Coronary Artery Disease & Acute Coronary Syndrome Cardiac Conduction (AV Blocks, VT, VF) Pacemakers, ICD Atherosclerosis • Disease of the large and medium-sized muscular arteries and is characterized by endothelial dysfunction, vascular inflammation, and the build up of lipids, cholesterol, calcium, and cellular debris within the intima of the vessel wall. • Plaque formation • Vascular remolding • Acute and chronic luminal obstruction • Abnormalities of blood flow • Diminished O2 supply IT ALL STATRS WITH THE FATTY STREAK KNOW YOUR FAT • Lipids • Total cholesterol • • • • < 200 low risk • 200-239 borderline • >239 high risk High Density Lipoprotein (HDL) • >35 • < 35 Low Density Lipoprotein (LDL) • <129 low • 130-159 medium • >159 high Triglycerides • <200 • 201-399 • 400-1000 • >1000 Cholesterol Medications • Six types of lipid-lowering agents: affect the lipid components somewhat differently • 3-Hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) (or statins) • Nicotinic acids • Fibric acids (or fibrates) • Bile acid sequestrants (or resins) • Cholesterol absorption inhibitors • Omega-3 acid-ethyl esters Atherosclerosis Atherosclerosis • Risk Factors • Modifiable: Smoking, obesity, lack of exercise, stress, diet • Controllable: HTN, hyperlipidemia, DM • Non modifiable: Gender, age, heredity (can be modified), ethnicity (can be modified when r/t systemic racism, poverty, etc.) Atherosclerosis • Signs & Symptoms • Hyperlipidemia • CAD • 4th heart sound, tachycardia, hypotension, HTN, angina • CV disease • Diminished carotid pulses, carotid artery bruits, focal neurological deficits, headaches • PVD • Decreased peripheral pulses, peripheral artery bruits, pallor, peripheral cyanosis, gangrene, ulceration, difficulty ambulating, pain with ambulation • AAA • Pulsatile abnormal mass, peripheral embolism, circulatory collapse, pre/syncope, weakness • Atheroembolism • Gangrene, cyanosis, ulceration Atherosclerosis • Diagnostics • History and physical • ECG • Risk factor assessment (diabetes, HLPD, gender, LV function, provocation of angina, genetics, stress) • Echocardiography (assess LV function, EF, predicts survival) • Echo or ECG cardiac stress test • CXR • Labs Coronary Artery Disease(CAD) Coronary arteries RCA, L main, LAD, circumflex Obstruction (thrombus or embolus) Spasm Caused by imbalance between myocardial O2 demand and supply ischemia Hypovolemia Causes of supply-demand imbalance Anemia HR BP Prevention of CAD Control cholesterol Dietary measures Physical activity Medications Cessation of tobacco use Manage HTN Control diabetes Angiography Risk Stratification High - Disease of left main or left anterior descending coronary artery, 3vessel disease with proximal stenosis Medium - Significant lesion in large or proximal artery, but no high-risk features Low - Normal coronary arteries or non obstructive plaques Angina Pectoris Cardiac Chest Pian Angina Pectoris A syndrome characterized by episodes or paroxysmal pain or pressure in the anterior chest caused by insufficient coronary blood flow Physical exertion or emotional stress increases myocardial oxygen demand, and the coronary vessels are unable to supply sufficient blood flow to meet the oxygen demand Types of Angina • Chronic Stable Angina • Decreased blood flow to myocardium usually caused by CAD • Temporary pain/pressure • Predictable, long term, familiar pattern • Resolves with NTG or rest • Exertional • Exercise, stress anxiety, large meals, tachycardia, anemia, hypoglycemia, hyperthyroidism • Resolves with rest or NTG • Lasts < 15 minutes • May radiate to arm, shoulder, back, jaw, neck, wrists • Variant or atypical or Prinzmetal • Not caused by exertion • Often caused by coronary artery spasm • Often there is no coronary artery