NCMB312 LECTURE: Prelim Week

02
Coronary Artery Disease
Bachelor of Science in Nursing 3YA
Professor: Ma’am Maria Sheila Mujemulta
CORONARY ARTERY DISEASE
- the major blood vessels that supply your heart become
damaged or diseased.
- Cause: Cholesterol-containing deposits (plaques) and
inflammation
- Plaque – the buildup of plaque can narrow these arteries,
decreasing blood flow to your heart.
- Reduced blood flow causes: chest pain (angina) &
shortness of breath. Complete blockage: Heart attack
Non-Modifiable
- Positive family history (a first-degree relative with
cardiovascular disease at age 55 years or younger for
males and at age 65 years or younger for females)
- Age (more than 45 years for men, more than 55 years for
women)
- Gender (men develop cardiovascular disease at an earlier
age than do women)
- Race (higher incidence

Arteriosclerosis
- Thickening or hardening of the arterial wall
- abnormal accumulation of lipid or fatty substances and
fibrous tissue in the vessel wall.
- involves a repetitious inflammatory response to injury of
the artery wall and subsequent alteration in the structural
and biochemical properties of the arterial walls.
- A type of arteriosclerosis caused by formation of PLAQUE
(chiefly composed of cholesterol)
- Leading contributor to coronary artery and
cerebrovascular disease
- Cause: unknown

Clinical Manifestations
- Ischemia
- Chest pain: angina pectoris
- Atypical symptoms of myocardial ischemia (shortness of
breath, nausea, and weakness)
- Myocardial infarction
- Dysrhythmias, sudden death
Assessment
- BP (hypertension)
Pathophysiology - Elevated cholesterol & triglycerides
- Elevated homocysteine (risk if level > 15mmol/L)
o Vascular damage (cause
• Blocks the production of nitric oxide on the
inflammation)
endothelium making cell wall less elastic & permitting
o Fatty streak development
plaque to build up
(intimal layer)
• Diet: B-complex vitamin rich diet (folic acid) -
o Plaque (partial or complete
homocysteine
occlusion of blood flow)
- Presence of abdominal obesity
o Complications
- Elevated FBS
- Calcifications
Interventions
- Ulceration
- Cholesterol screening
- Thrombosis
- Diet
- Smoking cessation
Risk Factors Modifiable
- Exercise
- High blood cholesterol (hyperlipidemia)
- Drug therapy
- Cigarette smoking, tobacco use
- HMG-CoA reductase inhibitors “Statins”. In combination
- Elevated blood pressure
with other substances, LDLs can lead to plaque formation,
- Hyperglycemia (diabetes mellitus)
greatly increasing the chances for myocardial infarction
- Obesity
and stroke. HDLs work to remove harmful LDLs from the
- Physical inactivity

