Coronary artery disease

Infection Valvular
heart heart dis
disease ease

By Pol.Capt. Aphisit Tamsat

Coronary artery disease







-


(Coronary Heart Disease: CHD; Coronary artery
disease: CAD)

(arteriosclerotic heart disease: ASHD)

(cardiovascular heart disease: CVHD)





2
left coronary artery right coron
ary artery left coronary artery
 Coronary artery
Left main coronary artery left
anterior descending artery (LAD)

intervertri
cular septum anterior papillary muscle

Right coronary artery
posterior
descending artery, artrioventricular node
posterior pappilary muscle
sinoatrial node
Coronary artery
Coronary artery
Coronary artery
Coronary artery
Adapted From http://ctvstexas.com/about-ctvs/our-services/
cardiac-services/coronary-artery-bypass-grafting-cabg/
 Pathophysiology of CAD

(low density lipoprotein c
holesterol: LDL-C) extracellular su
bendothelial space oxidided oxidided LDL
oxidided LDL
monocyte
macrophage foam
cell lipid-laden macrophage
foam cell (
fatty streak)



(fibrous plaque)
Plaque
normal artery

atherosclerotic plaque

CAD
 CAD

epithelial arteries
arteromatous plaque

non-
arterosclerotic

 Non-arterosclerotic

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Atherosclerosis
 Pathophysiology of CAD

(artherosclerosis)


70




(Acute coronar
y syndrome: ACS) (, 2546; , 2549)


(decrease perfusion of myocardial tissue)

(inadequate myocardial oxygen supply)

(, 2546)


(cardiac dysrhythmia)

(heart failure)
(sudden death)
( , ,
, 2552)
 Sign & Symptom of CAD


(inadequate blood supply)

(ischemia)
left
main artery
50% major branch
75%
 Sign & Symptom of CAD
Findings may be normal during asymptomatic
periods
Chest pain - due to lack of oxygen
Palpitations
Dyspnea
Syncope
Cough of hemoptysis
Excessive fatigue
 chest pain CAD

1.
(chronic stable angina)



2-3 15


 chest pain CAD

2. (unstable
angina)
(acute myocardial infarction)






EKG ST depression ST
elevation T-wave inversion


( , 2557)

90

2 (
, 2546)

(serum total cholesterol) 200

(low density lipoprotein

cholesterol: LDL-C) 130



40
2.7 1.9
(, 2550)


A

(homocysteine)

 CAD
1.
(beta
blocker) (nitrate)

Nitrate or NTG (nitroglycerin)

 CAD
2.
(percutaneous coronary
intervention: PCI)

Percutaneous Coronary Intervention (PCI)

Percutaneous Transluminal
Coronary Angioplasty
 PTCA
Compress the plaque against the walls of the
artery and dilate the vessel
 Stent
Vascular stent to prevent the artery from
closing and prevent restenosis


1. Cardiac arrhythmias
2.


2.1 24

(Early complications)
- Groin bleeding
- Retroperitoneal bleeding
- Hematoma
- Femoral neuropathy
- Vasovagal reaction


2.2
24
(Late complications) 1-30
PCI
- Femoral pseudoaneurysm
- Arteriovenous fistula
- Femoral artery thrombosis
- Embolism
- Femoral vein thrombosis


3. Infection
4. sudden death
0.1 - 0.45
5. (Cerebrovascular
events ) stroke 0.03 -
0.25
6.

 Nursing Care for PCI
1. Femoral artery
30

2
4-6
PCI


4

 Nursing Care for PCI
2. Radial artery

6-8
Nursing Care for
PCI

Normal air
injection = 13 ml.
(Max. = 18 ml.)
Nursing Care for PCI

1 cm
~70
mmHg

15
(pedal pulse is
palpable),

30
mmHg 12
hours
Coronary Artery Bypass Graft
To improve blood flow to the myocardial tissue that are at risk for ischemia
or infarction as a result of the occluded artery.
 Coronary Artery
Bypass Graft


angina

sudden
cardiac death

Open Heart Surgery
Heart Lung Machine


on-pump CABG
conventional CABG standard
CABG


off-pump CABG (OPCAB)


