PRESENTATION

On
Topic- Coronary Artery Disease

Presented By-
Rubani . T
M.Sc nursing
WE WILL LEARN ABOUT..

What is coronary circulation?

Why are the coronary arteries important?

What is atherosclerosis?

What is coronary artery disease ?

• Definition
• Incidence and prevalence
• Etiology and risk factors
• Pathophysiology
• Clinical manifestations
• Diagnostic tests
• Medical management
• Health education
• Evidences review
 INTRODUCTION

 Coronary circulation- It is the circulation of blood

in the blood vessels of the heart muscle
(myocardium).

 The heart muscle needs oxygen-rich blood to

function, coronary arteries supply blood to the
heart muscle.

 The coronary arteries wrap around the outside of

the heart.
CORONARY CIRCULATION
 WHY ARE THE CORONARY
ARTERIES IMPORTANT?

 Since coronary arteries deliver blood to the

heart muscle,

 any coronary artery disorder or disease can

have serious implications by reducing the flow
of oxygen and nutrients to the heart muscle.

 This can lead to a heart attack and possibly

death.
 ATHEROSCLEROSIS
 Atherosclerosis is a building up of plaque
in the inner lining of an artery causing it to
narrow or become blocked. Its the most
common cause of heart disease.
 CORONARY ARTERY
DISEASE
• CAD is narrowing or obstruction of one or more
coronary arteries because of atherosclerosis
which is the accumulation of lipid- containing
plaque in the arteries

• that decreases perfusion to myocardial tissue

and inadequate myocardial oxygen supply

• which leads to hypertension, infarction,

arrhythmias, heart failure and death
CONTI..

 Collateral circulation, more than 1 artery supplying

a muscle with blood, is normally present in the
coronary arteries, especially in older persons.

 The development of collateral circulation takes time

and develops when chronic ischemia occurs to meet
the metabolic demands; therefore, an occlusion of a
coronary artery in a younger individual is more
likely to be lethal than one in an older individual.

 Symptoms occur when the coronary artery is

occluded to the point that inadequate blood supply to
the muscle occurs, causing ischemia.
CONTI..

 CAD is characterized by the accumulation of

plaque within coronary arteries, which
progressively enlarge , thicken and calcify.

 Coronary artery narrowing is significant if the

lumen diameter of the left main artery is
reduced at least 50%, or if any major branch is
reduced at least 75%.

 The goal of treatment is to alter the

atherosclerotic progression.
INCIDENCE AND PREVALENCE
The 2016 Heart Disease and Stroke Statistics
update of the American Heart Association
(AHA) has reported that 15.5 million
persons ≥20 years of age in the USA have
CHD , prevalence increases with age for both
men and women
 ETIOLOGY AND RISK
FACTORS
NON-MODIFIABLE MODIFIABLE
 Heredity  Cigarette smoking
 Race  Hypertension
 Increasing age  Elevated serum
cholesterol levels
 Gender
 Physical inactivity
 Obesity
 Diabetes mellitus
 Lack of estrogen in
women
 Behavior patterns (
stress, aggressiveness)
CONTRIBUTING RISK FACTORS
 Response to stress
 Inflammatory response
 Menopause
 Homocysteine levels
 PATHOPHYSIOLOGY
Due to etiological factors injury to the endothelial cell

Fatty streaks of lipids deposit in arterial wall & Inflammation ,immune reactions start

T lymphocytes & monocytes Infiltrate Release biochemical sub Damage endothelial

the area to ingest the lipids & die attract platelets to initiate clotting

Smooth muscle cells proliferation form fibrous cap over dead fatty core (atheroma)

Protrusion of atheroma narrowing & obstruct the lumen of vessel

If cap has thin membrane the lipid core may grow and rupture

Hemorrhage into plaque & forming thrombus

Thrombus obstruct the blood flow leading to sudden cardiac death of myocardial infarction
 CLINICAL MANIFESTATIONS
 Chest pain (Angina pectoris)
 Palpitations
CLINICAL MANIFESTATIONS
Dyspnea
 CLINICAL MANIFESTATIONS

Syncope
 CLINICAL MANIFESTATIONS

Cough/ hemoptysis
 CLINICAL MANIFESTATIONS

Dysarrythmias
 CLINICAL MANIFESTATIONS

Chest heaviness
 CLINICAL MANIFESTATIONS

Dizziness
 CLINICAL MANIFESTATIONS

Sweating
 CLINICAL MANIFESTATIONS

Feeling of Anxiety
 CLINICAL MANIFESTATIONS

Excessive Fatigue
 DIAGNOSTIC TESTS
History collection
 DIAGNOSTIC TESTS
Physical examination
 DIAGNOSTIC TESTS
Cardiac Enzymes
 DIAGNOSTIC TESTS
Cardiac Enzymes

RETURN
CARDIAC
INCREASES PEAK TO COMMENTS
MARKER
BASELINE
Earliest marker, but non-specific with
Myoglobin 1–4 h 4–12 h 24–36 h
negative predictive value.

