MANAGEMENT OF PATIENTS WITH CORONARY VASCULAR DISORDERS

SLIDE 10
CAD
-most prevalent
-more on male
-more 10 years for female because of hormones
-due to atherosclerosis
-loss of oxygen and nutrients to myocardial tissue (that is what we call ischemia)
-becuase of diminished coronary blood flow

SLIDE 11
CORONARY ATHEROSCLEROSIS
-abnormal accumulation of lipid, substance and fibrous tissue in the vessel wall.
-plaques create blockages or narrow the blood vessels
-clot>platelets>plaque>thrombus>high bp>embolus>stroke or loss of oxygen and
nutrients
-low oxygen will activate anaerobic metabolism, it will now break down near organic
which is cell, it will break down cell to produce oxygen supply. But the problem
is, magpproduce din ang nabreak down na cell ng byproduct which is the Lactic Acid.
Ang lactic acid ang dahilan kung bakti may nararamdaman na pain. mataas si Lactic
Acid
-fibrous plaque dahil sa platelet, nag accumulate ng accumulate hanggang sa maging
complicated lesion na sya inside vessels
-SS: location and degree of narrowing of the arterial lumen, thrombus formation,
and obstruction of blood flow to myocardium, inadequate blood supply and nutrients
(ischemia) that deprives cells of oxygen for survival kaya bagsak din ang function
ni heart that can lead to necrosis or cell death, sudden cardiac death due to CAD
-CAD is PROGRESSIVE, pagtanda saka palang lalabas ang mga symptoms
-findings during symptomatic periods: chest pain due to lactic acid, plapitation
dahil nag cocompensate, dyspnea or difficulty of breathing dahil kulang ang O2 sa
katawan, syncope or loss of consciousness, cough or hemoptysis dahil connected ang
heart sa lungs dahil overload dahil sa HR mabilis din ang pagprocess ng RBC sa
lungs which is lumalabas yung iba through cough, excessive fatigue dahil kulang na
ng energy sa katawan

>Non modifiable risk factors

-family Hx of coronary heart disease
-increasing age (physical changes)
-gender (more on males
-Race (higher in african american)

>Modifiable Risk Factors

-High blood cholesterol level (magbigay ng meds like atorvastatin, mga stin yung
dulo kadalasan binibigay sa gabi)
-Cigarette smoking, tobacco use (mas deadly kaysa alcohol, kahit VAPE)
-hypertension (bestfriend ni DM, kapag may narrowing of blood vessel, affected si
insulin at di naopprocess ang pag gawa ng glucose then nandito lang sa blood stream
si glucose > high blood sugar > nagiging malapot ang dugo > hirap ngayon dumaan ang
blood carrying oxygen > high blood pressure
-diabetes mellitus
-lack of estrogen in women
-obesity (dakilang couch potato all his life) take BMI

>Metabolic syndrome
-insulin resistance (due to narrowing ng blood vessels, affected din ang
metabolism, makakita ka ng acantosis or maitim ang batok, singil, liki liki)
-central obesity (malaki ang katawan, maliit and extremetis)
-dyslipidemia (abnormalities sa lipid sa blood)
-BP persistentlu high
-high fibrinogen level (pag masyadong mataas ang clotting ni pt(thrombus),
nakakatakot dahil sa embolus causing stroke

>prevention
-control cholesterol abnormalities (by changhing lifestyle, statin statin meds)
-dietary measures (limit intake ng fatty foods, may maximum amount)
-promoitjng of cessation of tobacco use (stop smoking)
-managing HTN (lalo sa mtatanda)
-controlling diabetes
-*gender

>Dx studies
-ecg (pag ang pt may ischemia, meron tayong tinatawag na ST segment depression, T
wave inversion or both eto yung tinatawag na V Wave) (si infarction unlike
ischemia, may necrosis or cell death na, ST segment elevation naman folloewed by T
inversion)
-cardiac catheterization (jugular and femoral ang pasok papunta kay heart sa mga
arteries, its either tatanggalin ang plaque or connected sa x ray imaging para
makita kung may nakabara, elevated blood lipid levels laya need ng cholesterol -
lowering medications -statin)

