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Coronary Artery Disease
• Includes stable angina pectoris and acute
coronary syndromes
• Ischemia: oxygen supply insufficient to meet
requirements of the myocardium
• Infarction: necrosis or cell death that occurs
when severe ischemia is prolonged and
irreversible damage to tissue results
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Stable Angina Pectoris
• A feeling of “strangling of the chest”
• Temporary imbalance between the coronary
artery’s ability to supply oxygen and the cardiac
muscle’s demand for oxygen
• Ischemia limited in duration and does not cause
permanent damage to myocardial tissue
• Stable and unstable angina
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Acute Coronary Syndrome
• Atherosclerotic plaque in the coronary artery
ruptures, resulting in platelet aggregation,
thrombus formation, and vasoconstriction.
• Between 10% and 30% of clients with unstable
angina progress to having MI within 1 year.
• 29% die from MI within 5 years.
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Hospitalizations in the U.S. Due to Acute Coronary
Syndromes (ACS)
Acute Coronary Syndromes*
1.57 Million Hospital Admissions - ACS
UA/NSTEMI
1.24 million
†
Admissions per year
Heart Disease and Stroke Statistics – 2007 Update. Circulation 2007; 115:69-171. *Primary and secondary diagnoses. †About
0.57 million NSTEMI and 0.67 million UA.
STEMI
.33 million
Admissions per year
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Applying Classification of Recommendations and Level of Evidence
Class I
Class IIa
Class IIb
Class III
Benefit >>> Risk
Benefit >> Risk
Additional studies with
focused objectives
needed
Benefit ≥ Risk
Additional studies with
broad objectives
needed; Additional
registry data would be
helpful
Risk ≥ Benefit
No additional studies
needed
Procedure/ Treatment
SHOULD be
performed/
administered
IT IS REASONABLE
to perform
procedure/administer
treatment
should
is recommended
is indicated
is useful/effective/
beneficial
is reasonable
can be useful/effective/
beneficial
is probably recommended
or indicated
Procedure/Treatment
MAY BE CONSIDERED
may/might be considered
may/might be reasonable
usefulness/effectiveness is
unknown /unclear/uncertain
or not well established
Procedure/Treatment
should NOT be
performed/administered
SINCE IT IS NOT
HELPFUL AND MAY BE
HARMFUL
is not recommended
is not indicated
should not
is not
useful/effective/beneficial
may be harmful
5
Myocardial Infarction
• Most serious acute coronary syndrome
• Occurs when myocardial tissue is abruptly and
severely deprived of oxygen
• Dynamic process that does not occur instantly
but evolves over several hours
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Nonmodifiable Risk Factors
• Age
• Gender
• Family history
• Ethnic background
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Modifiable Risk Factors
• Elevated serum cholesterol
• Cigarette smoking
• Hypertension
• Impaired glucose tolerance
• Obesity
• Physical inactivity
• Stress
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Pain Assessment
• Discomfort in the chest, epigastric area, jaw,
back, or arm is noted. (Rate discomfort on scale
of 0 to 10.)
• Discomfort is often described as tightness,
burning, pressure, or indigestion.
• Anginal pain improves with rest and
nitroglycerine; MI does not.
(Continued)
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Pain Assessment (Continued)
• Other manifestations include nausea and
vomiting, diaphoresis, dizziness, weakness,
palpitations, and shortness of breath.
• What group of patients will not show classic
symptoms and why?
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What else will you assess?
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Diagnostic Assessment
• Electrocardiogram
• Stress test
• Myocardial perfusion imaging
• Magnetic response imaging
• Cardiac catheterization
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Lab Test
• CK
• CK-MB
• Tropopnin
• CBC
• Chem 7
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Acute Pain
• Interventions include:
– Provide pain relief modalities.
– Decrease myocardial oxygen demand.
– Increase myocardial oxygen supply.
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Pain Management MONA
• Morphine sulfate
• Nitroglycerine
• Oxygen
• ASA
• Position of comfort; semi-Fowler’s position
• Quiet and calm environment
• Deep breaths to increase oxygenation
GET PATIENT TO CATH LAB ASAP
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Ineffective Tissue Perfusion
(Cardiopulmonary)
• Interventions include:
– Restoration of perfusion to the injured area
often limits the amount of extension and
improves left ventricular function.
– Complete sustained reperfusion of coronary
arteries in the first few hours after an MI has
decreased mortality.
GET PATIENT TO CATH LAB ASAP
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Identification of Coronary Artery Reperfusion
• Abrupt cessation of pain or discomfort
• Sudden onset of ventricular dysrhythmias
• A peak at 12 hours of markers of myocardial
damage
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Oral Drug Therapy
• Aspirin
• Beta-adrenergic blocking agents
• ACE inhibitors
• Calcium channel blockers
• The study called “Clopidogrel in Unstable
Angina to Prevent Recurrent Ischemic Events
(CURE)” (Palatnik, 2001)
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Ineffective Coping Interventions
• Assess the client’s level of anxiety but allow
expression of any anxiety and attempt to define
its origin.
• Give simple explanations of therapies,
expectations, and surroundings, and
explanations of progress to help relieve anxiety.
• Provide coping enhancement.
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Potential for Dysrhythmias
• Dysrhythmias are the leading cause of death in
most clients with MI who die before they can be
hospitalized.
• Interventions include:
– Identify the dysrhythmias.
– Assess hemodynamic status.
– Evaluate for discomfort.
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Potential for Heart Failure Interventions
• Assessment
• Monitoring for signs of poor organ perfusion
• Hemodynamic monitoring
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Care of the patient going for PTCA/Stent
• Percutaneous transluminal coronary angioplasty
(PTCA)
• Assessment
• Plan
• Goals
• Interventions
• Evaluations
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Care of the patient Post PTCA/Stent
• Percutaneous transluminal coronary angioplasty
(PTCA)
• Assessment
• Plan
• Goals
• Interventions
• Evaluations
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Percutaneous Transluminal Coronary
Angioplasty
• Monitoring for acute closure of the vessel,
bleeding from the insertion site, reaction to dye,
hypotension, hypokalemia, and dysrhythmias
• Long-term nitrate, calcium channel blocker, and
aspirin therapy
• Beta blocker and ACE inhibitor if MI
• Infusions of GPIIa/IIIb inhibitors
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Health Teaching
• Smoking cessation
• Diet control
• Complementary and alternative therapies
• Physical activity
• Sexual activity
(Continued)
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Health Teaching (Continued)
• Blood pressure, blood glucose control
• Cardiac medications
• Self-monitoring; seeking medical assistance if
needed
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