Coronary artery disease

Coronary artery disease (CAD), also called coronary heart disease, is a condition in which plaque builds up inside the coronary arteries. These arteries supply your heart muscle with oxygen-rich blood. Plaque is made up of fat, cholesterol calcium, and other substances found in the blood. When plaque builds up in the arteries, the condition is called atherosclerosis. Atherosclerosis

Figure A shows a normal artery with normal blood flow. Figure B shows an artery with plaque buildup. Plaque narrows the arteries and reduces blood flow to your heart muscle. It also makes it more likely that blood clots will form in your arteries. Blood clots can partially or completely block blood flow. Overview When your coronary arteries are narrowed or blocked, oxygen-rich blood can't reach your heart muscle. This can cause angina or a heart attack.

Angina is chest pain or discomfort that occurs when not enough oxygen-rich blood is flowing to an area of your heart muscle. Angina may feel like pressure or squeezing in your chest. The pain also may occur in your shoulders, arms, neck, jaw, or back. A heart attack occurs when blood flow to an area of your heart muscle is completely blocked. This prevents oxygen-rich blood from reaching that area of heart muscle and causes it to die. Without quick treatment, a heart attack can lead to serious problems and even death. Over time, CAD can weaken the heart muscle and lead to heart failure and arrhythmias. Heart failure is a condition in which your heart can't pump enough blood throughout your body. Arrhythmias are problems with the speed or rhythm of your heartbeat. Outlook CAD is the most common type of heart disease. Lifestyle changes, medicines, and/or medical procedures can effectively prevent or treat CAD in most people. Other Names for Coronary Artery Disease

Atherosclerosis Coronary heart disease Hardening of the arteries Heart disease Ischemic heart disease Narrowing of the arteries

A. ANATOMY AND PHYSIOLOGY THE HEART Your heart is located under the ribcage in the center of your chest between your right and left lung. Its shaped like an upside-down pear. Its muscular walls beat, or contract, pumping blood continuously to all parts of your body. The size of your heart can vary depending on your age, size, or the condition of your heart. A normal, healthy, adult heart most often is the size of an average clenched adult fist. Some diseases of the heart can cause it to become larger.

The heart is the muscle in the lower half of the picture. The heart has four chambers. The right and left atria are shown in purple. The right and left ventricles are shown in red. Connected to the heart are some of the main blood vesselsarteries and veinsthat make up your blood circulatory system. The ventricle on the right side of your heart pumps blood from the heart to your lungs. When you breathe air in, oxygen passes from your lungs through blood vessels where its added to your blood. Carbon dioxide, a waste product, is passed from your blood through blood vessels to your lungs and is removed from your body when you breathe air out. The atrium on the left side of your heart receives oxygen-rich blood from the lungs. The pumping action of your left ventricle sends this oxygen-rich blood through the aorta (a main artery) to the rest of your body.

The Right Side of the Heart The superior and inferior vena cava are in blue to the left of the muscle as you look at the picture. These veins are the largest veins in your body. They carry used (oxygenpoor) blood to the right atrium of your heart. Used blood has had its oxygen removed and used by your bodys organs and tissues. The superior vena cava carries used blood from the upper parts of your body, including your head, chest, arms, and neck. The inferior vena cava carries used blood from the lower parts of your body. The used blood from the vena cava flows into your hearts right atrium and then on to the right ventricle. From the right ventricle, the used blood is pumped through the pulmonary arteries (in blue in the center of picture) to your lungs. Here, through many small, thin blood vessels called capillaries, your blood picks up oxygen needed by all the areas of your body. The oxygen-rich blood passes from your lungs back to your heart through the pulmonary veins (in red to the left of the right atrium in the picture).

The Left Side of the Heart Oxygen-rich blood from your lungs passes through the pulmonary veins (in red to the right of the left atrium in the picture). It enters the left atrium and is pumped into the left ventricle. From the left ventricle, your blood is pumped to the rest of your body through the aorta. Like all of your organs, your heart needs blood rich with oxygen. This oxygen is supplied through the coronary arteries as its pumped out of your hearts left ventricle. Your coronary arteries are located on your hearts surface at the beginning of the aorta. Your coronary arteries (shown in red in the drawing) carry oxygen-rich blood to all parts of your heart.

