Coronary Artery Disease, High
Cholesterol, Stable Angina, Unstable
Angina (ACS)
Brunner, ch 27, pp. 729-741
Coronary Artery Disease
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AKA:
CAD
 Ischemic Heart Disease
 Coronary Heart Disease (CHD)
 Arteriosclerotic Heart Disease (AHD)
 Arteriosclerotic Cardiovascular Disease
(ASCVD)
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Pathophysiology of CAD
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Abnormal accumulation of lipids and fibrous
tissues causes an atheroma (plaque).
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Progresses from fatty streak to fibrous plaque,
to ulcerated lesion with thrombus formation.
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Vessel wall becomes inflamed and damaged,
attracting platelets and WBCs, becoming a
complicated lesion.
Pathophysiology cont’d
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Atheroma protrudes into lumen of vessel,
obstructing blood flow (Figure 27-1, p. 730)
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Obstruction of blood flow causes lack of
oxygen (ischemia) to the area perfused by the
affected artery causing pain (angina).
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If collateral circulation does not develop,
permanent damage can occur.
Development of Collateral Circulation
Non-modifiable Risk Factors for CAD
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Chart 27-1, 731:
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Age: (M > 45; F > 55)
Gender: (M > 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 CAD—
Metabolic Syndrome
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Dyslipidemia—high LDL;low HDL (F<50; M<40);
triglycerides>150
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Proinflammatory state—C-reactive protein
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(CRP) 1 mg/L; 3 is hi-risk
Hypertension >130/85
Prothrombotic state (high fibrinogen)
Insulin resistance (FBS > 100)
Central obesity (waist: F: w>35; M: w>40)
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*Diagnosis
= 3/6
Modifiable Risk Factors cont’d
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Elevated homocysteine >2.3 mg/L damages
endothelial lining
Tobacco use; twice as bad in women.
Damages endothelial lining, increases
catecholamines, carbon monoxide replaces
O2 in blood
Physical inactivity
Hyperlipidemia; Atherogenic diet
HTN: 120/80 prehypertensive; 140/90 Stage I
Diabetes
Obesity
Metabolic syndrome
Pathophysiology of High Cholesterol
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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 
processed into lipoproteins  LDL portion adheres to
intimal wall
See Figure 27-4, p. 733
Cholesterol Norms

Total cholesterol <200
 HDL >60—good cholesterol
 LDL <100 (<70 in hi-risk pts)—bad cholesterol
 Triglycerides <150 (high sugar intake can
affect results)

LDL is targeted for therapy
Angina: Chronic, Stable
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Predictable and manageable
Caused from CAD, but also anything that
could increase the heart’s oxygen demand:
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Exertion
Emotion
Eating big meal
Tobacco use
Stimulants (cocaine, thyrotoxicosis)
Irregular, fast heart rhythms
Anemia
Manifestations of Chronic Stable
Angina
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Caused by partial occlusion with atheroma
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Squeezing, tightness, heaviness
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Epigastric, midsternal, or retrosternal pain
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May radiate to neck, jaw, arm, back
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May have nausea, diaphoresis, dizziness
Chronic Stable Angina cont’d
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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
Angina: Unstable
(Preinfarction angina)
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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 (Prinzmetal’s or
Variant angina). Pain is unpredictable. Reversible ST
elevation
Although if not treated can lead to an MI, it is not an
MI—that is death to the myocardial tissue (covered in
NUR 213)
Silent Angina
ECG changes with stress test show
ischemia but no pain is felt
 Can have atypical symptoms such as
nausea, diaphoresis, dizziness,
indigestion which are usually ignored or
blamed on something else
 More common in people with diabetes,
women, and elderly
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Manifestations of Angina
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Substernal, retrosternal, or epigastric pain and /or
choking sensation caused from partial occlusion
and/or coronary artery spasm. exacerbated by cold,
exertion, heavy meal, stress. Relieved by NTG
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Can radiate to neck, jaw, shoulders, inner left arm,
epigastric area
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Apprehension, fear of impending doom, weakness,
dizziness, N/V
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With unstable, pain is more severe and prolonged,
increasing in frequency and severity, and may occur at
rest. Unrelieved by NTG
Manifestations cont’d
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May last 10-20 minutes
Dyspnea, tachycardia, pulsus alternans, pulse
deficit
Gallop rhythm, murmur
Hyper or hypotension
Cool, pale skin
ECG changes—arrhythmias, ST depression,
T wave inversion
ECG Changes with Angina
Manifestations cont’d
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Negative serum cardiac markers
Positive stress test and thallium scans
(creates chest pain)
CXR may show cardiac enlargement or
pulmonary congestion
Echo may show abnormal wall motion
Positive coronary angiography (shows
occlusion)
Medical Management
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Goal is to improve oxygen to the myocardium by
decreasing demand and providing supplementation
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Medication therapy (Table 27-3, p. 737) and morphine
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Changing modifiable risk factors
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In some instances, interventional therapies are
needed (PCI, stents, arthrectomy, CABG)
Nursing Diagnoses for CAD
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Acute Pain
Ineffective tissue perfusion (cardiac/peripheral)
Risk for imbalanced fluid volume
Fear/Anxiety
Imbalanced nutrition
Ineffective health maintenance
Ineffective therapeutic regimen mgmt
Ineffective coping
Deficient knowledge
Nursing Management of CAD: Health
Promotion
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Diet—low sodium, low fat. Mediterranean diet is
promoted. Vegetarian diets are good. High fiber is
helpful.
Lose weight
Exercise—150” of moderate activity/wk; 75” of
intense
Stop tobacco products
Monitor and control blood sugar
Monitor BP and lipid levels
Reduce stress
Nursing Management cont’d
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Monitor effects of and provide education for
med therapy if indicated:
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Antilipidemics
Antiplatelets
Antidiabetics
Antihypertensives
Antianginals
Percutaneous Revascularization
Revascularization cont’d
Patient Education
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S&S 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.)
Preventative NTG tx
Control modifiable risk factors