Coronary Vascular Disorders

What is coronary atherosclerosis?

• Atherosclerosis is the abnormal accumulation of lipid deposits and fibrous tissue within arterial walls and lumen

• In coronary atherosclerosis, blockages and narrowing of the coronary vessels reduce blood flow to the myocardium

• Cardiovascular disease is the leading cause of death in the United States for men and women of all racial and ethnic groups

• Coronary artery disease (CAD) is the most prevalent cardiovascular disease in adults

What is the pathophysiology of artherosclerosis?

• Atherosclerosis begins as monocytes and lipids enter the intima of an injured vessel.

• Smooth muscle cells proliferate within the vessel wall

• Contributing to the development of fatty accumulations and atheroma

• As the plaque enlarges, the vessel narrows and blood flow decreases

• The plaque may rupture and a thrombus might form, obstructing blood flow.

What are the clinical manifestations of artherosclerosis?

• Symptoms are caused by myocardial ischemia

• Symptoms and complications are related to the location and degree of vessel obstruction

• Angina pectoris (most common manifestation)

• Other symptoms: epigastric distress, pain that radiates to jaw or left arm, SOB, atypical symptoms in women

• Myocardial infarction

• Heart failure

• Sudden cardiac death

• Older people pain sensation is decreased → weakness, fatigue

• Women also present differently

What are the four non modifiable and modifiable risk factors of CAD?

• Most prevalent type of cardiovascular disease in adults

• Four modifiable risk factors cited as major cholesterol abnormalities, tobacco use, HTN, and diabetes

  • Elevated LDL: primary target for cholesterol-lowering medication

  • Metabolic syndrome

  • hs-CRP (high- sensitivity C-reactive protien) → inflamatory marker

How is CAD prevented?

• Control cholesterol

• Dietary measures

• Physical activity

• Medications

• Cessation of tobacco use

• Manage HTN

• Control diabetes

What are the cholesterol medications?

• Six types of lipid-lowering agents: affect the lipid components somewhat differently

  • 3-Hydroxy-3-methylglutaryl coenzyme A (HMG- CoA) (or statins)

  • Nicotinic acids

  • Fibric acids (or fibrates)

  • Bile acid sequestrants (or resins)

  • Cholesterol absorption inhibitors

  • Omega-3 acid-ethyl esters

What are the thereaputic effects and considerations with Statins, Fibrates, Bile acid sequestrants, cholesterol absorption inhibitor, proprotien convertase subtilisin- Kexin Type 9 (PCSK9) Agents?

• Statins: lower LDL ("bad") cholesterol in the blood by slowing down its production in the liver

  • moniter LFTs → give them in evening (more cholesterol to remove)

  • Drug interactions

  • Myalgia & arthalgia are sommon adverse effects (Muscle & joint pain)

  • Myopathy & possible rhabomyolysis are potentially serious s/e (muscle disease- weakness & fatigue, muscle breakdown/destruction)

• Fibrates: decreasing your triglycerides and increasing your HDL cholesterol (also decrease lipids)

  • diarrhea, flatulance, rash, myalgia

  • Serious adverse effects pancreatitis, hepatotoxicity, and rhabomyolysis

  • Contraindicated severe kidney & liver disease

  • Caution with stains bc increase risk of rabdo & heptotaxicity

• Bile Acid sequestrants: causes choleterol to be in bile acid and reduce fat absorption, instead is excreted

  • Adjunct thereapy to statins

  • S/e constipation, abdominal pain, GI bleeding

  • can decrease absorption of other drugs, take before meals

• Cholesterol absorption inhibitor: inhibit absorption of cholesterol in small intestine

  • Better absorbed the bile acid sequestrants

  • used in combincation with statins

  • S/e abdominal pain, myalgia & arthalgia

  • Contraindicated in liver disease

• PCSK9 Agents: Block PCSK9 protein, allowing more receptors to remove LDL from the blood

  • Only SQ

  • S/E: rhinitis, sore throat, flu like symptoms, muscke pain, diarrhea, redness, pain, or bruising at injection site

What is angina pectoris?

• A syndrome characterized by episodes or paroxysmal pain or pressure in the anterior chest caused by insufficient coronary blood flow

• Physical exertion or emotional stress increases myocardial oxygen demand, and the coronary vessels are unable to supply sufficient blood flow to meet the oxygen demand

What are the types of angina?

• Stable angina: predictable and consistent pain that occurs on exertion and is relieved by rest and/or nitroglycerin

• Unstable angina (also called preinfarction angina or crescendo angina): symptoms increase in frequency and severity; may not be relieved with rest or nitroglycerin

• Intractable or refractory angina: severe incapacitating chest pain

• Varient angina (also called Prinzmetal’s angina): pain at rest with reversible ST- segment elevation; thought to be caused by coronary artery vasospasm

• Silent ischemia: objective evidence of ischemia (such as electrocardiographic changes with a stress test), but patient reports no pain

• Think of MI to rule it out

What are the assessment and findings for angina?

• May be described as tightness, choking, or a heavy sensation

• Frequently retrosternal and may radiate to neck, jaw, shoulders, back or arms (usually left)

• Anxiety frequently accompanies the pain

• Other symptoms may occur: dyspnea or shortness of breath, dizziness, nausea, and vomiting

• The pain of typical angina subsides with rest or NTG

• Unstable angina is characterized by increased frequency and severity and is not relieved by rest and NTG. Requires medical intervention!

What are the genterologic considerations for angina?