HEART INTERIOR

The Septum The right and left sides of your heart are divided by an internal wall of tissue called the septum. The area of the septum that divides the two upper chambers (atria) of your heart is called the atrial or interatrial septum. The area of the septum that divides the two lower chambers (ventricles) of your heart is called the ventricular or interventricular septum. Heart Chamber The picture shows the inside of your heart and how its divided into four chambers. The two upper chambers of your heart are called atria. The atria receive and collect blood. The two lower chambers of your heart are called ventricles. The ventricles pump blood out of your heart into the circulatory system to other parts of your body.

Heart Valves The picture shows your hearts four valves. Shown counterclockwise in the picture, the valves include the aortic valve, the tricuspid valve, the pulmonary valve, and the mitral valve or Bicuspid.

Blood Flow The arrows in the drawing show the direction that blood flows through your heart. The light blue arrows show that blood enters the right atrium of your heart from the superior and inferior vena cavae. From the right atrium, blood is pumped into the right ventricle. From the right ventricle, blood is pumped to your lungs through the pulmonary arteries.

The light red arrows show the oxygen-rich blood coming in from your lungs through the pulmonary veins into your hearts left atrium. From the left atrium, the blood is pumped into the left ventricle, where its pumped to the rest of your body through the aorta. For the heart to function properly, your blood flows in only one direction. Your hearts valves make this possible. Both of your hearts ventricles has an in (inlet) valve from the atria and an out (outlet) valve leading to your arteries. Healthy valves open and close in very exact coordination with the pumping action of your hearts atria and ventricles. Each valve has a set of flaps called leaflets or cusps, which seal or open the valves. This allows pumped blood to pass through the chambers and into your arteries without backing up or flowing backward.

Suferior Vena Cava Right Atrium Inferior Vena Cava Pulmonary Artery Tricuspid Valve Right Ventricle

Different Systems

Lungs

Aorta

Left Ventricle

Bicuspid

Left Atrium

Pulmonary Vein

B. PATHOPHYSIOLOGY
Modifiable Risk Factors High blood cholesterol level Cigarette smoking, tobacco use Hypertension Diabetes mellitus Lack of estrogen in women Physical inactivity Non-modifiable Risk Factors Family history of coronary heart disease Increasing age Gender (heart disease occurs three times more often in men than in premenopausal women) Race (higher incidence of heart disease in

Cholesterol

Foam Cells

Oxidized LDL

Plaque Formation

Blood Vessels Are Blocked

Affects Blood Supply

Reduces Oxygen And Nutrients In The Heart And Affects The Supply Of Oxygen To The Vital Organs

Death of Tissue Within These Organs And Their Eventual Failure

Heart Attack

Death

C. CAUSES Research suggests that coronary artery disease (CAD) starts when certain factors damage the inner layers of the coronary arteries. These factors include:

Smoking High amounts of certain fats and cholesterol in the blood High blood pressure High amounts of sugar in the blood due to insulin resistance or diabetes

When damage occurs, your body starts a healing process. Excess fatty tissues release compounds that promote this process. This healing causes plaque to build up where the arteries are damaged. The buildup of plaque in the coronary arteries may start in childhood. Over time, plaque can narrow or completely block some of your coronary arteries. This reduces the flow of oxygen-rich blood to your heart muscle. Plaque also can crack, which causes blood cells called platelets to clump together and form blood clots at the site of the cracks. This narrows the arteries more and worsens angina or causes a heart attack. D. RISK FACTORS Smoking Cigarette smoking contributes to the development of severity of CAD in the following three ways: 1. The inhalation of smoke increases the blood carbon monoxide level than with oxygen. A decrease amount of available oxygen may decrease the hearts ability to pump. 2. The nicotinic acid in Tobacco triggers the release of catecholamines, which raise the heart rate and blood pressure. 3. Use of tobacco causes a detrimental vascular response and increases platelet adhesion, leading to a higher probability of thrombus formation. Hypertension Long standing elevated blood pressure may result in increased stiffness of the vessel walls leading to a vessel injury and a resulting inflammatory response within the intima. Diabetes High blood sugars are linked with accelerated development of atherosclerosis. Age As you get older, your risk for CAD increases. Genetic or lifestyle factors cause plaque to build in your arteries as you age. By the time you're middle-aged or older, enough plaque has built up to cause signs or symptoms. o In men, the risk for CAD increases after age 45. o In women, the risk for CAD risk increases after age 55. Overweight or obesity Overweight is having extra body weight from muscle, bone, fat, and/or water. Obesity is having a high amount of extra body fat.

