Arteriosclerosis and Atherosclerosis

Arteriosclerosis, or “hardening of the arteries,” is the most common disease of the

arteries. It is a diffuse process whereby the muscle fibers and the endothelial lining
of the walls of small arteries and arterioles become thickened.

Atherosclerosis primarily affects the intima of the large and medium-sized arteries,
causing changes that include the accumulation of lipids (atheromas), calcium,
blood components, carbohydrates, and fibrous tissue on the intimal layer of the
artery. Although the pathologic processes of arteriosclerosis and atherosclerosis
differ, rarely does one occur without the other, and the terms often are used
interchangeably. The most common direct results of atherosclerosis in the arteries
include narrowing (stenosis) of the lumen and obstruction by thrombosis,
aneurysm, ulceration, and rupture; ischemia and necrosis occur if the supply of
blood, nutrients, and oxygen is severely and permanently disrupted.

Atherosclerosis can develop anywhere in the body but is most common in

bifurcation or branch areas of blood vessels. Atherosclerotic lesions are of two
types: fatty streaks (composed of lipids and elongated smooth muscle cells) and
fibrous plaques (predominantly found in the abdominal aorta and coronary,
popliteal, and internal carotid arteries).

Risk Factors

Many risk factors are associated with atherosclerosis; the greater the number of
risk factors, the greater the likelihood of developing the disease.

• The use of tobacco products (strongest risk factor)

• High fat intake (suspected risk factor, along with high serum cholesterol and
blood lipid levels)

• Hypertension

• Diabetes

• Obesity, stress, and lack of exercise

• Elevated C-reactive protein

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Clinical Manifestations

• Femoral, popliteal arteries.

• Sudden pain in the affected area because of spontaneous muscle contractions

due to the reduced oxygenation of tissue.

• Intermittent claudication—pain, numbness, and/or weakness with walking

due to increased oxygen demand of the muscle during activity.

• Weak or absence of pulse in affected area because blood flow is reduced or

blocked.

• Decreased temperature distal to the blockage because of restricted blood flow.

• Pallor or patchy coloring (mottling) of affected area because of reduced tissue

oxygenation.

• Dependent rubor (increased redness when legs are lower).

• Hair loss on extremities.

Clinical features depend on the tissue or organ affected: heart (angina and MI due
to coronary atherosclerosis), brain (transient ischemic attacks and stroke due to
cerebrovascular disease), peripheral vessels (includes hypertension and symptoms
of aneurysm of the aorta, renovascular disease, atherosclerotic lesions of the
extremities). See specific condition for greater detail.

Management

The goal of treatment is to maintain adequate blood flow to the area and avoid
tissue damage. Patients are encouraged to maintain activity and reduce risks for
disease, such as smoking, as well as to control blood pressure and monitoring
diabetes.

Medical treatment:

• Exercise.

• Smoking cessation.

• Decrease in lipids, depending on what the labwork shows.

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Surgical treatment:

• Femoropopliteal bypass graft: A vessel from another part of the body is removed
and grafted to the affected artery, permitting blood to bypass the blockage.

• Percutaneous transluminal angioplasty: A catheter containing a balloon is

inserted into the affected artery. The balloon is inflated, stretching the artery; this
causes a healing response that breaks up plaque on the artery wall.

• Atherectomy: A catheter containing a grinding tool is inserted into the affected

artery and is used to grind plaque from the artery wall. • Embolectomy: Surgical
removal of a blood clot from the affected artery.

• Thromboendarterectomy: Surgical removal of atherosclerotic tissue from the

affected artery.

• Laser angioplasty: A laser-tipped catheter is inserted into the affected artery to

remove the blockage.

• Stent: A metal mesh tube is inserted into the affected artery to keep the artery
open.

• Amputation: Surgical removal of the affected limb that contains gangrene caused
by low blood flow or complete blockage of blood to the affected limb.

• Administer antiplatelets medication to enhance blood flow to the lower

extremities. This helps to get blood through the vessels and alleviates symptoms.

• penoxifylline

• cilostazol

• aspirin

• clopidogrel

• dipyridamole

• ticlopidine

NURSING DIAGNOSES

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 • Fear

• Ineffective tissue perfusion

• Risk for injury

NURSING INTERVENTION

• Monitor most distal pulse to assure circulation exists.

