Coronary Artery Disease

1
Angina PectorisAcute Coronary Syndrome

• Coronary Artery Disease
• Cardiac Pharmacology
• Myocardial Infarction
• Lecture 2

2
Coronary Artery Disease

• Etiology
• Risk factors
• Nonmodifiable vs. modifiable risk factors
• Clinical manifestations
• Goals of therapy
• Medications

3
ATHEROSCLEROSIS
START
END
4

• STATINS aka (COENZYME INHIBITOR)
• Mevacor, Zocor, Lipitor
• BLOCKS BIOSYNTHESIS OF CHOLESTEROL
• HIGH FIRST PASS EFFECT
• MONITOR LFT
• SIDE EFFECTS
• N/V/D ABDOMINAL CRAMPS
• MYALGIA, ARTHRALGIA,Cataracts
• HEADACHES, DIZZINESS, INSOMNIA
• Liver and kidney dysfunction

5
Angina Pectoris

• Episode of chest pain or pressure due to
  insufficient artery flow of oxygenated blood.
• Myocardial 02 demand exceeds 02 supply. CAD is
  the most common cause.
• One coronary artery branch becomes completely
  occluded therefore, 02 is not perfused to the
  myocardium, resulting in transient ischemia and
  subsequent retrosternal pain.

6
Angina Pectoris

• Precipitating Factors Warning Sign for MI
• Clinical Signs Symptoms do not occur until
  lumen is 75 narrowed. Sternal pain mild to
  severe. May be described as heavy, squeezing,
  pressing, burning, crushing or aching. Onset
  sudden or gradual. May radiate to L. shoulder
  and arm. Radiates less commonly to R. shoulder,
  neck, jaw. Pt may have weakness/numbness of
  wrist, arm, hands. pain usually short duration
  and relieved by removal precipitating
  factors,rest or NTG. Can be gradual (CAD) or
  sudden(vasospasm)
• Associated Symptoms dyspnea, N V, tachycardia,
  palpitations, fatigue, diaphoresis, pallor,
  weakness, syncope, factors

7
Types of Angina

• Stable There is a stable pattern of onset,
  duration and
• intensity of sx, pain is triggered by a
  predictable degree of exertion or emotion.
• Variant Angina (Prinzmetal's)
• Cyclical, may occur at rest.
• Ventricular arrhythmia, brady arrhythmia
  and conduction disturbances occur.
• Syncope associated with arrhythmia
  may occur
• Nocturnal Angina only at night. Possible
  associated with REM sleep.
• Unstable Angina AKA Pre infarction angina
• Pain is more intense, lasts longer

8
Assesment

• 1. Hx
• 2. Physical Exam
• 3. EKG
• 4. Exercise EKG
• 5. Thallium Scan
• 6. Coronary Angiography
• 7. Cardiac Enzymes

9
Medications for Angina

• 1. Nitrates decrease myocardial 02 demand via
• peripheral vasodilation and reverse coronary
  artery spasm thus increase 02 supply to
  myocardial tissue.
• 2. Understanding how Nitrates Work peripheral
  vasodilation results in
• -decreased 02 demand
• -decreased venous return to heart
• -decreased ventricular filling which results
  in decreased wall tension and thus
• -decreased 02 demand

10
NTG Forms

• SL (Nitrostat)
• Lingual Sprays - similar to SL in use
  (Nitrolingual)
• Sustained release capsules/tablets (Nitrobid)
• Ointments 2 (Nitrobid)- wear gloves when
  applying
• Transdermal Patch (Nitro-Dur)
• IV (Tridil) For attacks unresponsive to other tx

11
Side/Adverse Effects

• Vascular HA (may be severe)
• Hypotension (may be marked)
• Tachycardia
• Palpitations

12
Acute Angina Treatment

• Goal Enhance 02 supply to myocardium
• M- Morphine for pain
• O- Oxygen 4-6L as ordered
• N- NTG sublingual, repeat q5 minutes x3
• A- Aspirin to prevent platelet aggregation

