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• Is characterized by the

accumulation of plaque
within coronary arteries,
which progressively
enlarge, thicken and
calcify. This causes critical
narrowing of the coronary
artery lumen (75%
occlusion), resulting in a
decrease in coronary blood
flow and an inadequate
supply of oxygen to the
heart muscle.
• Ischemia may be silent
(asymptomatic but
evidenced by ST
depression of 1 mm or more on electrocardiogram (ECG) or may be manifested by
angina pectoris (chest pain).
• Risk factor for Coronary Artery Disease include dyslipidemia, smoking, hypertension,
male gender (women are protected until menopause), aging, non-white race, family
history, obesity, sedimentary lifestyle, diabetes mellitus, metabolic syndrome, elevated
homocysteine, and stress.
• Acute coronary syndrome is a complication of CAD due to lack of oxygen to the
myocardium. Mnaifestations include unstable angina, non ST-segment elevation
infarction, and ST-segment elevation infarction.
• Other causes of angina include coronary artery spasm, aortic stenosis, cardiomyopathy,
severe anemia, and thyrotoxicosis.

Assessment:

Chest pain is provoked by exertion or stress and is


relieved by nitroglycerin and rest.

1. Character. Substernal chest pain, pressure,


heaviness, or discomfort. Other sensations
include a squeezing, aching, burning,
choking, strangling, or cramping pain.
2. Severity. Pain maybe mild or severe and
typically present with a gradual buildup of
discomfort and subsequent gradual fading
away.
3. Location. Behind middle or upper third of
sternum; the patient will generally will
make a fist over the site of pain (positive Levine sign; indicates diffuse deep visceral
pain), rather than point to it with fingers.
4. Radiation. Usually radiates to neck, jaw, shoulders, arms, hands, and posterior
intrascapular area. Pain occurs more commonly on the left side than the right; may
produce numbness or weakness in arms, wrist, or hands.
5. Duration. Usually last 2 to 10 minutes after stopping activity; nitroglycerin relieves pain
within 1 minute.
6. Precipitating factors. Physical activity, exposure to hot or cold weather, eating a heavy
meal, and sexual intercourse increase the workload of the heart and, therefore, increase
oxygen demand.
7. Associated manifestation. Diaphoresis, nausea, indigestion, dyspnea, tachycardia, and
increase in blood pressure.
8. Signs of unstable angina:

• A change in frequency, duration, and intensity of stable angina symptoms.


• Angina pain last longer than 10 minutes, is unrelieved by rest or
sublingual nitroglycerin, and mimics signs and symptoms of impending
myocardial infarction.

Diagnostic Evaluation:

1. Resting ECG may show left ventricular hypertrophy, ST-T changes, arrhythmias, and
possible Q waves.
2. Exercise stress testing with or without perfusion studies shows ischemia.
3. Cardiac catheterization shows blocked vessels.
4. Position emission tomography may show small perfusion defects.
5. Radionuclide ventriculography shows wall motion abnormalities and ejection fraction.
6. Fasting blood levels of cholesterol, low density lipoprotein, high density lipoprotein,
lipoprotein A, homocysteine, and triglycerides may be abnormal.
7. Coagulation studies, hemoglobin level, fasting blood sugar as baseline studies.

Pharmacologic Interventions:

1. Antianginal medications (nitrates, beta-adrenergic blockers, calcium channel blockers,


and angiotensin converting enzyme inhibitors) to promote a favorable balance of oxygen
supply and demand.
2. Antilipid medications to decrease blood cholesterol and tricglyceride levels in patients
with elevated levels.
3. Antiplatelet agents to inhibit thrombus formation.
4. Folic acid and B complex vitamins to reduce homocysteine levels.

Surgical Interventions:

1. Percutaneous transluminal coronary angioplasty or intracoronary atherectomy, or


placement of intracoronarystent.
2. Coronary artery bypass grafting.
3. Transmyocardial revascularization.

Nursing Interventions:

1. Monitor blood pressure, apical heart rate, and respirations every 5 minutes during an
anginal attack.
2. Maintain continuous ECG monitoring or obtain a 12-lead ECG, as directed, monitor for
arrhythmias and ST elevation.
3. Place patient in comfortable position and administer oxygen, if prescribed, to enhance
myocardial oxygen supply.
4. Identify specific activities patient may engage in that are below the level at which anginal
pain occurs.
5. Reinforce the importance of notifying nursing staff whenever angina pain is experienced.
6. Encourage supine position for dizziness caused by antianginals.
7. Be alert to adverse reaction related to abrupt discontinuation of beta-adrenergic blocker
and calcium channel blocker therapy. These drug must be tapered to prevent a “rebound
phenomenon”; tachycardia, increase in chest pain, and hypertension.
8. Explain to the patient the importance of anxiety reduction to assist to control angina.
9. Teach the patient relaxation techniques.
10. Review specific factors that affect CAD development and progression; highlight those
risk factors that can be modified and controlled to reduce the risk.