CORONARY ARTERY DISEASE /

ACUTE CORONARY
SYNDROME
 left anterior
decending

right
coronary
artery

:heart block

posterior
decending artery
What Is Coronary Artery Disease?

The arteries, which start out

smooth and elastic, get plaque on
their inner walls, which can make
them more rigid and narrowed.
This restricts blood flow to your
heart, which can then become
starved of oxygen.

The plaque could rupture, leading

to a heart attack or sudden cardiac
death.
Ischemia happens most
during:
• Exercise or other exertion
• Eating
• Excitement or stress
• Exposure to cold
What Are the Symptoms of Coronary Artery Disease?

The most common symptom is angina, or

chest pain.

Angina can be described as a:

• Heaviness
• Pressure
• Aching
• Burning
• Numbness
• Fullness
• Squeezing
• Painful feeling

It can be mistaken for indigestion or

heartburn.
Angina is usually felt in the chest,
but may also be felt in the:

• Left shoulder
• Arms
• Neck
• Back
• Jaw
 Angina

- Results when the lack

of oxygen supply is
temporary and
reversible.

Types:
• Chronic Stable Angina
• Unstable Angina
• Prinzmetal’s Angina
Chronic Stable Angina
- Is the most common angina
type.

- It can also be referred to as

exertional angina,
emotional stress, cold
weather, and large meal.

- With rest, the angina attack

symptoms generally
improve.
 Unstable Angina

- Second most common angina type.

- This is a dangerous condition that

requires emergency treatment.

- Can occur without physical exertion

and is not relieved by rest or
medicine.

- The condition is cause by blood clots

that partially or totally block a
coronary artery.
Prinzmetal’s Angina
- also called Variant
angina

- is a rare angina type

- Caused by a spasm in a
coronary artery.
How Is Coronary Artery Disease Diagnosed?

Your doctor can tell if you have coronary

artery disease after:
• He learns your symptoms, medical
history, and risk factors
• A physical exam.
• Diagnostic tests, including an
electrocardiogram (ECG or EKG),
echocardiogram, exercise stress
tests, CT scans, cardiac
catheterization, and others. These
tests help your doctor know the
extent of your coronary heart
disease, its effect on your heart, and
the best treatment for you.
How Is Coronary Artery Disease Treated?
It can involve:

Lifestyle changes: If you

smoke, quit. Avoid processed
foods and adopt a low-trans-
fat, low-salt, and low-sugar
diet. Keep your blood sugar in
control if you have diabetes.
Exercise regularly
Medications: If lifestyle
changes aren’t enough,
medications may be needed.
The drugs you’ll take depend on
your situation. If you’ve been
diagnosed with coronary artery
disease, you’ll probably be on
aspirin and a statin, if not other
things.
Surgery and other procedures:

Common ones to treat

coronary artery disease
include:
• Balloon angioplasty
• Stent placement
• Coronary artery bypass
surgery
Nursing Diagnosis
1. Decreased Cardiac Output related
to changes in the frequency of heart
rhythm.
2. Impaired Tissue Perfussion related
to decrease in cardiac output.
3. Ineffective Airway Clearance
related to accumulation of secretions.
4. Ineffective Breathing Pattern
related to lung development in not
optimal.
5. Impaired Gas Exchange related to
pulmonary edema.
 Nursing Mangement for CAD / ACS
• Take immediate action if pt reports
pain or if pt’s prodromal symptoms
suggest anginal ischemia.
• Direct pt to stop all activities & sit or
rest in bed in semi fowlers position.
• Take vital signs & observe for signs
or respirator distress.
• Administer nitroglycerin sublingually
& assess pt’s response.
• Administer O2 therapy if its
respiratory rate is increased.
 PQRST Method for Pain Assessment
P = Provokes
• What causes pain?
• What makes it better?
• Worse?
Q = Quality
• What does it feel like?
• Is it sharp?
• Dull?
• Stabbing?
• Burning?
• Crushing? ( Try to let patient describe the pain,
• sometimes they say what they think you would like to hear. )
R = Radiates
• Where does the pain radiate?
• Is it in one place?
• Does it go anywhere else?
• Did it start elsewhere and now localised to one spot?
S = Severity
• How severe is the pain on a scale of 1 - 10?
( This is a difficult one as the rating will differ
from patient to patient. )
T = Time
• Time pain started?
• How long did it last?
Acute Coronary Syndrome / ACS

- is a syndrome (set of signs

and symptoms) due to
decreased blood flow in the
coronary arteries such as the
part of the heart muscle is
unable to function properly or
dies.
• The blockage can be sudden and occur
in one instant, or it may come and go
over a period of time.

• The condition occurs due to the buildup

of fatty deposits in and on the walls of the
coronary arteries. These arteries are
responsible for delivering oxygen and
nutrients to heart muscles.

• Heart muscles need a steady and

constant supply of oxygen-rich blood to
function. A blood clot is the most common
cause of a blocked coronary artery.
Types of acute coronary syndrome:

• Unstable angina

• Non-ST-segment elevation
myocardial infarction or heart attack
(NSTEMI)

• ST-segment elevation myocardial

infarction or heart attack (STEMI)
If there is elevation of the blood
markers suggesting heart damage,
but no ST elevation seen on the
EKG tracing, this is known as a
NSTEMI. NSTEMI may be
associated with other EKG changes
such as ST segment depression.
• Patients experiencing acute STEMI are at risk for
developing life-threatening arrhythmias like
ventricular fibrillation which causes sudden
cardiac arrest, sometimes referred to as
a “massive heart attack”. These patients require
cardiopulmonary resuscitation (CPR) and
defibrillation — a “shock” to restore a normal heart
rhythm.