>Interventions
-kung ano ba purpose ng Dx, medical and surgical procedure, kung ano din yung
gagawin sa preprocedure at postprocedure expectations INSTRUCT
-assist client to identify risk factors that can be modified (lifestyle) tanungin
kung okay o makikipag cooperate ba si pt sa changes
-assist to set goals to promote lifestyle changes
-identify barriers to compliance (may tanim ba na foodie plant cuties na green
leafy veggies, work sa factories
-low calorie, sodium, choles, fat diet increase mo yung dietray fiber (pasko
problems)
-DIETARY MUST BE MENTAINED FOR LIFE (hindi lang pag pasko tanga)
-excercise, smoking cessation as appropriate

A-ACE INHIBITORS (may -pril sa dulo)

B-beta blockers (may mga -lol)
C-calcium channel blockers (may -pin sa dulo)
A-ARBS

>Meds
1. nitrates (dilate coronary arteries, mas maganda nag pasok ng blood pati
pagdeliver ng oxygen sa hearts and other parts of the body)
2. calcium channel blockers (pang dilate din at reduce vasospasm)
3. cholesterol-lowering meds (-statin)
4. B-blockers (reduce bp para sa hypertensive)

>Surgical Procedures (pag angioplasty may nirerepair)

1. PTCA (percutaneous transluminal coronary arteries)
2. Lasor Angioplasty (repair)
3. Atherectomy (removal or certain part of blood vessels
4. vascular stent (minsan with PTCA, may ipapasok na catheter tas ididilate ang
blood vessel tas tatanggalin after ibuka, si vascular stent naman may mesh na
permanent na)
5. coronary artery bypass grafting (CABG)
-kukuha ng other arteries from other parts

ANGINA PECTORIS
-acute chest pain due to inadequate oxyan supply or ischemia , si anaerobic
ibbreakdown ang nearest organic matter which is si cell, ang byproduct is si Lactic
Acid that produces pain
-pain or pressure in the anterior chest
-patho: can caused by atherosclerosis, when demand increases dahil sa oxygen, need
pa nya itaas ang flow ng coronary arteries, nagkakaroon ng problem pag wala nadin
maibigay si coronary artery due to plaque and thrombus

>several factors associated with anginal oain

-pain exertion (bawal heavy workload)
-exposure to cold (mas mataas ang risk magkaroon ng chest pain
-eating a heavy meal
-stress or any emotoion-provoking situating (baka atakihin like sa kdrama) pag
stress tumataas and work load ng puso mo, baka may tama na si myocardium kaya di na
kaya mag compensate

>types of Angina
1. Stable angina
-predictable (pag may ginawa na certain activity)
-pag magpahinga ka mawawala ang sakit
2. Unstable angina (preinfarction agina)
-mas mahaba ang frequency kay stable angina
-mas lower ang pain compare kay stable angina
3. Variant angina or Prinzmetal's angina
-pain at rest tapos may reversible ST-segment elevation
4. Infractable or refractory angina
-sobrang sakit dika na makakilos
5. Sildent Ischemia
-deadly
-walang symptoms
-makikita sa ECG with stress test

Angina pectoris
-poorly localized (dimo masabi kung saan talaga ang pain)
-nag raradiate sa neck, shoulders, chest
-RADIATE SA LEFT SIDE NG BODY , minsan sumasakit ang sikmura not knowing na may
ischemia

>SS
-retrosternal (masakit anterior and posterior)
-TIGHTNESS, SQUEEZING, CRUSHING sensation
-para kayong chinochoke or strangle
-pag may DM, bagsak ang nocireceptor (nagrereceive ng pain) , blunt na or late
reaction because of "diabetic neuropathy" kaya bawal magpa manicure pedicure kung
saan saan dahil di yon mararamdaman at poor healing sa injury , bawal din ang
footspa
-weakness and numbness in the arms, wrists, and hands, as well as shortness of
breath

