angina Unstable angina

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STABLE ANGINA

• Chest discomfort that occurs with moderate to
  prolonged exertion in a pattern that is familiar
  to the client
• Frequency, duration and intensity of symptoms
  remain stable over the preceding several months
• Results in only slight limitation of activity
• Associated with stable atherosclerotic plaque
• Usually relieved by Nitroglycerin or rest and
  managed medically with medication such as calcium
  channel blockers and betablocking medications

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OUTCOME MANAGEMENT FOR CHRONIC STABLE ANGINA

• Aspirin
• Beta-blockers
• Smoking cessation and lowering cholesterol
• Diet
• Exercise

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UNSTABLE ANGINA

• Part of the Acute Coronary Syndrome (ACS) which
  also includes MI
• Atherosclerotic plaque in the coronary artery
  ruptures, resulting in platelet aggregation,
  thrombus formation and vasoconstriction
• Between 10-30 of clients with unstable angina
  progress to having an MI within 1 year of onset
  and 29 diet of MI within 5 years of the disease
• Occurs with rest or with exertion and causes
  marked limitation of activity
• Last longer than l5 minutes or may be poorly
  relieved by rest or nitroglycerin

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MYOCARDIAL INFARCTION

• Common cause is complete or nearly complete
  occlusion of coronary artery
• There is a rupture of a vulnerable
  atherosclerotic plaque and thrombus formation
• Untreated angina can lead to a heart attack
• Myocardial tissue is abruptly and severely
  deprived of oxygen
• Ischemia develops which leads to injury and
  necrosis

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PROCESS OF INFARCTION

• Evolves over a period of several hours
• Hypoxia from ischemia
• Electrolyte imbalances (K, CA, Mg)
• Acidosis at the cellular level leading to
  suppression of normal conduction and contractile
  functions
• See ectopy
• Catecholamines (epinephrine/norepinephrine)
  released in response to hypoxia and pain results
  in increase in heart rate

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KEY FEATURES OF ANGINA AND MI

• ANGINA
• Substernal chest discomfort
• Radiating to the left arm
• Precipitated by exertion or stress
• Relieved by NTG
• Lasting less than 15 min
• Few associated symptoms

• Myocardial Infarction
• Substernal chest pressure
• Radiating to left arm, back, or jaw
• Occurring without cause
• Relieved only by opiods
• Lasting 30 min or more
• Sx Nausea, diaphoresis, dyspnea, fatigue,
  dysrhythmias, fear/anxiety

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ZONES OF INFARCTION

• Three factors
• Collateral circulation anaerobic
  metabolism, workload demands on the myocardium
• Subendocardial MI involves only the
  subendocardium
• Transmural involves all three layers of the
  cardiac muscle

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RISK FACTORS

• Modifiable Risk Weight, Smoking, Diet, physical
  inactivity, serum cholesterol, HTN, Stress
• Non-modifiable Risk age, gender, family
  history, and ethnic background

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MANAGEMENT/ASSESSMENT

• Pain Assessment on a scale of 0 to 10 with 10
  being the highest level of discomfort
• Have patient to describe the pain including
  location, radiation, intensity, duration, onset,
  precipitating factors, and relieving factors

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CARDIOVASCULAR ASSESSMENT

• Vital signs
• Heart rate and rhythm
• Distal pulses
• Auscultate heart sounds S3 may indicate heart
  failure which is a serious and common
  complication of MI. S4 is sometimes heard with a
  previous MI or HTN

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CARDIOVASCULAR ASSESSMENT

• Lab Assessment to include
• Troponin, Creatinine Kinase-MB is used
• Troponin A myocardial muscle protein released
  into the bloodstream with injury to myocardial
  muscle. Released immediately upon injury
• Value T lt 0.2 ng/mL
• - Troponin T remain elevated 14-21 days
• - Troponin I (more sensitive) remains
  elevate 5-7
• days
• Creatine Kinase (CK)- MB An enzyme specific to
  cells of the brain, myocardium, and skeletal
  muscle. The appearance of CK in the blood
  indicates tissue necrosis or injury. There is a
  rise and fall during 3 days with peak level
  occurring 24 hours after the onset of chest pain.
• Value CK-MB 0

