Coronary Heart Disease

Chronic coronary artery disease

Stable and variant angina

Acute coronary syndrome

Coronary artery vasospasm

Coronary heart disease

-Etiology: result of damage to intima of CA with buildup

-Patho: LDL damages intima → fixed atherosclerotic plaque → restriction of the lumen → restricts O2 → increased vasoconstriction → O2 insufficiency→ pain

Stable angina

Classic or exterional

-Precipitation by exercise, cold, emotional upset

-Same pattern of onset, duration, intensity

-Chronic pain may radiate to jaw / neck / shoulder / arms / back

-Brief, usually lasting 5 mins or less until O2 balance is restored

Variant angina

Occurs at rest

-Often at night

-Same time / day, comes and goes

Unstable angina

Pre-infarction angina

-Pain occurs at rest, lasts longer than 20 minutes

-Intensity, timing, and characteristics increase in severity and frequency

-Occurs hours or days before an MI

-No detectable troponin levels

Rx factors for CHD

Smokin, abnormal cholesterol, HTN, obesity, DM, hi C-reactive protein, low exercise, age, ethnicity, hx of preeclampsia, genetics

Non pharmacological management of CHD

Lifestyle changes

-Reduce BP

-Weight / cholesterol levels

-Exercise

-Smoking cessation

-Surgical revascularization CABG

-PCI, intracoronary laser, atherectomy

Nitroglycerin

Organic nitrates

-Action: relaxes smooth muscle in BV, causing dilation, and decreasing preload / afterload

-Use: relief of sudden-onset angina / recurrent or chronic angina

-AE’s: Headache, dizzy, Brady, syncope, hypo / ortho hypo

-Contras: Hypersensitivity, severe anemia, hypo / hypovol, WITH ANY OTHER ANTIHYPERTENSIVE AGENTS OR ABNORMAL KIDNEY FUNCION, with head injury or cerebral hemorrhage = IICP

-Inter: Hers and ed meds, don’t mix with alcohol, vit c, sildenafil / taadalafil (rx of life threatening hypotension)

Atenolol

Cardioselective beta-adrenergic blockers

-Action: - cardiac workload, doesn’t interfere with bronchi / peripheral vasodilation

-Use: angina / htn, prophylaxis and txt of MI, long term txt to decrease angina attacks

-AE’s: HF, - HR, bradydysrhythmias / depression of AV node, bronchospasm, CAN MASK EARLY SIGNS OF HYPOGLYCEMIA

-Contras: Hypersensitivity, 2nd-3rd degree heart block, cardiogenic shock, severe Brady, HF, Hypo

-Interactions: MANY

Metoprolol

Beta-adrenergic blockers: cardioselective

-Action: Relaxes BV / slows HR, short ½ life, metabolized by liver + excreted in urine, doesn’t interfere with bronchodilation or peripheral vasodilation

-Use: Txt stable angina and htn , improves survival after MI

-AE’s: Brady, hypo, dizzy, fatigue, impotence

-Contras: severe Brady, 2nd-3rd degree HB, cardiogenic shock, sick sinus syndrome

Nifedipine

CCB

-Action: inhibits influx of Ca+, produces vasodilation of the peripheral blood vessels and CA’s, doesn’t affect HR, high protein bound / metabolized in liver + excreted in urine -Txt of htn and angina

-Use: txt for all stable / unstable / variant angina, mild - severe htn, Raynaud’s phenomenon

-AE’s: hypo, flushing / headache / dizzy, low limb edema, reflex tachy, constipation, nausea, gingival hyperplasia

-Contras: known hypersensitivity, NOT TO USE IN TXT OF ANGINA RELATED TO OD WITH COCAINE, AMPHETAMINES OR OTHER ALPHA-ADRENERGIC STIMULANTS-CAUSING LIFE THREATENING HYPERTENSION

-Interactions: digoxin, quinidine, grapefruit juice

Nifedipine nursing implications/ed

Take BP prior to dose, many interacts, no grapefruit juice (will cause two-fold effect of the med), I go in - increasing plasma levels, quinidine = decreasing plasma levels, don’t crush, assess therapeutic effect (systolic less than 120)

-Pt ed: Sudden discontinuation may cause rebound tachycardia, increase water and fiber to decrease constipation, elevate feet during the day

Metoprolol implications

Sudden stoppage may cause “rebound”, aka spike hr + bp = angina, arrhythmias, and MI

-Rise slowly when standing, check daily pulse and BP

Nitroglycerin implication

Sit down before taking as it can cause a drop in BP, monitor BP and HR (hold med + notify provider for hypotension or Brady/tachy), DON’T administer w PDE-5 Inhibitors, assess chest pain before and after txt