13
Angina Treatment

• The focus is to relieve acute attacks and prevent
  further attacks.
• 1. Activity/exercise tolerance - a regular
  exercise prescription is established after
  stress testing
• and/or cardiac cath.
• Baseline
• Gradual increase
• Avoid
• Alternate
• ADLS
• NTG before exercise

14
Patient education

• Lifestyle modifications for controllable risk
  factors. Support groups are helpful, Example
  Weight watchers,
• Smoke-enders, stress workshops, cardiac
  rehabilitation. Supply patients with
  information, name of contact person and phone
  numbers
• Identify precipitating factors for Anginal pain
• Medication compliance

15
Cardiac Pharmacology
16
Beta-adrenergic Blockers

• Therapeutic effect - decrease the rate and force
  of the cardiac contraction (resulting in
  decreased 02 demand) and decrease
  vasoconstriction in the myocardium and
  vasculature.
• Mechanism of Action - inhibit circulating
  catecholamines from stimulating beta receptor
  sites. There are two type of beta receptors (B1
  B2).

17
Beta-adrenergic Blockers

• B1 receptor stimulation by catecholamines
• results in increased HR myocardial
  contractility so, blocking the B1 effect results
  in slowed HR decreased myocardial
  contractility.
• Cardio-selective
• Excess blockade can result in bradycardia, heart
  block, heart failure and/or hypotension.
• atenolol (Tenormin)
• metoprolol (Lopressor, Toprol)

18
Beta-adrenergic Blockers

• B2 receptor stimulation by catecholamines results
  in dilation of the bronchial tree, the coronary
  arteries and the peripheral vasculature
• Blocking the B2 effect results in
  bronchoconstriction, coronary artery
  vasoconstriction and peripheral vascular
  constriction.
• Drugs that have a B2 blockade effect are used
  cautiously/contraindicated in clients with COPD.
• Non-selective Beta Blockers - Block B1 and B2
  receptors
• propanolol (Inderal)
• carvedilol (Coreg)

19
Beta-adrenergic Blockers

• Side Effects - many may be predicted based upon
  understanding the mechanism of action.
• Hypotension Bradycardia
• Heart Failure Weakness/Fatigue
• Depression Impotence
• Hypoglycemia Hallucinations
• Patient Teaching
• Use with caution in clients prone to coronary
  artery spasm due to vasoconstrictive effects.
• Contraindicated in clients with CHF and second or
  third degree heart block due to the rate slowing
  and reduction in contractility.
• Non-selective beta blockers contraindicated with
  COPD.
• Do not abruptly discontinue beta blockers

20
Calcium Channel Blockers

• Action - inhibit flow of Ca across cell
  membrane. Ca is essential for cardiac
  stimulation, conduction, contractility and relax
  vascular smooth muscle which results in
  decreased 02 demand and increased coronaryblood
  supply?
• VASODILATION
• Indications angina, HTN, arrhythmia
• Drugs-
• verapamil (Calan, Isoptin)
• diltiazem (Cardizem)
• nifedipine (Procardia)
• amlodipine (Norvasc)

21
Calcium Channel Blockers

• Side Effects of Calcium Channel Blockers
• Constipation (with Verapamil)
• Dizziness
• Facial Flushing
• HA
• Edema of ankles/feet
• Bradycardia
• Hypotension

22
Epinenepherine (adrenalin)

• Vasoconstriction- Increase BP
• Alpha, Beta 1 and Beta 2 agonist
• Decrease congestion of nasal mucosa
• Catacholamine- produced by
• Tx of AV block and cardiac arrest

