Coronary Artery Disease

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Coronary Artery Disease

• Terri Slifer Lynch, MSN, RN, BC
• Fall 2006

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Arteriosclerosis

• Arteriosclerosis - hardening of the arteries.
• Atherosclerosis build up of plaque (atheroma)
  on the lining of arteries.
• End results for both are the same
• Stenosis of the lumen of artery
• Ulceration of plaque
• Rupture of plaque with thrombus formation
• Obstruction of blood flow
• Ischemia of tissue distal to thrombus

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• Inflammatory response secondary to injury is
  mostly widely accepted theory for development of
  atherosclerosis.
• Endothelial injury from shearing stresses,
  radiation, chemicals, hyperlipidemia
• Inflammatory response
• Beginning of atheroma

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Causes of Coronary Artery Disease

• Atherosclerosis
• Vasospasm
• Thrombus or embolus

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Non-modifiable Risk Factors Contributing To CAD

• Heredity
• Increasing age
• Gender

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Modifiable Risk Factors Contributing To CAD

• Hypercholesterolemia - dyslipidemia
• Measures to reduce cholesterol
• Diet Therapeutic Lifestyle Changes Diet - total
  fat lt 35, 50-60 CHO, 15 protein, cholesterol lt
  200 mg, 20-30 gms fiber
• Exercise
• Smoking cessation
• Plant stanols
• Red yeast rice
• Omega 3 fatty acids

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• Medications
• HMG-CoA Reductase Inhibitors (statins)
• Most commonly used to decrease LDL and
  triglycerides, and increase HDL
• Side effects myopathy (weakness),
  rhabdomyolysis, hepatotoxicity
• Precautions avoid grapefruit. Also, may
  interact with erythromycin, Ca channel blockers
  and ketoconazole
• Drugs pravastatin (Pravachol), simvastatin
  (Zocor), atorvastatin (Lipitor), rosuvastatin
  (Crestor)

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• Nicotinic acid (Vit B3)
• Most effective in increasing HDL and decreasing
  triglycerides
• Side effects flushing, hyperglycemia, upper GI
  distress, hepatotoxicity, hyperuricemia
• Precautions take with food, take at bedtime, or
  take ASA 325 mg 30 min before med
• Drugs Niaspan, Niacin

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• Fibric acid
• Used to decrease triglycerides and increase HDL
• Side effects GI distress, rash, myopathy,
  increased risk of cholilithiasis, renal failure
• Precautions can potentiate action of Coumadin
• Drugs Tricor (fenofibrate), (Lopid) gemfibrozil

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• Cholesterol Absorption Inhibitor
• Inhibits absorption of cholesterol in intestines
• Decreases LDL triglycerides, increases HDL
• Precautions liver disease
• Side effects abdominal pain, arthralgia,
  diarrhea, HA
• Drugs - Zetia (ezetimibe), Vytorin (Zetia
  Zocor)

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• Bile acid sequestrants (resins)
• Decrease absorption of bile acids in intestines
• Effective in decreasing LDL and slightly
  increasing HDL
• Side effects constipation, decreased absorption
  of other meds, increased flatulence
• Drugs - -cholestyramine (Questran), colesevelam
  (Welchol)

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• Hypertension
• Smoking
• Carbon monoxide displaces oxygen on Hgb
• Nicotinic acid triggers release of catecholamines
• Nicotine increases platelet aggregation

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• Diabetes
• Physical inactivity - beneficial effects of
  exercise
• Increases HDL
• Decreases LDL, triglycerides, glucose
• Increases insulin sensitivity
• Decreases BP and body mass
• Obesity

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• Metabolic syndrome
• Stress
• Elevated homocysteine levels
• Elevated C-reactive protein (CRP)
• Elevated Lp PLA2

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Angina Pectoris

• From Latin word meaning to choke
• Clinical syndrome characterized by episodes of
  discomfort or pressure in the upper chest
• Result of ischemia
• Atherosclerosis is most common cause

