CORONARY ARTERY DISEASE

VINEETHA SEBASTIAN MSC II YEAR NURSING

INTRODUCTION

CORONARY ARTERY DISORDERS/ DISEASE CORONARY HEART DISEASE

HEART DISEASE
ISCHEMIC HEART DISEASE

ANATOMY OF HEART

PHYSIOLOGY OF HEART

CORONARY ARTERIES

RIGHT CORONARY ARTERY (RCA)

Right

marginal artery Posterior descending artery

The right coronary artery supplies: Right atrium Right ventricle Bottom portion of both ventricles and back of the septum

LEFT MAIN CORONARY ARTERY

Circumflex artery left atrium, side and back of the left ventricle Left Anterior Descending artery (LAD) - front and bottom of the left ventricle and the front of the septum.

CORONARY ARTERY DISEASE

Coronary

artery disease is a disease characterized by the accumulation of plaque within the layers of the coronary arteries. (Lippincott,1997)

CORONARY ARTERY DISORDERS/ DISEASE

CORONARY

ATHEROSCLEROSIS ANGINA PECTORIS MYOCARDIAL INFARCTION

CORONARY ATHEROSCLEROSIS

An inflammatory disease characterized by the accumulation of white blood cells, cell debris, fatty substances (cholesterol and fatty acids), calcium, and fibrous tissue (plaque or atheromas) on the walls of the coronary arteries that supply the heart muscle.

ANGINA PECTORIS
Angina pectoris is a clinical syndrome usually characterized by episodes or paroxysms of pain or pressure in the anterior chest. The cause is usually insufficient coronary blood flow.(Phipps,2007)

MYOCARDIAL INFARCTION
MI refers to the process by which areas of myocardial cells in the heart are permanently destroyed. (Brunner, 2010)

INCIDENCE OF CAD
One

fifth of the deaths in India are from CAD. By the year 2020, it will account for one third of all deaths. There are an estimated 45 million patients of coronary artery disease in India. An increasing number of young Indians are falling prey to coronary artery disease

RISK FACTORS OF CAD

NON MODIFIABLE RISK FACTOR MODIFIABLE RISK FACTOR

CONTRIBUTING RISK FACTOR

NON MODIFIABLE MAJOR RISK FACTOR

HEREDITARY

RACE

AGE

GENDER

MODIFIABLE MAJOR RISK FACTOR

1. HYPERTENSION 2.DIABETICS MELLITUS 3. CIGARETTE SMOKING Damage and tighten blood vessels lead to unhealthy cholesterol levels Limit how much oxygen reaches the body's tissues. Raise blood pressure. Triples the risk of heart attack.

4. PHYSICAL INACTIVITY

Being physically inactive can worsen other risk factors for CHD, such as unhealthy blood cholesterol levels, high blood pressure, diabetes, and overweight or obesity.

5. OBESITY
BMI INTERPRETATION

less than 25

The goal for preventing and treating atherosclerosis.

25 and 29.9 30 or more

Overweight Obese

6. ELEVATED SERUM
CHOLESTEROL LEVEL:
Abnormal

Blood Lipids

Increase in LDL Cholesterol (low density lipoprotein) Decrease in HDL Cholesterol (high density lipoprotein)

CONTRIBUTING RISK FACTOR

1. Stress emotionally upsetting event anger. major changes in residence, occupation socioeconomic status 2. . Menopause Estrogen helps to maintain healthy levels of cholesterol Estrogen levels decline and the ovaries finally stop making estrogen

3. Homocysteine level 15-30 micromoles per liter as moderate 30-100 micromoles per liter as intermediate Greater than 100 micromoles per liter as severe

4. Inflammation is the body's response to injury or infection. > CRP level (0-10mg/dl )

PATHOPHYSIOLOGY OF CAD

CLINICAL MANIFESTATIONS
Sub sternal chest pain Pressure Heaviness Discomfort Location behind middle or upper third of sternum; the patient will generally make a fist over the site of the pain rather than point to it with his finger.

Other sensations include a Squeezing Aching Burning Choking

Strangling Cramping pain

CLINICAL MANIFESTATIONS
May produce numbness or weakness in arms, wrists, or hands. Associated symptoms include diaphoresis nausea indigestion dyspnea tachycardia increase in BP.