23
ACE INHIBITORS The prils

• Angiotensin Converting Enzymes Inhibitors
• Action Blocks production of Angiotensin II in
  kidneys
• Indications HF, HTN, MI, DM neuropathy
• Causes Vasodilation (mostly arteriole)
• Decreased BP
• Excretion of Na and H2O (but not
  K)
• Ex. captopril (Capoten)
• enalapril (Vasotec)
• fosinopril (Monopril)
• ramapril (Altace)
• SE ortho hypotension, dry cough, hyperkalemia

24
Angiotensin Receptor Blockers- ARBs

• Action- Block the binding of Angiotensin II
• to its receptor in the vascular and adrenal
  tissues
• Examples candesartan (Atacand)
• losartan (Cozaar)

25
Cardiac Glycoside digoxin (Lanoxin)

• Action Inotropic effect
• Increases force of myocardial contraction
• - Chronotropic effect- decreases HR
• Tx heart failure, afib
• Nsg Apical Pulse for 1 full minute, hold for
  lt60, same time daily
• Monitor Dig levels 0.5-0.8 ng/ml
• Monitor K levels
• Monitor for Dig toxicity anorexia,
  fatigue, weakness, vision changes (halos)

26
Myocardial Infarction

• Leading cause of death in US
• Thrombosis in atherosclerotic artery causes 90
  of MIs.
• A region of the myocardium is abruptly deprived
  of blood supply due to restricted coronary blood
  flow
• Ischemia results and may lead to necrosis within
  6 hours
• JCAHO Core Measures for AMI (4/10)

27
Gender Differences in MI

• Females, when compared to males
• -present with MI later in life
• -have poorer prognosis and high morbidity
• -are 2x as likely to die in the first weeks
• -are more likely to die from the first MI
• -have higher rates of unrecognized MI
• -NSTEMI MI vs STEMI

28
EKG changes with MI
29
Location of MI

• Depends on which artery is affected
• LV receives most of the CA supply and so it is
  the most affected
• Left Anterior Descending (LAD)
• Left Circumflex artery (LCA)
• Right Coronary Artery (RCA)

30
General Types of MI

• Transmural-invades full thickness of myocardium
• Subenedocardial-invades partial thickness

31
Collateral Circulation

• A network of blood vessels present at birth that
  can dilate and become functional a/r/o coronary
  artery occlusion and ischemia. collateral
  circulation
• Natural bypass mechanism helps decrease the
  size of the MI

32
Risk Factors and Etiology

• CAD and its risk factors
• Any situation requiring increased O2 in the
  presence of decreased O2 supply.
• Non atherosclerotic coronary artery occlusions

33
Effects of MI

• Cell death
• Contractility in the affected areas reduced or
  absent
• Electrical instability

34
Dysrhythmias occur in 90 of patients

• PVCs
• V tach
• V fib
• Bradycardia

35
Complications of MI

• CHF
• Mitral Valve Insufficiency
• Dysrhythmias
• Pericarditis
• Post Infarction MI
• Thromboembolic Complications
• Rupture of Ventricular Wall

36
MI Precipitating Factors

• None in most cases
• Severe exertion and stress
• 59 occur at rest or while asleep

37
Clinical Manifestations

• Angina-Chest Pain
• Vital Signs
• Heart and Lung
• Associated SS

38
Whats the difference?

• Angina

• Myocardial Infarction

39
Diagnosis of MI

• Based on 2 out of 3 criteria
• Chest pain indicative of ischemic heart disease
• Characteristic EKG changes (ST elevation)
• Marked rise and eventual decline in serum markers
  of cardiac injury

40
Diagnostic studies

• EKG
• Serum Enzymes/Cardiac Biomarkers
• Cardiac Catheterization
• Other lab tests
• Echocardiogram
• CXR
• Pulse Ox

41
Goals

• Limit size of infarct/prevent further damage
• Increase O2 supply and decrease O2 demand
• Prevent and /or recognize complications early
• Reduce pain

42
Nursing Diagnosis
43
Nursing InterventionsRemember MONA and Oh Batman

• Obtain EKGs
• Monitor mentation
• Assess heart sounds
• Assess lungs
• Assess peripheral circulation/skin
• Assess urinary output
• Assess GI function
• Assess pain

