Management of Patients With
Coronary Vascular Disease
• Question
• Is the following statement true or false?
• Individuals at highest risk for a cardiac risk for
a cardiac event within 10 years are those with
existing coronary disease.
Answer
• True
• Individuals at highest risk for a cardiac event
within 10 years are those with existing
coronary artery disease and those with
diabetes, peripheral arterial disease,
abdominal aortic aneurysm, and carotid artery
disease.
Coronary Atherosclerosis
• Atherosclerosis is the abnormal accumulation of
lipid deposits and fibrous tissue within arterial
walls and lumen.
• In coronary atherosclerosis, blockages and
narrowing, of the coronary vessels reduce blood
flow to the myocardium
• Cardiovascular disease is the leading cause of
death in the US for women and men of all racial
and ethnic groups.
• CAD, coronary artery disease, is the most
prevalent cardiovascular disease in adults
Clinical Manifestations
• Symptoms are due to myocardial ischemia
• Symptoms and complications are related to
the location and degree of vessel obstruction
• Angina Pectoris
• Myocardial Infarction
• Heart Failure
• Sudden Cardiac Death
Question
• Which is considered a modifiable risk for
coronary artery disease?
• A. Race
• B. Gender
• C. Family History
• D. Cigarette Smoking
Answer
• D. Cigarette Smoking-a modifiable risk factor
for coronary artery disease is cigarette
smoking. Race, gender, family history, are non
modifiable risk factors.
Clinical Manifestations-Continued
• The most common symptom of myocardial
ischemia chest pain; however, some
individuals may be asymptomatic or have
atypical symptoms such as weakness,
dyspnea, and nausea.
• Atypical symptoms are more common in
women and in persons who are older, or who
have a history of heart failure or diabetes. (see
hand outs on women with chest pain)
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 coronary
vessels are unable to supply blood flow to
meet the oxygen demand
Types of Angina
• Stable Angina-predictable and consistent pain that
occurs on exertion and is relieved by rest/or
nitroglycerin
• Unstable Angina-(also called preinfarction angina or
crescendo angina): symptoms increase in frequency
and severity; may not be relieved with rest or
nitroglycerin
• Intractable or Refractory Angina-severe or
incapacitating chest pain
• Variant Angina-(also, Prinzmetal’s angina); pain at rest
with reversible ST-segment elevation, thought to be
caused by coronary artery vasospasm.
Types of Angina-Continued
• Objective evidence of ischemia (such as EKG
changes with a stress test), but patient reports
no pain.
Angina pain varies from mild to severe
May be described as tightness, choking, or a
heavy sensation
Frequently, retrosternal and may radiate to
neck, jaw, shoulders, back or arms (usually left).
Anxiety frequently accompanies the pain.
Other symptoms may occur; dyspnea/sob,
dizziness, nausea and vomiting.
The pain of typical angina subsides with rest or
NTG.
Angina pain-Continued
• Unstable angina is characterized by increased
frequency and severity and is not relieved by
rest and NTG. Requires medical intervention!
Treatment
• Treatment seeks to decrease oxygen demand
and increase oxygen supply
• Medications
• Oxygen
• Reduce and Control Risk Factors
• Reperfusion Therapy may also be done
Summary of Meds Used to Treat
Angina
• Nitrates-Nitroglycerine (nitostat, nitrobid)-Short term and long term
reduction of myocardial oxygen consumption thru selective
vasodilation. Advise the patient to carry the medication at all times
as a precaution. However, because nitro, is very unstable, it should
be carried securely in original container, (eg. Capped dark glass
bottle); tablets should never be removed and stored in metal or
plastic pill boxes.
• Explain that nitro is volatile and is inactivated by heat, moisture, air,
light, and time. Instruct the pt to renew every 6 months.
• Instruct the pt to take in anticipation of any activity that may
produce pain. Because Nitro increases tolerance for exercise when
taken prophylactically (before angina producing activity, such as
exercise, stair climbing, and sexual intercourse), it is best taken
before pain develops.
Angina Meds-Continued
• Beta Adrenergic Blocking Agents (beta bloclers)Metoprolol (lopressor, toprol) Atenolol
(tenormin) Reduction of myocardial oxygen
consumption by blocking beta-adrenergic
stimulation of the heart.
• Calcium Ion Antagonists (calcium channel
blockers)-Amlodipine (norvasc), Diltiazem
(cardizem, tiazac), Felodipine (Plendil)-Negative
inotropic effects; indicated in patients not
responsive to beta-blockers; used as primary tx
for vasospasm
Angina Meds-Continued
• Antiplatelet Medications
• Aspirin
Prevention of platelet
Aggregation
• Clopidogrel (Plavix)
• Glycoprotein IIb/IIIa agents
-ReoPro
-Aggrastat
-Integrilin
Angina Meds-Continued
• Anticoagulants
• Heparin-Treating Pt’s with unstable angina with
heparin prevents the formation of new blood
clots and reduces the occurence of a new MI.