1 = single vessel disease
(SVD)
2 = double vessel
disease (DVD)
3 = triple vessel disease
(TVD)
Coronary Artery
Bypass Graft
 CABG
2
1. Venous Conduit (Greater
Saphenous Vein)
2. Arterial Conduit 3
Internal Mammary (Thoracic) Arterial
2

Radial Artery 2
Gastro-epiglottic Artery
 Post Operation CABG

, ICD,


Intra-aortic balloon
pump (IABP)
Intra-aortic balloon
pump (IABP)
 Intra-aortic balloon
pump (IABP)
IABP
Left ventricular failure
cardiogenic shock
Unstable angina

Thrombolytic therapy
Intervention (PTCA,
CABG)
 Nursing Diagnosis for CABG






 PCI or CABG ?
PCI or CABG
1.
LV function

2. LM > 50% or 2-
vessel or 3-vessel CAD with p LAD >
70% with LVEF <40% CABG
3. 1-vessel or 2-vessel CAD
PCI
 EF ?
Ejection fraction (EF)

1
EF

(echocardiography)
(radionuclide
angiography)
(left
ventriculography)
Level of Ejection Fraction
LVEF
greater than 70% Hyperdynamic

50% to 70% Normal

(midpoint 60%)

40% to 49% Mild dysfunction

(midpoint 45%)
(The American College of Cardiology, 2012)


1.

2.

3.

4.
5.
Example Nursing Care for CAD


1.
2.


3.


4. EKG ST depression ST elevation
T-wave inversion transient abnormal
Q wave


1.

2. V/S
3. EKG ST depress ST
elevated T inverted


MONA
1.

2. V/S, monitor EKG EKG 12 leads
3. 2-4 lit/min keep O2 sat 95%
4. : morphine sulfate
2-4 mg iv q 5 min

7
iv


5. Nitrate
1-5 mg
Nitrates BP < 90/60
mmHg, HR < 50 >100, Viagra
24-28
6. ASA: Aspirin 160 325 mg
1
Aspirin

7. Bed rest/ absolute bed rest

Inflammatory
Heart Disease




(Pericarditis)


(Myocarditis)


(Endocarditis
)

(Pericarditis)

Pericardium 2
parietal pericardium


visceral pericardium


Acute Pericarditis
Chronic pericarditis
 Acute Pericarditis

viral infection
fibrin







3

(Precordial pain)




(Dyspnea)




3

2

(Preicardial friction rub)
fibrinous exudate



 Chronic pericarditis


uremia,
SLE

engorged neck vein
(dyspnea)
(orthopnea)
Low cardiac output
shock hypo perfusion


(Pericardail effusion)
Pulsus paradoxus or paradoxical
pulse

SBP
( 8-10 )
SBP


Acute pericarditis
NSAID
corticosteroid
Chronic pericarditis


acute pericarditis

(Myocarditis)




(endocarditis)








( SBP 90
.)
pulsus
alternans





(Endocarditis)





Streptococcus viridans
Streptococcus ,
Enterococcus
Staphyloccus
beta histolytica


(murmur)



clubbing of fingers

antibiotic bactericidal


 Nursing Care
Bed rest

Bleeding precautions




 VALVULAR HEART DISEASE

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a&ved=0CHwQMyhWMFY&iact=rc&uact=3&dur=1023&page=4&start=63&ndsp=26

1.

2.