• Compare bilateral pulses.

• Monitor temperature, color of affected area indicating tissue perfusion.

• Support hose.

• Check capillary refill.

• Administer anticoagulant (such as heparin, warfarin) as directed.

• Administer pain medication as directed.

• Don’t elevate leg or apply heat if occlusion affects the femoral or popliteal
arteries.

• Elevation of the lower extremities makes it harder for the blood flow to get
to the tissues.

• Avoid prolonged sitting, which increases the risk of compression to vessels

(impeding blood flow to lower extremities) and increases risk of clot formation in
lower extremities.

• Explain to the patient:

• How to check pulses in the affected area if there is an absence of a pulse.

• Call the physician if the patient experiences numbness, paralysis, or pain.

• Don’t wear tight clothes; avoid tight knee-high hose, which constricts at the
popliteal space; avoid tight waist bands; ensure wide shoe box.

• Change his/her lifestyle to reduce the risk of peripheral arterial occlusive

disease.

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 • The importance of regular examinations.

• Foot check daily for open wounds, redness.

• Regular visits to podiatrist.

• Regular consults to vascular MD.

Thrombophlebitis

Throbmophlebitis is the inflammation of a vein as a result of the formation of one

or more blood clots (thrombus). It is usually seen in the lower extremities, calves,
or pelvis. This may be the result of injury to the area, may be precipitated by
certain medications or poor blood flow, or may be the result of a coagulation
disorder.

Prognosis

Prognosis is usually good unless embolization, or moving of the clot, occurs. It

may move to the lung or brain, which can be life-threatening.

Clinical Manifestations

• May be asymptomatic

• Edema, tenderness, and warmth in the affected area as part of an

inflammatory response

• Palpable tender cord

• Positive Homan’s sign—pain on dorsiflexion of the ipsalateral foot—is an

unreliable sign

• Cramping because blood flow to the area is impaired due to the presence of
the clot

• If the clot dislodges from the vein and travels to the lung, other symptoms will
develop:

• Difficulty breathing (dyspnea) when the clot has traveled to the lungs

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 • Rapid breathing >20 breaths per minute (tachypnea) because of a clot in the
lungs

• Chest pain in the area of clot

• Crackle sounds in lungs in the area of clot

Diagnostic Investigations

• Ultrasound determines if blood is flowing to the affected area.

• Photoplethysmography depicts any defects in venous filling in the affected

area.

• Lab investigation to look for clotting disorders.

Management

Patients with large deep vein thrombosis (DVT), or with comorbidities (a disease
coexisting with, and often impacting on, another disease present), and/or advanced
age should be managed in the hospital. Treatment consists of anticoagulation to
prevent further occurrences.

• Administer anti-inflammatory medication to decrease the inflammation

within the vessel

• aspirin, indomethacin

• Administer anticoagulant medication to prevent the clot from becoming

larger:

• heparin, warfarin, dalteparin, enoxaparin

• Limit activity initially to diminish risk of moving clot—bedrest with

bathroom priviledges

NURSING DIAGNOSES

• Ineffective tissue perfusion

• Acute pain

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 • Impaired skin integrity

NURSING INTERVENTION

• Monitor breathing because changes in respiratory status can signal that a clot
has dislodged and moved to the lung.

• Monitor labs because the patient is receiving anticoagulants. Monitor for

therapeutic effect.

• Apply warm moist compresses over affected area because it enhances blood
flow to area.

• Explain to the patient:

• Report signs of bleeding—anticoagulant may be too much.

• Report signs of clotting—pain in affected area, shortness of breath— patient

may have underlying clotting disorder.

• Move about frequently when allowed—discourages chances of developing

another clot.

• Don’t cross legs—avoid constriction of lower extremity vessels.

• Don’t use oral contraceptives—increases risk of clot formation.

• Support hose.

• Elevate affected area.