J.A.K.E 1 of 6
 312 LECTURE: WK2 – CORONARY ARTERY DISEASE

blood, thereby preventing fatty buildup and formation of Clinical Manifestations

plaque in arterial walls. - Pain – choking or heavy sensation in the upper chest
- The American Heart Association (AHA) now suggest the ranging from discomfort to agonizing pain.
term Acute Coronary Syndrome to describe any group of - Angina is accompanied by severe apprehension and a
clinical symptoms compatible with acute myocardial feeling of impending death.
ischemia - The pain is usually retrosternal, deep in the chest behind
 Ischemia – insufficient supply – decrease O2 the upper or middle third of the sternum.
 Atherosclerosis  ischemia Angina Pectoris - Discomfort is poorly localized and may radiate to the neck,
 Ischemia led to Myocardial Infarction jaw, shoulders, and inner aspect of the upper arms
(usually the left arm).
Angina Pectoris - A feeling of weakness or numbness in the arms, wrists,
- “Chest pain” of cardiac origin and hands, as well as shortness of breath, pallor,
- Most common clinical manifestation of myocardial diaphoresis, dizziness or lightheadedness, and nausea
ischemia and vomiting, may accompany the pain. Anxiety may
- Myocardial ischemia causes chemical and mechanical occur with angina.
stimulation of sensory afferent nerve endings in the - An important characteristic of anginal pain is that it
coronary vessels and myocardium subsides when the precipitating cause is removed or with
nitroglycerin.
Gerontologic Considerations
NOTE: The elderly person with angina may not exhibit the
typical pain profile because of the diminished responses of
neurotransmitters that occur with aging.
• Presenting symptom (elderly) – dyspnea.
- Elderly patients should be encouraged to recognize their
chest pain–like symptom (eg, weakness) as an indication
that they should rest or take prescribed medications.
Types Cause Symptoms Assessment and Diagnostic Methods
- Evaluation of clinical manifestations of pain and patient
- 75% coronary - Chest pain (15mins
history
occlusion that or less) and may
- Electrocardiogram changes (12-lead ECG), stress testing,
accompanies radiate
blood tests
exertion - Similar pain severity,
Stable - Echocardiogram, nuclear scan, or invasive procedures
- Elevated HR or frequency & duration
such as cardiac catheterization and coronary angiography
BP with each episode
Nursing Diagnoses
- Eating a large
- Ineffective cardiac tissue perfusion secondary to CAD as
meal
evidenced by chest pain or other prodromal symptoms
- Progressive - Chest pain of
- Death anxiety
worsening of increased frequency,
- Deficient knowledge about underlying disease and
stable angina severity & duration
Unstable methods for avoiding complications
with >90% poorly relieved by
- Noncompliance, ineffective management of therapeutic
coronary rest or oral nitrates
regimen related to failure to accept necessary lifestyle
occlusion
changes
- Arterial spasm -chest pain that occurs
in normal or at rest (usually bet. Potential Complications
Variant diseased 12 & 8am), sporadic • ACS and/or MI
(Prinzmetal’s) coronary over 3-6 mos & • Dysrhythmias and cardiac arrest
artery diminishes over time • Heart failure
(ECG: ST – elevation) • Cardiogenic shock
• Awareness of the disease process and understanding of
• What is the most serious acute coronary syndrome???
the prescribed care
- Subendocardial MI & Transmural MI
• Adherence to the self-care program
• Absence of complications
Planning and Goals
- Prevention of angina
Reduction of anxiety
Nursing Interventions
Treating Angina
- Take immediate action if patient reports pain or if the
person’s prodromal symptoms suggest anginal ischemia
J.A.K.E 2 of 6
 312 LECTURE: WK2 – CORONARY ARTERY DISEASE
- Direct the patient to stop all activities and sit or rest in bed
in a semi-Fowler’s position to reduce the oxygen
requirements of the ischemic myocardium.
- Measure vital signs and observe for signs of respiratory
distress.
- Administer nitroglycerin sublingually and asses the
patient’s response (repeat up to three doses).
- Administer oxygen therapy if the patient’s respiratory rate
is increased or if the oxygen saturation level is decreased.
- If the pain is significant and continues after these
interventions, the patient is further evaluated for acute MI
and may be transferred to a higher-acuity nursing unit.
Reducing Anxiety
- Explore implications that the diagnosis has for patient.
- Provide essential information about the illness and
methods of preventing progression. Explain importance of
following prescribed directives for the ambulatory patient
at home.
- Explore various stress reduction methods with patient (eg,
music therapy).
Preventing Pain
- Review the assessment findings, identify the level of
activity that causes the patient’s pain or prodromal
symptoms, and plan the patient’s activities accordingly
(Box A-1).
- If the patient has pain frequently or with minimal activity,
alternate the patient’s activities with rest periods.
Balancing activity and rest is an important aspect of the
educational plan for the patient and family.
Factors that Trigger Angina Episodes
- Sudden or excessive exertion
- Exposure to cold
- Tobacco use
- Heavy meals
- Excessive weight
- Some over-the-counter drugs, such as diet pills, nasal
decongestants, or drugs that increase heart rate and
blood pressure.
Medical Management
- Decrease the oxygen demand
- Increase the oxygen supply
Pharmacologic therapy
• Nitrates, the mainstay of therapy (nitroglycerin)
• Beta-adrenergic blockers (metoprolol and atenolol)
• Calcium channel blockers/calcium ion antagonists
(amlodipine and diltiazem)
• Antiplatelet and anticoagulant medications (aspirin,
clopidogrel, heparin, glycoprotein [GP] IIb/IIIa agents
[abciximab, tirofiban, eptifibatide])
• Oxygen therapy
• Eperfusion procedures – restore blood supply
Percutaneous Coronary Interventions Procedures:
• Percutaneous transluminal coronary angioplasty
[PTCA]
• Intracoronary stents,
• Atherectomy
• Coronary Artery Bypass Graft (CABG)
J.A.K.E 3 of 6
Myocardial Infarction
- an emergent situation characterized by an acute onset of
myocardial ischemia resulting myocardial death
- educed blood flow in a coronary artery often due to
rupture of an atherosclerotic plaque
- Plaque rupture and subsequent thrombus formation
result in complete occlusion of the artery
- Vasospasm (sudden constriction or narrowing) of a
coronary artery
- Decreased oxygen supply (eg, from acute blood loss,
anemia, or low blood pressure)
- Increased demand for oxygen (eg, from a rapid heart rate,
thyrotoxicosis, or ingestion of cocaine)
Etiology & Genetic Risk
- Primary Factor: Atherosclerosis
- Nonmodifiable risk factors
- Modifiable risk factors
• Elevated serum cholesterol levels
• Cigarette Smoking
• Hypertension
• Impaired glucose tolerance
• Obesity
• Physical inactivity
• Stress
Assessment and Diagnostic Methods
- Patient history (description of presenting symptom;
history of previous illnesses and family health history,
particularly of heart disease). Previous history should also
include information about patient’s risk factors for heart
disease.
- Electrocardiography (ECG) within 10 minutes of pain
onset or arrival at the emergency department;
echocardiography to evaluate ventricular function.
- Cardiac enzymes and biomarkers (creatine kinase
isoenzymes, myoglobin, and troponin).
Clinical Manifestations
- Chest pain that occurs suddenly and continues despite
rest and medication is the primary presenting symptom.
- Some patients have prodromal symptoms or a previous
diagnosis of coronary artery disease (CAD), but about half
report no previous symptoms.
- Patient may present with a combination of symptoms,
including chest pain, shortness of breath, indigestion,
nausea, and anxiety.
- Patient may have cool, pale, and moist skin; heart rate
and respiratory rate may be faster than normal. These
signs and symptoms, which are caused by stimulation of
the sympathetic nervous system, may be present for only
a short time or may persist.
 312 LECTURE: WK2 – CORONARY ARTERY DISEASE

