Med Surg: Exam 2- Chapter 23- CAD Atherosclerosis

acute coronary syndrome (ACS)

signs and symptoms that indicate unstable

angina or acute myocardial infarction

angina pectoris

chest pain brought about by myocardial ischemia

atheroma

fibrous cap composed of smooth muscle cells that forms over lipid

deposits within arterial vessels and protrudes into the lumen of the vessel,

narrowing the lumen and obstructing blood flow; also called plaque

atherosclerosis

abnormal accumulation of lipid deposits and fibrous tissue

within arterial walls and the lumen

contractility

ability of the cardiac muscle to shorten in response to an

electrical impulse

coronary artery bypass graft (CABG)

a surgical procedure in which a blood

vessel from another part of the body is grafted onto the occluded coronary

artery below the occlusion in such a way that blood flow bypasses the

blockage

high-density lipoprotein (HDL)

a protein-bound lipid that transports

cholesterol to the liver for excretion in the bile; composed of a higher

proportion of protein to lipid than low-density lipoprotein; exerts a beneficial

effect on the arterial wall

ischemia

insufficient tissue oxygenation

low-density lipoprotein (LDL)

a protein-bound lipid that transports

cholesterol to tissues in the body; composed of a lower proportion of protein

to lipid than high-density lipoprotein; exerts a harmful effect on the arterial

wall

metabolic syndrome

a cluster of metabolic abnormalities including insulin

resistance, obesity, dyslipidemia, and hypertension that increase the risk of

cardiovascular disease

myocardial infarction (MI)

death of heart tissue caused by lack of

oxygenated blood flow

percutaneous coronary intervention (PCI)

a procedure in which a catheter

is placed in a coronary artery, and one of several methods is employed to

reduce blockage within the artery

percutaneous transluminal coronary angioplasty (PTCA)

a type of

percutaneous coronary intervention in which a balloon is inflated within a

coronary artery to break an atheroma and open the vessel lumen, improving

coronary artery blood flow

stent

a metal mesh that provides structural support to a coronary vessel,

preventing its closure

sudden cardiac death

abrupt cessation of effective heart activity

thrombolytic

a pharmacologic agent that breaks down blood clots;

alternatively referred to as a fibrinolytic

troponin

a cardiac muscle biomarker; measurement is used as an indicator of

heart muscle injury

The abnormal accumulation of lipid deposits and fibrous tissue within arterial walls and lumen.

What is atherosclerosis?

Blockages and narrowing of the coronary vessels reduce blood flow to the myocardium.

What happens in coronary atherosclerosis?

Cardiovascular disease.

What is the leading cause of death in the United States for men and women of all racial and ethnic groups?

Coronary artery disease (CAD).

What is the most prevalent cardiovascular disease in adults?

A condition where coronary arteries (CA) that supply oxygen and nutrients to the heart muscle become narrowed or blocked by atherosclerotic plaque (fatty deposits).

What is CAD?

ischemia — a lack of oxygen going to the heart muscle.

What does reduced coronary blood flow cause?

Myocardial infarction (MI).

What can prolonged or worsening ischemia lead to?

Progressive

Is coronary atherosclerosis progressive or sudden?

Lipids (cholesterol and fatty substances), plus cellular debris along arterial walls.

What substances accumulate in coronary atherosclerosis?

They become hardened and narrowed, making it difficult for blood to flow.

What happens to arteries as plaque builds up?

The ascending aorta, right above the aortic valve.

Where do coronary arteries branch off from?

Oxygen-rich blood to the heart muscle.

What do coronary arteries supply?

Right coronary artery (RCA) and left coronary artery (LCA

What are the two main coronary arteries?

Right atrium and right ventricle

AV node and SA node

Inferior wall of the left ventricle

Branches into the descending artery (dominant circulation in many people)

What does the RCA supply?

The "lung connector," because it mainly supplies the right side of the heart.

What is the RCA sometimes called and why?

The left ventricle (LV), which is the powerhouse of the heart and pumps blood to the body.

What does the LCA supply?

Supplying blood to the apex (bottom) of the heart.

What is the LAD (left anterior descending artery) responsible for?