Arterioventicul
Tricuspid valve ar valve
Mitral valve
(semilunar valve )
Pulmonic valve



Aortic Stenosis
Mitral Stenosis
Aortic Regurgitation
Mitral Regurgitation











aortic valve
stenosis










Aortic Stenosis (AS)
Aortic Stenosis Overview:

Normal Aortic Valve Area: 3-4 cm2

Symptoms: Occur when valve area is

1/4th of normal area.
 Aortic Stenosis
Congenital
Rheumatic
Degenerative/Calcific

70 >50%

70 50%

 AS
Increased afterload
LV function initially maintained by
compensatory pressure
hypertrophy
When compensatory mechanisms
exhausted, LV function declines.
 AS
CLINICAL
TRIADS
1. Dyspnea

2. Angina blood supply
3. Syncope
aorta
4. Heart failure LV dysfunction
5. Sudden death
 AS
Slow rising carotid pulse (pulsus tardus)
& decreased pulse amplitude (pulsus
parvus)
Heart sounds- S4 gallop due to LVH.
Systolic ejection murmur-

CXR Pulmonary congestion (
)
Evaluation of AS
 AS
-

- Vasodilators are relatively
contraindicated in severe AS
- digitalis
Nitroglycerine
angina pain
Aortic Balloon Valvotomy
Surgical Replacement
Mitral Stenosis
 Mitral Stenosis Overview:

Normal MV Area: 4-6 cm2

MV < 2 cm2
Mitral Stenosis (MS)
 MS
1. Rheumatic heart disease:
77-99%
2. Infective endocarditis: 3.3%
3. Mitral annular calcification:
2.7%
 MS
LV

LA

LA hypertrophy

Atrial Fibrilation
 MS
LV
(turbulence)

Emboli

pulmonary pulmonary
edema

LV failure RV failure HF

MS





systemic
emboli
 MS
Thrill
Mid diastolic rumbling murmur
Jugular venous pulsations
pulmonary hypertension and right
ventricular hypertrophy
Signs of right-sided heart failure
 MS
ECG: may show atrial
fibrillation (AF) and LA
enlargement
CXR: LA enlargement and
pulmonary congestion.
Occasionally calcified MV
ECHO: The GOLD STANDARD
for diagnosis.
 Trans Esophageal
Echocardiography (TEE)
 MS

-blockers, CCBs, Digoxin which
control heart rate
Diuretics for fluid overload
LMWH, cordarone for prevention AF
Nitroglycerine for decrease
preload

Aortic Regurgitation
 Aortic Regurgitation Overview:

Definition: Leakage of blood into LV during

diastole due to ineffective coaptation of the
aortic cusps
 AR
Acute AR Chronic AR

Endocarditis Bicuspid aortic
valve
Aortic
Rheumatic
Dissection
Infective
endocarditis
 AR
LV

LV hypertrophy

SBP
DBP LV

Heart Failure

AR


 AR
Diastolic murmur
Pulse pressure
Corrigans sing
carotid
CXR LV hypertrophy
 AR
1.
2.
1. Inotrope: dopamine,
dobutamine
2. Vasodilators: nitroprusside
Mitral Regurgitation
 Mitral Regurgitation Overview:
Definition: Backflow of blood from the LV to
the LA during systole
 MR
Acute MR Chronic MR

Myxomatous
Endocarditis degeneration (MVP)

Acute MI: Ischemic MR

Malfunction Rheumatic heart
disease
or disruption Infective
of prostheti Endocarditis
c valve
 MR
LV LA

LV & LA hypertrophy

pulmonary vein

Pulmonary edema

RV failure 2

MR

Low cardiac output



AF
 MR
Pansystolic murmur

S1
LV heaving (
)
EKG show LV hypertrophy
CXR LA & LV hypertrophy

 MR
ECG: May show, LA enlargement, atrial
fibrillation and LV hypertrophy with severe MR
CXR: LA enlargement, central pulmonary artery
enlargement.
ECHO: Estimation of LA, LV size and function.
Valve structure assessment
TEE
 MR
Bed rest
afterload
Diuretics and nitrates
captopril
nitroprusside, even in the setting
of a normal blood pressure.
Myocardial infarction: Cardiac
catheter or thrombolytics




 Valve
replacement
 Nursing Care
Bed rest


low cardiac
output

EKG show arrhythmia BP drop <
90/60 mmHg. urine < 25-30 ml/hr

 Nursing Care



ASA Warfarin

bleeding precaution
Lab. WBC Neutrophil,
PTT PT INR