RESPONSES TO ALTERED

TISSUE PERFUSION
BY: MELENA V. QUINTOS, MAN
Coronary Artery Disease

• Coronary Artery Disease a.k.a. Coronary

Heart Disease
• Most prevalent type of cardiovascular
disease.
• It refers to a spectrum of illnesses that
range from the least life threatening to the
most life threatening Acute Coronary
Syndrome such as AMI / Heart attack.
Coronary Artery Disease

• Refers to the variety of pathologic

conditions that causes narrowing or
obstruction of the coronary arteries which
causes decreased perfusion in the
myocardium
• Results from narrowing of the large and
medium sized coronary arteries due to plaque
formation
• Primarily caused by atherosclerosis
Coronary Artery Disease

• A broad term that includes stable angina

pectoris and acute coronary syndromes.
• Affects the arteries that provide blood,
oxygen and nutrients to the myocardium.
• Partial Occlusion – Ischemia
• Complete Occlusion – Infarction
• The heart may pump harder to meet
demands which may cause Heart Failure
CORONARY ARTERY DISEASE

Stages of Development of Coronary Artery

Disease:
1. Myocardial Injury - Atherosclerosis
2. Myocardial Ischemia – Angina Pectoris
3. Myocardial Necrosis – Myocardial Infarction
CORONARY ATHEROSCLEROSIS

• An abnormal accumulation of lipid, or fatty

substances and fibrous tissue in the vessel
wall. (Plaque / Atheroma Formation)
• A repetitious inflammatory response to
artery wall injury and an alteration to its
biophysical and biochemical properties
• Atheromas / Plaques
– Consist of lipids, cells,
fibrin, cell debris
– Lipids usually transported
with lipoproteins
– Deposited in the intima of
the arterial wall
– Initiated by smoking,
hypertension and other
lifestyle factors
Coronary Artery Disease

▪ Increased blood levels of low-density lipoprotein (LDL) irritate or

damage the inner layer of coronary vessels; LDL enters the vessel
(after damaging the protective barrier), accumulates, and forms a fatty
streak. Smooth muscle cells move to the inner layer to engulf the fatty
substance, producing fibrous tissue and stimulating calcium
deposition; this cycle continues, resulting in transformation of the fatty
streak into fibrous plaque; a coronary artery disease (CAD) lesion then
develops. Oxygen deprivation forces the myocardium to shift from
aerobic to anaerobic metabolism, leading to accumulation of lactic
acid and reduction of cellular pH; the combination of hypoxia, reduced
energy availability, and acidosis rapidly impairs left ventricular
function. The strength of contractions in the affected myocardial region
wanes as the fibers shorten inadequately, resulting in less force and
velocity; abnormal wall motion in the ischemic area results in less
blood being ejected from the heart with each contraction.
Assessment

▪ Angina (stable, unstable, crescendo, Prinz metals or variant)

that may radiate to the left arm, neck, jaw, or shoulder
blade; occurring after physical exertion, during sleep,
emotional excitement, exposure to cold, or a large meal
▪ Nausea, vomiting
▪ Fainting, sweating, cool extremities
▪ Hypertension, positive Levine sign (holding fist to chest),
decreased or absent peripheral pulses
▪ Xanthoma, arteriovenous nicking of the eye
▪ Obesity
Acute Coronary Syndrome
▪ Acute coronary syndrome (ACS, formerly called ischemic
heart disease) refers to a large spectrum of clinical
conditions including unstable angina, myocardial injury, and
myocardial infarction (MI). ACS is caused by a sudden onset
of cardiac tissue ischemia secondary to impaired blood flow.
▪ Death of myocardial tissue in regions of the heart with
abrupt interruption of coronary blood supply brought about
by inadequate oxygenation and is often caused by sudden,
complete blockage
▪ Characterized by localized formation of necrosis with
subsequent healing by scar formation and fibrosis
Acute Coronary Syndrome

▪ Caused by undiagnosed and untreated angina

▪ Occurs when the myocardial tissue is abruptly and
severely deprived of oxygen
▪ Ischemia develops if blood flow is acutely reduced
by 80 – 90 %
Modifiable Risk Factors

▪ Stress ▪ Hyperlipidemia
▪ Diet ▪ Diabetes Mellitus
▪ Exercise
▪ Obesity
▪ Cigarette Smoking
▪ Personality Type or
▪ Alcohol Behavioral Factors
▪ Hypertension ▪ Contraceptive Pills
Sign and Symptoms

1. Chest pain
- Excruciating visceral, viselike pain located at substernal and
rarely in precordial
- Usually radiates from back, shoulder, arms, axilla, jaw and
abdominal muscles (abdominal ischemia) and hands
- Not usually relieved by rest or by nitroglycerine
2. Dyspnea
3. Increase in blood pressure (initial sign)
4. Hyperthermia
5. Ashen skin (pale), cool, clammy, diaphoretic
Assessment and Diagnostics