Because it supplies critical perfusion to the heart; if it gets blocked, it often causes fatal outcomes.

Why is the LAD called the "widowmaker"?

Wraps around the heart to supply the ventricles.

What does the left circumflex artery (arch) supply?

The smooth muscle of the arterial wall.

In early atherosclerosis, what part of the body is being affected?

Early deposits of fat that form along the artery walls.

What are "fatty streaks" in atherosclerosis?

Cellular debris that hardens and narrows the artery, reducing blood flow.

What is seen in advanced atherosclerosis?

Myocardial ischemia — when oxygen is not getting to the heart muscle.

What causes the symptoms of atherosclerosis?

The location and degree of vessel obstruction.

What determines the symptoms and complications of atherosclerosis?

Angina pectoris.

What is the most common manifestation of atherosclerosis?

Epigastric distress

Pain radiating to jaw or left arm

Shortness of breath (SOB)

Atypical symptoms in women

What are other symptoms of atherosclerosis besides angina?

Myocardial infarction (MI)

Heart failure (HF)

Sudden cardiac death

What are three major complications of atherosclerosis?

Chest pain or discomfort (pressure, squeezing, tightness, difficulty breathing) caused by reduced blood flow to the myocardium.

What is angina pectoris?

Exercise or emotional stress.

What usually triggers angina?

Rest or nitroglycerin.

How is angina relieved?

Predictable chest pain with exertion (e.g., walking), relieved by rest or nitroglycerin.

What is stable angina?

Worsening chest pain not relieved by rest or nitroglycerin, indicating severe tissue perfusion issues — may progress to MI.

What is unstable angina?

SOB, diaphoresis (extreme sweating), nausea, jaw pain, arm/shoulder pain (usually right side), anxiety, dizziness, fatigue.

What are symptoms of unstable angina (especially in men)?

Severe back pain, fatigue, nausea (though they may also experience classic male symptoms).

What are common atypical angina symptoms in women?

Blocked coronary arteries leading to necrosis of heart tissue.

What causes an MI?

Stabilize the patient quickly.

What is the priority in MI?

Chronic ischemia or infarction weakens the heart muscle, reducing cardiac output.

How does atherosclerosis lead to heart failure?

Edema and fluid retention (bloating) due to decreased pumping ability.

What are signs of heart failure?

Ventricular arrhythmias triggered by infarction.

What causes sudden cardiac arrest in CAD?

Atrial fibrillation

Ventricular fibrillation

What arrhythmias may occur suddenly in CAD?

Often no — they may occur suddenly while walking or talking.

Do these arrhythmias have warning signs?

Cholesterol abnormalities

Tobacco use

Hypertension

Diabetes

What are the four major modifiable risk factors for CAD?

Elevated LDL (low-density lipoprotein).

What cholesterol abnormality is the primary target for treatment?

HDL is protective ("good cholesterol").

What role does HDL (high-density lipoprotein) play?

The Framingham risk calculator.

What tool is used to estimate CAD risk?

The Framingham risk calculator.

Tool to estimate cardiovascular disease risk.

A cluster of conditions that increase CAD risk, including overweight/obesity, high blood pressure, and elevated fasting glucose.

What is metabolic syndrome?

A blood marker of inflammation; elevated hs-CRP indicates increased cardiovascular risk even if cholesterol is normal.

What is hs-CRP (high-sensitivity C-reactive protein)?

Smoke damages the endothelium (artery lining), promotes plaque formation, increases clot risk, and raises blood pressure.

How does smoking increase CAD risk?

Chronic high glucose damages blood vessels, accelerating atherosclerosis.

How does diabetes contribute to CAD?

Control cholesterol (diet + meds such as statins)

Heart-healthy diet (↓ fats/cholesterol, ↑ fiber, omega-3, DASH diet)

Physical activity (30 min/day, 3x per week, plus muscle strengthening)

Medications (antiplatelets, statins, diabetic meds if needed)

Tobacco cessation

Manage hypertension (goal BP < 130/80)

Control diabetes (monitor HbA1C every 3-6 months)

What are the main strategies for preventing CAD?

Normal: < 5.7%

Prediabetes: 5.7-6.4%

Diabetes: ≥ 6.5%

What do HbA1C results mean?

