Coronary Artery

Disease
Presented By
Ismansyah

Coronary
Atherosclerosis
definition- abnormal
accumulation of lipids and fibrous
tissue in the coronary arteries
which results in decreased blood
flow to myocardium
Atheroma comprises the lumen of
the vessel---clots may form and
obstruct the lumen

Clinical Manifestations
a) narrowing-angina (ischemia)
b) occlusion- AMI (necrosis)
c) other
-EKG changes
- aneurysms
-dysrhythmias
d) sudden cardiac death

Angina Pectoris
definition-chest discomfort (pain) due to
decreased blood flow resulting in
atheroma or spasm
decreased blood flow results in
myocardial ischemia-nerve endings
around cells send pain messages to brain
usually transient chest pain (3-5),
subsides when precipitating factor
removed

Types of Angina
Unstable- referred to as
preinfarction,Crescendo,unpredicta
ble,or
progressive (increase in frequency
and duration)
treated with ASA and Calcium
Channel Blocking Agents

Chronic, Stable Angina

referred to as predictable and
consistent
occurs on exertion
relieved with rest
EKG changes-ST depression
classic type of angina

Nocturnal Angina
referred to as Angina Decubiti
occurs at night due to lying flat
when the workload on the heart is
increased (increased venous return
or preload)
relieved by standing or sitting

Prinzmetals Angina
usually spontaneous and
accompanied by increased ST
elevations on the EKG due to
coronary artery spasm
associated with risk of MI
rare form of angina

Factors
Precipitating Angina
a) physical exertion-increases
workload of heart ( sex, exercise,
raking leaves ,or lifting heavy
objects)
b) exposure to heat or cold resulting
in vasoconstriction-elevated blood
pressure-increased demands of
body for oxygen

Factors Precipitating
Angina
c) heavy meals-divert blood to GI tract
(25%of CO)
d) strong emotions-increased release of
catecholamines
e) cigarette smoking
f) sexual activity
g) stimulants-coffee or cocaine
h) circadian rhythm patterns-early a.m.
after arising

Description of Pain
a) substernal-varies in intensity from
discomfort to pressure to agonizing
pain
adjectives used to describe pain
heavy feeling, pressure,weight
oppressive or sharp
tightness
viselike

Description of Pain
crushing
constricting

squeezing
suffocating
burning
indigestion

Types of Pain
b) deep-retrosternal
c) localized but may radiate to
neck,jaws,shoulder,inner aspects of
either armusually subsides when cause
removed
relieved by nitrates and rest
duration of pain -approximately 15
or less

Diagnostic Tests
a) EKG-changes occur only while having
angina
b) Stress tests results-look for changes in
ST segments
c) Thallium stress test-inject dye 1 minute
before peak exercise, scan immediately
and in 2-4 hours. Look for cold spots
indicating lack of Thallium uptake or
lack of perfusion

Diagnostic Tests
d) Cardiac CatheterizationAngiography Looks at oxygen
levels and pressure readings in
heart chambers as well as blood flow
through coronary arteries
e) Chest X-Ray- Identifies enlarged
heart, calcification,pulmonary
congestion
f) Lipids and Enzymes

Diagnostic Tests
g) PET-Positron Emission
Tomographynon invasive test that identifies
and
quantifies ischemia and
infarction
h) Echocardiography

Management of Angina
Objective-decrease the discrepancy
between the oxygen supply and demand
- Rest-decrease the amount of oxygen
needed by all tissues of body
- Percutaneous Transluminal Coronary
Angioplasty (PTCA)
-Intracoronary Stints
-Atherectomy

Interventions for
Angina
Acute Attack - Pain assessment quantify the pain using a 1-10
scale (1-least severe and 10-most
severe)
Remember that cardiac pain is
diffuse, deep and intense

Acute Anginal Attack

Provide oxygen at 2L/minute
Take Vital Signs
perform EKG - look for changes in
ST segments
Administer Nitrates or Analgesia
semi-Fowlers position

Nursing InterventionsAngina
Prevent Pain
-Avoid activities that cause pain
- Change ADL schedules if pain in
a.m.
- Unhurried pace
-Avoid causes

Nursing InterventionsAngina
Reduce Anxiety
- Fear of Death is common
- Stay with anxious client
- Educate client for discharge

Nursing InterventionsAngina
Objectives of Client EducationHome Care
- reduce frequency/ severity of
attacks
- delay disease progression
- protect from complications
- plan activities to minimize episodes
- modify risk factors

Medications To Treat
Angina
1) Nitroglycerin-,decreases preload and
afterload by dilating venous and arterial
system,decreases venous return and
arterial pressure
a) works in 2-3 minutes
b) dose-0.3-0.6 mg sl.x3 at 5-10 minute
intervals
c) effects last only 10-15 minute
maximum

Side Effects of
Nitroglycerin
Increased Heart Rate
Orthostatic Hypotension
Throbbing Headache
Flushing of face
Vertigo
Tachycardia

