Focus on Coronary Artery Disease and
Acute Coronary Syndrome ( Angina nd MI)
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Atherosclerosis: type of blood vessel
disorder
§ Begins as soft deposits of fat that harden with
age
§ Referred to as “hardening of arteries”
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Atherosclerosis (cont.)
§ Can occur in any artery in the body
§ Atheromas (fatty deposits)
• Preference for the coronary arteries
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Atherosclerosis (cont.)
§ Terms to describe the disease process
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Arteriosclerotic heart disease
Cardiovascular heart disease
Ischemic heart disease
Coronary artery disease (CAD)
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Atherosclerosis is the major cause of CAD.
§ Characterized by a focal deposit of lipids, primarily
within the intimal wall of the artery
§ Endothelial lining altered as a result of
inflammation and injury.
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C-reactive protein (CRP)
§ Nonspecific marker of inflammation
§ Increased in many clients with CAD
§ Chronic exposure to CRP associated with unstable
plaques and oxidation of LDL cholesterol
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Nonmodifiable risk factors
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Age
Gender
Ethnicity
Family history
Genetic predisposition
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§ Modifiable risk factors
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Elevated serum lipids
Hypertension
Tobacco use
Physical inactivity
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§ Modifiable risk factors (cont.)
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Obesity
Diabetes
Metabolic syndrome
Psychological states
Homocysteine level
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Identification of people at high risk
§ Health history, including use of
prescription/nonprescription medications
§ Presence of cardiovascular symptoms
§ Environmental patterns: diet, activity
§ Psychosocial history
§ Values and beliefs about health and illness
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Health-promoting behaviours
§ Physical fitness
• FITT formula: 30 minutes on most days of the week
• Regular physical activity contributes to
– weight reduction.
– reduction of systolic BP.
– in some men more than women, increase in HDL cholesterol.
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Health-promoting behaviours
§ Health education in schools
§ Nutritional therapy
• Therapeutic lifestyle changes
• Omega-3 fatty acids
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Health-promoting behaviours
§ Cholesterol-lowering drug therapy
• Drugs that restrict lipoprotein production: statins
• Drugs that increase lipoprotein removal: bile acid
sequestrants
• Drugs that decrease cholesterol absorption: Ezetimibe
(Ezetrol)
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Health-promoting behaviours (cont.)
§ Antiplatelet therapy
• ASA
• Clopidogrel (Plavix)
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Etiology and pathophysiology
§ Reversible (temporary) myocardial ischemia =
angina (chest pain)
• O2 demand > O2 supply
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Etiology and pathophysiology
§ Primary reason for insufficient blood flow is
narrowing of coronary arteries by atherosclerosis.
§ Referred pain in left shoulder and arm is from
transmission of the pain message to the cardiac
nerve roots.
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Intermittent chest pain that occurs over a
long period with the same pattern of onset,
duration, and intensity of symptoms
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Pain usually lasts 3–5 minutes.
§ Subsides when the precipitating factor is relieved.
§ Pain at rest is unusual.
§ ECG reveals ST-segment depression and/or Twave inversion.
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Silent ischemia
§ Ischemia that occurs in the absence of any
subjective symptoms
§ Associated with diabetic neuropathy
§ Confirmed by ECG changes
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Nocturnal angina
§ Occurs only at night but not necessarily during
sleep
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Prinzmetal’s (variant) angina
§ Occurs at rest usually in response to spasm of
major coronary artery
§ Seen in clients with a history of migraine
headaches and Raynaud’s phenomenon
§ Spasm may occur in the absence of CAD.
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Prinzmetal’s (variant) angina
§ When spasm occurs
• Chest pain
• Marked, transient ST-segment elevation
§ May occur during REM sleep
§ May be relieved by moderate exercise or may
disappear spontaneously
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Microvascular angina
§ May occur in the absence of significant coronary
atherosclerosis or coronary spasm
§ More common in women
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Drug therapy: goal: ↓ O2 demand and/or ↑ O2
supply
§ Short-acting nitrates: sublingual
§ Long-acting nitrates
• Nitroglycerin (NTG) ointment
• Transdermal controlled-release NTG
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Drug therapy: goal: ↓ O2 demand and/or ↑ O2
supply (cont.)
