Ch 37: Coronary Artery Disease

What is Coronary Artery Disease (CAD)?

a type of atherosclerosis that occurs when fatty deposits (atheromas) form in the coronary arteries, leading to reduced blood flow to the heart. Also called ASHD, CHD, CVHD, or IHD

What are common causes of endothelial injury in atherosclerosis?

• Tobacco use

• Hyperlipidemia

• Hypertension

• Diabetes

• Infections

• Inflammation

• Toxins

What is C-reactive protein (CRP), and how is it related to CAD?

CRP is a nonspecific inflammatory marker made by the liver. It increases with systemic inflammation and may be elevated in patients with CAD.

What is Lipoprotein(a), and how does it contribute to CAD?

A type of LDL bound to apo(a); elevated levels can damage vessel lining, increase plaque buildup, and change clotting mechanisms.

How does homocysteine increase CAD risk?

High levels may:

1. Damage blood vessels

2. Promote plaque buildup

3. Increase clot formation

Are CRP, lipoprotein(a), and homocysteine routinely assessed in CAD risk evaluation?

No. They are not part of routine screening but may be measured in intermediate- or high-risk patients.

What are the three developmental stages of atherosclerosis in CAD?

1. fatty streak

2. fibrous plaques

3. complicated lesson

what characterizes the fatty streak stage of CAD?

• Lipid-filled smooth muscle cells

• Yellow-tinged streaks in arteries (seen by age 20)

• Earliest stage of atherosclerosis

• LDL-lowering treatment can slow progression

At what age can fatty streaks begin to appear in coronary arteries?

By age 20, and they increase in surface area with age.

What characterizes the fibrous plaque stage of CAD?

• LDLs and platelet growth factors cause smooth muscle proliferation

• Thickening of arterial wall

• Lipids enter intima via damaged endothelium

• Collagen covers the fatty streak, forming a fibrous cap

• Appears gray or white, with smooth or jagged edges

• Narrows vessel lumen, reducing blood flow

What is the effect of a fibrous plaque on the coronary arteries?

It narrows the vessel lumen and decreases blood flow to distal tissues.

At what age can fibrous plaques start to develop in the coronary arteries?

As early as age 30, with progression increasing with age

What is a complicated lesion in CAD?

The most advanced and dangerous stage of atherosclerosis characterized by:

• Plaque instability, rupture, and ulceration

• Platelet aggregation at the rupture site

• Thrombus formation that can partially or fully occlude the artery

What happens when a plaque ruptures in a coronary artery?

• Platelets accumulate at the site

• Thrombus forms

• GP IIb/IIIa receptors are activated

• Fibrinogen binds, causing further platelet adhesion

• Can result in complete vessel occlusion

What is the role of glycoprotein IIb/IIIa (GP IIb/IIIa) in a complicated lesion?

GP IIb/IIIa receptors are expressed on activated platelets and bind fibrinogen, promoting platelet aggregation and thrombus enlargement

What is collateral circulation in coronary arteries?

Natural bypasses formed by arterial anastomoses that supply blood to myocardium when primary vessels are blocked.

What two factors contribute to the development of collateral circulation in the heart?

• Inherited predisposition for angiogenesis

• Chronic ischemia from gradually developing blockages

What are the nonmodifiable risk factors for coronary artery disease (CAD)?

• Increasing age

• Gender (more common in men until women reach menopause)

• Ethnicity (higher risk in Black women)

• Genetic predisposition

• Family history of heart disease

What are the major modifiable risk factors for CAD?

• Hypertension (BP >120/80 mm Hg)

• Diabetes

• Dyslipidemia (high total cholesterol, high LDL, low HDL, high triglycerides)

• Metabolic syndrome

• Obesity

• Physical inactivity

• Tobacco use

What are the contributing modifiable risk factors for CAD?

• Elevated CRP, homocysteine, and lipoprotein(a) levels

• Psychological states (e.g., depression, stress, hostility)

• Substance use (e.g., cocaine, alcohol)

Why are women often diagnosed with CAD later than men?

Due to the cardioprotective effects of estrogen before menopause; however, hormone replacement therapy does notreduce risk and may increase it.

Why is early identification of high-risk individuals important in CAD prevention?

because CAD is asymptomatic in early stages, early identification helps prevent or slow disease progression through lifestyle changes and medical intervention

what family history increases a person’s risk for CAD?

• first-degree relative (parent or sibling) with CAD

• especially if CAD occurred before age 55

what lifestyle and environmental factors should be assessed to identify CAD risk?

• Diet and eating habits

• Physical activity level

• Tobacco and alcohol use

• Type and stress level of employment

• Exposure to environmental toxins or pollutants

What psychosocial factors contribute to CAD risk?

• Recent major life events (e.g., loss of spouse)

• Depression, anxiety, anger

• Lack of social support

• Chronic stress

What aspects of a patient’s understanding and beliefs are important to assess in CAD prevention?

• Attitudes toward health and illness

• Beliefs about heart disease

• Educational level and health literacy

• Medication knowledge and adherence

What is a key strategy to help patients modify CAD risk factors?

