CORONARY ARTERY DISEASE

Awal Sher Khan

Lecturer INS-KMU
 Objectives
By the end of the session learners will be able to:
 Review anatomy and physiology of heart.

 Utilize Functional health pattern to identify patients problems related

to cardiovascular disorders including:
 Coronary artery disease (CAD)

 Atherosclerosis

 Angina Pactoris

 Integrate pathophysiology and pharmacology concepts of (CAD)

 Apply nursing process with support on Evidence-Based Nursing (EBN)

to provide to the clients with (CAD)
 Discuss the holistic approach for nursing management of the patient
with (CAD)
 Develop a teaching plan for a client experiencing disorders of the
(CAD)
Anatomy & Physiology of Heart
ss
 CORONARY
ATHEROSCLEROSIS
Atherosclerosis

It is an abnormal accumulation of

lipid, or fatty, substances and fibrous
tissue in the vessel wall.
These substances create blockages
or narrow the vessel in a way that
reduces blood flow to the
myocardium.
 Pathophysiology
 Atherosclerosis begins as fatty streaks, lipids
that are deposited in the intima of the arterial
wall.
 The continued development of atherosclerosis
involves an inflammatory response.
 T lymphocytes and monocytes (that become
macrophages) infiltrate the area to ingest the
lipids and then die; this causes smooth
muscle cells within the vessel to proliferate
and form a fibrous cap over the dead fatty
core.
Cont…
 These deposits, called atheromas or
plaques, protrude into the lumen of the
vessel, narrowing it and obstructing blood
flow.
 The anatomic structure of the coronary
arteries makes them particularly
susceptible to the mechanisms of
atherosclerosis.
 Clinical Manifestations
 Ischemia :The impediment to blood flow is usually
progressive, causing an inadequate blood supply
that deprives the muscle cells of oxygen needed for
their survival.
 Angina pectoris: Refers to chest pain that is
brought about by myocardial ischemia.
 If the decrease in blood supply is great enough, of
long enough duration, or both, irreversible damage
and death of myocardial cells, or MI, may result.
 The most common manifestation of myocardial
ischemia isacute onset of chest pain.
 Assessment and Diagnostic Findings
 Blood tests. Lab tests can detect increased levels of
cholesterol and blood sugar that may increase the risk of
atherosclerosis.
 You'll need to go without eating or drinking anything but
water for nine to 12 hours before your blood test.
 Doppler ultrasound. Your doctor may use a special
ultrasound device (Doppler ultrasound) to measure your
blood pressure at various points along your arm or leg.
 These measurements can help your doctor gauge the
degree of any blockages, as well as the speed of blood
flow in your arteries.
Cont…
 Electrocardiogram (ECG). An ECG can
often reveal evidence of a previous heart
attack. If your signs and symptoms occur
most often during exercise, your doctor
may ask you to walk on a treadmill or ride
a stationary bike during an ECG.
 Cardiac catheterization and
angiogram. This test can show if your
coronary arteries are narrowed or blocked.
 Other imaging tests.
Management & Prevention
 Four modifiable risk factors—cholesterol
abnormalities, cigarette smoking (tobacco
use), hypertension, and diabetes mellitus—
have been cited as major risk factors for
CAD and its consequent complications. As a
result, they receive much attention in
health promotion programs.
 CONTROLLING CHOLESTEROL
ABNORMALITIES
 Four elements of fat metabolism—total
cholesterol, LDL, HDL, and triglycerides—are
primary factors affecting the development of
heart disease.
 Cholesterol and the lipoproteins are synthesized
by the liver or ingested as part of the diet.
 All adults 20 years of age or older should have a
fasting lipid profile performed at least once
every 5 years and more often if the profile is
abnormal.
 Cont…
 LDL exerts a harmful effect on the arterial wall and
accelerates atherosclerosis.
 In contrast, HDL promotes the use of total
cholesterol by transporting LDL to the liver, where it
is biodegraded and then excreted.
 The desired goal is to have low LDL values and high
HDL values.
 The desired level of LDL depends on the patient:
• Less than 160 mg/dL for patients with one or no risk factors
• Less than 130 mg/dL for patients with two or more risk factors
• Less than 100 mg/dL for patients with CAD or a CAD risk equivalent
 Cont…
 The level of HDL should exceed 40 mg/dL and should ideally
be more than 60 mg/dL.
 A high HDL level is a strong negative risk factor (is
protective) for heart disease.
 Triglyceride is another fatty substance, made up of fatty
acids, that is transported through the blood by a lipoprotein.
 Although an elevated triglyceride level (>200 mg/dL) may
be genetic in origin, it also can be caused by obesity,
physical inactivity excessive alcohol intake, high-
carbohydrate diets, diabetes mellitus, kidney disease, and
certain medications, such as birth control pills,
corticosteroids
Cont…..
 Management of elevated triglyceride
focuses on weight reduction and increased
physical activity.
 Medications such as nicotinic acid and fibric
acids (eg, fenofibrate [Tricor], clofibrate
[Atromid-S]) may also be prescribed,
especially if the triglyceride level is above
500 mg/dL.
 Dietary Measures
 Soluble dietary fiber may also help lower
cholesterol levels.
 Soluble fibers, which are found in fresh fruit,
cereal grains, vegetables, and legumes,
enhance the excretion of metabolized
cholesterol.
 Intake of at least 20 to 30 grams of fiber
each day is recommended
 Physical Activity
 Regular, moderate physical activity
increases HDL levels and reduces
triglyceride levels.
 The goal for the average person is a
