Perfusion

Coronary Artery Disease

Acute Coronary Syndrome

Myocardial Infarction
Coronary Artery Disease
Coronary Artery Disease
• Coronary artery disease is the buildup of plaque
in the arteries that supply oxygen-rich blood to
your heart. Plaque causes a narrowing or
blockage that could result in a heart attack.
Symptoms include chest pain or discomfort and
shortness of breath.
Coronary Atherosclerosis

• Atherosclerosis is the abnormal accumulation of lipid deposits and fibrous

tissue within arterial walls and lumen
• In coronary atherosclerosis, blockages and narrowing of the coronary
vessels reduce blood flow to the myocardium
• Cardiovascular disease is the leading cause of death in the United States
for men and women of all racial and ethnic groups
• Coronary artery disease (CAD) is the most prevalent cardiovascular disease
in adults
Pathophysiology
of
Atherosclerosis
This image
describes
about the
Coronary
Arteries
Clinical Manifestations

Symptoms are caused by myocardial ischemia

Symptoms and complications are related to the location and degree of vessel
obstruction
Angina pectoris (most common manifestation)
Other symptoms: epigastric distress, pain that radiates to jaw or left arm, SOB,
atypical symptoms in women
Myocardial infarction
Heart failure
Sudden cardiac death
Risk Factors for Coronary Artery Disease (CAD)

• Refer to Chart
• Four modifiable risk factors cited as major (cholesterol abnormalities,
tobacco use, HTN, and diabetes)
• Elevated LDL: primary target for cholesterol-lowering medication
• Framingham risk calculator
• Metabolic syndrome
• hs-CRP (high-sensitivity C-reactive protein)
Prevention of CAD

• Control cholesterol
• Dietary measures
• Physical activity
• Medications
• Cessation of tobacco use
• Manage HTN
• Control diabetes
Cholesterol Medications

• Six types of lipid-lowering agents: affect the lipid components somewhat

differently (Table 27-2)
• 3-Hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) (or statins)
• Nicotinic acids
• Fibric acids (or fibrates)
• Bile acid sequestrants (or resins)
• Cholesterol absorption inhibitors
• Omega-3 acid-ethyl esters
Question #1

The nurse is caring for a patient with hypercholesterolemia who has been
prescribed atorvastatin (Lipitor). What serum levels should be monitored in
this patient?
A. Complete blood count (CBC)
B. Blood cultures
C. Na and K levels
D. Liver enzymes
Answer to Question #1

D. Liver enzymes
Rationale: Atorvastatin (Lipitor) is an HMG-CoA reductase inhibitor and is
hepatotoxic. Therefore, liver enzymes should be monitored in patients taking
this medication
Angina Pectoris

• A syndrome characterized by episodes or paroxysmal pain or pressure in

the anterior chest caused by insufficient coronary blood flow
• Physical exertion or emotional stress increases myocardial oxygen demand,
and the coronary vessels are unable to supply sufficient blood flow to meet
the oxygen demand

• Types of angina
• Refer to Chart 27-2
Assessment and Findings

• May be described as tightness, choking, or a heavy sensation

• Frequently retrosternal and may radiate to neck, jaw, shoulders, back or
arms (usually left)
• Anxiety frequently accompanies the pain
• Other symptoms may occur: dyspnea or shortness of breath, dizziness,
nausea, and vomiting
• The pain of typical angina subsides with rest or NTG
• Unstable angina is characterized by increased frequency and severity and is
not relieved by rest and NTG. Requires medical intervention!
Gerontologic Considerations

• Diminished pain transition that occurs with aging may affect presentation
of symptoms
• “Silent” CAD
• Teach older adults to recognize their “chest pain–like” symptoms (i.e.,
weakness)
• Pharmacologic stress testing; cardiac catheterization
• Medications should be used cautiously!
Treatment

• Treatment seeks to decrease myocardial oxygen demand and increase

oxygen supply
• Medications
• Oxygen
• Reduce and control risk factors
• Reperfusion therapy may also be done
Medications

