Coronary Artery Disease

Coronary Atherosclerosis
definition- abnormal accumulation of
lipids and fibrous tissue in the coronary
arteries which results in decreased
blood flow to myocardium
Atheroma comprises the lumen of the
vessel---clots may form and obstruct
the lumen
 Clinical Manifestations
a) narrowing-angina (ischemia)
b) occlusion- AMI (necrosis)
c) other
-EKG changes
- aneurysms
-dysrhythmias
d) sudden cardiac death
 Angina Pectoris
definition-chest discomfort (pain) due to
decreased blood flow resulting in atheroma or
spasm
decreased blood flow results in myocardial
ischemia-nerve endings around cells send
pain messages to brain
usually transient chest pain (3-5’), subsides
when precipitating factor removed
 Types of Angina
Unstable- referred to as
preinfarction,Crescendo,unpredictable,o
r
progressive (increase in frequency and
duration)
treated with ASA and Calcium Channel
Blocking Agents
 Chronic, Stable Angina
referred to as predictable and
consistent
occurs on exertion
relieved with rest
EKG changes-ST depression
classic type of angina
 Nocturnal Angina
referred to as Angina Decubiti
occurs at night due to lying flat when
the workload on the heart is increased
(increased venous return or preload)
relieved by standing or sitting
 Prinzmetal’s Angina
usually spontaneous and accompanied
by increased ST elevations on the EKG
due to coronary artery spasm
associated with risk of MI
rare form of angina
 Factors Precipitating
Angina
a) physical exertion-increases workload
of heart ( sex, exercise, raking leaves
,or lifting heavy objects)
b) exposure to heat or cold resulting in
vasoconstriction-elevated blood
pressure-increased demands of body for
oxygen
 Factors Precipitating
Angina
c) heavy meals-divert blood to GI tract (25%of
CO)
d) strong emotions-increased release of
catecholamines
e) cigarette smoking
f) sexual activity
g) stimulants-coffee or cocaine
h) circadian rhythm patterns-early a.m. after
arising
 Description of Pain
a) substernal-varies in intensity from
discomfort to pressure to agonizing pain
adjectives used to describe pain
heavy feeling, pressure,weight
oppressive or sharp
tightness
viselike
Description of Pain
crushing
constricting
squeezing
suffocating
burning
indigestion
 Types of Pain
b) deep-retrosternal
c) localized but may radiate to
neck,jaws,shoulder,inner aspects of
either arm-
usually subsides when cause removed
relieved by nitrates and rest
duration of pain -approximately 15’ or
less
 Diagnostic Tests
a) EKG-changes occur only while having angina
b) Stress tests results-look for changes in ST
segments
c) Thallium stress test-inject dye 1 minute
before peak exercise, scan immediately and
in 2-4 hours. Look for “cold spots” indicating
lack of Thallium uptake or lack of perfusion
 Diagnostic Tests
d) Cardiac Catheterization-Angiography
Looks at oxygen levels and pressure
readings in heart chambers as well as
blood flow through coronary arteries
e) Chest X-Ray- Identifies enlarged
heart, calcification,pulmonary
congestion
f) Lipids and Enzymes
 Diagnostic Tests
g) PET-Positron Emission Tomography-
non invasive test that identifies and
quantifies ischemia and infarction
h) Echocardiography
 Management of Angina
Objective-decrease the discrepancy
between the oxygen supply and demand
- Rest-decrease the amount of oxygen
needed by all tissues of body
- Percutaneous Transluminal Coronary
Angioplasty (PTCA)
-Intracoronary Stints
-Atherectomy
Interventions for Angina
Acute Attack - Pain assessment -
quantify the pain using a 1-10 scale (1-
least severe and 10-most severe)
Remember that cardiac pain is diffuse,
deep and intense
 Acute Anginal Attack
Provide oxygen at 2L/minute
Take Vital Signs
perform EKG - look for changes in ST
segments
Administer Nitrates or Analgesia
semi-Fowlers position
 Nursing Interventions-
Angina
Prevent Pain
-Avoid activities that cause pain
- Change ADL schedules if pain in a.m.
- Unhurried pace
-Avoid causes
 Nursing Interventions-
Angina
Reduce Anxiety
- “Fear of Death” is common
- Stay with anxious client
- Educate client for discharge
 Nursing Interventions-
Angina
Objectives of Client Education-
Home Care
- reduce frequency/ severity of
attacks
- delay disease progression
- protect from complications
- plan activities to minimize episodes
- modify risk factors
 Medications To Treat
Angina
1) Nitroglycerin-,decreases preload and
afterload by dilating venous and arterial
system,decreases venous return and arterial
pressure
a) works in 2-3 minutes
b) dose-0.3-0.6 mg sl.x3 at 5-10 minute
intervals
c) effects last only 10-15 minute maximum
 Side Effects of
Nitroglycerin
Increased Heart Rate
Orthostatic Hypotension
Throbbing Headache
Flushing of face
Vertigo
Tachycardia
 Nursing Implications
Associated With Nitroglycerin

