Coronary Artery Disease

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Coronary Artery Disease
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Coronary Artery Disease (CAD)

• ? O2 supply to heart
• Main Cause Atherosclerosis,
• Others
• extreme hypotension, anaemia,
  Carbon dioxide poisoning,
  Hypovolaemia, Clamydia infections

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Coronary Artery Disease (CAD)

• Atherosclerosis characterized by
• - fatty deposits
• - thickened intima
• - disruption of medial layer
• Slow progression - ? collateral circulation

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Formation of atheroma
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Risk Factors

• Modifiable vs Non modifiable
• 1. Heredity
• 2. Age Non modifiable
• 3. Sex
• 4. Smoking
• 5. ? BP
• 6. ? cholesterol
• 7. D.M. Modifiable
• 8. Inactivity
• 9. Obesity
• 10. Personality

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Cigarette Smoking

• Risk increases by two to three times than non
  smokers
• Co inhaled limits the amount of oxyhaemoglobin
  available
• Nicotine increases the myocardial O2 demand as HR
  and BP increase.
• CO increases platelet adhesions

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Hyperlipidemia

• This refers to the elevation of blood cholesterol
  and triglyceride level within the blood.
• Risk increases by four times
• Controlled by diet or cholesterol lowering drugs.
  

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Angina

• symptoms when arteries 75 occlude.
• transient paroxysmal onset of substernal pain
• radiates to left shoulder, left arm, neck, jaw
• heavy, squeezing, pressing, burning, crushing, or
  choking

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Angina cont...

• precipitated by exercise, cold, heavy meal,
  stress
• alleviated by rest, NTG
• lasts lt 3 min once NTG or rest
• also nausea vomiting, fatigue, pallor, sweating

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Patterns of Angina

• Stable - predictable
• Unstable
• Variant - Prinzmetal
• Intractable - unresponsive to intervention (nitro
  drip)
• Silent

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Diagnosis

• History
• Physical exam - between attack P.E. normal
• - with attacks ? P, ? or ? B/P,
  pallor
• EKG - changes _at_ time of attack
• - ST segment changes
• - t wave inversion

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Diagnostic Tests

• 1. EKG - suggest coronary artery involvement
• - extent of cardiac muscle altered
• 2. Stress testing - exercise until 85 of max.
  heart rate reached
• - evaluate effectiveness of drugs

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Diagnostic Tests

• 3. Radioisotope Imaging
• - inject isotope then scan
• - detect areas of poor perfusion
• - isotope not taken up in cold spots
• - areas disappear later ? angina

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Diagnostic Tests

• 4. Coronary Angiography
• - insert catheter into heart
• - inject radiopague dye
• - observe areas of blockage
• 5. Lab Data
• - not significant with angina
• - determine risk factors ..ie. ? LDL

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Interventions

• 1. Relief of acute attack
• 2. Prevention of future attacks
• PHARMACOLOGIC MAJOR intervention

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4 Classes Drugs

• 1. Vasodilators or Nitrates
• 2. Beta - adrenergic blockers
• 3. Calcium channel blockers
• 4. Antiplatelet
• O2 therapy

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Vasodilators (Nitrates)

• Examples - Nitroglycerin, Nitrong SR, Isordil
• 1. Short acting - ? HR, ? BP, ? O2 demand, -
  ? blood supply
• - ? preload ? afterload
• - Nitroglycerin SL Nitro drip

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Vasodilators (Nitrates)

• 2. Long Acting - prevent attack
• - constant delivery
• - oral, paste, patch
• - skin reactions positive
• - side effects vasodilation
• ? BP
• - Isordil Nitrong S
• - Nipride free period

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Beta Blockers

• - Block effects of SNS stimulation? cause other
  effects in other parts of body.
• i.e. epinephrine norepinephrine
• - monitor BP ?
• - use more cardiac selective B-blockers
• i.e. Lopressor, Atenolol

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Beta Blockers cont...

• - nonselective Inderal, Corgard
• ?
• caution in COPD - cause bronchoconstriction
• - overall reduce workload of heart O2 demands
• - side effects gt ? HR, ? contractibility
  therefore get bradycardia, fatigue, weakness

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Calcium Channel Blockers

• Ca important for electrical excitation
• inhibit flow of Ca
• ? O2 demand by? HR, vasodilation, ? O2 supply
• Adalat, Cardizem
• side effects gt headache, flushing, bradycardia, ?
  B/P

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Antiplatelets

• Suppress platelet aggregation
• Persantine, Lopid, ASA

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Non-pharmacological

• 1. Reduce risk factors
• - weight
• - diet
• - exercise
• - stress
• - smoking

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Non-pharmacological cont...

• 2. PTCA
• - percutaneous transluminal coronary angioplasty
• - reopen arteries with balloon
• - centered in block, inflate

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Stents
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Non-pharmacological cont...

• 3. CABG - open heart surgery
• - bypass graft use saphenous
  vein from leg or artery from
  chest
• - palliative Rx ?change lifestyle

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Management

• Onset - monitor signs, patient report
• During - good history, PQRST
• - vital signs, EKG
• - administer nitroglycerin
• - O2

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Prevention

• 1. Knowledge disease drugs
• 2. Need for follow up
• 3. What to do during attack
• 4. Use of nitro - carry _at_ all times
• - replace Q3 months
• - storage
• - repeats Q5 min. 3
• - take prior to stress activities
• - risk of tolerance when using patches
• 5. Control of precipitating factors