Angina Pectoris

Angina pectoris is a clinical syndrome characterized by paroxysms of pain or a

feeling of pressure in the anterior chest. The cause is insufficient coronary blood
flow, resulting in an inadequate supply of oxygen to meet the myocardial demand.
Angina is usually a result of atherosclerotic heart disease and is associated with a
significant obstruction of a major coronary artery. Factors affecting anginal pain

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are physical exertion, exposure to cold, eating a heavy meal, or stress or any
emotion-provoking situation that increases blood pressure, heart rate, and
myocardial workload. Unstable angina is not associated with the above and may
occur at rest.

Pathophysiology

A narrowing of blood vessels to the coronary artery, secondary to arteriosclerosis,

results in inadequate blood flow through blood vessels of the heart muscle, causing
chest pain. An episode of angina is typically precipitated by physical activity,
excitement, or emotional stress.

There are three categories of angina.

• Stable angina—pain is relieved by rest or nitrates and symptoms are consistent.

• Unstable angina—pain occurs at rest; is of new onset; is of increasing intensity,

force, or duration; isn't relieved by rest; and is slow to subside in response to
nitroglycerin.

• Prinzmetal’s or vasospastic angina—usually occurs at rest or with minimal

formal exercise or exertion; often occurs at night.

Atherosclerotic heart disease occurs when there is a build up of plaque within the
coronary arteries. Angina is often the first symptom that heart disease exists. When
the demand for oxygen by the heart muscle exceeds the available supply, chest
pain occurs.

Prognosis

Patients can often be managed with lifestyle modifications and medications to

control symptoms of angina. The most important factor is patient education.
Patients need to understand the importance of their symptoms and when to seek
medical attention. The pain must be evaluated initially and whenever a change in
pattern or lack of response to treatment occurs.

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Clinical Manifestations

• Pain varies from a feeling of indigestion to a choking or heavy sensation in the

upper chest ranging from discomfort to agonizing pain. The patient with diabetes
mellitus may not experience severe pain with angina.

• Angina is accompanied by severe apprehension and a feeling of impending death.

• The pain is usually retrosternal, deep in the chest behind the upper or middle third
of the sternum.

• Discomfort is poorly localized and may radiate to the neck, jaw, shoulders, and
inner aspect of the upper arms (usually the left arm).

• A feeling of weakness or numbness in the arms, wrists, and hands, as well as

shortness of breath, pallor, diaphoresis, dizziness or lightheadedness, and nausea
and vomiting, may accompany the pain. Anxiety may occur with angina.

• An important characteristic of anginal pain is that it subsides when the

precipitating cause is removed or with nitroglycerin.

Gerontologic Considerations

The elderly person with angina may not exhibit the typical pain profile because of
the diminished responses of neurotransmitters that occur with aging. Often, the
presenting symptom in the elderly is dyspnea. Sometimes, there are no symptoms
(“silent” CAD), making recognition and diagnosis a clinical challenge. Elderly
patients should be encouraged to recognize their chest pain–like symptom (eg,
weakness) as an indication that they should rest or take prescribed medications.

Assessment and Diagnostic Methods

• Evaluation of clinical manifestations of pain and patient history

• Electrocardiogram changes (12-lead ECG), stress testing, blood tests

• Echocardiogram, nuclear scan, or invasive procedures such as cardiac

catheterization and coronary angiography

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Medical Management

The goal of treatment is to deliver sufficient oxygen to the heart muscle to meet its
need. When suspecting chest pain, always give oxygen as the first line of defense.
Medications are used initially to treat symptoms and increase blood flow to the
heart muscle. Medications are used for symptom control and cholesterol
management in the long term. Cardiovascular interventions are used to maintain
adequate blood flow through the coronary arteries.

• 2 to 4 liters of oxygen.

• Administer beta-adrenergic blocker—this class has a cardioprotective effect,

decreasing cardiac workload and likelihood of arrhythmia.

• Drugs like propranolol, nadolol, atenolol, metoprolol.

• Administer nitrates—aids in getting oxygenated blood to heart muscle.

• Nitroglycerin—sublingual tablets or spray; timed-release tablets.

• Topical nitroglycerin—paste or timed-released patch.

• Aspirin for antiplatelet effect.

• Analgesic—typically morphine intravenously during acute pain. The medicine is

very fast-acting when given this way and will decrease myocardial oxygen demand
as well as decrease pain. The following should be watched separately.

