CORONARY ARTERY

DISEASE
 DEFINITION

 Type of blood vessel disorder that is included in

atherosclerosis
 Athero- fatty mush
 Sklerosis- hard
 ETIOLOGY

 Atherosclerosis
 Tobacco use
 Hyperlipidemia
 Hypertension
 Diabetes
 Hyperhomocytenemia
 infection
 RISK FACTORS

 NON MODIFIABLE
 Heredity- african american women
 INCREASING AGE- > 65 yrs
 GENDER- men= women
 MODIFIABLE RISK FACTORS
 Smoking
 Hypertension
 Elevated serum cholesterol levels
 Physical inactivity
 Obesity
 Diabetes
 CONTRIBUTING RISK FACTORS

 Response to stress
 Homocyteine levels
 Inflammatory responses- too much CRP
 Menopause- estrogen protects by raising HDL and
lowering LDL
 Injury to the
endothelial cells

Which causes inflammation &

immune reaction

Lipids, platelets & other clotting

factors accumulate

scar tissue replaces some arterial wall

Early indication of injury is fatty steak on

the lining of the artery

Leads to fatty deposit (plaque) on the lining of

the artery

Plaque has irregular, jagged edges that allows

blood cells & other materials to adhere to the
wall of the artery
 Over time this build up becomes calcified &
hardened (arteriosclerotic)

Causing turbulence that damages cells

(necrosis)

The area distal to the occlusion may become

ischemic

PATHOPHYSIOLOGY OF CORONARY ARTERY DISEASE

 DEVELOPMENT OF ATHEROSCLEROSIS

 FATTY STREAK- lipid filled smooth muscle cells

 FIBROUS PLAQUE- changes in edothelium of arterial
wall- endothelium is not replaced in CAD- thickening of
arterial walls due to cholesterol, lipids- narrowing of vessel
lumen
 COMPLICATED LESION- plaque instability- thrombus
enlargement
 COLLATERAL CIRCULATION- arterial anastamosis or
connections
 CLINICAL MANIFESTATIONS

 Occurs if supply demand imbalance occurs

 Angina
 MI- if complete block occurs
 INVESTIGATIONS

 ECG
 USG
 Doppler flow studies
 Intravascular ultrasound
 Stress test
 MANAGEMENT

 Identify high risk groups

 Educate on decreasing risk for high risk groups
 HYPERTENSION- regular BP, compliance to
medications, reduce salt, stop tobacco, reduce weight,
perform physical activity
 ELEVATED SERUM LEVELS- Reduce total fat intake,
compliance to medications, exercise
 TOBACCO USE- smoking cessation program, substitute
other activities for smoking
 PHYSICAL INACTIVITY- Routine for physical activity 5
or more times a week
 MANAGEMENT

 STRESSFUL LIFESTYLE- awareness of behaviours

detrimental to health, set realistic goals, get adequate sleep,
get professional help
 OBESITY- Change eating patterns, habits, reduce caloric,
expenditure
 DIABETES- follow diet, reduce weight, control diet
 MEDICAL MANAGEMENT

 HMG Co- A reductase inhibitors- statins- atorvastatin,

simvastatin
 NIACIN- niacin, nicotinic acid
 FIBRIC ACID DERIVATIVES- fenofibrate
 BILE ACID SEQUESTRANTS- cholestyramine
 CHOLESTEROL ABSORPTION INHIBITOR- ezetimibe
RESTORE BLOOD SUPPLY- INTERVENTIONAL
CARDIOLOGY

 PERCUTANEOUS TRANSLUMINAL CORONARY

ANGIOPLASTY (PTCA)
 Technique in which balloon tipped catheter is inserted into
a leg artery and threaded under X ray guidance into a
blocked coronary artery
 Balloon is inflated several times to reshape the lumen by
stretching and flattening the plaque against the arterial
wall
 INTRACORONARY STENTS

 Designed to reduce restenosis and abrupt closure of

coronary vessels
 Made from stainless steel or varying bioabsorbable
compounds
 PROCEDURE

 Same as angioplasty
 RECOVERY PERIOD- Client is given antiplatelet –
ticlopidine
 If anticoagulation after discharge- warfarin is given for 6
weeks after procedure
 COMPLICATIONS- stent occlusion
 Coronary artery dissection
 LASER ABLATION

 Lasers are used with balloon angioplasty to vapourize

atherosclerotic plaques
 After initial angioplasty- brief burst of laser radiation is
administered and remaining plaque is removed
 COMPLICATIONS- coronary dissection
 Acute occlusion
 Perforation
 embolism
TRANSMYOCARDIAL REVASCULARIZATION

 New type of laser catheter- for clients not able to do

angioplasty
 High powered laser guided into left ventricle between heart
beats when ventricle is filling with blood
 Controlled trauma creates channels and promote
angiogenesis
 SURGICAL MANAGEMENT

 CARDIAC SURGERY- 3 types:

 1. REPARATIVE PROCEDURES- Produces cure and
prolonged improvement- repair of mitral stenosis
 RECONSTRUCTIVE PROCEDURES- Reprocedure may
be needed- CABG, reconstruction of incompetent valve
 SUBSTITUTIONAL PROCEDURE- Not curative- valve
replacement, cardiac replacement by mechanical devices
 SURGICAL MANAGEMENT contd..