 Family history of early heart diseaseYour risk increases if your father or a brother was diagnosed with CAD before 55 years of age, or if your mother or a sister was diagnosed with CAD before 65 years of age. Stress Research shows that the most commonly reported "trigger" for a heart attack is an emotionally upsetting eventparticularly one involving anger. Alcohol Heavy drinking can damage the heart muscle and worsen other risk factors for heart disease. Men should have no more than two drinks containing alcohol a day. Women should have no more than one drink containing alcohol a day. Unhealthy blood cholesterol levels This includes high LDL cholesterol (sometimes called bad cholesterol) and low HDL cholesterol (sometimes called good cholesterol). E. SIGNS AND SYPMTOMS a. Chest pain b. Shortness of Breath c. Palpitations d. Fatigue e. Dizziness f. Nausea g. Weakness h. Peripheral Edema

F. DIAGNOSTIC TEST Diagnostic Tests and Procedures No single test can diagnose CAD. If your doctor thinks you have CAD, he or she will probably do one or more of the following tests. ECG (Electrocardiogram)

An ECG is a simple test that detects and records the electrical activity of your heart. An EKG shows how fast your heart is beating and whether it has a regular rhythm. It also shows the strength and timing of electrical signals as they pass through each part of your heart.

Certain electrical patterns that the EKG detects can suggest whether CAD is likely. An EKG also can show signs of a previous or current heart attack. Stress Testing During stress testing, you exercise to make your heart work hard and beat fast while heart tests are performed. If you can't exercise, you're given medicine to speed up your heart rate. When your heart is beating fast and working hard, it needs more blood and oxygen. Arteries narrowed by plaque can't supply enough oxygen-rich blood to meet your heart's needs. A stress test can show possible signs of CAD, such as:

Abnormal changes in your heart rate or blood pressure Symptoms such as shortness of breath or chest pain Abnormal changes in your heart rhythm or your heart's electrical activity

During the stress test, if you can't exercise for as long as what's considered normal for someone your age, it may be a sign that not enough blood is flowing to your heart. But other factors besides CAD can prevent you from exercising long enough (for example, lung diseases, anemia, or poor general fitness). Some stress tests use a radioactive dye, sound waves, positron emission tomography (PET), or cardiac magnetic resonance imaging (MRI) to take pictures of your heart when it's working hard and when it's at rest. These imaging stress tests can show how well blood is flowing in the different parts of your heart. They also can show how well your heart pumps blood when it beats Echocardiography

This test uses sound waves to create a moving picture of your heart. Echocardiography provides information about the size and shape of your heart and how well your heart chambers and valves are working. The test also can identify areas of poor blood flow to the heart, areas of heart muscle that aren't contracting normally, and previous injury to the heart muscle caused by poor blood flow.

Chest X-ray

A chest x ray takes a picture of the organs and structures inside the chest, including your heart, lungs, and blood vessels. A chest x ray can reveal signs of heart failure, as well as lung disorders and other causes of symptoms that aren't due to CAD. Blood Tests Blood tests check the levels of certain fats, cholesterol, sugar, and proteins in your blood. Abnormal levels may show that you have risk factors for CAD. Electron-Beam Computed Tomography Your doctor may recommend electron-beam computed tomography (EBCT). This test finds and measures calcium deposits (called calcifications) in and around the coronary arteries. The more calcium detected, the more likely you are to have CAD. EBCT isn't used routinely to diagnose CAD, because its accuracy isn't yet known. Coronary Angiography and Cardiac Catheterization Your doctor may ask you to have coronary angiography (an-jee-OG-ra-fee) if other tests or factors show that you're likely to have CAD. This test uses dye and special x rays to show the insides of your coronary arteries. To get the dye into your coronary arteries, your doctor will use a procedure called cardiac catheterization . A long, thin, flexible tube called a catheter is put into a blood vessel in your arm, groin (upper thigh), or neck. The tube is then threaded into your coronary arteries, and the dye is released into your bloodstream. Special x rays are taken while the dye is flowing through your coronary arteries. Cardiac catheterization is usually done in a hospital. You're awake during the procedure. It usually causes little to no pain, although you may feel some soreness in the blood vessel where your doctor put the catheter.