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Factors Known To Precipitate Typical Angina

• Physical exertion
• Exposure to cold
• Eating a heavy meal
• Stress or emotional situation

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Various Classifications of Angina

• Stable angina classic angina
• Unstable angina pre-infarction angina
• Variant angina Prinzmetals angina

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Clinical Manifestations of Typical Angina

• Heaviness, squeezing, pressure, tightness in
  upper chest
• Choking or smothering sensation
• Indigestion or gas
• Radiation to neck, jaw, shoulders and arms

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• Feeling of weakness or numbness in arms, wrists
  or hands
• Associated symptoms
• Dyspnea
• Diaphoresis
• Dizziness
• N/V
• Anxiety

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Diagnostic Findings With Angina

• Diagnosis often made by evaluating clinical
  manifestations and history
• 12 lead ECG
• Stress test with or without nuclear scan or ECHO
• Cardiac catheterization
• EBCT

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Objectives of Medical Management of Angina

• Decrease oxygen demands of myocardium or
  myocardial oxygen consumption
• Increase oxygen supply

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Treatment of Angina

• Pharmacologic therapy
• Control risk factors
• Revascularization
• Invasive interventional procedures
• Coronary artery bypass grafting (CABG)

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Pharmacologic Therapies For Angina

• Nitrates mainstay of treatment
• Dilate veins decreases preload
• Dilate arteries decreases afterload as well as
  dilates coronary arteries
• Administer- spray, sublingually, PO, IV,
  topically
• Side effects hypotension, HA, flushing,
  tachycardia
• Ex Nitrostat SL or Tridil (nitroglycerin),
  Imdur (isosorbide mononitrate)
• Need a nitrate free interval
• DO NOT administer with Viagra

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• Client teaching related to sublingual (SL)
  nitroglycerine (NTG)
• Carry NTG on person at all times
• Heat, light, and moisture cause NTG to lose its
  potency. Store in original container.
• Renew every 6 months
• Sit or lie down when taking
• Take one tablet under tongue every 5 min until
  angina relieved. If no relief after 3 tabs, call
  911!!
• May take immediately before activity causing
  angina

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• Beta blockers
• Reduce myocardial oxygen consumption by
  decreasing heart rate, contractility and blood
  pressure
• Caution client not to stop med abruptly may
  cause rebound angina
• Monitor heart failure clients for worsening
  failure
• Side effects hypotension, bradycardia,
  bronchial spasm, masks hypoglycemia
• Ex Lopressor or Toprol (metoprolol), Inderal
  (propranolol), Tenormin (Atenolol)

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• Calcium channel blockers
• Dilate arteries decreases SVR which decreases
  workload and O2 consumption
• Decrease heart rate and myocardial contractility
  decreases O2 consumption
• Avoid in clients with severe heart failure
• Side effects - hypotension, bradycardia,
  constipation, edema, AV blocks
• Ex Adalat or Procardia (nifedipine), Cardene
  (nicardipine), Cardizem (diltiazem)

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• Antiplatelet medications
• Prevent platelet aggregation on atheroma or
  thrombus
• ASA side effects GI irritation, bleeding,
  increased bruising
• Ticlid (ticlopidine) side effects neutropenia,
  GI upset, N/V/D, rash. Must monitor CBC
• Plavix (clopidogrel) side effects increased
  bleeding tendencies, N/V/D, rash

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• Anticoagulants
• Heparin
• Given IV in acute situations or subcutaneous in
  non-acute situations
• Monitor partial thromboplastin time (PTT) or
  anti-Xa level (measure of Factor Xa in coag
  cascade)
• Antidote Protamine Sulfate
• Observe bleeding precautions
• Monitor for signs and symptoms of bleeding
• Half-life of 1-2 hrs
• Monitor for Heparin induced thrombocytopenia (HIT)

