Management of Patients With Coronary Vascular Disease

• Question• Is the following statement true or false?• Individuals at highest risk for a cardiac risk for

a cardiac event within 10 years are those with existing coronary disease.

Answer

• True• Individuals at highest risk for a cardiac event

within 10 years are those with existing coronary artery disease and those with diabetes, peripheral arterial disease, abdominal aortic aneurysm, and carotid artery disease.

Coronary Atherosclerosis• Atherosclerosis is the abnormal accumulation of lipid

deposits and fibrous tissue within arterial walls and lumen.

• In coronary atherosclerosis, blockages and narrowing, of the coronary vessels reduce blood flow to the myocardium

• Cardiovascular disease is the leading cause of death in the US for women and men of all racial and ethnic groups.

• CAD, coronary artery disease, is the most prevalent cardiovascular disease in adults

Clinical Manifestations

• Symptoms are due to myocardial ischemia• Symptoms and complications are related to

the location and degree of vessel obstruction• Angina Pectoris• Myocardial Infarction• Heart Failure• Sudden Cardiac Death

Question

• Which is considered a modifiable risk for coronary artery disease?

• A. Race• B. Gender• C. Family History• D. Cigarette Smoking

Answer

• D. Cigarette Smoking-a modifiable risk factor for coronary artery disease is cigarette smoking. Race, gender, family history, are non modifiable risk factors.

Clinical Manifestations-Continued

• The most common symptom of myocardial ischemia chest pain; however, some individuals may be asymptomatic or have atypical symptoms such as weakness, dyspnea, and nausea.

• Atypical symptoms are more common in women and in persons who are older, or who have a history of heart failure or diabetes. (see hand outs on women with chest pain)

Angina Pectoris

• A syndrome characterized by episodes or paroxysmal pain or pressure in the anterior chest caused by insufficient coronary blood flow.

• Physical exertion or emotional stress increases myocardial oxygen demand and coronary vessels are unable to supply blood flow to meet the oxygen demand

Types of Angina

• Stable Angina-predictable and consistent pain that occurs on exertion and is relieved by rest/or nitroglycerin

• Unstable Angina-(also called preinfarction angina or crescendo angina): symptoms increase in frequency and severity; may not be relieved with rest or nitroglycerin

• Intractable or Refractory Angina-severe or incapacitating chest pain

• Variant Angina-(also, Prinzmetal’s angina); pain at rest with reversible ST-segment elevation, thought to be caused by coronary artery vasospasm.

Types of Angina-Continued• Objective evidence of ischemia (such as EKG

changes with a stress test), but patient reports no pain.

Angina pain varies from mild to severe

May be described as tightness, choking, or a heavy sensationFrequently, retrosternal and may radiate to neck, jaw, shoulders, back or arms (usually left).Anxiety frequently accompanies the pain.Other symptoms may occur; dyspnea/sob, dizziness, nausea and vomiting.The pain of typical angina subsides with rest or NTG.

Angina pain-Continued

• Unstable angina is characterized by increased frequency and severity and is not relieved by rest and NTG. Requires medical intervention!

Treatment

• Treatment seeks to decrease oxygen demand and increase oxygen supply

• Medications• Oxygen• Reduce and Control Risk Factors• Reperfusion Therapy may also be done

Summary of Meds Used to Treat Angina

• Nitrates-Nitroglycerine (nitostat, nitrobid)-Short term and long term reduction of myocardial oxygen consumption thru selective vasodilation. Advise the patient to carry the medication at all times as a precaution. However, because nitro, is very unstable, it should be carried securely in original container, (eg. Capped dark glass bottle); tablets should never be removed and stored in metal or plastic pill boxes.

• Explain that nitro is volatile and is inactivated by heat, moisture, air, light, and time. Instruct the pt to renew every 6 months.

• Instruct the pt to take in anticipation of any activity that may produce pain. Because Nitro increases tolerance for exercise when taken prophylactically (before angina producing activity, such as exercise, stair climbing, and sexual intercourse), it is best taken before pain develops.

Angina Meds-Continued

• Beta Adrenergic Blocking Agents (beta bloclers)-Metoprolol (lopressor, toprol) Atenolol (tenormin) Reduction of myocardial oxygen consumption by blocking beta-adrenergic stimulation of the heart.

• Calcium Ion Antagonists (calcium channel blockers)-Amlodipine (norvasc), Diltiazem (cardizem, tiazac), Felodipine (Plendil)-Negative inotropic effects; indicated in patients not responsive to beta-blockers; used as primary tx for vasospasm

Angina Meds-Continued

• Antiplatelet Medications• Aspirin Prevention of platelet Aggregation • Clopidogrel (Plavix)• Glycoprotein IIb/IIIa agents -ReoPro -Aggrastat -Integrilin

Angina Meds-Continued

• Anticoagulants• Heparin-Treating Pt’s with unstable angina with

heparin prevents the formation of new blood clots and reduces the occurence of a new MI.

