NUR 317 Exam 3 - Coronary Artery Disease and Acute Coronary Syndrome

Cardiovascular disease is the __ cause of death in the United States

#1 (leading)

Coronary artery disease (CAD)

Most common CVD

Asymptomatic CAD

Chronic stable angina (chest pain)

Acture coronary syndrome (ACS)

Unstable angina (UA) or myocardial infarction (MI)

Atherosclerosis

“Hardening of arteries”

• Begins as soft deposits of fat that harden with age

• Major cause of CAD

Atherosclerosis endothelium

Intact endothelium is normally nonreactive

• Damage causes localized inflammatory response

• C-reactive protein (CRP)

  • Nonspecific marker of inflammation

  • Increased in many patients with CAD

  • Chronic exposure to CRP triggers the rupture of plaques

Collateral circulation

A network of small blood vessels that develop in response to a blockage or narrowing (stenosis) of a larger artery or vein

These vessels provide an alternative pathway for blood to flow, bypassing the obstruction and delivering oxygen and nutrients to the affected tissues

Coronary artery disease non-modifable risk factors

• Age

• Gender

• Ethnicity

• Family history

• Genetic predisposition

Coronary artery disease modifable risk factors

• Elevated serum lipids

• Elevated BP

• Tobacco use

• Physical inactivity

• Obesity

• Diabetes

• Metabolic syndrome

• Psychologic states

• Elevated homocysteine level

• Substance use

Elevated serum lipids - risk factors for coronary artery disease

Cholesterol >200 mg/dL

Triglycerides >150 mg/dL

HDL <40 mg/dL

LDL >130 mg/dL

Promoting health equity

Ethnic consideration

• White males: highest mortality from CAD

• Native Americans: die earlier than expected

Gerontology Consideration

• Assess for readiness for enhanced learning

• Symptoms are determined to be a result of CAD not “normal aging”

• Need to modify guidelines for physical activity

Cardiac primary prevention: nutritional therapy

Goal: lower LDL cholesterol

• Decrease saturated fat and cholesterol

• Increase complex carbohydrates and fiber

• Increase intake of Omega-3 fatty acids

• Limit alcohol use

• Limit red meats, full-fat dairy, processed foods

Cardiac primary prevention: activity

Goal: get moving

• Track activity

• 30 minutes at least 5 days per week

• Increase weight training (2 days a week)

Chronic stable angina

Angina is the clinical manifestation of reversible cardiac ischemia

Characteristics

• Chest pain that occurs intermittently over long period of time

• Same pattern of onset, duration and intensity

• Pain at rest is unusual

Diagnostic studies

• Chest x-ray

• 12-lead ECG

• Laboratory studies

• Echocardiogram

• Exercise stress test

• Coronary CT angiography

• Cardiac catheterization

Cardiac catheterization

Cardiac catheterization - “gold standard” to identify and localize CAD

• Visualize blockages (diagnostic)

• Open blockages (interventional)

• Percutaneous coronary intervention (PCI)

• Balloon angioplasty

Acute coronary syndrome

A medical emergency caused by a sudden decrease in blood flow to the heart muscle

Acute coronary syndrome etiology

1. Deterioration of once stable plaque

2. Rupture

3. Platelet aggregation

4. Thrombus

Partial occlusion of coronary artery

Unstable angina or NSTEMI

Total occlusion of coronary artery

STEMI

Clinical manifestations of unstable angina

• New in onset

• Occurs at rest

• Increase in frequency, duration, or with less effort

• Pain last > 10 minures

• Needs immediate treatment

• Symptoms in women often under-recognized

• ECG changes

Clinical manifestations of unstable angina - pain

• Severe chest pain not relieved by rest, position change, or nitrate administration

• Often occurs in early morning

• Atypical in women, elderly

• No pain if cardiac neuropathy (diabetes)

Clinical manifestations of unstable angina - sympathetic nervous system stimulation

• Release of catecholamines

• Diaphoresis

• Increased HR and BP

• Vasoconstriction of peripheral blood vessels

• Skin: ashen, clammy, and/or cool to touch

Clinical manifestations of unstable angina - cardiovascular

• Initially, increased HR and BP, then decreased BP (secondary to decrease in CO)

• Decreased renal perfusion leads to decreased urine output

• Crackles

• Jugular venous distention

• Abnormal heart sounds

  • S3 or S4

  • New murmur

Clinical manifestations of unstable angina - nausea and vomiting

• Reflex stimulation of the vomiting center by severe pain

• Vasovagal reflex

Clinical manifestations of unstable angina - fever

• Up to 100.4° F (38° C) in first 24-48 hours

• Systemic inflammatory process caused by heart cell death

Unstable angina and myocardial infarction diagnostic studies

• Detailed health history

• 12-lead ECG

• Serum cardiac biomarkers

• Coronary angiography

• Pharmacologic stress testing

Unstable angina ECG changes

Unstable angina treatment

A:

• Antiplatelet/anticoagulant therapy

• Antianginal therapy

• ACE inihibitor/ARB

B:

• Beta blocker

• BP control

C:

• Cigarette smoking cessation

• Cholesterol management

• Calcium channel blocker

• Cardiac rehab

D:

• Diet/weight management

• Diabetes management

• Depression screening

E:

• Education

• Exercise

F:

• Flu vaccine

Serum cardiac biomarkers after myocardial infarction

Acute coronary syndrome treatment priorities

Initial interventions

• 12-lead ECG

• Upright position

• Oxygen – keep O2 sat > 93%

• IV access

• Nitroglycerin (SL) and ASA (chewable)

• Statin

• Morphine

Acute coronary syndrome treatment

Ongoing monitoring

• Treat dysrhythmias

• Frequent vital sign monitoring

• Bed rest/limited activity for 12–24 hours

UA or NSTEMI

• Dual antiplatelet therapy and heparin

• Cardiac catheterization with PCI once stable

Acute coronary syndrome treatment - emergent percutaneous coronary intervention (PCI)

• Treatment of choice for confirmed STEMI

• Goal: 90 minutes door to cath lab

  • Balloon angioplasty + stent(s)

  • Many advantages over CABG

Acute coronary syndrome treatment - thrombolytic therapy

• Only for patients with a STEMI

  • Agencies that do not have cardiac catheterization resources

• Given IV within 30 minutes of arrival to the ED

• Patient selection critical

Acute coronary syndrome treatment - CABG

Nursing:

• 24-48 hr ICU

• Hemodynamic monitoring

• Arterial line

• Chest tubes

• ECG monitoring

• Pacing wires

• Endotracheal tube

• Urinary catheter

• Nasogastric tube

Complication:

Bleeding, dysrhythmias, pain, DVT prevention, inflammation

Acute coronary syndrome nursing goals

• Relief of pain

• Preservation of heart muscle

• Effective coping with illness-associated anxiety

• Resumption of sexual activity

• Participation in a rehabiliatation plan

• Health promotion

Cardiac delegation

UAP

• VS

• I&O’s

• Assist with meals, toileting

• Report complications

LPN

• May handle stable patient

• Cannot administer thrombolytic medications

Sudden cardiac death (SCD)

• Unexpected death from cardiac causes

  • Occurs within 1 hour of symptom onset

• Dysrhythmia (e.g., VT, VF) causes disruption in cardiac function, resulting in loss of CO and cerebral blood flow

• If survive, increased risk of another event due to electrical instability from scarred muscle

• Psychosocial Adaptation

  • Brush with death”, “time bomb” mentality, anger, depression

• Additional issues: driving restrictions, change in occupation