Coronary Artery Disease, Angina, ACS

Lewis, ch 34

Coronary Artery Disease

AKA:CAD Ischemic Heart DiseaseCoronary 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).

Starts as a fatty streak, progresses to fibrous plaque, then to an ulcerated lesion with thrombus (clot) formation.

The vessel wall becomes inflamed and damaged, attracting platelets and WBCs. (complicated lesion)

Pathophysiology cont’d

The atheroma protrudes into the lumen of the vessel, obstructing blood flow (786)

Obstruction of blood flow causes lack of oxygen (ischemia) to the part of the cardiac muscle that is perfused by the affected artery, resulting in pain (angina).

If collateral circulation does not develop, permanent damage can occur.

Development of Collateral Circulation

Non-modifiable Risk Factors for CAD

Age (M > 40; F > 50)Gender (M > F until menopause)Family HxRace (WM > BM; BF > WF)Major cause of death in both genders

(785)

Modifiable Risk Factors for CAD

Elevated lipid levels*—LDL and low HDL, trig

C-reactive protein*-- > 1 mg; 3 is hi-riskTobacco use > 1 ppd; twice as bad in

womenHypertension* > 140/90Elevated glucose*—FBS > 110*Obesity*—BMI > 30, central obesity

Modifiable Risk Factors cont’d

Atherogenic dietAbnormal clotting* InactivityOral contraceptives and HRTStress

*Metabolic syndrome

Angina: Chronic, Stable

Predictable and manageable Caused from CAD, but also anything that

could increase the heart’s 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, heavinessEpigastric, midsternal, or retrosternal

painMay radiate to neck, jaw, arm, backMay have nausea, diaphoresis,

dizziness

Chronic Stable Angina cont’d

Usually lasts 3-5 minutesResponds to rest and nitrate therapySame each timeUsually follows pattern of activity-pain;

rest-relief

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

(Prinzmetal’s angina). Pain is unpredictable. Not an MI—that is death to the myocardial

tissue (covered in NUR 212)

Manifestations of ACS

Usually caused from partial occlusion and coronary artery spasm

Substernal or epigastric painRadiates to neck, left shoulder, left arm,

epigastric areaPain is more severe and prolonged,

increasing in frequency and severity; may occur at rest

ACS cont’d

Lasts 10-20 minutesDyspnea, tachycardia, hypotensionCool, pale skinECG changes

ECG Changes with Angina

Diagnostics for CAD and Angina with Nursing Responsibilities

Lipid levels—should be fastingCardiac markers (troponin, CK-MB)—let

patient know why blood is drawn often.ECG—apply leads and ask pt to lie stillStress test and nuclear scan—IV access

for nuclear med; monitor ECG and VS; crash cart available; let pt know radioactivity is small.

Diagnostics cont’d

Cardiac catheterization:Preprocedure:

requires consent; IV access; mark pulse sites, let pt know sensations; assess allergies.

Postprocedure: monitor VS & pulse sites, and for hemorrhage.

Nursing Diagnoses for CAD

Ineffective Tissue PerfusionAcute PainImbalanced NutritionIneffective Health MaintenanceIneffective Therapeutic Regimen MgmtIneffective CopingFear

Nursing Management of CAD

Encourage health promotion thru decreasing risk factors:Diet—low sodium, low fatLose weightExercise—at least 30” of aerobic 5x wkStop tobacco productsMonitor and control blood sugarMonitor BP and lipid levelsReduce stress

Nursing Management cont’d

Monitor effects of and provide education for med therapy if indicated (see Cardiac Meds ppt):AntilipidemicsAntiplateletsAntidiabeticsAntihypertensives Antianginals

Nursing Management of ACS

ICU or CCU admission 24-48hRest, O2, liquidsVS, pulse ox, telemetry, IV accessNTG q 5” x3 if BP ok or ASA; MS if

neededIf markers are negative, but angina

continues, HCP may order ASA, heparin, and/or Aggrestat

PCI, atherectomy

Percutaneous Revascularization

Revascularization cont’d

Patient Education

S&S of CP Avoid activities that cause CPIf pain occurs, stop activity and take NTGIf no relief, BP gets too low, or weakness,

dizziness, or syncopy occurs, call 911Med therapy (self adm, storage, etc)Preventative NTG txControl modifiable risk factors