▪ Patient History of illnesses

▪ Family Health History
▪ Echocardiogram
▪ ECG – done within 10 minutes upon presentation of symptoms
▪ Usual changes are: T-wave inversion, ST segment elevation
and an abnormal Q wave
Assessment and Diagnostics

1. Cardiac Enzymes
a. CPK – MB
- Creatinine phosphokinase is increased
- Heart only, 12 – 24 hours
b. LDH – Lactic dehydroginase is increased
c. SGPT – Serum glutamic pyruvate transaminase is increased
d. SGOT – Serum glutamic oxal-acetic transaminase is
increased
Assessment and Diagnostics

2. Troponin Test – is increased (protein in myocardial)

3. ECG tracing reveals
a. ST segment elevation
b. T wave inversion
c. Widening of QRS complexes indicates that there is
arrhythmia in MI
4. Serum Cholesterol and uric acid are both increased
5. CBC – increased WBC
Assessment and Diagnostics

▪ Coronary Angiogram
▪ allows to visualize narrowings or obstructions
▪ therapeutic measures can follow immediately.
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).
Goal of Treatment

▪ Pain relief 
▪ Reduction of myocardial oxygen consumption
▪ Prevention and treatment of complications
Medical Interventions

▪ Admit to the CCU/ ICU

▪ Activity
▪ Day 1: bed rest, if stable
▪ Day 2-3: bed rest, but patient may be allowed to sit on a
chair for 15-20 minutes
▪ Early mobilization is recommended for uncomplicated AMI
Medical Interventions

Monitoring Vital Signs:

▪ First 6 hours- q30-60 minutes
▪  Next 24 hours- q 2 hours
▪ Thereafter q 4 hours
Diet:
▪  NPO: 1st 24 hours
▪ If stable low salt, low cholesterol diet
Medical Interventions

IV Fluids:
▪ D5W to KVO
▪ 1000ml/8 hours (If unable to take food/fluid per orem)
Pain Medication:
 Morphine SO4
Tranquilizers:
 To decrease anxiety
▪ Diazepam (5-10 mg per IV/orem)
Decrease myocardial oxygen demand
1. Decrease myocardial workload (rest heart)
- Administer narcotic analgesic/morphine sulfate
- Side Effects: respiratory depression
- Antidote: Narcan/Naloxone
- Side Effects of Naloxone Toxicity is tremors
Medical Interventions

Laxatives:
▪ To prevent straining during defecation
▪ Lactulose (HS)
Drugs to Limit Infarct Size:
▪ Beta Blockers
▪ Reduce myocardial oxygen consumption by decreasing: BP.
Heart Rate, Myocardial Contractility and calcium output. Can
help relieve angina
▪ Ex: Propranolol, Metoprolol, Atenolol
Medical Interventions

Nitrates:
▪ Act by augmenting perfusion at the border of ischemic zone.
▪ Generalized vasodilation
▪ Reducing myocardial O2 demand
▪ Lowering preload
▪ Lowering afterload
▪ Ex: IV Nitroglycerine,
Sublingual Nitroglycerine,Oral/Transdermal Nitroglycerine
Medical Interventions

Nursing Considerations:
▪ Only a maximum of 3 doses at 5 min. interval.
▪ Offer sips of water before giving it
sublingually.
▪ Store the medication in a cool, dry place; use
dark /amber container.
▪ If side effects is noticed do not discontinue
the drug this is usual in the first few doses
of medication.
▪ Rotate skin sites for nitro patch.
Medical Interventions

ACE inhibitors:
▪ reduce mortality rates after MI.
▪ Angiotensin –converting enzyme (ACE) inhibitors help relax
the vein and arteries to lower BP
▪ Prevent an enzyme in the body from producing angiotensin
II, a vasoconstrictor
▪ Continue ACE inhibitors indefinitely after MI.
▪ Common side effect –dry cough
▪ Example: Enalapril, captopril, Perindopril
Medical Interventions

Calcium Channel Blocker

▪ Used to lower BP by preventing calcium from entering the cells
of the heart and arteries.
▪ It relaxes blood vessels and improves blood flow
▪ Example: Amlodipine, Felodipine, Nifedipine, Diltiazem,
Nicardipine
Statin
▪ lower the amount of cholesterol moving in the blood and may
stabilize plaque deposits, making them less likely to rupture.
Statins include atorvastatin (Lipitor), simvastatin (Zocor,
Flolipid) and several others.
Medical Interventions

Aspirin and/or antiplatelet therapy:

▪ help prevent blood clots from forming
▪ Clopidogrel may be used as an alternative only if resistance or
allergy to aspirin
Nursing Considerations:
▪ Assess for signs and symptoms of Bleeding.
▪ Avoid straining at stool to avoid rectal bleeding.
▪ It should be given with food.
▪ Observe for toxicity- Tinnitus (ringing of ears).
▪ May cause Bronchoconstriction- Observe for wheezing.
Medical Interventions