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• Coumadin (warfarin)
• Used long term given PO
• Effects do not occur for 3-5 days
• Monitor Prothrombin time (PT) or International
  Normalized Ratio (INR)
• Antidote Vitamin K (AquaMEPHYTON)
• Affected by certain foods
• Contraindicated in pregnancy, clients with liver
  dysfunction or those at risk for bleeding

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• Oxygen therapy
• Administered usually at 2 L/min per nasal cannula
• Increases amount of O2 delivered to myocardium

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Nursing Interventions For Client With Angina

• Treat pain indicates ischemia
• Instruct client to stop activities and sit or
  lie in semi-Fowlers position
• Assess pain, monitor VS, observe for dyspnea
• Administer O2 at 2L per NC if hospitalized
• Obtain 12 lead ECG
• Administer NTG - reassess client and vital signs
  every 5 min.
• Inform physician if pain severe or unrelieved

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• Reduce anxiety
• Teach self care
• Risk factor modification
• Medications
• When to call physician
• When to call 911

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Invasive Intracoronary Interventions

• Percutaneous Transluminal Coronary Angioplasty
  (PTCA)
• Directional Coronary Atherectomy (DCA)
• Laser ablation
• Intracoronary stent

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Complications Related To Invasive Intracoronary
Interventions

• Dissection, perforation, abrupt closure,
  vasospasm
• Acute MI
• Dysrhythmias
• Cardiac arrest

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• Restenosis of coronary artery
• Bleeding or hematoma formation
• Retroperitoneal bleeding
• Pseudoaneurysm
• Arteriovenous fistula
• Arterial thrombosis

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Post Procedure Nursing Care

• Achieve homeostasis after sheath removed
• Frequent monitoring of VS and cath site for
  bleeding
• Frequent monitoring of access limb for vascular
  problems
• Administration of Heparin or platelet inhibitor
  (Integrelin, Aggrastat) as ordered

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• Administration of IV NTG as ordered
• Bed rest with HOB elevated 30 degrees
• Keep access extremity straight
• Monitor for complications
• Force fluids

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Coronary Artery Revascularization

• Classic coronary artery bypass grafting (CABG)
• Minimally invasive direct CABG MIDCABG
• Port access coronary artery bypass grafting
• Transmyocardial laser revascularization

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Graft Selection For CABG

• Greater saphenous vein
• Lesser saphenous vein
• Cephalic and basilic vein
• Internal mammary arteries
• Radial artery

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Complications After CABG

• Dysrhythmias
• Hemorrhage
• Fluid and electrolyte imbalances
• Respiratory dysfunction
• Wound infection and dehiscence

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• Thrombus and embolus
• Intra-operative stroke or MI
• Renal failure
• Multiple organ failure
• Death

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Nursing Interventions Post CABG

• Maintain patent airway
• Promote lung re-expansion
• Monitor cardiac status
• Monitor and maintain fluid and electrolyte
  balance
• Monitor cerebral circulation

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• Provide pain relief
• Monitor GI function
• Monitor and prevent thrombophlebitis
• Monitor for dysrhythmias

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• Post operative education
• Walking
• Activity restrictions
• Resumption of sexual activity
• Wound cleaning
• Symptoms to report to MD

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Expected Outcomes

• Relief of angina
• Decreased anxiety
• Absence of complications
• Verbalizes understanding of treatment regimen
• Adheres to self-care program

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Pathophysiology of Myocardial Infarction

• Interruption of blood flow
• Ischemia develops
• Ischemia lasting greater than 20 min results in
  infarction
• Acidosis in myocardial cells leads to conduction
  disorders

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• Zones of damage
• Zone of infarction
• Zone of hypoxic injury
• Zone of ischemia
• Remodeling occurs

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Depth Of Myocardial Infarction

• Transmural infarction Q wave MI or ST segment
  elevation MI (STEMI)
• Subendocardial infarction Non Q-wave MI or
  non-ST segment elevation MI (Non-STEMI)