Fresh supply every 6-9 months

Take at earliest sign of pain or
discomfort
Keep in brown bottle and cool spot-it is
volatile to air
Sit or lie down when taking
Remove cotton from bottle
Does not always sting under tongue
 Nitrate Preparations
Nitroglycerin sublingual-If no relief from 3
pills taken 5 minutes apart-seek medical
attention
Long Acting Nitrates
a) Topical Ointments-duration of effect
is 4 hours so client needs 4-6
applications a day
Apply to arms, legs ,any unhairy body
area
 Long Acting Nitrate
Preparations
DM preparation-long acting
examples-Peritrate, Isordil -last 6-8
hours
Nitrodiscs-apply in a.m., remove at
h.s.to provide a nitrate free period
Examples-Transderm NitroDur discs
where drugs are continually
released to skin absorption site
Intravenous Nitroglycerin
rationale-increase collateral blood flow
to ischemic area, decrease myocardial
oxygen demand by decreasing preload
and decreasing afterload
examples- Nitrol IV, Nitrostat IV,
Nitrobid or Tridil IV
 Beta Blockers
action-decrease myocardial oxygen
consumption by blocking sympathetic
impulses to heart, smooth muscle of
bronchi and blood vessels. It lowers
heart rate and blood pressure and
decreases myocardial contractility
 Beta Blockers
Common Drugs in Use
- Inderal-80-320mg BID or QID
- Atenolol (Tenormin)-50-100mg/day
may take up to 200 mg/day
-Metoprolol (Lopressor) -50-100mg/day
may take up to 450mg/day
 Beta Blockers
Timolol (Blocadren10 mg. BID or up to
100
mg./day
 Side Effects of Beta
Blockers
Musculoskeletal Bronchospasm-
Weakness watch clients with
Hypertension history of Asthma
Bradycardia .COPD
Depression Hyperglycemia-
watch for DM
Fatigue
Weight gain
Sexual dysfunction
Calcium Channel Blocking
Agents
Calcium influences cardiac contraction
and electrical stimulation
Action--dilates smooth muscle of
coronary arteries thus, increasing
oxygen supply,decreases systemic
arterial pressure and decreases
workload of LV (decreasing peripheral
resistance)
Calcium Channel Blocking
Agents
Effects-
- Systemic vasodilatation with
decreased systemic vascular resistance
- Decreased myocardial contractility
- Coronary vasodilatation
Common Calcium Channel
Blocking Agents
Nifedipine (Procardia) -10-30 mg.q4-8
hours
Verapamil (Isoptin, Calan)-60-80 mg.
q8 hrs. po or IV
Diltiazem (Cardizem) -60-90- mg. q8
hrs.po
Nicarpine (Cardene) -
 Side Effects of Calcium
Channel Blocking Agents
Orthostatic Hypotension
Bradycardia
Flushing
Headache
Pedal Edema-Nifedipine
Constipation- (Verapamil)
 Common Nursing
Diagnoses-Angina
a) Pain rel.to ischemia of myocardium
b) Activity Intolerance rel. to fatigue
or weakness
c) Altered Health Maintenance rel to
knowledge deficit
d) Anxiety rel. to fear of cardiac
disease, future sudden death
Percutaneous Transluminal
Coronary Angioplasty
(PTCA)
rationale- attempts to improve blood
flow within the coronary artery by
cracking the plaque or atheroma that is
interfering with the circulation of blood
to the heart
Procedure is done in Cath Lab-cardiac
catheterization documents stenosis
 PTCA
Catheter equipped with an inflatable ballon
tip is inserted into coronary artery and passed
beyond lesion
Ballon is inflated (3-4 seconds) and
atherosclerotic plaque is compressed resulting
in vasodilation
Ballon is deflated
Procedure may be repeated several times
 Advantages of PTCA
Alternative to surgery
Local anesthesia used
Eliminates Thoracotomy Incision
Client is ambulatory within 24 hours
Hospital stay is 1-3 days not 5-7 days
as with CABG procedure
Rapid return to work-1week instead of
8weeks with CABG procedure
Advancements with PTCA
Use of more flexible
guidewire/catheters
Dilates stenosed CABG grafts
Provide blood flow to distal myocardium
during inflation
 Complications of PTCA
Dissection of dilated artery
Rupture of artery causing tamponade,
ischemia, infarct, decreased CO,death
Occlusion of vessel distal to catheter
Coronary spasm from mechanical or chemical
irritation from dye
abrupt closure-24 hours
Restenosis rates of 30% within 3-6 months
 Newer Treatments
Radiation with Intravascular Stent
Placements-expandable, meshlike
structures to maintain vessel patency
requires anticoagulants for 3 months

Atherectomy-shave plaque using

rotating blade when proximal or middle
part of artery involved
 Newer Treatments for
Angina
Laser Angioplasty-A small laser on tip
of catheter welds the area open or
melts the plaque areas facilitating
blood flow
Is still a new technique and needs
refinement