§ β-Adrenergic blockers
§ Calcium channel blockers
• If β-adrenergic blockers are poorly tolerated,
contraindicated, or do not control angina
• Used to manage Prinzmetal’s angina
§ Angiotensin-converting enzyme inhibitors
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Diagnostic studies
§ Health history/physical examination
§ Laboratory studies
§ 12-lead ECG
§ Chest x-ray
§ Echocardiogram
§ Exercise stress test
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Diagnostic studies (cont.)
§ Cardiac catheterization/coronary angiography
• Diagnostic
• Coronary revascularization: percutaneous coronary
intervention (PCI)
– Balloon angioplasty
– Stent
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The animation referenced below can be viewed in the PowerPoint Animations asset.
Angioplasty with Stent
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When ischemia is prolonged and is not
immediately reversible, acute coronary
syndrome (ACS) develops.
ACS encompasses
§ Unstable angina (UA)
§ Non–ST-segment-elevation myocardial infarction
(NSTEMI)
§ ST-segment-elevation MI (STEMI)
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Deterioration
of once-stable
plaque
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Rupture
Platelet
aggregation
Thrombus
Result
§ Partial occlusion of coronary artery: UA or NSTEMI
§ Total occlusion of coronary artery: STEMI
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Unstable angina
§ Change in usual pattern
§ New in onset
§ Occurs at rest
§ Has a worsening pattern
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UA is unpredictable and represents a
medical emergency.
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Result of sustained ischemia
(>20 minutes), causing irreversible
myocardial cell death (necrosis)
Necrosis of entire thickness of myocardium
takes 5–6 hours
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The degree of altered function depends on
the area of the heart involved and the size of
the infarct.
Contractile function of the heart is disrupted
in areas of myocardial necrosis.
Most MIs involve the left ventricle (LV).
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Pain
§ Total occlusion → anaerobic metabolism and lactic
acid accumulation → severe, immobilizing chest
pain not relieved by rest, position change, or
nitrate administration
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Pain (cont.)
§ Described as heaviness, constriction, tightness,
burning, pressure, or crushing
§ Common locations: substernal, retrosternal, or
epigastric areas; pain may radiate to neck, jaw,
arms, back
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Stimulation of sympathetic nervous system
results in
§ Release of glycogen
§ Diaphoresis
§ Vasoconstriction of peripheral blood vessels
§ Skin: ashen, clammy, and/or cool to touch
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Cardiovascular
§ Initially, ↑ HR and BP, then ↓ BP (secondary to ↓ in
CO)
§ Crackles
§ Jugular venous distension
§ Abnormal heart sounds
• S3 or S4
• New murmur
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Nausea and vomiting
§ Can result from reflex stimulation of the vomiting
centre by severe pain
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Fever
§ Systemic manifestation of the inflammatory
process caused by cell death
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Detailed health history and physical
12-lead ECG: changes in QRS complex, ST
segment, and T wave can rule out or confirm
UA or MI.
Serum cardiac markers
Coronary angiography
Others: exercise stress testing,
echocardiogram
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Emergency management
§ Initial interventions
§ Ongoing monitoring
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Emergent PCI
§ Treatment of choice for confirmed MI
§ Balloon angioplasty + drug-eluting stent(s)
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Fibrinolytic therapy
§ Indications and contraindications
§ Best marker of reperfusion: return of ST segment
to baseline
§ Rescue PCI if thrombolysis fails.