Provide individualized education and supportive counseling based on their health literacy, beliefs, and readiness to change.

What are key teaching points to reduce the risk of CAD in patients with hypertension?

• Monitor home BP regularly

• Take prescribed antihypertensives

• Reduce salt intake

• Quit tobacco and avoid secondhand smoke

• Control weight

• Engage in daily physical activity

What lifestyle changes are recommended to reduce high serum lipid levels?

• Reduce total and saturated fat intake

• Take prescribed lipid-lowering medications

• Adjust calorie intake for ideal body weight

• Engage in daily physical activity

• Increase fiber, complex carbs, and plant proteins

• Get regular lipid panel tests

What are important interventions to help a patient stop using tobacco?

• Begin a tobacco cessation program

• Identify and change routines linked to smoking

• Replace smoking with other activities

• Seek support from caregivers

• Avoid secondhand smoke

What physical activity recommendations reduce CAD risk?

• Perform at least 30 minutes of moderate activity daily, 5 days/week

• Gradually increase activity to a fitness level

What are stress-reducing strategies to lower CAD risk?

• Identify and modify harmful behaviors

• Set realistic goals

• Reassess life priorities

• Learn stress management techniques

• Get enough rest and sleep

• Seek help for depression, anxiety, or anger

What should obese patients be taught to help reduce CAD risk?

• Change eating habits and reduce calorie intake

• Aim for BMI of 18.5–24.9 kg/m²

• Increase physical activity

• Avoid fad diets and large meals

• Eat smaller, more frequent meals

What are critical diabetes management behaviors to reduce CAD risk?

• Follow a diabetic diet

• Control or lose weight

• Take prescribed antidiabetic medications

• Monitor blood glucose regularly

• See HCP regularly for follow-up

What role does the nurse play in managing persons at risk for CAD?

The nurse educates and encourages patients to adopt health-promoting behaviors to reduce CAD risk and helps clarify values, discuss risk factors, and set realistic goals.

How should lifestyle changes be approached for people less motivated to reduce CAD risk?

Help clarify their personal values, discuss individual risks, and support them in setting realistic goals. Recommend changing one risk factor at a time rather than many simultaneously

Why might some people be reluctant to change lifestyle habits related to CAD risk?

Some do not perceive risk without symptoms; others may resist change even after events like a myocardial infarction (MI)

How should healthcare providers respond to patients unwilling to change lifestyle habits despite risk?

Respect their decisions, review options, and continue to provide support and education to promote health

what should be included in the warm-up and cool-down for patients with CAD, angina, or ACS?

Mild stretching for 3–5 minutes before and 5 minutes after activity. Avoid starting or stopping activity abruptly

How frequently should physical activity be performed for patients with CAD or chronic angina?

On most days of the week.

How is exercise intensity determined for CAD patients?

By monitoring heart rate (HR)

• Post-MI patients should not exceed 20 bpm over resting HR

• Patients on β-blockers should consult their HCP for specific HR targets.

What types of physical activity are best for patients with CAD, stable angina, or ACS?

Regular, rhythmic, and repetitive activities that use large muscle groups and build endurance (e.g., walking, swimming, cycling, rowing)

How long should physical activity sessions last for patients with CAD or ACS?

Aim for at least 30 minutes per session. Start with tolerance (even 5–10 minutes) and gradually increase to 30 minutes

What percentage of total daily calories should come from fat in a heart-healthy diet?

25%–35% of total daily calories, with less than 7% from saturated fats.

What are examples of saturated fats that should be limited in the diet?

Lard, butter, whole-milk products, fatty cuts of meat, and bacon.

What are trans fats and where are they commonly found?

Trans fats are in foods made with hydrogenated vegetable oils, such as many hard margarines and shortenings.

What is the recommended daily intake of cholesterol for CAD prevention?

Less than 200 mg per day.

What are monounsaturated fats and where are they found?

Healthy fats found in olives, avocados, and canola, sunflower, and peanut oils

What are polyunsaturated fats and what is one key type beneficial for heart health?

Found in nuts, seeds, fish, seed oils, and oysters; Omega-3 fatty acids are a key polyunsaturated fat that helps reduce CAD risk.

What is the recommended daily intake of plant stanols or sterols to help lower LDL?

2 grams per day

what is the recommended daily intake of soluble fiber for heart health?

10-25 g of soluble fiber per day

How many total calories should be consumed daily for CAD risk reduction?

only enough to reach or maintain healthy weight

What is the first general step in making diet and lifestyle changes for heart health?

Know your calorie needs to achieve and maintain a healthy weight.

How can you monitor progress toward heart health goals?

track weight, physical activity, and calorie intake regularly

what eating strategy can help with portion control and metabolism?

prepare and eat smaller, more frequent meals

what are two ways to reduce sedentary activity?

limit screen time (TV/computer) and take stairs or extra steps during the day

what is the recommendation regarding tobacco use?

Do not smoke or use tobacco products.

What is the moderate alcohol limit for heart health?

