Ch30 Care of CAD^J Athero^J Angina

Coordinating Care for Patients With Cardiac Disorders

Overview

• Chapters covered: 30 (pages 628-636) and 31 (pages 659-669)

Introduction to Blood Vessels

• Importance of blood vessels:

  • Transport blood for metabolic activities.

  • Remove waste products from metabolism.

  • Distribute cardiac output based on:

    1. Pressure differences driving blood flow.

    2. Resistance in specific blood vessels.

Atherosclerosis/Arteriosclerosis

Risk Factors (Labs)

• High total cholesterol.

• High triglycerides.

• High LDL (Low-Density Lipoprotein).

• Low HDL (High-Density Lipoprotein).

Risk Factors (Lifestyle and Conditions)

• High-fat diet.

• Family history of cardiovascular diseases.

• Obesity.

• Diabetes mellitus.

• Smoking.

• Age-related risks.

• Sedentary lifestyle.

• Hypertension (high blood pressure).

• High alcohol intake.

Pathophysiology of atherosclerosis

• A. Location of atherosclerosis in the coronary arteries.

• B. Normal vs. narrowed coronary artery:

  • Normal: unrestricted blood flow.

  • Narrowing is indicative of damage.

  • Resulting abnormal blood flow can lead to cardiovascular issues.

• Inflammatory response leads to plaque formation, resulting in narrowed arteries.

Progression Stages of Atherosclerosis

• Normal artery versus mild and severe atherosclerosis.

• Pathological changes include:

  • Chronic endothelial injury leading to plaque formation.

  • Response to injury includes infiltration of lipids, platelets, and macrophages.

  • Formation of complicated lesions may result in serious events like myocardial infarction (MI) and stroke.

Medical Management

Identification and Control of Risk Factors

• Lifestyle modifications including:

  • Diet: low in cholesterol, saturated fats, and sodium.

  • Smoking cessation.

  • Regular exercise.

  • Stress reduction techniques.

  • Effective management of diabetes.

Surgical Management

• Indicated for irreversible manifestations such as:

  • Chest pain.

  • Gangrene.

• Procedures:

  • Coronary revascularization.

  • Amputation if necessary.

• Importance of assessing risks vs. benefits.

Atherosclerosis Complications

• Consequences include:

  • Hypertension.

  • Carotid artery disease.

  • Peripheral vascular disease.

Assessments and Actions

Patient Assessment

• Complete patient history focusing on cardiovascular health.

• Assess blood pressure in both arms.

• Evaluate pulses and auscultate for bruits.

• Obtain laboratory tests.

Nursing Actions

• Administer medications as ordered:

  • Antihypertensive medications.

  • Lipid-lowering therapies including statins and lifestyle modifications.

Patient Education

Blood Pressure Management

• Teach patients about:

  • Monitoring blood pressure.

  • Lifestyle changes to improve heart health.

Lifestyle Changes

• Promote:

  • Healthy diet: low-fat, low-cholesterol, enriched with B vitamins, high in fiber.

  • Smoking cessation to reduce HDL and increase LDL levels.

  • Regular physical exercise to modify risk factors.

Hypertension Statistics

• Epidemiology:

  • Affects 78 million people in the US.

  • Awareness: 82% of people with hypertension know their condition.

  • Medication usage: 75% are using antihypertensive medications.

  • Difficulty achieving target BP control in 53% of patients.

  • 670,000 deaths attributed to hypertension in 2020.

Hypertension Complications

• Factors influencing complications:

  • Race, gender, socioeconomic status, and other health conditions.

High Blood Pressure Categories

Guidelines for Managing Hypertension

• Normal: <120/80 mmHg.

• Prehypertension: 120-129/<80 mmHg (focus on modifiable risk factors).

• Stage 1 HTN: 130-139/80-89 mmHg (recommend at least one antihypertensive medication).

• Stage 2 HTN: >140/90 mmHg (recommend at least two antihypertensive medications).

First-line Antihypertensive Drugs

• Includes:

  • ACE inhibitors.