Statins (HMG-CoA inhibitors) → lower LDL

Nicotinic acid (B3) → raises HDL

Fibric acids (fibrates) → lower triglycerides

Bile acid sequestrants → lower LDL (used if statins don't work)

Cholesterol absorption inhibitors (Ezetimibe, sometimes with statins)

Omega-3 acid-ethyl esters

What are the six types of lipid-lowering agents?

Liver enzymes (due to hepatotoxicity).

What labs should be monitored in patients taking atorvastatin (Lipitor)?

A syndrome of chest pain/pressure caused by insufficient coronary blood flow.

What is angina pectoris?

Physical exertion or emotional stress (↑ oxygen demand).

What triggers angina episodes?

Stable: Predictable, occurs with exertion, relieved by rest/NTG.

Unstable: Worsening, not relieved by rest/NTG → medical emergency → sign of impending MI.

Prinzmetal's (variant): Coronary artery spasm (not always plaque), often linked to ST changes; treated with calcium channel blockers

What are the three main types of angina?

Tightness, choking, heavy sensation.

How might angina be described?

Neck, jaw, shoulders, back, or arms (usually left).

Where does angina pain commonly radiate?

Anxiety

What often accompanies angina pain?

Dyspnea, dizziness, nausea, vomiting.

What other symptoms may occur with angina?

Rest or nitroglycerin.

How is typical angina relieved?

Increased frequency/severity, not relieved by rest or NTG → requires medical intervention.

What characterizes unstable angina?

Diminished pain perception and nerve signaling with age.

Why may older adults not feel typical chest pain?

CAD without obvious chest pain — may present as confusion, dizziness, fatigue, or SOB.

What is "silent CAD"?

Identify "chest pain-like" symptoms such as weakness or unusual fatigue.

How should older adults be taught to recognize angina?

Pharmacologic stress testing or cardiac catheterization.

What test may be used in older adults to assess CAD if pain is atypical?

They may be more sensitive to side effects and comorbidities.

Why must medications be used cautiously in older adults with CAD?

Decrease myocardial oxygen demand and increase oxygen supply.

What are the main goals of angina treatment?

Oxygen administration

Medications (NTG, beta blockers, calcium channel blockers, antiplatelets, statins, ACE inhibitors)

Control risk factors

Reperfusion therapy (PCI with balloon or stent)

What are general treatment measures?

Dilates coronary arteries, reduces preload, improves blood flow.

How does nitroglycerin work?

Hypotension, dizziness, throbbing headache.

What are common side effects of nitroglycerin?

To decrease heart rate and myocardial oxygen demand.

Why are beta blockers used in angina?

To reduce arterial spasm (especially in Prinzmetal's angina) and lower BP.

Why are calcium channel blockers used in angina?

Prevent clot formation and plaque buildup (aspirin, clopidogrel, ticlopidine, glycoprotein IIb/IIIa inhibitors).

What role do antiplatelets play in CAD treatment?

Heparin

What anticoagulants may be used in angina/MI?

Restoring blood flow by PCI (percutaneous coronary intervention) — balloon angioplasty or stent placement.

What is reperfusion therapy and what does it involve?

Liver enzymes.

A patient with hypercholesterolemia is prescribed atorvastatin (Lipitor). What lab values should be monitored?

Blood pressure of 86/58 mm Hg (due to risk of decreased cardiac output from venous pooling).

A patient presents with severe chest pain after working outside on a hot day. The nurse gives nitroglycerin. Which side effect is most concerning?

Zone of Ischemia

Blood flow reduced <30 minutes.

ECG: T-wave inversion or flattening.

Reversible if treated promptly.

Zone of Injury

Ischemia has persisted >20 minutes.

ECG: ST-segment elevation.

Some reversibility possible with urgent intervention (e.g., reperfusion therapy).

Zone of Infarction

Prolonged ischemia → cell death/necrosis.

ECG: Q waves may appear.

Irreversible damage → myocardial infarction (MI).

Rhythm from the SA node with HR <60 bpm. Can ↓ cardiac output → treat only if symptomatic (e.g., dizziness, hypotension) with atropine or pacing.

What is sinus bradycardia?