DIAGNOSIS
HISTORY PHYSICAL EXAMINATION Bruit A weak or absent pulse can be a sign of a blocked artery. BLOOD TESTS Lipid Profile Blood Sugar Proteins CRP, Homocystene level Cardiac Enzymes

DIAGNOSTIC TESTS
ECG CHEST X-RAY ECHOCARDIOGRAM HOLTER MONITORING STRESS TESTING (TMT) CT HEART MRI PET SCAN ANIOGRAPHY

ECHOCARDIOGRAM

STRESS TESTING

COMPUTED TOMOGRAPHY SCAN

A computed tomography (CT) scan creates computer-generated pictures of the heart, brain, or other areas of the body. The test can show hardening and narrowing of large arteries.

ANGIOGRAPHY
A thin, flexible tube called a catheter is put into a blood vessel in your arm, groin (upper thigh), or neck. Dye that can be seen on an x-ray picture is injected through the catheter into the arteries.

TREATMENT
Therapeutic Lifestyle Changes (TLC). (high blood cholesterol) TLC is a three-part program that includes HEALTHY DIET PHYSICAL ACTIVITY WEIGHT MANAGEMENT

1. HEALTHY DIET
Foods high in soluble fiber also are part of a healthy diet.. Whole-grain cereals such as oatmeal and oat bran Fruits such as apples, bananas, oranges. Legumes such as kidney beans, lentils A healthy diet also includes some types of fish, such as salmon, tuna. These fish are a good source of omega-3 fatty acids. Limit the amount of sodium (salt) Try to limit drinks with alcohol.

DIETARY APPROACHES TO STOP HYPERTENSION (DASH).

DASH also focuses on fat-free or low-fat milk and dairy products, fish, poultry, and nuts. The DASH eating plan is reduced in red meats (including lean red meats), sweets, added sugars, and sugar-containing beverages. The plan is rich in nutrients, protein, and fiber.

2. BE PHYSICALLY ACTIVE
Regular physical activity can lower many atherosclerosis risk factors, including LDL ("bad") cholesterol, high blood pressure, and excess weight. Do at least 150 minutes of moderate-intensity aerobic activity or 75 minutes of vigorous-intensity aerobic activity each week.

3. MAINTAIN A HEALTHY WEIGHT

BMI INTERPRETATION

Less than 25

The goal for preventing and treating atherosclerosis.

25 and 29.9 30 or more

Overweight Obese

QUIT SMOKING

MANAGE STRESS
Relax , and cope with problems can improve your emotional and physical health. Having supportive people in your life with whom you can share your feelings or concerns can help relieve stress. Physical activity, medicine, and relaxation therapy also can help relieve stress.

MEDICINES CHOLESTEROL LOWERING DRUGS

1.Hydroxymethyleglutaryl Lovastatin (Mevachor) Atorvastatin (Lipitor) 2. Niacin (nicotinic acid) 3. Bile acid sequestrants Cholestyramine (Prevalite, Questran) 4. Cholesterol absorption inhibitors Ezetimibe (Zetia) 5. Fibric acid derivatives Lopid Fenofibrate (Tricor, Lofibra)

BLOOD PRESSURE LOWERING DRUGS

1. Beta blockers - Atenolol, Metoprolol

2. ACE inhibitors - Captopril , Ramipril 3. Calcium channel blockers Amlodipine, Diltiazem , Nifedipine 4. Angiotensin II receptor blockers (ARBs) Losartan (Cozaar) 5. Diuretics. Thiazide diuretics -Hydrocholorothiazide Loop diuretics Potassium sparing diuretics

BLOOD THINNING DRUGS

Antiplatelet agents and anticoagulants Aspirin Ticlodipine - for people who cannot take aspirin (due to allergies) or do not improve from aspirin; has more side effects than aspirin Dipyridamole - not as effective as aspirin when used alone but may be used in combination with aspirin or warfarin (another blood thinner) Clopidogrel (Plavix) Heparin Warfarin (Coumadin)

OTHERS
ANALGESICS: Morphine sulphate- vasodilator and decreasing preload ANXIOLYTICS: Alprazolam (Xanax) binds at several sites within CNS, including limbic system and recticular system

SURGERY AND OTHER PROCEDURES

Non-surgical techniques Angioplasty -- used to widen narrowed arteries. A surgeon inserts a catheter with a deflated balloon into the narrowed part of the artery. The balloon is inflated, widening the blood vessel so blood can flow more easily. The balloon is then deflated, and the catheter is removed. A permanent stent (wire mesh) may be put in to hold the artery open and improve blood flow. Atherectomy -- a procedure to remove plaque from the arteries. It uses a laser catheter or a rotating shaver.