Gold standard before troponin was

CK-MB 4–9 h 24 h 48–72 h introduced. Mostly found in cytosol but
may increase in non-MI situation.

Most specific marker. Found in small

amounts in cytosol, but mostly in
sarcomere of cardiac myocytes (both
Troponin I/T 4–9 h 12–24 h 7–14 days
early and late marker). Troponin T is less
specific than troponin I because troponin
T is also found in muscle.
 DIAGNOSTIC TESTS
Cardiac Enzymes
 DIAGNOSTIC TESTS
Cardiac Enzymes
 DIAGNOSTIC TESTS
Serum cholesterol levels
 DIAGNOSTIC TESTS
Electrocardiograms
 DIAGNOSTIC TESTS
Echocardiograms
 DIAGNOSTIC TESTS
Treadmill Test (TMT)
 DIAGNOSTIC TESTS
Cardiac catheterization or Angiography
 MEDICAL MANAGEMENT
Goal-
 Decrease myocardial oxygen demand
 Increase oxygen supply

It include-
 Pharmacological Therapy
 Surgical Management
 Nursing Management
 Lifestyle Changes
 PHARMACOLOGICAL
THERAPY
 Nitrates(nitroglycerine) – to dilate coronary arteries and decrease
preload and afterload. These actions help relieve chest pain.

 SUBLINGUALTABLET:
0.3 to 0.6 mg sublingually or in the buccal pouch every 5 minutes as
needed, up to 3 doses in 15 minutes; if pain persists after maximum
dose, prompt medical attention is recommended.

 EXTENDED RELEASE CAPSULE:

2.5 to 6 mg orally 3 to 4 times a day; titrate as needed and tolerated.
 5 mcg/min continuous IV infusion via non-absorptive tubing;
increase by 5 mcg/min every 3 to 5 minutes as needed up to 20
mcg/min, then by 10 or 20 mcg/min if needed.
 PHARMACOLOGICAL
THERAPY
 Beta-Adrenergic Blockers (Atenolol, Metroprolol) - decrease
myocardial oxygen consumption, decrease heart rate.
Increasing the amount of oxygen delivered to the heart
increases the chances of survival of individuals having a heart
attack. These actions help relieve chest pain.

 DOSAGE-
 Atenolol- 25 milligrams (mg), 50 mg, and 100 mg.
 Metoprolol- 25, 50 and 100 mg. IV begins with a 5 mg
injection.
 PHARMACOLOGICAL
THERAPY
 Calcium channel blockers- Calcium channel blockers help
lower blood pressure by relaxing the blood vessels throughout
your body. As a result, less pressure is built up and your heart
does not have to work as hard to pump blood.

 Nifedipine- Oral capsule- 10 mg, 20 mg. Oral extended-

release tablet- 30 mg, 60 mg, 90 mg.

 Amlodipine- 2.5 mg, 5mg, 10mg.

 PHARMACOLOGICAL
THERAPY
 Antiplatelet and anticoagulant agents- to inhibit thrombus
formation.
 Aspirin- Immediate-release: 50 to 325 mg orally once a day
Extended-release (ER): 162.5 mg orally once a day.

 Clopdidogrel- 75 mg orally once a day.

Conti..

 Antilipid medications (atorvastatin) to decrease

blood cholesterol and triglyceride levels.
 Atorvastatin-
 Initial dose: 10 mg or 20 mg orally once a day
 Maintenance dose: 10 mg to 80 mg orally once a
day.
Conti..

 Angiotensin converting enzyme inhibitors

(captopril) to promote a favorable balance of
oxygen supply and demand.
 Captopril-
 Initial dose: 25 mg orally 2 to 3 times a day
one hour before meals.
 Maintenance dose: May increase every 1 to 2
weeks up to 50 mg orally three times a day.
 Maximum dose: 450 mg/day.
Conti..

 Imipramine, morphine sulphate for

analgesia. Dose- imipramine- 100 mg and
150 mg daily. Morphine- 10mg, 15 mg.