total of 30 minutes of exercise, three
to four times per week.
 Medications
 Medications (Table 28-2) are used in some
instances to control cholesterol levels.
 If diet alone cannot normalize serum
cholesterol levels, several medications have a
synergistic effect with the prescribed diet.
 Lipid-lowering medications can reduce CAD
mortality in patients with elevated lipid levels.
 PROMOTING CESSATION OF
TOBACCO USE
 Cigarette smoking contributes to the
development and severity of CAD in three ways.
 First, the inhalation of smoke increases the
blood carbon monoxide level, causing
hemoglobin, the oxygen carrying component of
blood, to combine more readily with carbon
monoxide than with oxygen.
 A decreased amount of available oxygen may
decrease the heart’s ability to pump.
 Cont….
 Second, the nicotinic acid in tobacco triggers
the release of catecholamines, which raise the
heart rate and blood pressure.
 Nicotinic acid can also cause the coronary
arteries to constrict.
 Smokers have a tenfold increase in risk for
sudden cardiac death.
 The increase in catecholamines may be a factor
in the increased incidence of sudden cardiac
death.
 Cont…
 Third, use of tobacco causes a detrimental
vascular response and increases platelet
adhesion, leading to a higher probability of
thrombus formation.
 A person with increased risk for heart disease is
encouraged to stop tobacco use through any
means possible: counseling, consistent
motivation and reinforcement messages,
support groups, and medications.
 MANAGING HYPERTENSION
 Hypertension is defined as blood pressure
measurements that repeatedly exceed 140/90 mm Hg.
 Long-standing elevated blood pressure may result in
increased stiffness of the vessel walls, leading to vessel
injury and a resulting inflammatory response within the
intima.
 Hypertension can also increase the work of the left
ventricle, which must pump harder to eject blood into
the arteries.
 Over time, the increased workload causes the heart to
enlarge and thicken (ie, hypertrophy), a condition that
may eventually lead to cardiac failure.
 CONTROLLING DIABETES
MELLITUS
 Hyperglycemia fosters dyslipidemia, increased
platelet aggregation, and altered red blood
cell function, which can lead to thrombus
formation.
ANGINA PECTORIS
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.
 The insufficient flow results in a decreased
oxygen supply to meet an increased myocardial
demand for oxygen in response to physical
exertion or emotional stress.
 Pathophysiology
 Angina is usually caused by atherosclerotic
disease. Almost invariably, angina is associated
with a significant obstruction of a major coronary
artery.
 Several factors are associated with typical anginal
pain:
 Physical exertion, which can precipitate an attack
by increasing myocardial oxygen demand.
 Exposure to cold, which can cause
vasoconstriction and an elevated blood pressure,
with increased oxygen demand
 Cont….
 Eating a heavy meal, which increases the blood
flow to the mesenteric area for digestion,
thereby reducing the blood supply available to
the heart muscle.
 Stress or any emotion-provoking situation,
causing the release of adrenaline and increasing
blood pressure, which may accelerate the heart
rate and increase the myocardial workload.
 Clinical Manifestations
 Angina symptoms include chest pain and
discomfort, possibly described as pressure,
squeezing, burning or fullness.
 You may also have pain in your arms, neck, jaw,
shoulder or back.
 Other symptoms that you may have with angina
include:
o Dizziness
o Fatigue
o Nausea
o Shortness of breath
o Sweating
 Risk factors
 Tobacco use. Chewing tobacco, smoking and long-
term exposure to secondhand smoke damage the
interior walls of arteries — including arteries to your
heart — allowing deposits of cholesterol to collect
and block blood flow.
 Diabetes. Diabetes increases the risk of coronary
artery disease, which leads to angina and heart
attacks by speeding up atherosclerosis and
increasing your cholesterol levels.
 High blood pressure. Over time, high blood
pressure damages arteries by accelerating
hardening of the arteries.
 Cont…
 High blood cholesterol or triglyceride
levels. Cholesterol is a major part of the deposits that can
narrow arteries throughout your body, including those that
supply your heart. A high level of low-density lipoprotein
(LDL) cholesterol, also known as "bad" cholesterol,
increases your risk of angina and heart attacks. A high
level of triglycerides, a type of blood fat related to your
diet, also is unhealthy.
 Family history of heart disease. If a family member has
coronary artery disease or has had a heart attack, you're
at a greater risk of developing angina.
 Older age. Men older than 45 and women older than 55
have a greater risk than do younger adults.
 Cont…
 Lack of exercise. An inactive lifestyle contributes to
high cholesterol, high blood pressure, type 2 diabetes
and obesity. However, it is important to talk with your
doctor before starting an exercise program.
 Obesity. Obesity is linked with high blood cholesterol
levels, high blood pressure and diabetes, all which
increase your risk of angina and heart disease. If
you're overweight, your heart has to work harder to
supply blood to the body.
 Stress. Stress can increase your risk of angina and
heart attacks. Too much stress, as well as anger, also
can raise your blood pressure.
Medical Management
 The objectives of the medical management
of angina are to decrease the oxygen
demand of the myocardium and to increase
the oxygen supply.
 Medically, these objectives are met through
pharmacologic therapy and control of risk
factors.
Pharmacologic Therapy

