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• severe pain riginating from the heart • inadequate oxygen supply to the myocardial cells. • pain of angina : radiate down the left arm, to the back, to the jaw, or into the abdominal area
• workload of any tissue increases oxygen demand increase • Inc. oxygen demand increases the coronary arteries dilate and bring more blood flow and oxygen to the muscle. • If the coronary arteries are stiffened or narrowed with atherosclerosis and cannot dilate in response to an increased demand for oxygen, myocardial ischemia (inadequate blood supply) occurs
• Anaerobic glycolysis
• is very inefficient • production of lactic acid.
• Lactic acid
• decreases myocardial pH and causes the pain associated with angina pectoris.
• If the energy demands of the cardiac cells are lessened, the oxygen supply becomes adequate and the muscle cells revert to oxidative phosphorylation for energy production.
Types of Angina
• There are three types of angina: • Stable • Prinzmetal's (variant) • Unstable.
• also called classic angina • occurs when atherosclerotic coronary arteries cannot dilate to increase flow when oxygen demand is increased.
• Increased work of the heart can accompany physical exercise such as sports participation or climbing stairs. • Exposure to the cold • increases the metabolic demands of the heart • a strong stimulator of classic angina.
• Mental stress • anger • mental tasks such as mathematic . The pain of stable angina typically goes away when the individual stops the activity.
• without any obvious increase in the workload of the heart • during rest or sleep • a coronary artery undergoes a spasm • Sometimes the site of spasm is related to atherosclerosis. •
• damage to the endothelial layer may be present. • This allows vasoactive peptides access directly to the smooth muscle layer, causing its contraction. • Dysrhythmias are common with variant angina.
Unstable angina • combination of classic and variant angina • individual with worsening coronary artery disease. • accompanies an increased workload of the heart
• result from coronary atherosclerosis, characterized by a growing, spasm-prone thrombus. • Spasm occurs in response to vasoactive peptides released from platelets drawn to the area of damage
• The most potent constrictors released by the platelets are • Thromboxane • Serotonin • platelet-derived growth factors.
• Constricting or squeezing pain in the pericardial or substernal area of the chest • radiating to the arms, jaw, or thorax. • Stable and unstable angina • pain is typically relieved by rest. • Prinzmetal's angina • unrelieved by rest • usually disappears in about 5 minutes.
• Alteration in the ST segment of the ECG may occur. • Areas of reduced blood flow may be observed using radioactive imaging during an induced angina episode as part of an exercise stress test. • Cardiac enzymes and proteins may be measured to rule out MI.
• Prevention: • Aspirin is sometimes prescribed to prevent anginal symptoms. • Avoid stressors • They are strongly encouraged not to smoke.
• Invasive techniques • percutaneous transluminal coronary angioplasty (PTCA) • coronary artery bypass surgery • reduce episodes of classic angina.
• PTCA • the atherosclerotic lesion is dilated by a catheter inserted through the skin into the femoral or brachial artery and fed into the heart. • Once in the affected coronary vessel, a balloon in the catheter is inflated. • This cracks the plaque and stretches the artery
• Bypass surgery • the diseased piece of a coronary artery is tied off • an artery or vein taken from elsewhere in the body is connected to nondamaged areas. • Flow is reinstated through this new vessel. • saphenous vein and the internal mammary artery.
• Treatment is geared at reducing energy demands: • Rest • allows the heart to pump out less blood (decreased stroke volume) at a slower rate (decreased heart rate). • therefore its oxygen requirements. • Sitting is the preferable posture for rest, since lying down increases blood return to the heart, leading to increased end-diastolic volume, stroke volume, and cardiac output.
• Nitroglycerin and other nitrates • act as potent dilators of the venous system • decreasing venous return of blood to the heart • A decreased venous return decreases end diastolic volume, allowing the heart to decrease stroke volume. • Nitrates dilate the arterial system as well, reducing the afterload against which the heart must pump, and increasing coronary blood flow. •
Treatment • Beta-adrenergic blockers • reduce angina by reducing heart rate and contractility of the heart, thereby reducing its oxygen demands.
• Calcium channel blockers • reduce the afterload against which the heart must pump by dilating the arteries and arterioles downstream and are particularly effective in reducing the spasm of variant angina.. • Oxygen therapy eases demands on the heart.