§ Major complication: bleeding
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Coronary surgical revascularization
§ Failed medical management
§ Presence of left main coronary artery or threevessel disease
§ Not a candidate for PCI (e.g., lesions are long or
difficult to access)
§ Failed PCI with ongoing chest pain
§ History of diabetes mellitus
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Coronary surgical revascularization
§ Coronary artery bypass graft (CABG) surgery
• Requires sternotomy and cardiopulmonary bypass (CPB)
• Uses arteries and veins for grafts
§ Minimally invasive direct coronary artery bypass
(MIDCAB)
• Alternative to traditional CABG
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The animation referenced below can be viewed in the PowerPoint Animations asset.
Coronary Artery Bypass Graft (CABG)
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Coronary surgical revascularization
§ Off-pump coronary artery bypass
• Does not require CPB
§ Transmyocardial laser revascularization
• For clients with advanced CAD who are not surgical
candidates or who have failed maximum medical therapy
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Drug therapy
§ IV nitroglycerin
§ Morphine sulphate
§ β-Adrenergic blockers
§ Angiotensin-converting enzyme inhibitors
§ Antidysrhythmic drugs
§ Cholesterol-lowering drugs
§ Stool softeners
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Nutritional therapy
§ Initially NPO
§ Progress to
• Low salt
• Low saturated fat
• Low cholesterol
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Nursing assessment
§ Subjective data
• Important health information
• Symptoms
§ Objective data
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Nursing diagnoses
§ Acute pain
§ Decreased cardiac output
§ Anxiety
§ Activity intolerance
§ Ineffective health management
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Planning: Overall goals
§ Relief of pain
§ Preservation of myocardium
§ Immediate and appropriate treatment
§ Effective coping with illness-associated anxiety
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Planning: Overall goals (cont.)
§ Participation in a rehabilitation plan
§ Reduction of risk factors
§ Health promotion
• Therapeutic lifestyle changes to reduce cardiac risk factors
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Acute interventions for anginal attack
§ Administration of supplemental oxygen
§ Assess vital signs, pulse oximetry
§ 12-lead ECG
§ Prompt pain relief first with a nitrate followed by an
opioid analgesic, if needed
§ Auscultation of heart sounds
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Ambulatory and home care
§ Client teaching: CAD and angina
• Precipitating factors for angina
• Risk factor reduction
• Medications
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Acute intervention
• Pain: nitroglycerin, morphine, oxygen
• Continuous monitoring
– ECG
– VS, pulse oximetry
– Heart and lung sounds
• Rest and comfort
– Balance rest and activity.
– Begin cardiac rehabilitation.
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Acute intervention (cont.)
§ Anxiety
§ Emotional and behavioural reaction
• Maximize client’s social support systems.
• Consider open visitation.
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Coronary revascularization—CABG: ICU for
first 24–36 hours
§ Pulmonary artery catheter for measuring CO, other
hemodynamic parameters
§ Intra-arterial line for continuous BP monitoring
§ Pleural/mediastinal chest tubes for chest drainage
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CABG (cont.)
§ Continuous ECG monitoring to detect
dysrhythmias (esp. atrial dysrhythmias)
§ Endotracheal tube/mechanical ventilation
• Extubation within 12 hours
§ Epicardial pacing wires for emergency pacing of
the heart
§ Urinary catheter to monitor urine output
§ NG tube for gastric decompression
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CABG: Complications related to CPB
§ Bleeding and anemia from damage to RBCs and
platelets
§ Fluid and electrolyte imbalances
§ Hypothermia as blood is cooled as it passes
through the bypass machine.
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CABG: Care is focused on
§ assessing the client for bleeding
(e.g., chest tube drainage, incision sites).
§ monitoring fluid status.
§ replacing electrolytes PRN.
§ restoring temperature (e.g., warming blankets).
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Ambulatory and home care
§ Client and caregiver teaching
§ Physical exercise
§ Resumption of sexual activity
• Emotional readiness of client and partner
• Physical expenditure
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Evaluation
§ Relief of pain
§ Preservation of myocardium
§ Immediate and appropriate treatment
§ Effective coping with illness-associated anxiety
§ Participation in a rehabilitation plan
§ Reduction of risk factors
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