Among medications used to control

angina are nitroglycerin, beta-
adrenergic blocking agents, calcium
channel blockers, and antiplatelet
agents.
 Nitroglycerin
 Nitrates remain the mainstay for treatment of
angina pectoris.
 A vasoactive agent, nitroglycerin (Nitrostat, Nitrol,
Nitrobid IV) is administered to reduce myocardial
oxygen consumption, which decreases ischemia
and relieves pain.
 Nitroglycerin dilates primarily the veins and, in
higher doses, also dilates the arteries.
 Sublingual nitroglycerin is generally placed under
the tongue or in the cheek (buccal pouch) and
alleviates the pain of ischemia within 3 minutes.
 Beta-Adrenergic Blocking
Agents
 Beta-blockers such as propranolol (Inderal), metoprolol
(Lopressor, Toprol), and atenolol (Tenormin) appear to
reduce myocardial oxygen consumption by blocking the
beta-adrenergic sympathetic stimulation to the heart.
 The result is a reduction in heart rate, slowed
conduction of an impulse through the heart, decreased
blood pressure, and reduced myocardial contractility
(force of contraction) that establishesa more favorable
balance between myocardial oxygen needs (demands)
and the amount of oxygen available (supply).
 This helps to control chest pain and delays the onset of
ischemia during work or exercise.
Calcium Channel Blocking Agents
 Calcium channel blockers slower heart rate and a
decrease in the strength of the heart muscle
contraction (negative inotropic effect).
 These effects decrease the workload of the
heart.
 Calcium channel blockers also relax the blood
vessels, causing a decrease in blood pressure
and an increase in coronary artery perfusion.
 The calcium channel blockers most commonly
used are amlodipine (Norvasc), verapamil
(Calan, Isoptin, Verelan), and diltiazem
(Cardizem, Dilacor, Tiazac).
Antiplatelet and Anticoagulant Medications.