Coronary Artery Anatomy
• Lack of blood flow in a coronary artery causes injury to the heart • Improvement in blood flow will reverse the injury
• Prolonged lack of blood flow leads to death of myocardial cells • This is called a myocardial infarction (“heart attack in layman’s terms) • MIs are irreversible
Stress, diet, sedentary living, Smoking, Alcohol, HPN, DM, Obesity, Contraceptive pills, Hyperlipidemia/hypercholesterolemia
Age, gender, race, heredity
Desquamation of endothelial lining (peeling off)
Increased permeability/ adhesion of molecules LDLs & platelets assimilate into the area Plaques begins to form Decreased coronary tissue perfusion Coronary ischemia Decreased myocardial oxygenation ANGINA PECTORIS MYOCARDIAL INFARCTION
Risk factors for Coronary Artery Disease
• • • • • • • • • Age Gender Family history Hyperlipidemia Smoking Hypertension Diet Diabetes Obesity
Diagnosis of CAD
• Patient History • • • • Physical exam Lab studies Diagnostic studies Invasive studies
Angina - classic description is a heavy, tight sensation under the sternum that is provoked with exertion Arm pain Jaw pain Indigestion Shortness of breath
• • • • • • Lightheadedness Palpitations Fear or dread Diaphoresis (sweating) Atypical (often in women) Cardiac arrest/Sudden death
• Acute - infarcted heart cells release chemicals in blood stream:
• Troponin • CPK isoenzyme
• Lab Studies
• Lipid studies • Blood glucose
• Acute - looks for specific changes • Stable - looks for signs of prior MIs
• Resting EKG
• Stress testing is used to evaluate patients for ischemia when they are stable • EKG tracings at rest are compared with those during taken during exercise
• Myocardial perfusion study- uses radioactive contrast in conjunction with a “stressor” medication
• Cardiac catheterization
• • • • • • Emergent care - cardiovascular resuscitation Oxygen Aspirin Nitrates Thrombolytic therapy (“clot busters”) Surgical management
• Balloon angioplasty
• Coronary artery bypass grafting
Decrease Risk Factors Drugs that reduce clots:
• Aspirin • Plavix
Drugs that reduce work on heart:
• Nitrates (nitroglycerine) • Calcium channel blockers • Beta-blockers
• Also known as Thromboangiitis obliterans • Usually a disease of heavy cigarette smoker/tobacco user men • 25-40y/o • Inflammatory arterial disorder that causes thrombus formation often extends to adjacent veins & nerves
• Affects medium-sized arteries (usually plantar & digital vessels in the foot or lower legs) • unknown pathogenesis but it had been suggested that: • tobacco may trigger an immune response or • unmask a clotting defect; → these 2 can incite an inflammatory reaction of the vessel wall
Pain – predominant symptom; R/T distal arterial ischemia Intermittent claudication in the arch of foot & digits Increased sensitivity to cold (due to impaired circulation Absent/diminished peripheral pulses
Color changes in extremity (cyanotic on dependent position; digits may turn reddish blue) Thick malformed nails (chronic ischemia) Disease progression ulcerate tissues & gangrenous changes may arise; may necessitate amputation
Diagnosis & Treatment
• Diagnostic methods – those that assess blood flow (Doppler ultrasound & MRI) • Tx: mandatory to stop smoking or using tobacco
• Meds to increase blood flow to extremities • Surgery (surgical sympathectomy) • amputation
Mechanism: intensive vasospasm of arteries & arterioles in the fingers Cause: unknown Usually affects young women Precipitated by exposure to cold & strong emotions
• Raynaud’s phenomenon – associated with previous injury • Frostbite, occupational trauma associated with use of heavy vibrating tools, collagen diseases, neuro d/o, chronic arterial occlusive d/o)
• Period of ischemia (ischemia due to vasospasm)
• • • • change in skin color = pallor to cyanotic 1st noticed at the fingertips later moving to distal phalanges Cold sensation Sensory perception changes (numbness & tingling)
Period of hyperemia – intense redness
• Throbbing • Paresthesia • of fingers (rare occasions)
• Return to normal color • Note: although all of the fingers are affected symmetrically, only 1-2digits may be involved • Severe cases: arthritis may arise (due to nutritional impairment) • Brittle nails • Thickening of the skin of fingertips • Ulceration & superficial gangrene
Diagnosis & Treatment
Dx: initial = based on Hx of vasospastic attacks Immersion of hand in cold water to initiate attack aids in the Dx Doppler flow velocimetry – used to quantify blood flow during temperature changes Serial Computed thermography (finger skin temp) – for diagnosing the extent of disease
Tx: directed towards eliminating factors causing vasospasm & protecting fingers from injury during ischemic attacks PRIORITIES: Abstinence in smoking & protection from cold
Avoidance of emotional stress (anxiety & stress may precipitate vascular spasm) Meds: avoid vasoconstrictors (i.e.. Decongestants) -Calcium channel blockers (Diltiazem, Nifedipine, Nicardipine) – decrease ine episodes of attacks
Care Plan for Clients with Altered Cardiovascular Oxygenation
A. Assessment: 1. Hx of symptoms (pain, esp. chest pain; palpitations; dyspnea) 2. v/s B. Nursing Dx: 1. ineffective tissue perfusion (cardiopulmonary) 2. Impaired gas exchange 3. Anxiety due to fear of death (clients with MI or Angina) An
C. Goals: 1. Relief of pain & symptoms 2. Prevention of further cardiac damage D. Nursing Interventions: 1. Pain control 2. Proper medications 3. Decrease client’s anxiety 4. Health teachings (meds, activities, diet, exercise, etc)
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