• Low-molecular weight Heparin (LMWH’s)
• Lovenox
• Fragmin
• Prevention of thrombus formation
Question
• Is the following statement true of false?
• Nitro tablets should never be removed and
stored in metal or plastic pillboxes.
Answer
• True
• Nitro tablets should never be removed and
stored in metal or plastic pillboxes.
Nursing Process: The Care Of the
Patient with Angina - Assessment
• Symptoms and Activities, especially those that
precede and precipitate attacks
• Risk factors, lifestyle, and health promotion
activities
• Patient and family knowledge
• Adherence to the plan of care
Assessing Angina
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Where is the pain?
Is the pain radiating anywhere else?
How would you describe the pain?
Is it like pain you have ever had before?
Can you rate the pain on a 0-10 scale with 10 being the
worse pain.
When did the pain begin?
How long did it last?
What brings on the pain?
What helps the pain to go away?
Do you have any other symptoms with the pain?
Nursing Process: The Care of the
Patient with Angina-Diagnosis
• Ineffective cardiac tissue perfussion secondary
to CAD
• Death anxiety related to cardiac symptoms
• Deficient knowledge related about the
underlying disease and methods for avoiding
complications
• Noncompliance, ineffective therapeutic
regimen related to failure to accept necessary
lifestyle changes
Collaborative Problems
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Acute Pulmonary Edema
Heart Failure
Cardiogenic Shock
Dysrhythmias and Cardiac Arrest
MI
Nursing Process: The Care of the
Patient with Angina-Planning
• Goals include the immediate and appropriate
treatment of angina, prevention of angina,
reduction of anxiety, awareness of the disease
process, understanding of prescribed care,
adherence to the self care program and
absence of complications.
Treatment of Angina Pain
• Treatment of Angina pain is a priority nursing
concern.
• Patient is to stop all activity and sit or rest in bed
• Assess the patient while performing other
necessary interventions-VS, observing for
respiratory distress, assessing for pain, and if in
the hospital setting, the ECG is being obtained.
• Administer oxygen
• Administer medications as ordered or by
protocol, usually NTG.
Anxiety
• Patients with Angina often fear loss of their
roles within society and the family.
• They may also fear the pain (or Prodromal
symptoms) may lead to MI or death.
• Use various stress reduction techniques:
guided imagery or music therapy etc.
• Assisting the patient and the patient’s family
with spiritual needs may allay fears and
anxieties.
Patient Teaching
• Lifestyle Changes and Reduction of Risk Factors
• Explore, Recognize, and adapt Behaviors to avoid
to reduce the incidence of episodes of ischemia
• Teaching regarding disease process
• Medications
• Stress reduction
• When to seek emergency care
Myocardial Infarction
• An area of the myocardium is permanently destroyed.
Usually caused by reduced blood flow in a coronary
artery due to rupture of an atherosclerotic plaque and
subsequent occlusion of the artery by a thrombus.
• In unstable angina, the plaque ruptures but the artery
is not completely occluded. Unstable Angina and
Acute MI are considered the same process but at a
different point on the continuum.
• The term acute coronary syndrome includes unstable
angina and MI.
Clinical Manifestations and Diagnosis
• Chest Pain and other symptoms-what are
they?
• ECG
• Lab Tests-bio markers
• CK-MB
• Myoglobin
• Troponin T or I
Question
• What is the purpose of the Echocardiogram?
A. Evaluate arterial function of the heart
B. Evaluate ventricular function of the heart
C. Detect hyperkinetic wall motion
D. Identify ischemia changes
Answer
• B
• The echocardiogram is used to evaluate
ventricular function. It can detect hypokinetic
and akinetic wall motion and determine the
ejection fraction.
Treatment of Acute MI
• Obtain Diagnostic Tests including ECG within 10
minutes of admission to the ED
• Oxygen
• Aspirin, Nitroglycerine, Morphine, beta-blocker
(Why these meds?)
• Evaluate for percutaneous coronary intervention
or thrombolytic therapy
• As indicated, IV Heparin or LMWH, Plavix, or
Triclopidine, glycoprotein IIb/IIIa inhibitor
• Bed rest
Nursing Process: The Care of the
Patient with ACS-Assessment
• A vital component of nursing care!
• Assess all symptoms carefully and compare to
previous and baseline data to detect any
changes or complications.
• Monitor ECG
Nursing Process: The Care of the
Patient with ACS-Diagnosis
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Ineffective cardiac tissue perfusion
Risk for fluid intolerance
Risk for ineffective peripheral tissue perfusion
Death anxiety
Deficient Knowlege
Collaborative Problems
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Acute Pulmonary Edema
Heart Failure
Cardiogenic Shock
Dysrhythmias and Cardiac Arrest
Pericardial effusion and cardiac tamponade
Nursing Process: The Care of the
Patient with ACS-Planning
• Goals include the relief of pain or ischemic
signs and symptoms, prevention of further
myocardial damage, absence or respiratory,
maintenance of or attainment of adequate
tissue perfusion, reduced anxiety, adherence
to the self-care program, and absence or early
recognition of complications. See page 777