 Folic acid and B complex vitamins to
reduce homocysteine levels.
Procedures for CAD
PERCUTANEOUS TRANSLUMINAL
CORONARY ANGIOPLASTY
DIRECTIONAL CORONARY
ATHERECTOMY
INTRACORONARY STENTS
LASER ABLATION
TRANSMYOCARDIAL
REVASCULARIZATION
SURGICAL MANAGEMENT
 OPEN HEART SURGERY

 Cardiopulmonary bypass is used during cardiac

surgery to divert the client’s unoxygenated
blood to a machine in which oxygenation &
circulation occurs.

 This technique called extracorporeal circulation

(ECC) allows the surgeon to stop the heart
during time of surgery.

 The heart lung machine does the following:

CORONARY ARTERY BYPASS
GRAFTING
 It involves the bypass of a blockage in one
or more of the coronary arteries using the
saphenous veins, mammary artery or
radial artery.
 GRAFTS FOR CABG
 Typically, the left internal thoracic artery (LITA) (previously
referred to as left internal mammary artery or LIMA) is grafted
to the left anterior descending artery and a combination of other
arteries and veins is used for other coronary arteries.

 The great saphenous vein from the leg is used approximately

in 80% of all grafts for CABG.

 The right internal thoracic (mammary) artery (RITA or

RIMA) and the radial artery from the forearm are frequently
used as well; these vessels are usually harvested either
endoscopically, using a technique known as endoscopic vessel
harvesting (EVH), or with the open-bridging technique,
employing two or three small incisions.

 The right gastroepiploic artery from the stomach is

infrequently used given the difficult mobilization from the
abdomen.
 LIFESTYLE CHANGES
 Weight control
 Smoking cessation
 Exercise
 Healthy diet
 NURSING MANAGEMENT
ASSESSMENT
 Gather information about patient present signs and
symptoms.
 Assess patients risk factors for CAD
 Perform the physical examination
 Obtain and assess ECG
 Check vital signs and report lab investigations
 Evaluate patients past health history such as DM2, heart
failure, previous MI, obstructive lung disease that may
influence choice of drug therapy
 Identify patient and family’s knowledge about diagnosis,
their level of anxiety and use of appropriate coping
mechanisms
 NURSING DIAGNOSIS
 Acute Pain related to decreased myocardial blood flow
or increased cardiac workload/oxygen consumption as
evidenced by reports of pain varying in frequency,
duration, and intensity.
 Ineffective tissue perfusion related to decreased cardiac
output as evidenced by dyspnea.
 Decreased cardiac output related to alteration in heart
rate
 Impaired gas exchange related to decreased cardiac
output as evidenced by dyspnea and decreased SpO2
 Activity intolerance related to decreased cardiac output
 Anxiety related to hospital admission evidenced by
patients verbal response
 Risk to constipation related to bed rest as evidenced by
subjective feeling of fullness.
Acute Pain
 Instruct patient to notify nurse immediately when
chest pain occurs.
 Assess and document patient response to medication.
 Identify precipitating event, if any: frequency,
duration, intensity, and location of pain. Observe for
associated symptoms: dyspnea, nausea and vomiting,
dizziness, palpitations, desire to micturate.
 Evaluate reports of pain in jaw, neck, shoulder, arm,
or hand (typically on left side).
 Place patient at complete rest during anginal
episodes.
 Elevate head of bed if patient is short of breath.
Acute Pain

 Monitor heart rate and rhythm.

 Monitor vital signs every 5 min during initial
anginal attack.
 Stay with patient who is experiencing pain or
appears anxious.
 Maintain quiet, comfortable environment. Restrict
visitors as necessary.
 Provide supplemental oxygen as indicated.
 Administer antianginal medication(s) promptly as
indicated: Nitroglycerin: sublingual , atenolol,
nifedipine, Analgesics, Morphine sulphate (MS).
INEFFECTIVE TISSUE PERFUSION
 Assess V/S.
 Assess spO2 of patient.
 Review laboratory data (ABGs, BUN, creatinine,
electrolytes, international normalized ratio, and
prothrombin time or partial thromboplastin time.
 Check respirations and absence of work of breathing.
 Check Hgb levels
 Check for pallor, cyanosis, mottling, cool or clammy
skin. Assess quality of every pulse.
 Check for optimal fluid balance. Administer IV fluids as
ordered.
 Maintain optimal cardiac output.
 Administer nitroglycerin (NTG) sublingually for
complaints of angina.
 Maintain oxygen therapy as ordered.
DECREASED CARDIAC OUTPUT
RELATED TO ALTERATION IN
HEART RATE