• Nitroglycerin
• Beta-adrenergic blocking agents
• Calcium channel blocking agents
• Antiplatelet and anticoagulant medications
• Aspirin
• Clopidogrel and ticlopidine
• Heparin
• Glycoprotein IIb/IIIa agents
Question #2

The nurse is caring for a patient who has severe chest pain after working
outside on a hot day and is brought to the emergency center. The nurse
administers nitroglycerin to help alleviate chest pain. What side effect
should concern the nurse the most?
A. Dry mucous membranes
B. Heart rate of 88 bpm
C. Blood pressure of 86/58 mm Hg
D. Complaints of headache
Answer to Question #2

C. Blood pressure of 86/58 mm Hg

Rationale: Nitroglycerin dilates vessels in the body. Dilation of the veins
causes venous pooling of blood throughout the body. As a result, less blood
returns to the heart, and filling pressure (preload) is reduced. If the patient is
hypovolemic, the decrease in filling pressure can cause a significant decrease
in cardiac output and blood pressure. This patient was working outside on a
hot day, and the possibility of dehydration and hypovolemia should be
considered. Dry mucous membranes can cause poor absorption of sublingual
nitroglycerin but is not the most concerning. B and D are insignificant
findings
 Assessment

• Symptoms and activities, especially those that precede and precipitate

attacks (Chart 27-4)
• Risk factors, lifestyle, and health promotion activities
• Patient and family knowledge
• Adherence to the plan of care
 Diagnoses

• Risk for decreased cardiac tissue perfusion

• Anxiety related to cardiac symptoms and possible death
• Deficient knowledge about the underlying disease and methods for
avoiding complications
• Noncompliance, ineffective management of therapeutic regimen related to
failure to accept necessary lifestyle changes
Collaborative Problems

• ACS, MI, or both

• Dysrhythmias and cardiac arrest (see Chapters 26 and 29)
• Heart failure (see Chapter 29)
• Cardiogenic shock (see Chapter 14)
 Planning

• Goals
• Immediate and appropriate treatment of angina
• Prevention of angina
• Reduction of anxiety
• Awareness of the disease process
• Understanding of prescribed care and adherence to the self-care
program
• Absence of complications
 Interventions

• Treat angina
• Reduce anxiety
• Prevent pain
• Educate patients about self-care
• Continuing care
 Treat Angina

• Priority
• Patient is to stop all activity and sit or rest in bed (semi-Fowler positioning)
• Assess the patient while performing other necessary interventions.
Assessment includes VS, observation for respiratory distress, and
assessment of pain. In the hospital setting, the ECG is assessed or obtained
• Administer medications as ordered or by protocol, usually NTG. Reassess
pain and administer NTG up to three doses
• Administer oxygen 2 L/min by nasal cannula
 Reduce Anxiety

• Use a calm manner

• Stress-reduction techniques
• Patient teaching
• Addressing patient’s spiritual needs may assist in allaying anxieties
• Address both patient and family needs
 Preventing Pain

• Identify level of activity that causes patients prodromal S&S

• Plan activities accordingly
• Alternate activities with rest periods
• Teach patient and family
 Patient Teaching

• Balance activity with rest

• Follow prescribed exercise regimen
• Avoid exercising in extreme temperatures
• Use resources for emotional support (counselor)
• Avoid over-the-counter medications that may increase HR or BP before
consulting with health care provider
• Stop using tobacco products (nicotine increases HR and BP)
• Diet low in fat and high in fiber
 Patient Teaching

• Medication teaching (carry NTG at all times!)

