Dr Ibraheem Bashayreh
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Heart Anatomy
Facts:
– The heart is about the size of a fist and
weighs less than 1 pound
– The average bpm is 72
– The average adult heart pumps about 6000-
7500 liters of blood per day through 60,000
miles of blood vessels each minute at rest.
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Heart
Structure
– Covered by pericardium
Parietal
Visceral (epicardium)
Dr Ibrahim Bashayreh 24
Contents Overview
Coronary Artery Disease
Heart Anatomy
Atherosclerotic Plaque/Atheroma
Angina Pectoris
Myocardial Infarction
Sudden Death
Overall Management
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Coronary Artery Disease
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CAD: Statistics
CAD is the largest killer of American males and females
13 million Americans have CAD
1.1 million MI’s per year
Every 26 seconds an American will suffer from a
coronary event
Every 60 seconds an American will die because of a
coronary event
@ 42% of those having a coronary event will die from it
@350K people die per year because of a coronary event in
the Emergency Department before even being admitted to
the hospital
Death Rate in 2001:
– 177 in 100,000
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CAD: Demographics and Statistics
84% of those who die from CAD are 65 or older
If under the age of 65, 80% mortality rate with the first myocardial
infarction
Within 1 year of initial MI:
– 25% of men and 38% of women will die
Within 8 years of initial MI:
50% of men and women under 65 will die
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Exactly what is Coronary Artery
Disease (Ischemic Heart Disease)
and how/why does it occur?
Start with anatomy…
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Definition
" Ischaemia " refers to an insufficient
amount of blood. The coronary arteries
are the only source of blood for the heart
muscle. If this coronary arteries are
blocked, the blood supply will reduce.
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Key Concepts
Ischemic heart disease (IHD): caused by
coronary atherosclerotic plaque formation
which leads to imbalance between O2 supply &
demand
– results in myocardial ischemia
Chest pain: cardinal symptom of myocardial
ischemia caused by coronary artery disease
(CAD)
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Ischemic Cycle
Ischemia / infarction
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Risk Factors
Uncontrollable Controllable
•Sex •High blood pressure
•Race •Smoking
•Physical activity
•Age
•Obesity
•Diabetes
•Stress and anger
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Why would there be an insufficient blood
supply to the heart?
– Remember that the coronary arteries are the
only source of fuel to the heart
– The coronary arteries may become
partially/completely occluded:
Atherosclerotic Plaques
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Atherosclerotic Plaque:
Definition and Formation
Focal accumulation of smooth muscle cells,
foam cells, cholesterol crystals and lipid under
the endothelium of the artery (within the Tunica
Intima)
Given time, this plaque can protrude into the
lumen of the vessel reducing blood flow
Often develops at branch points or curves
within the vasculature blood is slowed and/or
turbulent
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Atheroma/ Atherosclerotic
Plaque
Where does the plaque begin?
within the Tunica Intima, the
innermost wall of the artery
What is a plaque made of?
– Superficial fibrous cap made of
smooth muscle cells, collagen,
elastin and proteins
Also contains Macrophages,
Foam Cells, T Cells
Foam cells are one of the first cells
found at the site of the fatty streak,
which is the beginning of
atherosclerotic plaque formation in
vessels
– Necrotic Center of cholesterol
crystals, lipids, Apolipoprotein B
LDL
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Atheroma: Continued
As the atheroma within the coronary arteries
enlarges, the blood flow to the heart decreases
and therefore so does the O2 supply
The heart is not in danger of hypoxia until 50%
of the vessel is occluded
As the heart senses a decrease in O2, there is
attempted compensation:
– Increase Heart Rate
– Increase Blood Pressure
– Aggravation/Worsening of the atheroma
When 70% of the artery is occluded, Angina
Pectoris will occur
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Ischemic Heart Disease
Classification = mainly 4 types
– Myocardial infarction (MI)
– Sudden cardiac death
– Angina pectoris
– Chronic IHD with heart failure
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Angina Pectoris
At least 70% occlusion of coronary artery
resulting in pain. What kind of pain?
– Chest pain
– Radiating pain to:
Left shoulder
Jaw
Left or Right arm
Usually brought on by physical exertion
as the heart is trying to pump blood to the
muscles, it requires more blood that is not
available due to the blockage of the
coronary artery(ies)
Is self limiting usually stops when
exertion is ceased
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Angina Pectoris Continued
Angina Pectoris can be Stable or Unstable:
Stable:
– The pain and pattern of events is unchanged
over a period of time (months years)
Unstable:
– The pain and pattern is changing, be it in
duration, intensity or frequency
– A Myocardial Infarction waiting to happen
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Myocardial Infarction
Partial or total occlusion of one or more of the
coronary arteries due to an atheroma,
thrombus or emboli resulting in cell death
(infarction) of the heart muscle
When an MI occurs, there is usually
involvement of 3 or 4 occluded coronary vessels
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Myocardial Infarctions:
Statistics
250,000 deaths per year.