 Assess cardiac output, pulse, arterial BP,

ECG
 Assess heart rhythm and treat dysthymias
 Auscultate heart sounds and lung sounds
 Administer vasodilators
 Administer calcium channel blockers
 Administer antiarryrthmatics
IMPAIRED GAS EXCHANGE RELATED TO
DECREASED CARDIAC OUTPUT AS
EVIDENCED BY DYSPNEA AND DECREASED
SPO2
 Assess respiratory rate, SpO2 and ABG
 Assess capillary refill, LOC, dyspnea
 Auscultate chest for breath sounds
 Provide high fowlers position
 Administer oxygen as ordered
 Administer nebulization
 Encourage the use of spirometry and deep
breathing exercise.
 Perform chest physiotherapy
ACTIVITY INTOLERANCE R/T
DECREASED CARDIAC OUTPUT
 Assess the general condition of patient
 Assess the vitals before and after activity
 Monitor the clients response to activities
 Space the nursing activities
 Schedule the rest periods
 Increase activity as ordered
 Instruct the client to avoid activity that
increase cardiac workload
ANXIETY RELATED TO HOSPITAL
ADMISSION EVIDENCED BY PATIENTS
VERBAL RESPONSE

 Assess the level of anxiety

 Allow and encourage the client and family to
ask questions
 Allow the patient to verbalize the feelings
 Provide comfortable and quiet environment
 Administer anti anxiety drugs.
RISK TO CONSTIPATION RELATED TO
BED REST AS EVIDENCED BY
SUBJECTIVE FEELING OF FULLNESS

 Assess the intake output of patient

 Ensure that patient has adequate bulk in
diet and fluid intake
 Monitor the effectiveness of softeners or
laxatives
 Encourage the client to use beside
commodate rather than bedpan
 SCREENING TESTS FOR CAD

Radionuclide Stress Pharmacologic Coronary

TMT stress test echocardiography stress test CT scanning angiography
 HEALTH EDUCATION
Physical exercise
 HEALTH EDUCATION
Decreasing obesity
 HEALTH EDUCATION
Treating high blood pressure
 HEALTH EDUCATION
Eating a healthy diet
 HEALTH EDUCATION
Adequate rest
 HEALTH EDUCATION
Controlling blood sugar
 HEALTH EDUCATION
Decreasing cholesterol levels
 HEALTH EDUCATION
Stop smoking
 HEALTH EDUCATION
Decrease psychosocial stress
 HEALTH EDUCATION
Regular follow-ups
 HEALTH EDUCATION
Walk
 HEALTH EDUCATION
Swimming
 HEALTH EDUCATION
 Decreasing cholesterol levels
 Stopping smoking
 Decrease psychosocial stress.
 Regular follow-ups
 Exercise. Aerobic exercise, like walking,
jogging, or swimming, can reduce the
risk of mortality from coronary artery
disease.
 EVIDENCES REVIEW
 Evidence also suggests that the Mediterranean diet
and a high fiber diet lower the risk.

 The World Health Organization (WHO) recommends

"low to moderate alcohol intake" to reduce risk of
coronary artery disease while high intake increases
the risk

 Evidence does not support a beneficial role for

omega-3 fatty acid supplementation in preventing
cardiovascular disease (including myocardial
infarction and sudden cardiac death).
 Conti..
 High levels of physical activity reduce the
risk of coronary artery disease by about
25%.

 In diabetes mellitus, there is little evidence

that very tight blood sugar control improves
cardiac risk although improved sugar control
appears to decrease other problems such as
kidney failure and blindness.
 RECAPTUALIZATION
1. Which of the following illness is the leading cause of
death in the world?
a) Cancer
b) Coronary Artery Disease
c) Liver Failure
d) Renal Failure
Answer: b.
2. There are number of risk factors associated with CAD.
Which of the following is a modifiable risk factor?
a) Obesity
b) Heredity
c) Gender
d) Age
Answer: a.
 RECAPTUALIZATION
3. Which of the following conditions most commonly
results in CAD?
a) Atherosclerosis
b) Diabetes mellitus
c) Myocardial Infarction
d) Renal Failure
Answer: a.
4. Atherosclerosis impedes coronary blood flow by which
of the following mechanisms?
a) Plaques obstruct the vein
b) Plaques obstructs the artery
c) Blood clots from outside the vessel wall
d) Hardened vessels dilate to allow the blood flow through
Answer: b.
 BIBLIOGRAPHY

 Brunner & Suddarth. Text book of

medical & surgical nursing, edition 8th,
28th chapter; (859-64).

 Lippincott J.B. Text book of medical&

surgical nursing. 4th ed.; (1347-48).

 Black J.M. Text book of medical&

surgical nursing, 7th ed; 56 chapter;
(1410-1415).