• Follow up with health care provider
• Report increase in S&S to provider
• Maintain normal BP and blood glucose levels
 Acute Coronary
Syndrome (ACS) and
Myocardial Infarction
(MI)
Acute Coronary Syndrome (ACS) and Myocardial
Infarction (MI)

• Emergent situation
• Characterized by an acute onset of myocardial ischemia that results in
myocardial death (i.e., MI) if definitive interventions do not occur promptly
• Although the terms coronary occlusion, heart attack, and MI are used
synonymously, the preferred term is MI
Effects of
Ischemia,
Injury, and
Infarction on
ECG
 Assessment

• Chest pain
• Occurs suddenly and continues despite rest and medication
• Other S&S: SOB; C/O indigestion; nausea; anxiety; cool, pale skin;
increased HR, RR
• ECG changes
• Elevation in the ST segment in two contiguous leads is a key diagnostic
indicator for MI
• Lab studies: cardiac enzymes, troponin, creatine kinase, myoglobin
 Diagnoses

• Acute pain related to increased myocardial oxygen demand and decreased

myocardial oxygen supply
• Risk for decreased cardiac tissue perfusion related to reduced coronary
blood flow
• Risk for imbalanced fluid volume
• Risk for ineffective peripheral tissue perfusion related to decreased cardiac
output from left ventricular dysfunction
• Anxiety related to cardiac event and possible death
• Deficient knowledge about post-ACS self-care
Collaborative Problems

• Acute pulmonary edema (see Chapter 29)

• Heart failure (see Chapter 29)
• Cardiogenic shock (see Chapter 14)
• Dysrhythmias and cardiac arrest (see Chapters 26 and 29)
• Pericardial effusion and cardiac tamponade (see Chapter 29)
 Planning

• Goals:
• Relief of pain or ischemic signs (e.g., ST-segment changes) and
symptoms
• Prevention of myocardial damage
• Maintenance of effective respiratory function, adequate tissue
perfusion
• Reduction of anxiety
• Adherence to the self-care program
• Early recognition of complications
 Nursing Interventions

• Relieve pain and S&S of ischemia

• Improve respiratory function
• Promote adequate tissue perfusion
• Reduce anxiety
• Monitor and manage potential complications
• Educate patient and family
• Provide continuing care
Nursing Management: ACS/MI

• Oxygen and medication therapy

• Frequent VS assessment
• Physical rest in bed with head of bed elevated
• Relief of pain helps decrease workload of heart
• Monitor I&O and tissue perfusion
• Frequent position changes to prevent respiratory complications
• Report changes in patient’s condition
• Evaluate interventions!
Invasive Coronary Artery Procedures

• Percutaneous transluminal coronary angioplasty (PTCA)

• Coronary artery stent
• Coronary artery bypass graft (CABG)
• Cardiac surgery
Percutaneous
Coronary
Intervention
Coronary
Artery
Bypass
Grafts
Greater and
Lesser
Saphenous Veins
Are Commonly
Used for Bypass
Graft vocedures
Cardiopulmonary
Bypass System
Nursing Management: Patient Requiring Invasive
Cardiac Intervention

• Assessment of patient
• Reduce fear and anxiety
• Monitor and manage potential complications
• Provide patient education
• Maintain cardiac output
• Promote adequate gas exchange
• Maintain fluid and electrolyte balance
• Minimize sensory–perception imbalance
Nursing Management: Patient Requiring Invasive
Cardiac Intervention

• Relieve pain
• Maintain adequate tissue perfusion
• Maintain body temperature
• Promote health and community-based care
Question #3

The nurse is caring for a patient after cardiac surgery. Which nursing
intervention is appropriate to help prevent complications arising from
venous stasis?
A. Encourage crossing of legs
B. Use pillows in the popliteal space to elevate the knees in the bed
C. Discourage exercising
D. Apply sequential pneumatic compression devices as prescribed
Answer to Question #3

D. Apply sequential pneumatic compression devices as prescribed.

Rationale: Sequential pneumatic compression devices should be used when
prescribed to help prevent venous stasis and clotting complications such as
deep vein thrombosis and pulmonary embolism. Patients should be
discouraged to cross their legs. Pillows should not be used in the popliteal
space to elevate the knees; rather, this should be avoided. Exercises, passive
and active, should be encouraged