• Diminished pain transition that occurs with aging may affect presentation of symptoms

• “Silent” CAD

• Teach older adults to recognize their “chest pain– like” symptoms (i.e., weakness)

• Pharmacologic stress testing or cardiac catheterization used to diagnose CAD

• Medications should be used cautiously d/t increased risk of adverse reactions!

What are the nursing interventions for patient with angina pectoris?

• Treat angina

• Reduce anxiety

• Prevent pain

• Educate patients about self-care

• Continuing care

• Patient w Angina Pectoris Goals

  • Immediate and appropriate treatment of angina

  • Prevention of angina

  • Reduction of anxiety

  • Awareness of the disease process

  • Understanding of prescribed care and adherence to the self-care program

  • Absence of complications

How is angina pectoris treated?

• Treatment seeks to decrease myocardial oxygen demand and increase oxygen supply

• Medications (Table 23-2 next slide)

• Oxygen

• Reduce and control risk factors

• Reperfusion therapy may also be done

  • PCI procedures (e.g., percutaneous transluminal coronary angioplasty [PTCA] and intracoronary stents) and CABG

Stable angina meds- What is Nitroglycerin, Beta- andergenic blocking agent, calcium channel blocking agents, Antiplatlet & asprin, heprin, abciximab or eptifibatide side effects/ contraindications, use?

• Nitroglycerin: Short & long- term reducation of myocardial oxygen consumtion through selective vasodilation

  • S/E: dizziness & h/a

• Beta-adrenergic blocking agents: Block adrenaline, Reducation of myocardial O2 consumption by blocking beta- adrenergic stimulation of the heart

  • Contraindication: severe bradycardia ( bpm), cardiogenic shock, low blood pressure, 2nd/3rd-degree heart block (bc slow down conduction which can make matters worse), and severe, unstable heart failure. They should generally be avoided in patients with active asthma or severe COPD due to potential bronchospasm

• Calcium channel blocking agents: negative inotropic effect; indicated in pts not responsive to BB, used as treatment for vasospasm

  • Common drugs used amiodipine & diltazem

  • Can cause brady, constipation

• Antiplatelet and anticoagulant medications: Prevention of thrombus forrmation

  • Aspirin

    • Common side effects: mild stomach irritation, heartburn, nausea, and an increased risk of bruising or bleeding

  • Clopidogrel and ticlopidine- P2Y12 inhibitors

  • Heparin

    • SQ vs IV

    • S&S of bleeding: eccymosis, hematoma, bright red/ tarry stool, hematemesis

  • Glycoprotein IIb/IIIa agents (abciximab or eptifibatide)

    • high-risk Acute Coronary Syndrome (ACS) patients undergoing PCI, those with heavy thrombus burden, or as an alternative to P2Y12 inhibitors in patients allergic to them

  • Heprin check PTT (60-80)

  • Warfrain PT/INR (2-3)

What is Acute Coronary Syndrome (ACS) and Myocardial Infarction (MI)?

• Emergent situation

• Characterized by an acute onset of myocardial ischemia that results in myocardial death (i.e., MI) if definitive interventions do not occur promptly

• Although the terms coronary occlusion, heart attack, and MI are used synonymously, the preferred term is MI

  • Unstable angina

  • NSTEMI

  • STEMI

How is ischemia, injury, and infarction on ECG?

• EKG should be obtained within 10 minutes from the time a patient reports pain or arrives in the ED.

• By monitoring serial ECG changes over time, the location, evolution, and resolution of an MI can be identified and monitored.

How is ACS assessed in patient?

• Chest pain

  • Occurs suddenly and continues despite rest and medication

  • Other S&S: SOB; C/O indigestion; nausea; anxiety; cool, pale skin; increased HR, RR

• ECG changes

  • Elevation in the ST segment in two contiguous leads is a key diagnostic indicator for MI

• Lab studies: cardiac enzymes and biomarkers, which include troponin, creatine kinase, myoglobin

What is the nursing intervention for patient for ACS?

• Relieve pain and S&S of ischemia

• Improve respiratory function

• Promote adequate tissue perfusion

• Reduce anxiety

• Monitor and manage potential complications

• Educate patient and family

• Provide continuing care

• Goals for Pt w ACS:

  • Relief of pain or ischemic signs (e.g., ST-segment changes) and symptoms

  • Prevention of myocardial damage

  • Maintenance of effective respiratory function, adequate tissue perfusion

  • Reduction of anxiety

  • Adherence to the self-care program

  • Early recognition of complications

What is invasive coronary artery procedure?

• Percutaneous transluminal coronary angioplasty (PTCA): a balloon-tipped catheter is used to open blocked coronary vessels and resolve ischemia → done in cath lab

• Coronary artery stent

  • Stent: a metal mesh that provides structural support to a vessel at risk of closing

• Coronary artery bypass graft (CABG): a surgical procedure in which a blood vessel is grafted to an occluded (at least 50-70%) coronary artery so that blood can flow beyond the occlusion

• Cardiac surgery

  • Cardiopulmonary bypass (extracorporeal circulation)

What is the Nursing Management for Patient Requiring Invasive Cardiac Intervention Invasive Cardiac Intervention?

• Assessment of patient

• Reduce fear and anxiety

• Monitor and manage potential complications

• Provide patient education

• Maintain cardiac output

• Promote adequate gas exchange

• Maintain fluid and electrolyte balance

• Minimize sensory–perception imbalance

• Relieve pain

• Maintain adequate tissue perfusion

• Maintain body temperature

• Promote health and community-based care

• PTCA: henmatoma, pedal pulses, vitals, signs of infection, signs of bleeding

  • If they come out with chest pain it prob means that there is another area that is lacking blood flow