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Locations Of Myocardial Infarction

• Anterior myocardial infarction (AMI)
• From occlusion of LAD
• Risk for failure, shock, conduction problems
• Inferior myocardial infarction (IMI)
• From occlusion of RCA
• Risk for dysrhythmias due to effect on SA AV
  node
• Lateral infarction (LMI)
• From occlusion of LCX
• Posterior infarction (PMI)
• From occlusion of LCX or PDA

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Clinical Manifestations Of An MI

• Similar to unstable angina
• Discomfort not relieved with rest or 3 NTG
• Lasts longer then 20 min
• Sense of impending doom

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Diagnostic Tests For MI

• 12 lead ECG
• Cardiac enzymes
• ECHO
• Cardiac catheterization

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Major Goals For Care Of Client With MI

• Initiate prompt care
• Minimize myocardial damage
• Manage complications
• Rehabilitate and educate client and family

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Provide Immediate Care To Client With Suspected MI

• Keep client calm and quiet
• O2 per NC
• Assess VS
• Connect client to heart monitor

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• Perform 12 lead ECG
• Administer NTG
• Start IV lines, draw blood for labs
• Administer ASA

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MONA Greets Everyone At The Door

• M
• O
• N
• A

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Minimize Myocardial Damage

• Interventions to reduce pain indicates ischemia
  
• O2
• Coronary vasodilators
• Morphine sulfate
• Beta blockers

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• Reperfuse coronary artery
• Thrombolytics - lyse clots by converting
  plasminogen to plasmin
• Ex Streptokinase, Urokinase, recombinant tissue
  plasminogen activator (tPA) ie. Activase or
  Retavase

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• Nursing interventions with thrombolytics
• Minimize number of skin punctures
• Avoid IM injections
• Start at least 2 IV lines
• Monitor for signs and symptoms of bleeding
• Monitor for reperfusion dysrhythmias
• Monitor for allergic reactions with Streptokinase
• Treat bleeding with direct pressure and notify
  physician

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• ASA
• Heparin
• PCI

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• Reduce myocardial oxygen consumption or demand
• Bed rest
• Gradually increase activity. Rest 1hr after
  meals. No isometric exercises or straining
• ACE inhibitors
• Beta blockers

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Monitor For And Manage Complications

• Dysrhythmias
• Provide continuous cardiac monitoring
• Assess clients tolerance
• Inform physician
• Administer anti-dysrhythmics as ordered or per
  protocol (Lidocaine, Atropine, Adenosine,
  Verapamil)
• Defibrillation
• Temporary pacing

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• Cardiogenic shock occurs due to loss of
  contractile forces in heart
• Monitor for signs of shock
• Improve cardiac output positive inotropic drugs
  (Inocor, Dobutamine, Dopamine) or IABP

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• Heart failure and pulmonary edema may occur at
  onset of MI or later
• Monitor for signs and symptoms
• Monitor daily weights and IO
• May limit fluid intake 2000cc/24 hrs
• Restrict diet to 2gm NA
• Meds to tx Lasix, ACE inhibitors, Lanoxin
• For PE high Fowlers, O2, MS, Lasix

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• Pericarditis inflamed area of MI rubs against
  pericardium causing loss of lubricating fluid
• Monitor for chest pain that increases with
  movement or deep inspiration
• Monitor for pericardial friction rub
• Administer anti-inflammatory agents Indocin
  (indomethacin), ASA, ibuprofen, steroids
• Administer analgesics

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• Dresslers Syndrome
• Form of pericarditis that occurs as late as 6 wks
  to months after MI
• Treatment same as pericarditis

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Complications Less Likely To Occur

• Papillary muscle rupture
• Monitor for new systolic murmur, heart failure
• Emergency valve surgery required
• Ventricular septal rupture
• Monitor for new systolic murmur
• Emergency surgical correction required
• Cardiac rupture
• Monitor for CP, hypotension, elevated JVD,
  dyspnea
• Death occurs