Enoxaparin Sodium
▪ Enoxaparin binds to and potentiates
antithrombin (a circulating anticoagulant)
to form a complex that irreversibly
inactivates clotting factor Xa
▪ A class of medications called low molecular
weight heparins. It works by stopping the
formation of substances that cause clots
▪ Antidote: Protamine
▪ Given SQ
Isoket Drip
Surgical Interventions

Surgical Care:
▪ Percutaneous Transluminal Coronary Angioplasty -treatment
of choice
▪ PCI provides greater coronary patency
▪ lower risk of bleeding and instant knowledge about the
extent of the underlying disease.
▪ A specially designed balloon – tipped catheter is inserted
under fluoroscopic guidance and advance to the site of the
obstruction.
Surgical Interventions

Intravascular Stenting
▪ Biologic Stent is produced through coagulation of collagen,
ellastin and other tissues in the vessel wall by
laser, photocoagulation or radio frequency.
▪ It is done to prevent restenosis after Percutaneous
Transluminal Coronary Angioplasty.
Surgical Interventions

Surgical Care
▪ Percutaneous Transluminal Coronary Angioplasty
Surgical Interventions

Coronary Artery Graft Bypass Surgery

▪ (CABG) is indicated if angioplasty fails
▪ Severe narrowing of 1 or more coronary artery.
Surgical Interventions

▪ Coronary Artery Graft Bypass Surgery

Contraindication CABG

▪ Several populations of patients may be considered poor

candidates for coronary bypass, including the
▪ very elderly,
▪ debilitated patients,
▪ patients with severely diseased distal coronary vasculature
(eg, some diabetics), and patients with extremely low LVEF
(eg, < 5%-15%).
▪ Patients those related to general anesthesia risk, including
pulmonary edema, severe chronic obstructive pulmonary
disease, or pulmonary hypertension.
Post-operative Management

The following is a general overview of the early postoperative

management of CABG patients.
▪ Maintain hemodynamic stability: A variety of cardiac drugs are
administered to maintain hemodynamic stability in the first 24 hours
postoperatively. The following hemodynamic values may serve as
guides for inotropic and vasopressor administration along with
intravascular fluid therapy
▪ Maintain ventilation and oxygenation: Ventilation and oxygenation are
maximized in the early postoperative period with mechanical
ventilation. Within 2 to 12 hours, most patients have recovered from
the anesthesia effects and are sufficiently stable to allow weaning
from mechanical ventilation and extubation. Individuals with
preexisting pulmonary problems may require longer periods of
intubation until weaning can be successfully
Prevention of postoperative complications
▪ Bleeding from vascular graft anastomosis sites
▪ Cardiac tamponade: Frequent assessment for signs and symptoms of
tamponade, which include tachycardia, SOB, anxiety/decreased LOC,
paradoxus, sinus tachycardia decreased mediastinal tube drainage
▪ Infection: Antibiotics may be used prophylactically for 48 hours; temperature
spike within 24 hours postoperatively is not abnormal (may be related to
pulmonary atelectasis).
▪ Cardiac arrhythmias: ECG and continuous ST segment monitoring, treat
unstable rhythms, maintain K+ and Mg+ within normal limits with IV
replacement.
▪ Relief of postoperative pain and anxiety: Analgesic administration is typically
required to ensure pain relief, especially to facilitate ambulation, coughing, and
deep breathing.
▪ 
Cardiac Rehabilitation

▪ A process which a person restored to health and

maintains optimal physiologic, psychosocial and
recreational functions.
▪ Begins with the moment a client is admitted to the
hospital for emergency care, it continues for
months and even years after the client is
discharged from the health care facility.

▪ To live as full, vital and productive life as possible.

▪ Remain within the limits of the hearth’s ability to
respond to activity and stress.
Cardiac Rehabilitation

Activities:
▪ Exercise may gradually implemented from the
hospital onwards.
▪ Exercise session is terminated if anyone of the
following occurs: cyanosis, cold sweats,
faintness, extreme fatigue, severe dyspnea,
pallor, chest pain, PR more than 100/ min.,
dysrhythmias greater than 160/95mmHg
Cardiac Rehabilitation

Teaching and Counseling

▪ Self management education guide.
▪ Control hypertension with continued medical supervision.
▪ Diet
▪ Weight reduction program
▪ Progressive exercise
▪ Stress management techniques
▪ Resumption of sexual activity after 4-6 weeks from
discharge, if appropriate.
Cardiac Rehabilitation

Teaching guide on resumption of sexual activities:

▪ Assume less fatiguing position.
▪ The non- MI partner take the active role
▪ Take nitroglycerine before sexual activity
▪ If dyspnea, chest pain or palpitations occur,
moderation should be observed; if symptom persist
stop sexual activity
▪ Develop other means of sexual expression.