• Percutaneous transluminal coronary angioplasty. This is a nonsurgical procedure

in which a long tube with a small balloon is passed through blood vessels into the
narrowed artery. The balloon is inflated, causing the artery to expand.

• Coronary artery stent. This is a small, stainless steel mesh tube that is placed
within the coronary artery to keep it open.

• Coronary artery bypass graph (CABG). This is a surgical procedure in which a

vein from a leg or an artery from an arm or the chest is removed and graphed to
coronary arteries, bypassing the blockage and restoring free flow of blood to heart
muscles.

• Low-cholesterol, low-sodium, and low-fat diet.

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Nursing Diagnoses

• Anxiety

• Decreased cardiac output

• Acute pain

Nursing Process

The Patient With Angina

Assessment Gather information about the patient’s symptoms and activities,

especially those that precede and precipitate attacks of angina pectoris. In addition,
assess the patient’s risk factors for CAD, the patient’s response to angina, the
patient’s and family’s understanding of the diagnosis, and adherence to the current
treatment plan.

Diagnosis

Nursing Diagnoses

• Ineffective cardiac tissue perfusion secondary to CAD as evidenced by chest pain

or other prodromal symptoms

• Death anxiety

• Deficient knowledge about underlying disease and methods for avoiding

complications

• Noncompliance, ineffective management of therapeutic regimen related to failure

to accept necessary lifestyle changes

Nursing Intervention

• Monitor vital signs—look for change in BP, P, R; irregular pulse; pulse deficit;
when a discrepancy is found between an atrial rate and a radial rate, when
measured simultaneously; pulse oximetry.

• Notify physician if systolic blood pressure is less than 90 mmHg. Nitrates dilate
arteries to the heart and increase blood flow. You may have an order to hold

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nitrates if SBP <90 mmHg to reduce risk of patient passing out from lack of blood
flow to brain.

• Notify physician if heart rate is less than 60 beats per minute. Beta-adrenergic
blockers slow conduction through the AV node and reduce the heart rate and
contractility. You may have an order to hold beta blockers if heart rate goes below
60; you should continuously monitor the patient’s pulse rate.

• Assess chest pain each time the patient reports it.

• Remember PQRST (an acronym for a method of pain assessment) as

follows.

Determine the place, quality (describe the pain—stabbing, squeezing, etc.),

radiation (does the pain travel anywhere else?), severity (on a scale of 1 to 10), and
timing (when it started and how long it lasts and what preceded the pain).

• Monitor cardiac status using a 12-lead electrocardiogram (EKG) while the patient
is experiencing an angina attack. Each time the patient has pain, a new 12-lead
EKG is done to assess for changes, even if one was already done that day.

• Record fluid intake and output. Assess for renal function. • Place patient in a
semi-Fowler's position (semi-sitting with knees flexed).

• Explain to patient:

• Rest when pain begins to decrease oxygen demands.

• Take nitroglycerin when any pain begins—it helps dilate coronary arteries
and get more oxygen to heart muscle.

• Avoid stress and activities that bring on an angina attack.

• Call 911 if the pain continues for more than 10 minutes or as the patient is
taking the third nitroglycerine dose (1 sublingual dose every 5 minutes, if BP
allows, for maximum of 3 doses).

• Stop smoking! Smoking is associated with heart disease.

• Adhere to the prescribed diet and exercise plan. Lower cholesterol and fat
intake to decrease further plaque build-up, and decrease excess salt intake to help
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BP control. Slowly increase exercise to build up activity tolerance. Possibly
exercise with cardiac rehabilitation.

• How to recognize the symptoms of a myocardial infarction: Pay attention to

chest pains as well as changes in patterns of pain and response to treatment. Be
aware of changes in respiratory patterns, increase in shortness of breath, swelling,
and general feelings of malaise.

Factors that Trigger Angina Episodes

• Sudden or excessive exertion

• Exposure to cold

• Tobacco use

• Heavy meals

• Excessive weight

• Some over-the-counter drugs, such as diet pills, nasal decongestants, or drugs that
increase heart rate and blood pressure

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