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


Coronary Artery Disease, High Cholesterol, Stable Angina, Unstable Angina (ACS) Brunner, ch 28, pp. 756-768 – PowerPoint PPT presentation

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

Coronary Artery Disease, High Cholesterol, Stable
Angina, Unstable Angina (ACS)
  • Brunner, ch 28, pp. 756-768

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

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.

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.

Development of Collateral Circulation
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.

Modifiable Risk Factors for CADMetabolic Syndrome
  • Dyslipidemiahigh LDLlow HDL (Flt50 Mlt40)
  • 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

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

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

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

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

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

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

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)

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

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

ECG Changes with Angina
Manifestations contd
  • Negative or positive serum cardiac markers,
    increased lipids, elevated WBC
  • Positive stress test and thallium scans
  • CXR shows cardiac enlargement or pulmonary
  • Echo shows abnormal wall motion
  • Positive coronary angiography

Diagnostics for CAD and Angina with Nursing
  • 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

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
  • Monitor ECG and VS crash cart available let pt
    know radioactivity is small.

Diagnostics contd
  • Left sided cardiac catheterization (diagnostic or
  • Preprocedure
  • requires consent IV access mark pulse sites,
    let pt know sensations assess allergies.
  • Postprocedure
  • monitor VS pulse sites, and for hemorrhage.

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)

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

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

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

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

Percutaneous Revascularization
Revascularization contd
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
  • Preventative NTG tx
  • Control modifiable risk factors
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