Physical assessment/ Clinical Manifestations:

Medical Management
- Reperfusion via emergency use of thrombolytic
medications or percutaneous coronary intervention (PCI). Nursing Process
- Reduce myocardial oxygen demand and increase oxygen Assessment
supply with medications, oxygen administration, and bed - Assess level of consciousness.
rest. - Evaluate chest pain (most important clinical finding).
- Coronary artery bypass or minimally invasive direct - Assess heart rate and rhythm; dysrhythmias may indicate
coronary artery bypass (MIDCAB). not enough oxygen to the myocardium.
- The goals of medical management are to minimize - Assess heart sounds; S3 can be an early sign of impending
myocardial damage, preserve myocardial function, and left ventricular failure.
prevent complications such as lethal dysrhythmias and - Measure blood pressure to determine response to pain
cardiogenic shock. and treatment; note pulse pressure, which may be
Pharmacologic Therapy narrowed after an MI, suggesting ineffective ventricular
• Nitrates (nitroglycerin) to increase oxygen supply contraction.
• Anticoagulants (aspirin, heparin) - Assess peripheral pulses: rate, rhythm, and volume.
• Analgesics (morphine sulfate) - Evaluate skin color and temperature.
• Angiotensin-converting enzyme (ACE) inhibitors - Auscultate lung fields at frequent intervals for signs of
• Beta-blocker initially, and a prescription to continue its ventricular failure (crackles in lung bases).
use after hospital discharge - Assess bowel motility; mesenteric artery thrombosis is a
• Thrombolytics (alteplase [t-PA, Activase] and reteplase [r- potentially fatal complication.
PA, TNKase]): must be administered as early as possible - Observe urinary output and check for edema; an early sign
after the onset of symptoms, generally within 3 to 6 hours of cardiogenic shock is hypotension with oliguria.
Interventions - Examine IV lines and sites frequently.
- Pain management: MONA Nursing Diagnoses
• Morphine - Ineffective cardiac tissue perfusion related to reduced
o 2- to 10-mg IV q 5-15 minutes coronary blood flow
o AE: respiratory depression, hypotension, - Risk for imbalanced fluid volume
bradycardia, severe vomiting - Risk for ineffective peripheral tissue perfusion related to
o Antidote: Naloxone (Narcan) 0.2 – 0.8 mg IV decreased cardiac output from left ventricular dysfunction
o Oxygen: 2-4L/min by nasal cannula - Death anxiety
o Nitroglycerin - Deficient knowledge about post-ACS self-care
o Aspirin Potential Complications
- Positioning – semifowler’s • Acute pulmonary edema
- Provide a quiet & calm environment • Heart failure
Medications • Cardiogenic shock
• Nitrates • Dysrhythmias and cardiac arrest
- Nitroglycerine, Isosorbide dinitrate (Isordil), Isosorbide • Pericardial effusion and cardiac tamponade
mononitrate (Imdur) Planning and Goals
• Beta Blockers - The major goals of the patient include relief of pain or
• Calcium Channel Blockers ischemic signs (eg, ST-segment changes) and symptoms,
• Thrombolytics/ Fibrinolytics prevention of myocardial damage, absence of respiratory
dysfunction, maintenance or attainment of adequate
tissue perfusion, reduced anxiety, adherence to the self-