>Assessment
-history taking muna (may symptoms naba, makimarites
-12-lead ECG
-cardiac biomarker testing (?)
-serum lipid and enzyme values (HDL AND LDL)
-treadmill stress test
-echocardiogram (2d echo)
-nuclear scan
-invasive procedure: cardiac catheterization/coronary

MED mgt: o2 therapy

-decrease the oxygen deman of the myocardium and
-increase the oxygen supply

>Pharma therapy
1. NTG
-nitrates are the standard treatment for angina pectorus
-pwedeng by mouth, IM, topical, NTG patch
-vasodilator
-i check and BP, it should not be lower than 90/60 , and hr

>Read
1. instruct pt to make sure mouth is moist, if severe can crush the tablet, don't
swallow, only sublingual
2. Ready meds at all times and in the orig containes (capped dark glass bottle)
because it is highly volatile and it adheres to plastic , shouldn't be stored in
metal and plastic pillboxes
3. "volatile and is inactivated by heat", moisture, air, light, and time. time
shelf: 6 months
4. should be taken in anticipation of any activity , best taken before pain
develops
5. pwedeng itake 3 times na sunod sunod withing 5 minute interval ex:8:00 , 8:05,
8:10 pag di nabawasan ang pain, magatwag na ng emergency medical service
6. side effects: flushing, tachycardia

Take note!
-exclude midnight dose
-3 or 4 times daily or every 6 hrs
-may 6 t0 8 hrs na nitrate free and pt para hindi magkaron ng tolerance ang pt ng
NTG
-di mo dapat biglaan na tatanggalin, mag tataper down kayo. 6 hrs, 4 hrs, 2 hrs

>Beta Adrenergic Blocking Agents

-reduced myocardial oxygen consumption by blocking the beta-adrenerguc sympathetic
stimulation to the heart
-ibblock and sympathetic stimulation kaya nagkakaroon ng reduction in our heart
rate
-pinapabagal
-propanolol, metoprolol,

>Calcium Channel Blocking Agents

-pril
-calcium ion antagonists
-calcium is a type ng substance na nagpapa contract kay heart
-ibblock ang calcium, instead icontract ang heart, magrerelax ang blood vessels
-pag naka dilate na, bababa na ang BP dina need mag double time

>Aspirin
-connected ng platelet activation
-platelet is for clotting
-natatanggal si platelet so wala ng clotting para maprevent si thrombus na
dislodged. para maiwasan si aspirin
-side effects: GASTROINTESTINAL UPSET AND BLEEDING
-160 to 325 mg as soon as diagnosed is given

>Heparin
-wlang solid form, liquid
-thru IV not IM binibigay
-prevents formation of new blood clots
-reduces occurence of MI
-bleeding precautions: pressure on bleeding site (maglagay ng pressure atleast 5 to
10 minutes sa punctured site dahil wala si platelet), bawal ang IM, bawal ang
continuos na pagccheck ng blood pressure dahil sa BP cuff dahil madali magsugat at
magkapasa pasa

>O2 administration
-initiated at the onset of chest pain
-2 to 3 L via nasal cannula
-increase amount of oxygen na dinadala kay myocardium so nadedecrease ang pain
-observe rate and rythm of respirations para malaman kung effective

>Interentions
1. Assess pain (ask kung kaya ituro ang pain, kung nagraradiate ba, or pain scale)
then give pain relief measures
2. administer 3L o2 via nasal cannula
3. Assess vital signs and provide cardiac monitoring and NTG as prescribed

M-MORPHINE (side effects is resp depression, para kay pain because it is opiod
analgesic, check RR, AND HR. pag mababa ang RR wag ibigay si morphine)
O-OXYGEN (check rate and rythm)
N-NTG
A-ASPIRIN
B-BETA BLOCKERS

>Interventions
immidiate mgt
d. bed rest is maintaines, semi fowler's , stay with the client
e. obtain a 12 lead ECG
f. establish IV route

ACUTE CORONARY SYNDROME (ACS)

-emergent situation
-acute onsent of myocardial ischemia

>spectrum of acs include

1. unstable angina
2. non ST elevation myocardial infarction NSTEMI
3. ST elevation myocardial infarction
STEMI