VI. TREATMENT Treatment for coronary artery disease (CAD) may include lifestyle changes, medicines, and medical procedures. The goals of treatments are to:

Relieve symptoms Reduce risk factors in an effort to slow, stop, or reverse the buildup of plaque Lower the risk of blood clots forming, which can cause a heart attack Widen or bypass clogged arteries Prevent complications of CAD

Lifestyle Changes Making lifestyle changes can often help prevent or treat CAD. For some people, these changes may be the only treatment needed:

Follow a heart healthy eating plan to prevent or reduce high blood pressure and high blood cholesterol and to maintain a healthy weight Increase your physical activity. Check with your doctor first to find out how much and what kinds of activity are safe for you. Lose weight, if you're overweight or obese. Quit smoking, if you smoke. Avoid exposure to secondhand smoke. Learn to cope with and reduce stress.

Therapeutic Lifestyle Changes (TLC). Your doctor may recommend TLC if you have high cholesterol. TLC is a three-part program that includes a healthy diet, physical activity, and weight management. With the TLC diet, less than 7 percent of your daily calories should come from saturated fat. This kind of fat is mainly found in meat and poultry, including dairy products. No more than 25 to 35 percent of your daily calories should come from all fats, including saturated, trans, monounsaturated, and polyunsaturated fats. You also should have less than 200 mg a day of cholesterol. The amounts of cholesterol and the different kinds of fat in prepared foods can be found on the Nutrition Facts label. Foods high in soluble fiber also are part of a healthy eating plan. They help block the digestive track from absorbing cholesterol. These foods include:

Whole grain cereals such as oatmeal and oat bran Fruits such as apples, bananas, oranges, pears, and prunes Legumes such as kidney beans, lentils, chick peas, black-eyed peas, and lima beans

A diet high in fruits and vegetables can increase important cholesterol-lowering compounds in your diet. These compounds, called plant stanols or sterols, work like soluble fiber.

Fish are an important part of a heart healthy diet. They're a good source of omega-3 fatty acids, which may help protect the heart from blood clots and inflammation and reduce the risk for heart attack. Try to have about two fish meals every week. Fish high in omega-3 fats are salmon, tuna (canned or fresh), and mackerel. You also should try to limit the amount of sodium (salt) that you eat. This means choosing lowsodium and low-salt foods and "no added salt" foods and seasonings at the table or when cooking. The Nutrition Facts label on food packaging shows the amount of sodium in the item. Try to limit alcoholic drinks. Too much alcohol will raise your blood pressure and triglyceride level. (Triglycerides are a type of fat found in the blood.) Alcohol also adds extra calories, which will cause weight gain. Men should have no more than two alcoholic drinks a day. Women should have no more than one alcoholic drink a day. Dietary Approaches to Stop Hypertension (DASH) eating plan. Your doctor may recommend the DASH eating plan if you have high blood pressure. The DASH eating plan focuses on fruits, vegetables, whole grains, and other foods that are heart healthy and lower in salt/sodium. This eating plan is low in fat and cholesterol. It also focuses on fat-free or low-fat milk and dairy products, fish, poultry, and nuts. The DASH eating plan is reduced in red meat (including lean red meat), sweets, added sugars, and sugar-containing beverages. It's rich in nutrients, protein, and fiber. Increase Physical Activity Regular physical activity can lower many CAD risk factors, including LDL ("bad") cholesterol, high blood pressure, and excess weight. Physical activity also can lower your risk for diabetes and raise your levels of HDL cholesterol (the "good" cholesterol that helps prevent CAD). Check with your doctor about how much and what kinds of physical activity are safe for you. Unless your doctor tells you otherwise, try to get at least 30 minutes of moderate-intensity activity on most or all days of the week. You can do the activity all at once or break it up into shorter periods of at least 10 minutes each. Moderate-intensity activities include brisk walking, dancing, bowling, bicycling, gardening, and housecleaning. More intense activities, such as jogging, swimming, and various sports, also may be appropriate for shorter periods. Maintain a Healthy Weight Maintaining a healthy weight can decrease risk factors for CAD. If you're overweight, aim to reduce your weight by 7 to 10 percent during your first year of treatment. This amount of weight loss can lower your risk for CAD and other health problems.