44
OH BATMAN!

• O
• H
• B
• A
• T
• M
• A
• N

45
Nursing Interventions

• Activity
• Safety
• Reduce anxiety
• Patient Education
• Nutrition

46
Pharmacology Therapy for MI

• Thrombolytic Agents a/k/a Plasminogen Activators
  (Streptokinase, T-PA,Retavase)
• -decrease infarct size
• -improved ventricular function
• -increased survival rates
• Glycoprotein IIB and IIIA

47
Pharmacology Therapy

• ASA
• Nitrates
• Morphine Sulfate
• Beta blockers
• Calcium channel blockers
• ACEs and ARBs

48
Antiarrhythmics

• Class IA- Na channel blockers
• Class IB- Na channel blockers
• Class II- Beta blockers
• Class III- Amiodarone
• Class IV- Ca Channel blockers

49
Anticoagulants

• Heparin
• LMWH- Lovenox, Fragmin

50
Post MI Cardiac rehab

• Begins in acute phase and continues indefinitely
  as outpatient
• Includes
• education
• activity progression
• counseling
• medical management

51
Non-Pharmacologic Therapy

• Percutaneous transluminal coronary angioplasty
  (PTCA)
• Dilates coronary arteries obstructed by plague.
  30 restenosis rate within first 6 months.
• Patient Criteria
• Non-calcified lesions less than 2 cm. The ideal
  candidate would have less than a one year history
  of angina and be able to undergo coronary artery
  by-pass grafting if necessary. Patients with
  calcified lesions or lesions in branch vessels
  are not considered good candidates

52
Non-Pharmacologic Therapy

• Cardiac Catheterization/ Balloon Angioplasty
• Performed in the cardiac cath lab. A catheter
  with a balloon tip is passed into the obstructed
  artery and is alternately inflated and deflated
  to increase arterial diameter and perfusion.
• Complications
• Arterial rupture, spasm, emboli, MI
• Post-procedure care

53
Other Procedures

• Coronary Artery Stents
• Stainless steel mesh stent is placed in lumen to
  prevent restenosis after angioplasty. Requires
  anticoagulation and antiplatelet tx to prevent
  local-thrombosis.
• Coronary Laser Surgery
• Laser can destroy atherosclerotic plaque.
  Research is being conducted in transluminal laser
  angioplasty to coronary arteries.
• Atherectomy - surgical removal of atheroma.

54
Coronary Artery By-Pass Grafting (CABG)

• Procedure - Surgical revascularization to
  increase coronary blood flow.
• Patients with severe disease may not be
  candidates. Longevity after surgery still being
  debated. Surgery does not cure atherosclerosis
  and patients must still control risk factors

55
Post-op CABG

• Post-Operative Nursing Assessments Care
• Cardiovascular function
• Respiratory function - pt may be on mechanical
  ventilator for short time.
• Renal Function
• Neurologic Function
• Peripheral Vascular Function
• Fluid Electrolyte Balance
• Pain management
• Psychological Status
• Safety - Pt may be restrained to present self
  extubation

56
Cardiac Tamponade of CABG

• Etiology - heart is compressed by fluid within
  the pericardial sac. Ventricular filling is thus
  impaired resulting in decreased cardiac output
  and circulatory collapse.
• Clinical Signs
• Pulsus Paradoxus Blood Pressure
• Neck Veins Heart Sounds
• Respirations Mental Status
• Pain
• Treatment
• Thoracotomy Pericardiocentesis

57
NCLEX TIME

• Modifiable risk factors associated with CAD
  include
• age, weight, cholesterol level
• Smoking, diet, BP
• Family hx, weight, BP
• Blood glucose, activity level, family hx

