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CORONARY ARTERY
DISEASE & ACUTE
CORONARY SYNDROME
Anne Lucero
ALTERED TISSUE PERFUSION
Definition • CORONARY ARTERY DISEASE is a type of blood
vessel disorder included under the category of
atherosclerosis
• ACUTE CORONARY SYNDROME spectrum of clinical
syndromes representing degrees of coronary artery
occlusion, including unstable angina, non-ST-segment
Elevation MI, and ST-segment Elevation MI, or sudden
death.
• ATHEROSCLEROSIS The accumulation of lipid
containing materials found in the intima of the arteries,
begins as soft deposits of fat and hardens with age
The Beginning of Atherosclerosis
Photos courtesy of Boehringer Ingleheim International GmbH, by Lennart Nilsson.
American Heart Association
(AHA)
• 79,400,000 Americans
suffer with Cardiovascular
disease
• 15,800,000 Americans
have CAD
• Underlying cause of death,
CAD is 58% in 2002, 36%
in 2004.
• 2007 Direct or indirect
cause of death=431.8
Billion
Normal Coronary Artery
• LAYERS:
• Tunica Adventia (outer
coat) ,
• Tunica Media ( muscle
coat),
• Tunica Intima ( lining)
Coronary Artery location and
service
• Right coronary artery (RCA) descends to
the right along the atrioventricular groove
and turns posteriorly along the inferior
margin of the right ventricle and
diaphragmatic surface of the left ventricle.
Supplies the Right atrium, right ventricle,
posterior wall left ventricle and 90% of the
AV node
.
Coronary Artery, cont.
• Left coronary artery (LCA) has two
branches, the left anterior descending
(LAD) supplies the anterior portion of the
LV and lower half of the LV, and a portion
of the interventricular septum, terminates
before reaching the posterior area. The left
circumflex artery (LC) supplies the left
atrium, high lateral wall LV
Artery Cross Section
Evolution to the Major Acute
Coronary Syndromes
• Early Lipid formation,lipid deposits lead to
narrowing of the artery lumen, with in the intimal
wall
• Unstable plaque are not hemodynamically
significant before rupture
• Inflammation in subendotheial area further
weakens, predisposes plaque to rupture
• Speed of flow, turbulence, vessel anatomy
contribute
• Endothelium injury is site for fibrous plaque
thickening
Atherosclerotic Plaque
Photos courtesy of Boehringer Ingleheim International GmbH, by Lennart Nilsson.
Pathophysiology cont
• Plaque Rupture,
• Monolayer of platelets cover surface of rupture
• Platelet adhesion
Plaque Rupture
Photos courtesy of Boehringer Ingleheim International GmbH, by Lennart Nilsson.
Plaque Rupture
•
•
•
•
•
Rupture attracts and activates more platelets,
Aggregation occurs,
Fibrinogen cross-links platelets,
Coagulation system activated,
Thrombin generation
Platelet Activation
Photos courtesy of Boehringer Ingleheim International GmbH, by Lennart Nilsson.
Platelet Aggregation
Photos courtesy of Boehringer Ingleheim International GmbH, by Lennart Nilsson.
Thrombus formation
• Leads to intramural hemorrhage,
• Platelet formation leads to thrombus
• Leading to necrotic hard tissue and increased
stenosis of the artery
Microembolization
Photos courtesy of Boehringer Ingleheim International GmbH, by Lennart Nilsson.
Unstable Angina
• Partially occluding thrombus produces symptoms
of ischemia
• Thrombus is platelet-rich,( tx with antiplatelet
agents( asa),Glycoprotein Iib/IIIa
inhibitors(RePro, Aggrastat) most effective
• Fibrinolytic tx is NOT effective, can cause
paradoxical accelerate occlusion by release of clot
bound thrombin, further activating platelets
• Intermittently occlusive thrombus may cause
Myocardial necrosis, producing a non- elevated
ST-segment MI
Occlusive Thrombus
• Clot enlarges, microemboli from distal thrombus
lodge in coronary microvasculature, small
elevations in cardiac troponin, high risk for MI
• If occludes flow for prolonged period,ST-segment
elevation MI occurs, clot rich in Thrombin
• Prompt fibrinolysis( TPA, Activase, TNKase) or
PTCA, may limit size, increase survival
Clot Stabilization
Photos courtesy of Boehringer Ingleheim International GmbH, by Lennart Nilsson.
Risk Factors
• Characteristics or conditions that are
statistically associated with high
incidence of CAD, ACS
• Two types are: Unmodifiable and
Modifiable
MODIFIABLE RISK FACTOR
Unmodifiable / Modifiable
•
•
•
•
gender
age
family history
race
• hypertension
• elevated serum
lipids
• nutrition/
homocysteine level
• smoking
• obesity
• physical activity
Contributing Factors
• Diabetes
• Life style
• Personal stress
CASE STUDY
• MRS. JOHNSON, 52 years old, Father died
of Cancer at 72, Mother has Hypertension
and recently had cataract surgery. No
siblings, has two daughters in good health.
• Visits Physicians office with a complaint of
chest discomfort, 5’7” 190#, B/P 156/78,
HR 95, RR 22, works out with a trainer 2X
week, not a smoker.
Clinical Manifestations
• Angina : literally from the Greek,
“Strangling of the breast bone”
• Physiology for Angina: CAD causes narrow
lumen, less O2 carried to the myocardium,
anaerobic metabolism stimulates nerve
endings, transmits PAIN to cardiac nerves,
Ischemia.
Angina Types/ Patterns
• Stable angina- brought on by exercise,
relieved at rest
• Unstable angina-occurs with little effort,
often stress induced
• Prinzmetal’s- chest discomfort at rest
• Nocturnal angina- only at night
• Angina decubitus- only laying down
• Intractable angina- refractory to medication,
chronic
Chest Pain
•
•
•
•
•
TIME-1-15 min duration, >30 min=MI
QUALITY- stab, dull, burning
QUANTIFY- scale of 1-10
LOCATION-chest, jaw, groin,
PRECIPITATING FACTORS- activity,
sleep, family
• RELIEF FACTORS- rest, NTG, O2, MS
Diagnostics
• EKG
• Labs-CPK-mb, Troponin, CRP(C-reactive
protein), Chem panel, pt/ptt, CBC,
• History and Physical
• CXR
• Stress Test
• Echocardiography
• Coronary Angiography
UNFOLDING CASE
• MRS Johnson now has had an EKG in the
office, it is abnormal
• Further studies are indicated and she is sent
to the Hospital ER
• What would you want to know at this point?
Treatment Options
• Health Promotion
• Nutrition
• Pharmacology: Morphine, Oxygen,
Nitroglycerin, ASA (MONA) Beta
blockers, Calcium Channel, Antiplatelet
aggregation agents, Glycoprotein IIb/IIIa
Inhibitors
Nursing Diagnosis
• PAIN : related to Ischemia
• ANXIETY : related to diagnosis awareness
• DECREASED CARDIAC OUTPUT :
related to myocardial ischemia
• ACTIVITY INTOLERENCE : related to
myocardial ischemia
References
• [http://www.acc.org] American College of
Cardiology
• [http://www.americanheart.org/cpr]
American Heart Association
• Understanding the Pathophysiology of
Acute Coronary Syndrome, A Crusade
Educational tool. Duke Clinical Research
Institute, Durham, NC 27705