No more than 1 drink/day for women and 2 drinks/day for men.

What is a helpful tool on packaged foods to guide healthy choices?

The Nutrition Facts panel and ingredients list.

What should you replace canned vegetables and fruits with?

Fresh or frozen vegetables and fruits.

Name four high-fiber foods that support heart health.

Beans (legumes), whole grains, fruits, and vegetables.

What should you replace solid fats with when cooking?

Liquid vegetable oils (e.g., olive, canola).

What should you choose when selecting grain products?

Whole grains like whole wheat, oats, rye, brown rice, barley, buckwheat.

What types of baked goods should be avoided?

Pastries and high-calorie bakery items like muffins and doughnuts.

What type of dairy products should be selected?

Fat-free or low-fat milk and dairy products.

What are heart-healthy ways to prepare meat and poultry?

Grill, bake, or broil; use lean cuts and remove poultry skin

What types of meats should be avoided for heart health?

Processed meats like deli meats, which are high in saturated fat and sodium.

What are some examples of plant-based meat substitutes?

Soy, tofu, and quinoa

Why should whole fruits and vegetables be preferred over juices?

whole produce has more fiber and nutrients, with less sugar

What is the leading cause of death in older persons?

Heart disease, including coronary artery disease (CAD).

What are common risk factors for CAD in older adults?

Nonmodifiable (age) and lifelong modifiable behaviors (e.g., inactivity, tobacco use).

Are CAD risk reduction and treatment strategies effective in older adults?

Yes, aggressive treatment of hypertension, hyperlipidemia, and tobacco cessation is effective.

What are some benefits of physical activity in older adults with CAD?

Improves performance, endurance, stress tolerance, self-esteem, emotional well-being, and body image.

For obese older adults, what approach is more beneficial than aiming for significant weight loss?

Modest dietary changes and gradually increasing physical activity, such as walking.

What temperature-related precaution should older adults take when exercising?

Avoid exercising in extreme heat or cold due to reduced heat tolerance and inefficient sweating.

What physical activity modifications are recommended for older adults?

Longer warm-ups, longer low-level activity periods, and longer rest periods.

What type of disease is coronary artery disease (CAD)?

CAD is a chronic and progressive disease.

What causes myocardial ischemia?

When the demand for myocardial oxygen exceeds the coronary arteries' ability to supply it.

What is angina?

Chest pain caused by myocardial ischemia due to either increased oxygen demand or decreased oxygen supply.

What is the most common cause of angina?

Significant narrowing of one or more coronary arteries due to atherosclerosis.

What level of arterial stenosis usually causes ischemia?

70% or more blockage (or 50% or more in the left main coronary artery).

What characterizes chronic stable angina?

Chest pain that occurs intermittently over time with a consistent pattern of onset, duration, and intensity.

What are common triggers for chronic stable angina?

Physical exertion, emotional stress, or emotional upset

How might patients describe angina besides pain?

As pressure, heaviness, squeezing, tightness, or a suffocating sensation

What other symptoms may occur with chronic stable angina?

Dyspnea (shortness of breath) or fatigue.

Does chronic angina pain change with position or breathing?

No, it usually does not.

Where is angina pain most commonly located?

Substernal area, possibly radiating to the jaw, neck, shoulders, and/or arms

What are common atypical symptoms of angina, especially in women and older adults?

Dyspnea, nausea, mid-epigastric discomfort, and/or fatigue (angina equivalents).

How might some patients misinterpret angina pain?

As indigestion or a burning sensation in the epigastric region or between the shoulder blades.

How long does chronic stable angina typically last and what relieves it?

It usually lasts a few minutes and is relieved by rest, calming down, or sublingual nitroglycerin (SL NTG).

What ECG changes may indicate myocardial ischemia?

ST segment depression and/or T wave inversion.

When do ischemic ECG changes usually return to baseline?

When adequate blood flow is restored and pain is relieved

How is drug therapy timed for chronic stable angina?

Drugs are given to peak during times when angina is most likely to occur (e.g., in the morning).

What is silent ischemia and who is at higher risk?

Ischemia without subjective symptoms; common in patients with diabetes due to autonomic neuropathy.

Does silent ischemia have a different prognosis than painful ischemia?

No, both types have the same prognosis.

What can chronic stable angina potentially progress into?

Acute Coronary Syndrome (ACS), which includes unstable angina (UA) or myocardial infarction (MI).

Why should any change in the usual pattern of angina be evaluated?

It may indicate progression to UA or MI and requires immediate assessment.

What is the primary treatment goal for a patient admitted with angina?

Decrease myocardial oxygen demand and/or increase oxygen supply.

What are the priority nursing care goals for a patient with angina?

• Manage acute pain

• reduce anxiety

• improve myocardial oxygen delivery

What are the six overall treatment goals for a patient presenting with angina?

• Pain relief

• Immediate and appropriate treatment

• Preservation of heart muscle (if MI is suspected)

• Effective coping with illness-related anxiety

• Participation in rehabilitation

• Risk factor reduction