CAD and chronic stable angina

perfusion

depends on the heart’s cardiac output to distribute blood to tissues and itself

CAD/angina

perfusion and adequate oxygenation

PVD

vascular resistance and adequate oxygenation

Coronary Artery Disease

most common type of heart disease and leading cause of death in the US

CAD etiology/patho

Atherosclerosis: lipid deposits in intima (innermost wall) of artery

develops after injury to endothelium (cells lining intimal layer) plus inflammation response

can happen to any artery

Pathogenesis of atherosclerosis

chronic endothelial injury → fatty streak → fibrous plaque → complicated lesion

CAD risk factors: modifiable

high serum lipid levels

hypertension

tobacco use

physical inactivity

obesity

diabetes

metabolic syndrome

metabolic syndrome

central obesity, hypertension, abnormal serum lipids, and a high fasting glucose level

lab values that come together and cause a risk

CAD Risk factor: non-modifiable

increasing age, gender, ethnicity, family history, genetics

CAD Risk factor: contributing modifiable

psychological states

substance abuse

Labs: High- CRP, LDL, Homocysteine levels

CAD Collaborative Care

Goal: prevent, modify or slow disease

start patient education early and continue across lifespan

identity person at risk: screening and history

reduce risk: address risk factors; lifestyle nid

manage those at high risk: address risk factors, make targeted plan

Physical Activity: FITT formula (AHA)

Frequency: most days a week (5 days)

Intensity: as tolerated, but goal to do moderate aerobic and possibly some vigorous

Type: something enjoyable such as walking, biking, swimming, jogging, tennis, yoga

Time: 30 min/day; 150 of moderate/ week or 75 vigorous/week

Nutrition Therapy

decrease total fat, saturated fat, calories and salt

increase amount of complex carbohydrates, fiber, and vegetables proteins in diet

prepare and eat smaller, more frequent meals

omega-3 fatty acids

may require specific diet for certain populations

Complementary and Alternative Therapy

Acupuncture

Acupoint (medicated plasters, patches)

Tunia (therapeutic massage)

Traditional Chinese medicines/herbs

Lipid-Lowering Medications

Statins

Niacin

Fibric Acid Derivatives

Bile acid sequestrants

cholesterol absorption inhibitors

antiplatelet therapy

statins

widely used

examples: rosuvastatin, simvastatin

SE: rate, but include liver damage, myalgia that can progress to rhabdomyolysis

Niacin

SE: flushing, take with food, elevates homocysteine

Fibric Acid Derivatives

Example: gemfibrozil

SE: GI irritability, caution with statins- increased r/f myopathy, increases effects of warfarin

Bile acid sequestrants

examples: colesevelam, colestipol

decreases absorption of many other drugs, tell patient to take 1 hour before or 3-4 hours after other drugs

SE: GI upset, bad taste

Cholesterol absorption inhibitors

example; ezetimibe

may see combined with a statin: ezetimibe + simvastatin

Antiplatelet therapy

ASA low does 81-mg

long term, mostly with known CAD
coated pills help with GI issues

Patient Education

What is CAD?

Risk Factors and how to reduce their effects

Symptoms and what to do when they have symptoms

about to discuss Chronic Stable Angina

Medication: What, When, Where, How

Chronic Stable Angina

chronic and progressive

the clinical manifestation of myocardial ischemia

• when demand for O2 exceeds the supply

from the narrowing or blocking of coronary artery pathways d/t

• the process of atherosclerosis (most common reason)- stable plaque

• or spam (Prinzmetal’s rare)- at rest, hx of Raynaud’s syndrome

Silent Ischemia

Ischemia that occurs in absence of any subjective symptoms

Associated with diabetic neuropathy

Confirmed by ECG changes

Same prognosis as ischemia with pain

Symptoms

pain or pressure, heaviness, discomfort, squeezing, tightness, suffocating, dyspnea, fatigue

• provoked, unusual at rest (usually indicates acute issue

• does not change with position or breathing

• Predicable: onset, duration, and intensity

• Last 5-15 minutes, resolves with precipitating factor

• Most pain is substernal, and may radiate to the jaw, neck, shoulders, and/or arms

• Ischemic change on 12 lead ECG that return to normal when blood flow restored and pain relieved (MSII)

Precipitating Factors

Circadian rhythm patterns

Post heavy meal

Physical activity

Stimulants

Strong emotions

Temperature extremes

Tobacco use

PQRST Pain assessment for chronic stable angina

Precipitating factors- what event or activity were you doing when it started?

Quality of pain? what does it feel like?

Region of pain- where is the pain? Point. Does it radiate?

Severity of pain- 0-10, make sure to explain scale

Timing- When did it begin? Has it changed? Have you had this before?

ABCDEF for treatment for chronic stable angina

antiplatelet, anticoagulant, antianginal treatment, ACEs/ARBs

B-blocker, BP control

Cigarette smoking cessation, cholesterol (lipid) management, cardiac rehab., CCB

Diet, diabetes management, depression screening, drug therapy

education, exercise

flu vaccination

Chronic Stable Angina, Collaborative Care

overall goal: decrease O2 demand, increase O2 supply

pain relief, immediate and appropriate treatment, preservation of heart muscle if an MI suspected, effective coping with illness-associated anxiety, identify precipitating factors, reduction/management of risk factors

Diagnostic Studies

12-lead ECG

Laboratory studies: cardiac biomarkers, lipid profile, CRP

Chest x-ray

Echocardiogram- ultrasound of heart

Exercise stress test- treadmill with monitoring (heart rhythm, VS)

Computed tomography- x-ray + computer tech. imaging, uses dye

Cardiac Catheterization: The Gold Standard- ID CAD (catheterization) and intervene (PCI), min invasive, uses dye, nursing assessment Q15 min for 1st hour

Chronic Stable Angina Drug Therapy

Goal: reduce angina symptoms and risk for MI and death, Most common to optimize myocardial perfusion: Nitrates (short and long acting), ACE inhibitors, B-blockersm Calcium Channel Blockers

Others: Antiplatelet (clopidogrel, ASA), Lipid-lowering drugs (stains, fibric acid derivatives)

When chronic stable angina becomes unstable…

new-onset angina

chronic stable angina that increases in frequency, duration, or severity

occurs at rest or with minimal exertion

lasts more than 10 min

Nitroglycerin

open up vessels

quick or slow release

SE: hypotension, tachycardia, dizziness, headache, & syncope

ACE Inhibitors

Angiotensin- Converting Enzyme Inhibitors

Captoperil (Capoten), Lisinopril (Zestril), Enalapril (Vasotec), Quinapril (Accupril)

SE: postural hypotension, fatigue, renal insufficiency, cough

Beta- Blockers

propanolol (Inderal), Atenolol (tenormin), Metoprolol (lopressor)

SE: Hypotension, bradycardia, symptoms of heart failure (coughing, SOB, edema, fatigue), drowsiness, depression

CCC (calcium channel blocker)

action: blocks calcium access to cells

SE: decrease demand for O2, hypotension bradycardia, AV block, headache, abdominal discomfort, peripheral edema

Patient Education: Chronic Care

What is chronic Stable angina?

Risk Factors and how to reduce their effects

Symptoms and what to do if you have them

Medications: What, when, where, how