  • Angiotensin receptor blockers (ARBs).

  • Calcium channel blockers.

  • Thiazide diuretics.

Second-Line Antihypertensive Medications

• Includes:

  • Beta-adrenergic blockers.

  • Direct-acting vasodilators.

  • Direct renin blockers.

  • Loop and potassium-sparing diuretics.

Hypertension Pathophysiology

• Mechanisms leading to hypertension:

  • Increased sodium intake.

  • Activation of the renin-angiotensin-aldosterone system (RAAS).

  • Activation of the sympathetic nervous system.

Clinical Manifestations of Hypertension

• Common signs and symptoms:

  • Headaches, chest pain, fatigue, dizziness, changes in heartbeat, and vision issues.

Medical Management of Hypertension

Diagnosis

• Requires two or more BP readings on separate visits.

Treatment Strategies

• Involving diuretics, antihypertensives, and lifestyle management.

Nursing Assessment and Interventions

• Focus on neurological assessments and comprehensive lab evaluations.

• Monitor blood pressure, assess for edema, and evaluate other relevant signs.

Teaching Points

• Emphasis on adherence to medication and lifestyle changes.

• Importance of monitoring BP at home and recognizing signs of complications.

Coronary Artery Disease (CAD)

Risk Factors

Modifiable

• Increased total cholesterol, hypertension, diabetes, obesity, smoking, and lack of physical activity.

Nonmodifiable

• Gender, race, heredity, and age.

Anatomy of the Arterial Wall

• Structure:

  • Tunica intima, tunica media, tunica adventitia, internal and external elastic membranes.

CAD Pathophysiology

• Development of atherosclerosis leading to:

  • Unstable angina.

  • Myocardial infarction (MI) and sudden cardiac death.

  • Ischemic symptoms due to reduced blood flow.

Diagnosis of CAD

• Necessary tests include:

  • Lipid panel (total cholesterol, triglycerides, LDL, HDL), cardiac enzymes, ECG, stress tests, and coronary angiography.

Clinical Manifestations of Angina

• Types of Angina:

  • Stable Angina: Predictable chest pain related to exertion and relieved by rest.

  • Prinzmetal’s Angina: Occurs at rest due to coronary spasm, often at night.

  • Unstable Angina: Unpredictable chest pain that occurs at rest, indicating decreased myocardial blood flow; requires emergency intervention.

Acute Coronary Syndrome (ACS) Assessment

Laboratory and Imaging Assessments

• Key indicators include troponin levels, ECG changes, and imaging tests to rule out aortic dissection or other pathologies.

Management of ACS

• Focus on relieving pain, improving tissue perfusion, and monitoring for dysrhythmias and potential heart failure.

Pharmacological Management in ACS

Nitroglycerin

• Cardiac vasodilator; patient should take sublingual doses with specific timing guidelines.

• IV NTG can be used for severe cases with side effects monitored.

Other Essential Medications

• Include aspirin, morphine sulfate, and oxygen therapy for symptom relief and management of MI.

Surgical Management for CAD

Interventional Procedures

• Percutaneous Coronary Intervention (PCI)/CABG:

  • Coronary angioplasty and stent placement as a common procedure.

  • CABG as a surgical option to bypass blocked arteries.

Lifestyle Management Recommendations for CAD

• Importance of maintaining a healthy weight, proper diet, and regular exercise.

• Encouragement of smoking cessation and comprehensive screenings.

Patient Assessment and Nursing Interventions

Key Assessments

• Involves thorough evaluation of chest pain and nonspecific symptoms like nausea or diaphoresis.

• Vital signs and ECG are critical in managing CAD.

Nursing Actions

• Administer oxygen and prescribed medications as needed.

Post-Surgical Care for PCI

• Monitor the site for complications such as hematoma and bleeding, managing pain effectively, and ensuring continuous cardiac monitoring.

Patient Teaching and Education

• Stress the importance of medication adherence, lifestyle changes, and recognizing emergency symptoms associated with cardiac conditions.