management of a pt w/ coronary heart disease

describe coronary heart disease

caused by impaired blood flow to myocardium resulting in ischemia, a lot of times it is atherosclerosis

resulting in: no symptoms, angina pectoris, acute coronary syndrome, myocardial infarction, dysrhythmias, heart failure

what can cause MI?

coronary perfusion issues: atherosclerosis, thrombosis, vasospasm, poor perfusion pressure

what can affect myocardial workload?

tachycardia: too fast, LV not filling up properly

increased preload, after load, and contractility

increased metabolic demands: hyperthyroidism

define preload and afterload

preload: amount of blood in LV right before it contracts

afterload: whatever the LV has to push against to get the blood out

what is the widow maker?

the main coronary artery since if that gets blocked, then the rest of the heart will not receive oxygen

what is atherosclerosis?

plaque blood up in the intimal and medial layer of vessels

lipoproteins and fibrous tissue accumulate in the arterial wall

what is the pathophysiology of atherosclerosis?

stable or unstable plaque

plaque rupture outcomes: new, larger plaque develops, residual fibrous clot develops, large fibrous clot (first stage of acute coronary syndrome resulting in MI)

what causes collateral circulation?

growth of small vessels to continue to supply nutrients when there is a blockage

attributed to 2 factors: inherited predisposition to develop new blood vessels or presence of chronic ischemia

what is arteriosclerosis?

hardening of the artery, normally age related

what is the incidence and prevalence of CAD?

native Americans: highest

white males > 45

women> 55 (estrogen protects heart)

list non-modifiable risk factors fro CAD

age: over 65

gender: men>women

race

family history/genetics: 1st degree relative under 55 increase risk

what are the simple 7?

7 things that can improve heart healthy: diet, weight, exercise, smoking, BP, cholesterol, blood sugar

what are some modifiable risk factors of CAD?

HTN, DM, hyperlipidemia, smoking, obesity, sedentary life style, metabolic syndrome, elevated homocysteine levels

how can DM affect the heart?

associated with high blood lipids levels

higher incidence of hypertension and obesity

affects endothelium of BV

hyperglycemia and hyperinsulinemia alter platelet function, elevated fibrinogen levels, inflammation

what does high cholesterol do?

promotes atherosclerosis

how does smoking affect the heart?

male cigarette smoker has 2-3 x risk of developing CHD

female has up to 4x risk

second hand smoke increases risk of death by 30%

promotes CHD: CO damages vascular endothelium, nicotine stimulates catecholamine release

catecholamine: increase BP, HR, MVO2, contracts arteries, reduces HDL, increase platelet aggregation

how can physical activity and diet affect CHD?

maintain gin a regular program of exercise decreases risk

diets high in fruits, veggies, whole grains, and unsaturated fats appear to have protective effect

what is metabolic syndrome?

a cluster of three of these symptoms:

abdominal obesity: 40+ in men, 35+ in women

dyslipidemia: triglyceride 150+, HDL <40

HTN: sys 130 < or dys 85<

insulin resistance: fasting glucose 100+

we see: pro inflammatory state (elevations of C reactive protein and/or prothombotic state (increased plasma plasminogen activator inhibitor and fibrinogen)

what are unique risk factors for women?

premature menopause: HDL drops and LDL rises

oral contraceptive use

hormone replacement therapy: increase risk of CHD, stroke, and PE

what are prevention methods for CHD?

dietary measures, physical activity, medications, tobacco cessation, HTN management, DM management, control cholesterol abnormalities

describe anti-hyperlipidemic agents

action: lowers the LDL levels and may increase the HDL

reduces plasma lipids and lipoproteins

reduces total cholesterol and LDL’s

statins are the most common

bile acid sequestrates, nicotinic acid, and fibrates

what is angina pectoris?

chest pain resulting from reduced coronary blood flow

causes: CHD, atherosclerosis, vasospasm, hyper metabolic conditions, anemia, HF, ventricular hypertrophy, or pulmonary disease

describe stable angina

short duration

predictable

resolves when o2 demand is lowered

EKG: ST depression

can medicate: nitroglycerin, can take up to 3 with 5 min apart

what is unstable angina?

can occur at rest, no identifiable precipitating factors

long duration, unpredictable, requires intervention

MONA: morphine, oxygen, nitroglycerin, aspirin

what is prinzmetal’s angina?

atypical and unpredicatable

often occurs at night

caused by a coronary artery spasm (may or ma y not have atherosclerosis)

list the manifestations of angina

pain in one or both arms, the jaw, neck, scapula region

mild indigestion, tightness, SOB, dizziness

anxiety, pale cool diaphoretic skin, squeezing/choking, N/V

what are manifestations of angina specific for women?

SOB, back pain, overwhelming fatigue, weakness, nausea, loss of appetite

what is medical management for angina?

goal is to decrease o2 demand and increase o2 supply to myocardium

pharmacologic therapy, diet, DM management, exercise, tobacco cessation, repercussion procedures

how does an EKG look with angina?

ST segment depression, t wave inversion

what can be used to identify an issue with the heart?

12-lead EKG, troponin level, stress test, percutaneous transluminal coronary angioplasty

describe nitrates

reduces myocardial oxygen consumption, which decreases ischemia and pain

low dose: mainly affects veins, less blood returning to heart, filling pressures is reduced (preload)

high dose: affects arteries, lowers BP, lowers afterload