• STEMI can be treated with “clot-busting” drugs

called thrombolytics (also called fibrinolytics) or
with a primary percutaneous coronary intervention
(PCI) in a cardiac catheterization lab.
• Patients experiencing acute STEMI are at risk for
developing life-threatening arrhythmias like
ventricular fibrillation which causes sudden
cardiac arrest, sometimes referred to as
a “massive heart attack”. These patients require
cardiopulmonary resuscitation (CPR) and
defibrillation — a “shock” to restore a normal heart
rhythm.

• STEMI can be treated with “clot-busting” drugs

called thrombolytics (also called fibrinolytics) or
with a primary percutaneous coronary intervention
(PCI) in a cardiac catheterization lab.
If the supply of oxygen to the cells
becomes too low, the cells of the heart
muscles can die. The lack of blood
supply to any tissue is called
ischemia. The death of the cells
results in damage to muscle tissue,
and this is a heart attack or
myocardial infarction.
 Signs and Symptoms
The signs and symptoms of acute coronary syndrome
generally begin quickly, sometimes without warning, and can
alert a person that something is wrong. Common symptoms
include:

• Chest pain or discomfort

• Pain or discomfort in one or both arms, the back, jaw, neck,

or stomach

• Shortness of breath

• Dizziness or feeling lightheaded

• Indigestion

• Nausea or vomiting

• Sweating
In other cases, the pain can be
unpredictable and get noticeably
worse even after rest, which is a
symptom of unstable angina.
Chest pain or discomfort is
typically the most common
symptom of acute coronary
syndrome, but signs and
symptoms vary depending on age,
sex, and the presence of other
medical conditions.
Risk factors
There are certain risk factors associated with acute
coronary syndrome that people should be aware of.
Risk factors include:

• Older age - men of 45 years or older, women aged

55 years or older

• High blood pressure or cholesterol

• Smoking

• Lack of physical activity

• Unhealthy diet, obesity, or overweight

• Diabetes

• Family history
Diagnosis

To make a quick and accurate diagnosis, a

doctor will perform tests as well as inquire
about any symptoms and previous medical
history. Typical tests include:

• Electrocardiogram (ECG): This test

measures the electrical activity in the
heart via electrodes attached to the skin.
Abnormal or irregular impulses may
indicate poor heart function due to a lack
of oxygen to the heart. Certain electrical
signal patterns may also help to indicate
the location of a blockage.
• Blood tests: Certain enzymes may
be detectable in the blood if cell
death results in damage to the heart
tissue. A positive result indicates a
heart attack.
• Cardiac perfusion scan: This scan can
show if the heart is getting enough
blood and can check areas of damage
after a heart attack.

*Information from these tests, as well as the

actual signs and symptoms, are used to help
diagnose acute coronary syndrome and
determine whether it should be classified as a
heart attack or unstable angina.
Treatment

- This is a medical emergency.

Immediate treatment is ordered for
acute coronary syndrome. The short-
term goals include relieving pain and
improving blood flow to help restore
heart function as quickly as possible.
- Long-term goals include improving
overall heart function, managing risk
factors, and lowering the risk of a
heart attack. Typical treatment
includes a combination of medical
drugs and surgical procedures.
Medications include:

• Nitroglycerin

• Antiplatelet drugs

• Beta blockers

• Angiotensin-converting enzyme (ACE)

inhibitors

• Angiotensin receptor blockers (ARBs)

• Statins
Lifestyle changes
In some people, acute coronary syndrome
may be prevented. Heart disease can lead
directly to acute coronary syndrome, but
those who do not have heart disease can
protect themselves by practicing a healthy
lifestyle:

• Following a heart-healthy diet: Eating

a diet that includes fruits, vegetables,
whole grains, and lean protein.
 Review
• What is the difference between
an Ischemia and an Infarct?
• Ischemia - occurs when a blood flow
to your heart is reduced,
preventing it from receiving
enough oxygen.

• Infarction -is tissue death

(necrosis)
due to inadequate blood supply
to the affected area.
• What are the common drugs used
in treating coronary artery disease?

• Nitroglycerin - widens arteries

• Aspirin - can prevent clots
• Beta Blockers - improve blood flow
• ACE Inhibitors - controls high blood
pressure & for the prevention
of heart attacks.
• Lipid Management - helps control
cholesterol that can block arteries
• What does PQRST pain assessment stands for?

P - provocative factors
- What makes the pain worse?
Q - quality
- Describe the pain
R - radiation
- Where is the pain?
- What area of the body is affected?
S - everity
- How does the pain compare with
other pain you have experienced?
T - ime
- Does the intensity of the pain
change in time?
• Types of acute coronary syndrome?

• Unstable Angina - chest pain that

occurs at rest or with exertion or stress.

• NSTEMI - may not cause changes on ECG.

The blockage may be partial or temporary,
and so the extent of the damage is relatively small.

• STEMI - caused by an abrupt and prolonged

blocked blood supply. It affects a large area
of the heart muscle, and so causes changes
ont he ECG.
• What are the invasive procedures
in treating CAD?

• PCI - Percutaneous Coronary Intervention also

known as coronary angioplasty.

• CABG - Coronary Artery Bypass Graft

• What is the difference between
CAD and ACS?

• CAD - Damage to the walls of the coronary

artery, mostly due to atherosclerotic plaque,
narrowing the coronary artery.

• ACS - An acute situation caused by a

sudden reduction of coronary blood flow, e.g.
by plaque rapture and/or thrombus formation
in a narrowing coronary artery.