Coronary Artery Disease, High Cholesterol, Stable Angina, Unstable Angina (ACS)

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Coronary Artery Disease, High Cholesterol, Stable
Angina, Unstable Angina (ACS)

• Brunner, ch 28, pp. 756-768

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Coronary Artery Disease

• AKA
• CAD
• Ischemic Heart Disease
• Coronary Heart Disease (CHD)
• Arteriosclerotic Heart Disease (AHD)
• Arteriosclerotic Cardiovascular Disease (ASCVD)

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Pathophysiology of CAD

• Abnormal accumulation of lipids and fibrous
  tissues causes an atheroma (plaque).
• Progresses from fatty streak to fibrous plaque,
  to ulcerated lesion with thrombus formation.
• Vessel wall becomes inflamed and damaged,
  attracting platelets and WBCs, becoming a
  complicated lesion.

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Pathophysiology contd

• Atheroma protrudes into lumen of vessel,
  obstructing blood flow (Figure 28-1, 756).
• Obstruction of blood flow causes lack of oxygen
  (ischemia) to the area perfused by the affected
  artery (Figure 28-2, 757), causing pain (angina).
• If collateral circulation does not develop,
  permanent damage can occur.

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Development of Collateral Circulation
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Non-modifiable Risk Factors for CAD

• Chart 28-1, 758
• Age (M gt 45 F gt 55)
• Gender (M gt F until menopause)
• Family hx esp first degree relative
• Race higher in African Americans
• Leading cause of death in both genders and in all
  races and ethnic groups.

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Modifiable Risk Factors for CADMetabolic Syndrome

• Dyslipidemiahigh LDLlow HDL (Flt50 Mlt40)
  triglyceridesgt150
• Proinflammatory stateC-reactive protein (CRP) 1
  mg/L 3 is hi-risk
• Hypertension gt135/85
• Prothrombotic state (high fibrinogen)
• Insulin resistance (FBS gt 100)
• Central obesity (F wgt35 M wgt40)
• Diagnosis 3/6

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Modifiable Risk Factors contd

• Elevated homocysteine gt2.3 mg/L
• Tobacco use gt 1 ppd twice as bad in women
• Physical inactivity
• Atherogenic diet
• Oral contraceptives and HRT
• Stress

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Pathophysiology of High Cholesterol

• Metabolism of fats is important contributor to
  development of HD
• Fats are encased in lipoproteins that allow them
  to circulate
• Lipoproteins are categorized by their protein
  content more protein. more dense
• High fat meal?broken down into chylomicrons?proces
  sed into lipoproteins?LDL portion adheres to
  intimal wall

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Cholesterol Norms

• Total cholesterol lt200
• HDL gt60good cholesterol
• LDL lt100 (lt70 in hi-risk pts)bad cholesterol
• Triglycerides lt150 (high sugar intake can affect
  results)
• LDL is targeted for therapy

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Angina Chronic, Stable

• Predictable and manageable
• Caused from CAD, but also anything that could
  increase the hearts oxygen demand
• Exertion
• Emotion
• Eating big meal
• Tobacco use
• Stimulants (cocaine, thyrotoxicosis)
• Irregular, fast heart rhythms
• Anemia

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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

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Chronic Stable Angina contd

• Usually lasts 3-5 minutes
• Responds to rest and nitrate therapy
• Same each time
• Usually has 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

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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 (Prinzmetals or
  Variant angina). Pain is unpredictable.
• Although if not treated can lead to an MI, it is
  not an MIthat is death to the myocardial tissue
  (covered in NUR 213)

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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

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Manifestations contd

• Lasts 10-20 minutes
• Dyspnea, tachycardia, pulsus alternans, pulse
  deficit
• Gallop rhythm, murmur
• Hyper or hypotension
• Cool, pale skin
• ECG changesarrhythmias, ST depression,
• T wave inversion

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ECG Changes with Angina
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Manifestations contd

• 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

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Diagnostics for CAD and Angina with Nursing
Responsibilities

• Lipid levelsshould be fasting
• Cardiac markers
• Troponin (protein released with injury)
• Creatine kinase-Myocardial bands (CK-MB)enzyme
  released with cardiac injury. Let patient know
  why blood is drawn often.
• ECGapply leads and ask pt to lie still

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Diagnostics contd

• Exercise stress test
• Non-exercise stress test
• Nuclear stress test (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.

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Diagnostics contd

• 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.

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Medical Management

• Goal is to improve oxygen to the myocardium.
• Usually done through medication therapy and
  changing modifiable risk factors.
• In some instances, interventional therapies are
  needed (PCI, stents, arthrectomy, CABG)

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Nursing Diagnoses for CAD

• Ineffective tissue perfusion (cardiac/peripheral)
• Acute pain
• Imbalanced nutrition
• Ineffective health maintenance
• Ineffective therapeutic regimen mgmt
• Ineffective coping
• Fear/Anxiety
• Risk for imbalanced fluid volume
• Deficient knowledge

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Nursing Management of CAD Health Promotion

• Dietlow sodium, low fat. Mediterranean diet is
  promoted. Vegetarian diets are good. High fiber
  is helpful.
• Lose weight
• Exercise30 of moderate activity at least 5x wk
• Stop tobacco products
• Monitor and control blood sugar
• Monitor BP and lipid levels
• Reduce stress

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Nursing Management contd

• Monitor effects of and provide education for med
  therapy if indicated (see Cardiac Meds ppt)
• Antilipidemics
• Antiplatelets
• Antidiabetics
• Antihypertensives
• Antianginals

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Nursing Management of ACS

• ICU or CCU admission 24-48h
• Rest, O2, liquids, limited OOB
• VS, pulse ox, telemetry, IV access x2
• 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

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Percutaneous Revascularization
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Revascularization contd
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Patient Education

• SS of CP
• Avoid activities that cause CP
• Avoid OTC meds that raise P and BP
• 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. See cardiac
  ppt)
• Preventative NTG tx
• Control modifiable risk factors