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EMERGENCY CARE FOR PATIENTS WITH CHEST DISCOMFORT

• Obtain clients description of the chest
  discomfort
• Obtain vital signs
• Assess the clients vascular access
• Obtain a 12-lead EKG
• Provide pain relief
• Administer O2 as prescribed
• Assess and reassess

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DIAGNOSTIC TESTS

• Chest x-ray
• 12 Lead EKG ( looking for elevated T-Wave and
  Q waves)
• Stress Test to determine EKG changes consistent
  with ischemia
• Thallium scans to assess for ischemia and
  necrotic muscle tissue
• MRI
• Cardiac catherizations

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NURSING DIAGNOSIS

• Acute Pain related to biologic injury
• Ineffective Tissue Perfusion related to
  interruption of arterial blood flow
• Activity Intolerance related to fatigue
• Ineffective coping

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PLANNING AND EXPECTED OUTCOMES

• Pain relief
• Decrease myocardial oxygen demand and
• Drug Therapy Nitroglycerin, Morphine
• Supplemental Oxygen 2 to 4 L/min by nasal cannula

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Nitroglycerin

• Nitrate
• Increases collateral blood flow
• Placed under the tongue
• Repeat times 3 if needed every 5 minutes
• May cause lowered blood pressure
• IV NTG for chest pain management.
• Monitor BP continuously

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MORPHINE SULFATE

• Opiate
• Relieves pain
• Decreases myocardial oxygen demand
• Relaxes smooth muscle
• Side Effects hypotension, bradycardia, vomiting

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CRITICAL THINKING CHALLENGE

• Five hours ago, a 48-year-old AA man becomes
  nauseated and short of breath while mowing his
  yard. His wife brings him to the emergency
  department with excruciating pain between his
  shoulders. He states that the pain is a 10 on a
  scale of 0 to 10 and radiates down his left arm.
• What are four essential components you should
  include in your initial assessment of this
  client?
• What diagnostic testing will most likely be done?
• What are the priorities of care for this client
  over the next 4 hours?

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INTERVENTIONS FOR MI

• For patients with Chest Pain and no
  contraindications give an Aspirin 81mg to 325 mg
  tab PO
• Beta Adrenergic agent (Metoprolol, Toprol) to
  decrease size of the infarct and decrease
  ventricular dysrhythmias
• Thrombolytics if indicated (IV)
• ACE inhibitors within 24 hrs are indicated to
  prevent ventricular remodeling and heart failure
• Immediate Heart Catherization and/or PTCA may be
  indicated
• Vital signs
• Pain medication

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COMPLICATIONS OF MI

• Dysrhythmias i.e. heart block, PVCs, symptomatic
  bradycardia
• Cardiogenic Shock (diaphoresis, rapid pulse,
  restlessness, cold/clammy skin)
• HF, Pulmonary Edema
• PE
• Recurrent MI
• Pericarditis
• Death

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CARDIOGENIC SHOCK

• Prevention is early treatment of MI
• If patient goes into shock given vasopressors,
  vasodilators, positive inotropic agents, O2 and
  antidysrhythmic agents

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DRUGS FOR CARDIOGENIC SHOCK

• Vasopressors (dopamine, dobutamine) increases
  blood pressure
• Vasodilators (nitroprusside, nitroglycerin)
  promote better blood flow in the circulation and
  reduce afterload
• Positive inotropic agents (dobutamine,
  epinephrine, milrinone) increase cardiac
  contractility and cardiac output improving tissue
  perfusion

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PERICARDITIS

• Inflammation of the infarcted area that rubs
  against the pericardial surface
• Here a pericardial friction rub across the
  precordium
• Client complains of chest pain that gets worse
  with movement and deep inspiration
• Treatment analgesics, NSAIDS, reduce anxiety
• Dresslers Syndrome occur as late as 6 weeks to
  months after AMI. See fever, chest pain,
  friction rub, pleuritis with pleural effusions.
  Self-limiting. Treat with ASA, prednisone,
  analgesics. Do not give anticoagulation therapy
  because it may cause cardiac tamponade.