J.A.K.E 4 of 6
 312 LECTURE: WK2 – CORONARY ARTERY DISEASE
care program, and absence or early recognition of
complications.
Nursing Interventions
Relieving Pain and Other Signs and Symptoms of Ischemia
- Administer oxygen in tandem with medication therapy to
assist with relief of symptoms (inhalation of oxygen
reduces pain associated with low levels of circulating
oxygen).
- Assess vital signs frequently as long as patient is
experiencing pain.
- Assist patient to rest with back elevated or in cardiac chair
to decrease chest discomfort and dyspnea.
Improving Respiratory Function
- Assess respiratory function to detect early signs of
complications.
- Monitor fluid volume status to prevent overloading the
heart and lungs.
- Encourage patient to breathe deeply and change position
often to prevent pooling of fluid in lung bases.
Promoting Adequate Tissue Perfusion
- Keep patient on bed or chair rest to reduce myocardial
oxygen consumption.
- Check skin temperature and peripheral pulses frequently
to determine adequate tissue perfusion.
Reducing Anxiety
- Develop a trusting and caring relationship with patient;
provide information to the patient and family in an honest
and supportive manner.
- Ensure a quiet environment, prevent interruptions that
disturb sleep, use a caring and appropriate touch, teach
relaxation techniques, use humor, and provide spiritual
support consistent with the patient’s beliefs. Music
therapy and pet therapy may also be helpful.
- Provide frequent and private opportunities to share
concerns and fears.
- Provide an atmosphere of acceptance to help patient
know that his or her feelings are realistic and normal.
Monitoring and Managing Complications
- Monitor closely for cardinal signs and symptoms that
signal onset of complications.
- Promoting Home- and Community-Based Care
Teaching Patients Self-Care
- Identify the patient’s priorities, provide adequate
education about heart-healthy living, and facilitate the
patient’s involvement in a cardiac rehabilitation program.
- Work with the patient to develop a plan to meet specific
needs to enhance compliance.
Continuing Care
- Provide home care referral if warranted.
- Assist the patient with scheduling and keeping follow-up
appointments and with adhering to the prescribed cardiac
rehabilitation regimen.
- Provide reminders about follow-up monitoring, including
periodic laboratory testing and ECGs, as well as general
health screening.
- Monitor the patient’s adherence to dietary restrictions and
to prescribed medications.
J.A.K.E 5 of 6
- If the patient is receiving home oxygen, ensure that the
patient is using the oxygen as prescribed and that
appropriate home safety measures are maintained.
- If the patient has evidence of heart failure secondary to an
MI, appropriate home care guidelines for the patient with
heart failure are followed.
Evaluation
• Experiences relief of angina
• Has stable cardiac and respiratory status
• Maintains adequate tissue perfusion
• Exhibits decreased anxiety
• Complies with self-care program
• Experiences absence of complications
Surgical Procedure: Coronary Artery Revascularization
- CAD has been treated by myocardial revascularization
since the 1960s, and the most common CABG techniques
have been performed for more than 35 years.
- CABG is a surgical procedure in which a blood vessel is
grafted to an occluded coronary artery so that blood can
flow beyond the occlusion
The major indications for CABG are:
• Alleviation of angina that cannot be controlled with
medication or PCI
• Treatment of left main coronary artery stenosis or
multivessel CAD
• Prevention and treatment of MI, dysrhythmias, or heart
failure
• Treatment for complications from an unsuccessful PCI
Traditional Coronary Artery Bypass Graft
- the surgeon performs a median sternotomy and connects
the patient to the cardiopulmonary bypass (CPB) machine.
- Next, a blood vessel from another part of the patient’s
body (eg, saphenous vein, left internal mammary artery) is
grafted distal to the coronary artery lesion, bypassing the
obstruction
- CPB is then discontinued, chest tubes and epicardial
pacing wires are placed, a critical care unit.
Cardiopulmonary Bypass
- The procedure mechanically circulates and oxygenates
blood for the body while bypassing the heart and lungs.
CPB maintains perfusion to body organs and tissues and
allows the surgeon to complete the anastomoses in a
motionless, bloodless surgical field.
- Accomplished by placing a cannula in the right atrium,
vena cava, or femoral vein to withdraw blood from the
body.
 312 LECTURE: WK2 – CORONARY ARTERY DISEASE

- The cannula is connected to tubing filled with an isotonic

crystalloid solution. Venous blood removed from the body
by the cannula is filtered, oxygenated, cooled or warmed
by the machine, and then returned to the body.
- The cannula used to return the oxygenated blood is
usually inserted in the ascending aorta, or it may be
inserted in the femoral artery

Alternative Coronary Artery Bypass Graft Techniques

- OPCAB involves a standard median sternotomy incision,
but the surgery is performed without CPB. A beta-
adrenergic blocker may be used to slow the heart rate.
- The surgeon also uses a myocardial stabilization device to
hold the site still for the anastomosis of the bypass graft
into the coronary artery while
- the heart continues to beat

J.A.K.E 6 of 6