 Antiplatelet medications are administered to

prevent platelet aggregation, which impedes
blood flow.
 Aspirin. Aspirin prevents platelet activation.
 A 160- to 325-mg dose of aspirin should be
given to the patient with angina as soon as
the diagnosis is made and then continued with
81 to 325 mg daily.
Cont…
 Clopidogrel and Ticlopidine.
 Clopidogrel (Plavix) or ticlopidine (Ticlid) is
given to patients who are allergic to aspirin
or given in addition to aspirin in patients at
high risk for MI.
 Unlike aspirin, these medications take a few
days to achieve their antiplatelet
effect.
 They also cause gastrointestinal upset,
including nausea, vomiting, and diarrhea,
and they decrease the neutrophil level.
 Cont….
 Heparin. Heparin prevents the formation of
new blood clots.
 Use of heparin alone in treating patients with
unstable angina reduces the occurrence of MI.
 If the patient’s signs and symptoms indicate a
significant risk for a cardiac event, the patient
is hospitalized and may be given an
intravenous bolus of heparin and started on a
continuous infusion.
 Cont…
 The patient receiving heparin is placed on
bleeding precautions, which include:
• Applying pressure to the site of any needle
puncture for a longer time than usual
• Avoiding intramuscular injections
• Avoiding tissue injury and bruising from
trauma or use of constrictive devices (eg,
continuous use of an automatic blood
pressure cuff)
 Oxygen Administration.
 Oxygen therapy is usually initiated at the onset of
chest pain in an attempt to increase the amount of
oxygen delivered to the myocardium and to
decrease pain.
 Oxygen inhaled directly increases the amount of
oxygen in the blood.
 The therapeutic effectiveness of oxygen is
determined by observing the rate and rhythm of
respirations.
 Blood oxygen saturation is monitored by pulse
oximetry; the normal oxygen saturation (SpO2) level
is greater than 93%.
Prevention
 Quitting smoking.
 Monitoring and controlling other health
conditions, such as high blood pressure, high
cholesterol and diabetes.
 Eating a healthy diet and maintaining a
healthy weight.
 Increasing your physical activity after you get
your doctor's OK. 150 minutes of moderate
activity each week.
 Reducing your stress level.
 Limiting alcohol consumption.
NURSING PROCESS
 Assessment
 The nurse gathers information about the
patient’s symptoms and activities, especially
those that precede and precipitate attacks of
angina pectoris.
 Other helpful questions may be asked.
 How long does the angina usually last?
 Does nitroglycerin relieve the angina?
 If so, how many tablets or sprays are needed
to achieve relief?
 How long does it takes for relief to occur?
 Nursing Diagnosis
 Ineffective myocardial tissue perfusion
secondary to CAD, as evidenced by chest pain
or equivalent symptoms
 Anxiety related to fear of death
 Deficient knowledge about the underlying
disease and methods for avoiding complications
 Noncompliance, ineffective management of
therapeutic regimen related to failure to accept
necessary lifestyle changes
Planning and Goals
 The major patient goals include
immediate and appropriate treatment
 when angina occurs, prevention of
angina, reduction of anxiety,
awareness of the disease process and
understanding of the prescribed care,
adherence to the self-care program,
and absence of complications.
 Nursing Interventions
TREATING ANGINA
When a patient experiences angina, the nurse
should direct the patient to stop all activities and
sit or rest in bed in a semi-Fowler position to
reduce the oxygen requirements of the ischemic
myocardium.
The nurse assesses the patient’s angina, asking
questions to determine whether the angina is the
same as the patient typically experiences. A
difference may indicate a worsening of the
disease or a different cause
 Cont…
 The nurse then continues to assess the patient,
measuring vital signs and observing for signs of
respiratory distress.
 If the patient is in the hospital, a 12-lead ECG is
usually obtained and scrutinized for ST-segment and
T-wave changes.
 Nitroglycerin is administered sublingually, and the
patient’s response is assessed (relief of chest pain
and effect on blood pressure and heart rate).
 If the chest pain is unchanged or is lessened but still
present, nitroglycerin administration is repeated up
to three doses.
 Cont…
 The nurse administers oxygen therapy if the
patient’s respiratory rate is increased or the
oxygen saturation level is decreased.
 Although there is no documentation of its effect
on outcome, oxygen is usually administered at 2
L/min by nasal cannula, even without evidence
of respiratory distress.
 REDUCING ANXIETY
 Patients with angina often fear loss of their
roles within society and the family.
 They may also be fearful that the pain may lead
to an MI or death.
 Exploring the implications that the diagnosis
has for the patient and providing information
about the illness, its treatment, and methods of
preventing its progression are important
nursing interventions.
 Cont….
 Various stress reduction methods should be
explored with the patient. For example, music
therapy, in which patients are given the
opportunity to listen to selected music through
headphones for a predetermined duration, has
been shown to reduce anxiety in patients who
are in a coronary care unit.
 Addressing the spiritual needs of the patient and
family may also assist in allaying anxieties and
fears.
 PREVENTING PAIN
 The nurse reviews the assessment findings,
identifies the level of activity that causes the
patient’s pain, and plans the patient’s activities
accordingly.
 If the patient has pain frequently or with
minimal activity, the nurse alternates the
patient’s activities with rest periods.
 Balance of activity and rest is an important
aspect of the educational plan for the patient
and family.
 PROMOTING HOME AND COMMUNITY-
BASED CARE

 Learning about the modifiable risk factors that

contribute to the continued development of
CAD and resulting angina is essential.
 The teaching program for the patient with
angina is designed so that the patient and
family can explain the illness, identify the
symptoms of myocardial ischemia, state the
actions to take when symptoms develop, and
discuss methods to prevent chest pain and
the advancement of CAD.
 Cont….
 The goals of the educational program are to
reduce the frequency and severity of anginal
attacks, to delay the progress of the underlying
disease, if possible, and to prevent any
complications.
 The self-care program is prepared in
collaboration with the patient and family or
friends.
 Activities should be planned to minimize the
occurrence of angina episodes.
 Evaluation
 Expected patient outcomes may include:
1. Reports that pain is relieved promptly

2. Reports decreased anxiety

3. Understands ways to avoid complications

and demonstrates freedom from
complications
4. Adheres to self-care program
References
 Bruner & sudarth (Medical &
Surgical Nursing) 10th Edition.