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PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY
(PTCA)

• Nonsurgical technique
• Indicated for patients with one or two vessel
  disease with discrete, proximal, non-calcified
  lesions
• Balloon is inflated which flattens plaque against
  the artery wall
• Will not open complex lesions
• Stent may be used after balloon inflation

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CORONARY ARTERY BYPASS GRAFT SURGERY

• Used when client do not respond to medical
  management of CAD or when disease progression is
  evident
• Used with occlusion of the left main coronary
  artery greater than 50
• Used with unstable angina with severe two-vessel
  or moderate three-vessel disease
• PTCA is ineffective

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POST SURGICAL CARE

• Assess for dysrhythmias
• Monitor for fluid and electrolyte imbalance,
  hypotension, hypothermia, hypertension, bleeding,
  cardiac tamponade, and altered cerebral perfusion

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CLIENT EDUCATION FOR CAD AND MI

• Exercise
• Medication regimen and compliance including
  keeping Nitroglycerin tabs available
• Carry a medical identification care and wear a
  bracelet
• Nutrition
• Smoking Cessation
• Weight loss
• Know signs and symptoms of MI

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CARDIAC CARE REHABILITATION

• Promotion of maximum functional activity for a
  client who has experienced an episode of impaired
  cardiac function
• Monitor clients activity tolerance
• Maintain ambulation schedule
• Education on exercise regimen

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CARDIAC REHABILITION

• Phase I Begins with acute illness and ends with
  discharge from the hospital
• Phase 2 Begins after discharge and continues
  through convalescence at home
• Phase 3 Long-term conditioning

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CRITICAL THINKING CHALLENGE

• A 55-year-old female clients visits an urgent
  care center with a complaint of burning
  epigastric pain. She states that she believes it
  is a bad case of persistent heartburn.
  Assessment findings show slight SOB, diaphoresis,
  and nausea and vomiting. Vital signs are BP
  122/78. P 82 R20, T 98.2. She is 5 feet 2
  inches tall and weighs 168 pounds. Her tentative
  diagnosis is to r/o MI.

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QUESTIONS

• What additional data and assessments should you
  collect at this time?
• What risk factors may have contributed to this
  health problem?
• How do this clients initial symptoms differ from
  those of a male client who has an MI?

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PULMONARY EMBOLISM

• Collection of matter (solid, liquid, or gaseous
  substances) that enters venous circulation and
  lodges in the pulmonary vessels
• Large emboli obstruct pulmonary blood flow
• Leads to decreased systemic oxygenation,
  pulmonary tissue hypoxia and possibly death
• Most common emboli is blood clot
• Most common acute pulmonary disease

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CAUSES

• Prolonged immobilization
• Central venous catheters
• Surgery
• Obesity
• Advancing age
• Hypercoagulability
• Prior history of thromboembolism
• Cancer (lung or prostate)
• Fat, oil, air, tumor cells, amniotic fluid,
  foreign objects (broken IV catheters), injected
  particles

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KEY FEATURES

• Sudden onset of dyspnea
• Pleuritic chest pain
• Apprehension, restlessness
• Feeling of impending doom
• Cough
• Hemoptysis
• Tachypnea
• Crackles
• Pleural friction rub
• S3 or S4
• Diaphoresis
• Petechiae over chest and axillae

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LAB and Diagnostic ASSESSMENT

• See Respiratory alkalosis initially
• Spiral CT scan is the gold standard
• X-ray will only see a large clot

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NURSING DIAGNOSIS

• Decreased CO
• Anxiety
• Risk for Injury (Bleeding)
• Impaired Gas Exchange

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MANAGEMENT

• Oxygen
• Telemetry monitoring
• Check lung sounds and respiratory status
• Anticoagulation/Fibrinolytic Therapy
• Surgical (Embolectomy) or inferior vena cava
  filter