After the first year, you may have to continue to lose weight so you can lower your body mass index (BMI) to less than 25. BMI measures your weight in relation to your height and gives an estimate of your total body fat. A BMI between 25 and 29 is considered overweight. A BMI of 30 or more is considered obese. A BMI of less than 25 is the goal for preventing and treating CAD. Quit Smoking If you smoke or use tobacco, quit. Smoking can damage and tighten blood vessels and raise your risk for CAD. You also should avoid exposure to secondhand smoke. Reduce Stress Research shows that the most commonly reported "trigger" for a heart attack is an emotionally upsetting eventparticularly one involving anger. Also, some of the ways people cope with stress, such as drinking, smoking, or overeating, aren't heart healthy. Physical activity can help relieve stress and reduce other CAD risk factors. Many people also find that meditation or relaxation therapy helps them reduce stress. Medicines You may need medicines to treat CAD if lifestyle changes aren't enough. Medicines can:

Decrease the workload on your heart and relieve CAD symptoms Decrease your chance of having a heart attack or dying suddenly Lower your cholesterol and blood pressure Prevent blood clots Prevent or delay the need for a special procedure (for example, angioplasty or coronary artery bypass grafting (CABG)

Medicines used to treat CAD include anticoagulants, aspirin and other antiplatelet medicines, ACE inhibitors, beta blockers, calcium channel blockers, nitroglycerin, glycoprotein IIb-IIIa, statins, and fish oil and other supplements high in omega-3 fatty acids.

Medical Procedures:

Angioplasty Opens blocked or narrowed coronary arteries. During angioplasty, a thin tube with a balloon or other device on the end is threaded through a blood vessel to the narrowed or blocked coronary artery. Once in place, the balloon is inflated to push the plaque outward against the wall of the artery. This widens the artery and restores the flow of blood. Angioplasty can improve blood flow to your heart, relieve chest pain, and possibly prevent a heart attack. Sometimes a small mesh tube called a stent is placed in the artery to keep it open after the procedure. CABG

Coronary artery bypass surgery, also coronary artery bypass graft surgery, and colloquially heart bypass or bypass surgery is a surgical procedure performed to relieve angina and reduce the risk of death from coronary artery disease. Arteries or veins from elsewhere in the patient's body are grafted to the coronary arteries to bypass atherosclerotic narrowings and improve the blood supply to the coronary circulation supplying the myocardium (heart muscle). This surgery is usually performed with the heart stopped, necessitating the usage of cardiopulmonary bypass; techniques are available to perform CABG on a beating heart, so-called "off-pump" surgery. Cardiac Rehabilitation Your doctor may prescribe cardiac rehabilitation (rehab) for angina or after CABG, angioplasty, or a heart attack. Cardiac rehab, when combined with medicine and surgical treatments, can help you recover faster, feel better, and develop a healthier lifestyle. Almost everyone with CAD can benefit from cardiac rehab. The cardiac rehab team may include doctors, nurses, exercise specialists, physical and occupational therapists, dietitians, and psychologists or other behavioral therapists.

NURSING INTERVENTION 1. Monitor blood pressure, apical heart rate, and respirations every 5 minutes during an anginal attack. 2. Maintain continuous ECG monitoring or obtain a 12-lead ECG, as directed, monitor for arrhythmias and ST elevation. 3. Place patient in comfortable position and administer oxygen, if prescribed, to enhance myocardial oxygen supply. 4. Identify specific activities patient may engage in that are below the level at which anginal pain occurs. 5. Reinforce the importance of notifying nursing staff whenever angina pain is experienced. 6. Encourage supine position for dizziness caused by antianginals. 7. Be alert to adverse reaction related to abrupt discontinuation of beta-adrenergic blocker and calcium channel blocker therapy. These drug must be tapered to prevent a rebound phenomenon; tachycardia, increase in chest pain, and hypertension. 8. Explain to the patient the importance of anxiety reduction to assist to control angina. 9. Teach the patient relaxation techniques. 10. Review specific factors that affect CAD development and progression; highlight those risk factors that can be modified and controlled to reduce the risk.