58
NCLEX TIME

• A patient has just returned from cardiac cath.
  Which nursing intervention is most appropriate?
• Assist pt to ambulate to the BR
• Restrict fluids
• Monitor peripheral pulses
• Insert an indwelling catheter

59
NCLEX TIME

• A 63 man is resuscitated successfully after
  cardiac arrest. Blood studies show that he is
  acidotic. Why?
• Decreased tissue perfusion causes lactic acid
  production
• The pt typically has an irregular heart beat
• The pt was treated inappropriately with Na Bicarb
• Fat forming ketoacids are breaking down

60
NCLEX TIME

• Rosie is preparing her client for discharge
  following his inpatient stay with angina, which
  is now stable. Rosie is reviewing both modifiable
  and nonmodifiable risk factors. Select all
  factors below that are nonmodifiable.
• A.Age
• B.Gender
• C.Obesity
• D.Family history
• E.Hypertension

61
NCLEX TIME

• Following her inferior wall MI, Mrs. Green is
  quiet, reserved, and avoiding contact with her
  family. Understanding the psychosocial aspects of
  ACS, which intervention would be best for the
  nurse to do first?
• A.Have the clients cardiologist write for a
  psychiatric referral.
• B.Provide an atmosphere of acceptance.
• C.Foster mechanisms to suppress anger and
  hostility.
• D.Provide factual information to the clients
  family alone.

62
NCLEX TIME

• When Rosie is assessing her client with chest
  pain, she is evaluating whether or not the client
  is suffering from angina or MI. Which symptom
  would be indicative of an MI?
• A.Substernal chest discomfort
• B.Chest pain brought on by exertion or stress
• C.Substernal chest discomfort relieved by
  nitroglycerin or rest
• D.Substernal chest pressure relieved only by
  opioids

63
NCLEX TIME

• All of the following clients are being cared for
  on the coronary care stepdown unit. When making
  client assignments, which client will be best for
  the charge nurse to assign to a new graduate RN
  who has completed 6 months of orientation to the
  unit?
• A.A client who has a new diagnosis of heart
  failure and needs discharge teaching about
  medications
• B.A client who has just returned to the unit
  after having a coronary arteriogram and has
  orders for vital signs every 15 minutes
• C.A client with a history of angina who is
  requesting nitroglycerin for left anterior chest
  pain
• D.A client who has many questions about the
  electrophysiology studies that are scheduled

64
NCLEX TIME

• 4.An RN and an LPN who both have several years of
  experience in the intensive care unit are caring
  for a group of clients. Which task will be most
  appropriate for the RN to delegate to the LPN?
• A.Obtaining pulmonary artery wedge pressures
  every hour for a client admitted with pulmonary
  edema
• B.Monitoring vital signs and assessing the
  catheter insertion site for a client who returned
  from a coronary arteriogram an hour ago
• C.Teaching the family members of a client who is
  scheduled for myocardial nuclear perfusion
  imaging about the procedure
• D.Completing the admission assessment for a
  client admitted to the unit with acute coronary
  syndrome

65
NCLEX TIME

• The nurse is caring for a client who has been
  admitted with chest pain of unknown etiology. All
  of the following laboratory tests are obtained.
  Which test results require the most immediate
  action by the nurse.
• A.Troponin T is elevated.
• B.Creatinine kinase is decreased.
• C.Myoglobin is increased.
• D.High-density lipoproteins are decreased.

66
Cardiac Case Study

• A 57yo male is admitted to your unit c/o dull
  pain in the left side of his chest and radiating
  to his neck. Theres no diaphoresis or SOB. Risk
  factors include hypercholesteremia and a 70 pack
  year hx of smoking.
• PE reveals BP 140/86, HR 110, normal heart sounds
  and clear lungs bilat. Cardiac markers drawn ½
  hour after the onset of pain show Myoglobin
  45mcg. Troponin I at 0.01ng/mL and CPK-MB of
  10u/L. EKG shows nonspecific ST wave changes in
  the anterior leads.