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Educate and Rehabilitate Client and Family

• Provide education on
• Progressive activity guidelines
• Diet
• Medications
• When to call 911
• Symptoms to inform physician of

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• Begin Myocardial Infarction Rehabilitation
  Program (MIRP)
• Phase I
• Phase II
• Phase III
• Phase IV

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Expected Outcomes

• Relief of angina
• No signs of respiratory difficulties
• Adequate tissue perfusion
• Absence of complications
• Decreased anxiety
• Adherence to self-care program

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Pacemaker

• Provides an electrical stimulation to the atria
  or ventricles, or both, which causes contraction
• Indications
• SA node fails to fire or generates impulses too
  slowly
• Conduction system fails to conduct impulses
  properly
• Tachydysrhythmias that are unresponsive to meds

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Time Frames For Pacemaker Use

• Temporary
• Permanent

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Pacemaker Design

• Electronic pulse generator
• Circuitry that senses cardiac activity
• Battery that generates impulses

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• Lead wire
• Flexible conductive wire with electrode at end
• Relays cardiac info back to generator and
  delivers impulse to myocardium

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Pacing Methods

• Transcutaneous (External) pacing
• Used in emergencies
• Large amounts of energy needed to traverse
  tissues to heart resulting in burns
• Epicardial (Transthoracic) pacing
• Generally used with open heart surgeries
• Four electrodes attached to epicardium

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• Transvenous (Endocardial) pacing
• Used in temporary and permanent situations
• Lead wires inserted into subclavian, brachial,
  jugular, femoral vein
• Temporary use external generator
• Permanent use generator implanted under skin

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Pacemaker Modes

• Fixed rate mode (asynchronous)
• Set to fire continuously at preset rate
• If fires during repolarization, can cause VT or
  VF
• Demand mode
• Senses hearts intrinsic activity
• Fires only when heart rate fall below preset rate

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Complications Associated With Pacemaker Insertion

• Infection
• Thrombophlebitis
• Bleeding or hematoma
• Ventricular dysrhythmias

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• Pneumothorax, hemothorax
• Lead displacement
• Pacemaker malfunction
• Stimulation of phrenic nerve or diaphragm
• Cardiac tamponade

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Nursing Care of Client Post Pacemaker Insertion

• Monitor VS frequently
• Obtain chest x-ray
• Continuous ECG monitoring

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• Obtain 12 lead ECG with and without magnet if
  demand pacer
• Monitor for infection at insertion site of pulse
  generator or leads
• Exposed epicardial wires must be covered with
  nonconductive material

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• Avoid excessive extension or abduction of arm on
  operative site
• Assess client for anxiety
• Assess and medicate for pain
• Elevate HOB
• Educate client and family on home care

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Teaching For Client With Pacemaker

• Assess wound daily and report any swelling,
  redness, warmth, drainage
• Wear loose fitting clothes over generator
• Do not lift more than 5-10 lbs with affected arm
  for 6 wks
• Do not raise elbow above shoulder or toward back
  for 6 wks
• Check pulse daily for 1 minute. Report decreases
  or increases

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• Report sensations of heart racing, beating
  irregularly, dizziness, fainting
• Avoid strong electromagnetic fields
• Can safely use most appliances and tools that are
  grounded
• Metal detectors may be triggered. Avoid use of
  hand scanners over generator

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• Do not carry cell phone, turned on, directly over
  generator
• Avoid contact sports
• Carry medical ID with pacer and physician info
• Explain importance of pacer follow-up. Generator
  will need to be changed out periodically

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Implantable Cardiovertor Defibrillator (ICD)

• Cardioverts/defibrillates lethal dysrhythmias
• Can perform overdrive pacing or demand pacing
• Inserted the same as permanent pacer
• Complications same as permanent pacer