 OPEN HEART SURGERY- CPB (extracorporeal

circulation –ECC) used during heart surgery- allows
surgeon to stop heart during surgery
 3 components of CPB- hemodilution, hypothermia,
anticoagulation
 HEMODILUTION occurs when client’s blood becomes
diluted with isotonic crystalloid solution used to prime
bypass machine
 HYPOTHERMIA (28- 36 degrees C)- to reduce tissue
oxygen requirement- to protect organs from ischemic
injury
 SURGICAL MANAGEMENT contd..

 ANTICOAGULATION- to prevent coagulation in CPB

machine when client’s blood comes in contact with the
machine
 Complications increase when CPB >2 hrs
 CABG- CORONARY ARTERY BYPASS
GRAFTING

 Involves bypass of blockage of one or more coronary

arteries.
 GRAFTS USED- saphenous vein, mammary artery, radial
artery
 PROCEDURE- median sternotomy incision made
 Client placed on CPB-
 Heart is stopped using cardioplegia- solution of iced saline
containing potassium
 After bypass- client is taken off machine, heart takes over
 CABG- CORONARY ARTERY BYPASS
GRAFTING

 LESS INVASIVE CABG:

 Off- bypass CABG- median sternotomy with smaller
incision
 Minimally invasive direct CABG(MIDCABG)- limited
incision- no CPB required
 BEATING HEART CABG
 COMPLICATIONS OF CABG

 CARDIOVASCULAR- dysrrythmais, decreased cardiac

output, persistent hypotension
 Due to low cardiac output- decreased blood to brain and
kidney- SHOCK
 IABP
 NURSING MANAGEMENT
 PRE OP TEACHING
 DESCRIBE SURGICAL PROCEDURE- heart lung
machine, anat and physio of heart and valves, length of
surgery, explain technical terms
 DESCRIBE ICU ENVIRONMENT AND MONITORING
EQUIPMENT- Cardiac monitor and alarm, ET tube
placement, mechanical ventilator, suctioning procedure,
invasive lines, high noise level in ICU, visiting restrictions
 DESCRIBE PRE OP PREPARATION- showering with
antimicrobial soap, shaving- chest, abdomen, neck , groin,
cardiac studies- echo, ECG, catheterization
 DESCRIBE COMFORT MEASURES- Pain reduction,
ROM, out of bed next morning, medications
 NURSING DIAGNOSIS

 Decreased cardiac output related to alterations in function

of heart
 Ineffective airway clearance related to excess secretions
 Impaired gas exchange related to ventilation perfusion
mismatch
 Acute pain related to tissue trauma secondary to
sternotomy
 Risk for hemorrhage related to inadequate hemostasis,
coagulopathy
 Risk for infection related to sternotomy incision
 REHABILITATION

 PHASE 1- IN HOSPITAL REHABILITATION

PROGRAM
 Turn every 2 hours
 Once extubated- gets up in chair and ambulates,
 Assess BP, HR, ECG, Oxygen saturation
 SBP not > 20mmHg
 DBP- not > 10-15mmHg
 HR- not > 20 beats / min
 Deep breathing coughing exercise- splinting incision site
 REHABILITATION

 PHASE 2- OUTPATIENT EXERCISE TRAINING

 Medically supervised exercise- outpatient monitoring
 Exercise therapy- 3 times weekly- for 2-3 months
 Duration of aerobic exercise- 20-40 minutes
 During and after exercise- BP, HR, ECG RR – monitored
 Nutritionist- for diet
 Psychologist- stress management
 Social worker- risk prevention behaviour
 Periodic evaluation
 REHABILITATION
 PHASE 3- COMMUNITY REHABILITATION
PROGRAM
 Exercises consist of walking, jogging, weight training,
recreational games
 Clients not monitored while exercising
 Exercise ECG on monthly basis
 Clients monitor own HR, BP when exercising
 REHABILITATION

HOME EXERCISE REHABILITATION PROGRAM

 Done along with outpatient program

 Clients are given detailed exercise instructions

 Told to keep log of HR, exercise parameters, problems that

may occur during home exercise program
 Once client reaches functional capacity- continue exercises
three times weekly