30% mortality within the first 2 hours
45 Minutes of Ischemia:
– Cardiac muscle death occurs
How is the Diagnosis Made?
– Electrocardiographic changes
ST elevation
– Myocardial enzyme elevation
Creatine kinase
Troponin
C Reactive Protein
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MI, Atheroma
When there is an atheroma, as mentioned before there
can be rupture resulting in thrombus formation
because of the build up of platelets
When there is breakage of the thrombus there is
emboli formation
An emboli can travel to the brain (cerebral infarct)
can remain in the heart (myocardial infarct) or even
travel to the extremities cutting off blood supply
As the area beneath the is disrupted atheroma
hemorrhages, there can is increased risk of abscess
formation and infection
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Complications of
Myocardial Infarctions
Infarction leading to inability of the heart to
function properly leading to Heart Failure
Angina/Pain
Cardiogenic shock
Ventricular aneurysm and rupture
Embolism Formation
Arrhythmias Myocardial Infarctions can
lead to Ventricular Fibrillation (shockable!)
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Sudden Death
Sudden Death :
– 250,000 deaths in the US per year are caused by what
is referred to as “sudden” cardiac death
– Sudden Cardiac Death is also known as a “Massive
Heart Attack” in which the heart converts from sinus
rhythm to ventricular fibrillation
– In V-Fib, the heart is unable to contract fully resulting
in lack of blood being pumped to the vital organs
– V-Fib requires shock from defibrillator
“SHOCKABLE RHYTHM”
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Many people are able to manage
coronary artery disease with lifestyle
changes and medications.
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Management of Ischemic
Heart Disease:
Pharmaceuticals:
– Beta Blockers
Act either selectively or non-selectively on Beta receptors:
– Nitrates
Vasculature vasodilation
– Anti-Hypercholesterolemia
HMG CoA Reductase Inhibitors reduction in “manmade”
Aspirin 53
Surgical Treatment
1) Stenting
2) Angioplasty (balloon)
3) Bypass surgery
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Management of Ischemic
Heart Disease:
Lifestyle:
– Diet
– Exercise Preventive treatment
• Low fat, low cholesterol diet
• Cessation of smoking
• Red wine (in moderation)
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Nursing Assessment
1.
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Nursing Diagnosis
1. Pain related to myocardial ischemia.
2. Altered tissue perfusion: related to
imbalance between myocardial oxygen
supply and demand.
3. Anxiety related to fear of death and
knowledge deficit
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Nursing Plan and Interventions
Goals
1. Prevention of pain.
2. Improved tissue perfusion as evidenced
by absence of chest pain and absence of
dysrhythmias.
3. Reduction of anxiety and increased
knowledge of disease process.
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Nursing Interventions
1. The nurse must teach the client the link between symptoms and
activity and the need to avoid activities known to cause angina, such
as sudden exertion, exposure to cold, and emotional excitement.
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Nursing Interventions
7. Clients with unstable angina are at high risk for myocardial
infarction (MI) and sudden death. The nurse watches for
development of heart failure and dysrhythmias.
8. Relieving pain is the top priority for the client with an acute MI,
and medication therapy is administered to accomplish this goal.
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Nursing Interventions
11. Whether CABG is planned as an elective procedure or
performed on an emergency basis, the nurse should try
to alleviate the client’s and the family’s anxiety and
assist them in understanding the need for this life-saving
procedure.
12. The nurse describes the postoperative course,
emphasizing the close monitoring and use of
sophisticated equipment. The client is encourage to tell
the nurse about any discomfort post-op.
13. Encourage the client and family members to verbalize
their fears and concerns.
14. Teach the client the nature of the illness and the facts
needed to reorganize living habits in order to reduce the
frequency and severity of anginal attacks, delay the
progress of the disease, and avoid other complications .
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Evaluation
1. Verbalizes relief of chest pain.
2. No signs of respiratory difficulties.
3. Modifies lifestyle in order to prevent
future attacks.
4. Demonstrates increased knowledge of
disease process and reduction in anxiety.
5. Absence of complications.
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وفي النهاية
،نسأل الله أن يعلمنا ما ينفعنا
،وأن ينفعنا بما علمنا
وأن يزيدنا علما
2/11/2009 64