• Low-molecular weight Heparin (LMWH’s)• Lovenox• Fragmin• Prevention of thrombus formation

Question

• Is the following statement true of false?

• Nitro tablets should never be removed and stored in metal or plastic pillboxes.

Answer

• True

• Nitro tablets should never be removed and stored in metal or plastic pillboxes.

Nursing Process: The Care Of the Patient with Angina - Assessment

• Symptoms and Activities, especially those that precede and precipitate attacks

• Risk factors, lifestyle, and health promotion activities

• Patient and family knowledge• Adherence to the plan of care

Assessing Angina• Where is the pain?• Is the pain radiating anywhere else?• How would you describe the pain?• Is it like pain you have ever had before?• Can you rate the pain on a 0-10 scale with 10 being the worse

pain.• When did the pain begin?• How long did it last?• What brings on the pain?• What helps the pain to go away?• Do you have any other symptoms with the pain?

Nursing Process: The Care of the Patient with Angina-Diagnosis

• Ineffective cardiac tissue perfussion secondary to CAD

• Death anxiety related to cardiac symptoms• Deficient knowledge related about the

underlying disease and methods for avoiding complications

• Noncompliance, ineffective therapeutic regimen related to failure to accept necessary lifestyle changes

Collaborative Problems

• Acute Pulmonary Edema• Heart Failure• Cardiogenic Shock• Dysrhythmias and Cardiac Arrest• MI

Nursing Process: The Care of the Patient with Angina-Planning

• Goals include the immediate and appropriate treatment of angina, prevention of angina, reduction of anxiety, awareness of the disease process, understanding of prescribed care, adherence to the self care program and absence of complications.

Treatment of Angina Pain

• Treatment of Angina pain is a priority nursing concern.• Patient is to stop all activity and sit or rest in bed• Assess the patient while performing other necessary

interventions-VS, observing for respiratory distress, assessing for pain, and if in the hospital setting, the ECG is being obtained.

• Administer oxygen• Administer medications as ordered or by protocol,

usually NTG.

Anxiety

• Patients with Angina often fear loss of their roles within society and the family.

• They may also fear the pain (or Prodromal symptoms) may lead to MI or death.

• Use various stress reduction techniques: guided imagery or music therapy etc.

• Assisting the patient and the patient’s family with spiritual needs may allay fears and anxieties.

Patient Teaching

• Lifestyle Changes and Reduction of Risk Factors• Explore, Recognize, and adapt Behaviors to

avoid to reduce the incidence of episodes of ischemia

• Teaching regarding disease process• Medications• Stress reduction• When to seek emergency care

Myocardial Infarction

• An area of the myocardium is permanently destroyed. Usually caused by reduced blood flow in a coronary artery due to rupture of an atherosclerotic plaque and subsequent occlusion of the artery by a thrombus.

• In unstable angina, the plaque ruptures but the artery is not completely occluded. Unstable Angina and Acute MI are considered the same process but at a different point on the continuum.

• The term acute coronary syndrome includes unstable angina and MI.

Clinical Manifestations and Diagnosis

• Chest Pain and other symptoms-what are they?

• ECG• Lab Tests-bio markers• CK-MB• Myoglobin• Troponin T or I

Question

• What is the purpose of the Echocardiogram? A. Evaluate arterial function of the heart B. Evaluate ventricular function of the heart C. Detect hyperkinetic wall motion D. Identify ischemia changes

Answer

• B

• The echocardiogram is used to evaluate ventricular function. It can detect hypokinetic and akinetic wall motion and determine the ejection fraction.

Treatment of Acute MI

• Obtain Diagnostic Tests including ECG within 10 minutes of admission to the ED

• Oxygen• Aspirin, Nitroglycerine, Morphine, beta-blocker (Why

these meds?)• Evaluate for percutaneous coronary intervention or

thrombolytic therapy• As indicated, IV Heparin or LMWH, Plavix, or

Triclopidine, glycoprotein IIb/IIIa inhibitor • Bed rest

Nursing Process: The Care of the Patient with ACS-Assessment

• A vital component of nursing care!• Assess all symptoms carefully and compare to

previous and baseline data to detect any changes or complications.

• Monitor ECG

Nursing Process: The Care of the Patient with ACS-Diagnosis

• Ineffective cardiac tissue perfusion• Risk for fluid intolerance• Risk for ineffective peripheral tissue perfusion• Death anxiety• Deficient Knowlege

Collaborative Problems

• Acute Pulmonary Edema• Heart Failure• Cardiogenic Shock• Dysrhythmias and Cardiac Arrest• Pericardial effusion and cardiac tamponade

Nursing Process: The Care of the Patient with ACS-Planning

• Goals include the relief of pain or ischemic signs and symptoms, prevention of further myocardial damage, absence or respiratory, maintenance of or attainment of adequate tissue perfusion, reduced anxiety, adherence to the self-care program, and absence or early recognition of complications. See page 777