blockage or atherosclerosis Angina Types & MI Symptoms Assessment and Findings May be described as tightness, choking, or a heavy sensation Other symptoms may occur: dyspnea or shortness of breath, dizziness, nausea, and vomiting Frequently retrosternal and may radiate to neck, jaw, shoulders, back or arms (usually left) Anxiety frequently accompanies the pain The pain of typical angina subsides with rest or NTG Unstable angina is characterized by increased frequency and severity and is not relieved by rest and NTG. Requires medical intervention! Assessing Patients and their Chest Pain Language of Chest Pain Patient Assessment Assessment of Chest pain • Scale of 1-10 • Quality • Severity • Frequency • Location and radiation • Duration • Precipitating factors • Relieving factors Chest Pain Patterns Chest Pain Signs & Symptoms Gerontologic Considerations • Diminished pain transition that occurs with aging may affect presentation of symptoms • “Silent” CAD • Teach older adults to recognize their “chest pain–like” symptoms (i.e., weakness) • Pharmacologic stress testing; cardiac catheterization • Medications should be used cautiously! Angina Management 3 Goals 1. Identify and respond ASAP 2. Establish prophylactic drug regimen 3. Widen or circumvent narrowed arteries Treatment Treatment seeks to decrease myocardial oxygen demand and increase oxygen supply Medications Reduce and control risk factors Oxygen Reperfusion therapy may also be done Nitroglycerin Beta-adrenergic blocking agents Calcium channel blocking agents Medications Antiplatelet and anticoagulant medications • Aspirin • Clopidogrel and ticlopidine • Heparin • Glycoprotein IIb/IIIa agents (abciximab, eptifibatide, and tirofiban) ASA • Acetylsalicylic Acid • Antiplatelet effect • 81-325 mg • Chewable NTG • Nitroglycerin • Causes venous and arterial dilation and dilation of coronary arteries, resulting in decreased preload, afterload and increased blood flow to the myocardium • Take 1 every 5 minutes X 3 doses sublingually • Don’t swallow • Take out cotton ball in container as it absorbs the drug • Keep in a dark, glass bottle, dry, cool & renew every 6 months • Usually burns/fizzes under tongue • HA • Check BP before and after administration • AHA recommends contacting EMS (911) after the client takes the first dose of NTG. Don’t wait more than 5 minutes to call 911 • Morphine –decreases cardiac workload MSO4 • Analgesic effects decreases the sympathetic response thereby decreased diaphoresis lightheadedness, & Decreases HR, BP and venous return • Stimulates local histamine mediated responses • Might inhibit or delay of antiplatelet absorption O2 Beta Blockers Calcium Channel Blockers • Oxygen • Beta Blockers (beta1 selective • Decrease BP, P and myocardial contractility • Improve LV function • Calcium Channel Blockers • Decrease BP and dilate coronary arteries Management of Chronic Stable Angina Patient Education • • • • • • • • • • • • Avoid isometric exercise Avoid overeating Rest frequently Avoid excess caffeine or any drugs the increase HR Wait 2 hours after eating to exercise Dress warmly in cold weather Adhere to medication regimen Take NTG prophylactically Stop smoking Manage diabetes Lose weight if overweight Diet modifications/changes Unstable Angina • Change in pattern = severity or > time • Not relieved by NTG or rest • Occurs at rest or awakens patient at night • > 15 minutes Acute Coronary Syndromes Decreased blood flow to the myocardium resulting in ischemia, necrosis or both usually unrelated to predisposing factor and unrelieved by NTG • MI (non ST segment elevation) • Unstable Angina Signs and symptoms • Pain • Cold and clammy • Increased WBC and increased temp • ECG changes •N & V Serial Cardiac Enzymes CPK • CK-MM, CK-BB, CK-MB • CK-MB elevate at 3-8 hours after the onset of chest pain • Peak in 12-24 hours and return to baseline within 3 days LDH • Helps determine the location of the tissue damage • Normal: 5-150 U/L • LDH 1 found primarily in heart and RBC & LDH 2 is concentrated in WBC Troponin • Highly specific for myocardial cell injury • Detected 3-4 hours after onset of chest pain • Peak in 4-24 hours and returns to normal in 13 weeks • Normal : 0.0-0.1 ng/mL • Always normal in non-cardiac muscle diseases ACS • Common Precipitating Factors • Exercise 13% • Unusual exertion 18% • Surgery 6% • Rest 51% • Sleep 8% • Signs & Symptoms CP > 30 min severe. Not relieved by NTG and/or rest Dyspnea Orthopnea N&V Diaphoresis Weakness and/or fatigue Anxiety, apprehension, denial Palpitations Dizziness ACS Dysrhythmias ACS Diagnosis • • • • Patient history Signs & Symptoms Type of pain ECG changes • Inverted T waves • ST elevation • Q waves • Other tests • Cardiac enzymes • Cardiac markers Effects of Ischemia, Injury, and Infarction on ECG ECG evolution with MI Phases • Hyper acute phase • Early acute phase • Later acute Phase • Fully Evolved • Healed Locating MI by ECG changes • V1, V2, V3, V4/LAD/Anterior wall • II, III, aVF/RCA/Inferior wall • V1, V2, V3, V4/RCA or left circumflex/posterior wall • I, aVL, V5, V6/left circumflex/Lateral wall Time is Muscle Door to Balloon Initiative < 90 minutes • Treatment • Medications • ASA, O2, NTG, morphine = vasodilation and decrease workload of heart • AONMT • Positioning • Head up decreases workload on heart and increases CO • Medical Interventions • PCI • PTCA, stents • CABG • Fibrinolytics Fibrinolytics • Goal is to dissolve the clot that is blocking the blood flow to the heart and thereby decreasing the size of the infarction • Medications • Nursing considerations • Detailed H & P are critical (bleeding and time of onset) • Initiate bleeding precautions, assess ECG, minimize anything that causes bleeding • Must be given in a compressible site • F/U therapy • Antiplatelet • ASA, clopidogrel (Plavix), abciximad (ReoPro IV), eclientifibatide (Integrilin) Fibrinolytic Therapy Fibrinolytic Therapy Nursing Considerations Nursing Management: ACS/MI • • • • • • Oxygen and medication therapy Frequent VS assessment Physical rest in bed with head of bed elevated Relief of pain helps decrease workload of heart Monitor I&O and tissue perfusion Frequent position changes to prevent respiratory complications • Report changes in patient’s condition • Evaluate interventions! Invasive Coronary Artery Procedures • Percutaneous transluminal coronary angioplasty (PTCA) • Coronary artery stent • Coronary artery bypass graft (CABG) • Cardiac surgery Percutaneous Coronary Intervention Known as balloon angioplasty or percutaneous transluminal angioplasty Minimally invasive PCI Used to treat CAD, angina, acute MI in order to re-perfuse and save cardiac muscle Often combined with stent placement • Bare-metal stent • Drug eluting stent Location and extent of blockage Thoracic surgery Size of coronary arteries Coronary Artery Bypass Graft (CABG) The choice of bypass graft depends on Availability of arteries and veins Graft choices Patient condition/conditions Left Internal thoracic artery ITA (internal mamary) and right ITA Radial artery, gastropiploic artery and saphenous vein Coronary Artery Bypass Grafts Greater and Lesser Saphenous Veins Are Commonly Used for Bypass Graft Procedures Cardiopulmonary Bypass System Advanced Support • Pulmonary artery catheter (PA) used to measure intracardiac pressures , volume status • Intra aortic balloon pump( IABP)used for counter pulsation to improved perfusion while LV heals • Left ventricular assist device (LVAD) is a pump • Patients will only have a MAP, no pulse