PCI PROCEDURAL REFINEMENTS: STENTS

Expandable metal mesh tubes that buttresses the dilated segment, limit restenosis. Drug eluting stents: further reduce cellular proliferation in response to the injury of dilatation.

SURGICAL PROCEDURES
Bypass surgery -- a surgeon uses a blood vessel from another part of your body or an artificial tube to reroute blood around clogged arteries. Minimally invasive bypass surgery -- uses a small incision rather than the broad opening in the chest wall created during regular bypass surgery. Endarterectomy -- used to remove plaque in the carotid (neck) or peripheral arteries.

COMPLICATIONS
Hypertension Embolism PVD (Peripheral Vascular Disease) Aneurysm -> Rupture Thrombosis -> Stenosis

NURSING ASSESSMENT
HISTORY Pain Previous attack Personal history Past medical and surgical history Use of any medication Previous health records
PHYSICAL EXAMINATON Assess patient's and family's knowledge of disease. Identify patient's and family's level of anxiety ECG, Blood levels and report of other tests.

ACUTE PAIN RELATED TO AN IMBALANCE IN

OXYGEN SUPPLY AND DEMAND Determine intensity of patient's angina. Position patient for comfort; Fowler's position promotes ventilation. Administer oxygen if prescribed. Obtain BP, apical heart rate, and respiratory rate.

Obtain a 12-lead ECG as directed. Administer antianginal drug as prescribed. Report findings to health care providers. Monitor for relief of pain, and note duration of anginal episode.

DECREASED CARDIAC OUTPUT RELATED TO REDUCED PRELOAD, AFTERLOAD,

CONTRACTILITY

Monitor the patient's response to drug therapy. Take BP and heart rate in a sitting and a lying position on initiation of long-term therapy (provides baseline data to evaluate for orthostatic hypotension that may occur with drug therapy). Recheck vital signs as indicated by onset of action of drug and at time of drug's peak effect. Note patient complaints of headache (especially with use of nitrates) and dizziness Continuous ECG monitoring Monitor laboratory tests as indicated.

ANXIETY RELATED TO CHEST PAIN, UNCERTAIN PROGNOSIS, AND THREATENING ENVIRONMENT

Assess patient for signs of hypoperfusion, auscultate heart and lung sounds, obtain a rhythm strip, and administer oxygen as prescribed.
Explain to patient and family reasons for hospitalization, diagnostic tests, and therapies administered. Encourage patient to verbalize fears and concerns about illness Answer patient's questions with concise explanations. Administer medications to relieve patient's anxiety as directed.

Explain to patient the importance of anxiety reduction to assist in control of angina. Teach relaxation techniques. Discuss measures to be taken when an anginal episode occurs.

IDENTIFY SUITABLE ACTIVITY LEVEL TO PREVENT ANGINA

Participate in a normal daily program of activities that do not produce chest discomfort, shortness of breath, and undue fatigue. Spread daily activities out over the course of the day, avoid doing everything at one time. Begin regular exercise regimen as directed by health care provider. Do not perform activities requiring heavy effort Try to avoid cold weather if possible Reduce weight

NITROGLYCERIN

Place nitroglycerin under the tongue at first sign of chest discomfort. Stop all effort or activity; sit, and take nitroglycerin tablet relief should be obtained in a few minutes. Bite the tablet between front teeth and slip under tongue to dissolve if quick action is desired. Repeat dosage in a few minutes for total of three tablets if relief is not obtained. Keep a record of the number of tablets taken to evaluate change in anginal pattern. Take nitroglycerin prophylactically to avoid pain known to occur with certain activities.

EVALUATION: EXPECTED OUTCOMES

Verbalizes

relief of pain Blood pressure and heart rate stable Verbalizes lessening anxiety, ability to cope

ASSIGNMENT
Write a short essay on the nurses responsibility of patient undergone angioplasty? Introduction: 1 marks Content: 6 marks Conclusion: 1 mark Reference :2 marks

STUDENT REFERENCE
Chantamani, LEWIS MEDICAL SURGICAL NURSING 1st Indian edition, 2011 elsiver publisher. Monahan Sands Neighbours and Mark Green, PHIPPS MEDICAL SURGICAL NURSINGALTH AND ILLNESS PERSPECTIVES, 8th edition, Mosby publishers Black, J. M., Hawks, J. H. Medical-Surgical Nursing. Noida: Elsevier Suzanne C smeltzer and Bare Brenda, BRUNNERS TEXT BOOK OF MEDICAL SURGICAL NURSING, 12th Edition, 2009.