Nursing Implications
Associated With
Nitroglycerin
Fresh supply every 6-9 months
Take at earliest sign of pain or
discomfort
Keep in brown bottle and cool spotit is volatile to air
Sit or lie down when taking
Remove cotton from bottle
Does not always sting under tongue

Nitrate Preparations
Nitroglycerin sublingual-If no relief from 3
pills taken 5 minutes apart-seek medical
attention
Long Acting Nitrates
a) Topical Ointments-duration of effect
is 4 hours so client needs 4-6
applications a day
Apply to arms, legs ,any unhairy body
area

Long Acting Nitrate

Preparations
DM preparation-long acting
examples-Peritrate, Isordil -last 68 hours
Nitrodiscs-apply in a.m., remove at
h.s.to provide a nitrate free period
Examples-Transderm NitroDur
discs where drugs are continually
released to skin absorption site

Intravenous
Nitroglycerin
rationale-increase collateral blood
flow to ischemic area, decrease
myocardial oxygen demand by
decreasing preload and decreasing
afterload
examples- Nitrol IV, Nitrostat IV,
Nitrobid or Tridil IV

Beta Blockers
action-decrease myocardial oxygen
consumption by blocking
sympathetic impulses to heart,
smooth muscle of bronchi and
blood vessels. It lowers heart rate
and blood pressure and decreases
myocardial contractility

Beta Blockers
Common Drugs in Use
- Inderal-80-320mg BID or QID
- Atenolol (Tenormin)-50-100mg/day
may take up to 200 mg/day
-Metoprolol (Lopressor) -50100mg/day
may take up to 450mg/day

Beta Blockers
Timolol (Blocadren10 mg. BID or
up to 100
mg./day

Side Effects of Beta

Blockers
Musculoskeletal
Weakness
Hypertension
Bradycardia
Depression
Fatigue
Sexual
dysfunction

Bronchospasmwatch clients with

history of
Asthma .COPD
Hyperglycemiawatch for DM
Weight gain

Calcium Channel
Blocking Agents
Calcium influences cardiac
contraction and electrical stimulation
Action--dilates smooth muscle of
coronary arteries thus, increasing
oxygen supply,decreases systemic
arterial pressure and decreases
workload of LV (decreasing peripheral
resistance)

Calcium Channel
Blocking Agents
Effects- Systemic vasodilatation with
decreased systemic vascular
resistance
- Decreased myocardial
contractility
- Coronary vasodilatation

Common Calcium
Channel Blocking
Agents
Nifedipine (Procardia) -10-30
mg.q4-8 hours
Verapamil (Isoptin, Calan)-60-80
mg. q8 hrs. po or IV
Diltiazem (Cardizem) -60-90- mg. q8
hrs.po

Nicarpine (Cardene) -

Side Effects of Calcium

Channel Blocking
Agents
Orthostatic Hypotension
Bradycardia
Flushing
Headache
Pedal Edema-Nifedipine
Constipation- (Verapamil)

Common Nursing
Diagnoses-Angina
a) Pain rel.to ischemia of
myocardium
b) Activity Intolerance rel. to
fatigue or weakness
c) Altered Health Maintenance rel
to knowledge deficit
d) Anxiety rel. to fear of cardiac
disease, future sudden death

Percutaneous
Transluminal Coronary
Angioplasty

(PTCA)
rationale- attempts to improve
blood flow within the coronary artery
by cracking the plaque or atheroma
that is interfering with the circulation
of blood to the heart
Procedure is done in Cath Labcardiac catheterization documents
stenosis

PTCA
Catheter equipped with an inflatable
ballon tip is inserted into coronary artery
and passed beyond lesion
Ballon is inflated (3-4 seconds) and
atherosclerotic plaque is compressed
resulting in vasodilation
Ballon is deflated
Procedure may be repeated several times

Advantages of PTCA
Alternative to surgery
Local anesthesia used
Eliminates Thoracotomy Incision
Client is ambulatory within 24 hours
Hospital stay is 1-3 days not 5-7
days as with CABG procedure
Rapid return to work-1week instead
of 8weeks with CABG procedure

Advancements with
PTCA
Use of more flexible
guidewire/catheters
Dilates stenosed CABG grafts
Provide blood flow to distal
myocardium during inflation

Complications of PTCA
Dissection of dilated artery
Rupture of artery causing tamponade,
ischemia, infarct, decreased CO,death
Occlusion of vessel distal to catheter
Coronary spasm from mechanical or
chemical irritation from dye
abrupt closure-24 hours
Restenosis rates of 30% within 3-6 months

Newer Treatments
Radiation with Intravascular Stent
Placements-expandable, meshlike
structures to maintain vessel patency
requires anticoagulants for 3 months
Atherectomy-shave plaque using
rotating blade when proximal or
middle part of artery involved

Newer Treatments for

Angina
Laser Angioplasty-A small laser
on tip of catheter welds the area
open or melts the plaque areas
facilitating blood flow
Is still a new technique and needs
refinement