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Focus on Coronary Artery Disease and Acute Coronary Syndrome (Relates to Chapter 34, “Nursing Management: Coronary Artery Disease and Acute Coronary Syndrome,” in the textbook) Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Coronary Artery Disease and Acute Coronary Syndrome • A type of blood vessel disorder that is included in the general category of atherosclerosis • Begins as soft deposits of fat that harden with age • Referred to as “hardening of arteries” Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Coronary Artery Disease and Acute Coronary Syndrome • Atherosclerosis (cont’d) • Can occur in any artery in the body • Atheromas (fatty deposits) • Preference for the coronary arteries Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Coronary Artery Disease and Acute Coronary Syndrome • Cardiovascular diseases are the major cause of death in the United States • Heart attacks are still the leading cause of all cardiovascular disease deaths and deaths in general Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Progression of Atherosclerosis Fig. 34-2 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Coronary Artery Disease Etiology and Pathophysiology Fatty streaks Fibrous plaque • Result = narrowing of vessel lumen Complicated lesion • Continued inflammation can result in plaque instability, ulceration, and rupture • Platelets accumulate and thrombus forms • Increased narrowing or total occlusion of lumen Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Development of Collateral Circulation Fig. 34-3 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Risk Factors for CAD • Risk factors can be categorized as • Nonmodifiable risk factors • Age • Gender • Ethnicity • Family history • Genetic predisposition Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Risk Factors for CAD • Risk factors can be categorized as • Modifiable risk factors • Elevated serum lipids • Hypertension • Tobacco use • Physical inactivity • Obesity • Diabetes • Metabolic syndrome • Psychologic states • Homocysteine level Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Risk Factors for CAD Health Promotion • Identification of people at high risk • Health history, including use of prescription/nonprescription medications • Presence of cardiovascular symptoms • Environmental patterns: diet, activity • Values and beliefs about health and illness Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Risk Factors for CAD Health Promotion • Health-promoting behaviors • Physical fitness 30 minutes >5 days/week • Regular physical activity contributes to: • Weight reduction • Reduction of BP • increase in HDL cholesterol Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Risk Factors for CAD Health Promotion • Health-promoting behaviors • Nutritional therapy • Therapeutic Lifestyle Changes • Omega-3 fatty acids Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Risk Factors for CAD Health Promotion • Health-promoting behaviors • Cholesterol-lowering drug therapy • Drugs that restrict lipoprotein production: Statins, niacin • Drugs that increase lipoprotein removal: Bile acid sequestrants • Drugs that decrease cholesterol absorption: Ezetimibe (Zetia) Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Risk Factors for CAD Health Promotion • Health-promoting behaviors • Antiplatelet therapy • ASA • Clopidogrel (Plavix) Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations of CAD Chronic Stable Angina • Etiology and Pathophysiology • Reversible (temporary) myocardial ischemia = angina (chest pain) • O2 demand > O2 supply Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations of CAD Chronic Stable Angina • Etiology and Pathophysiology • Primary reason for insufficient blood flow is narrowing of coronary arteries by atherosclerosis • For ischemia to occur, the artery is usually 75% or more stenosed Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations of CAD Chronic Stable Angina • Intermittent chest pain that occurs over a long period with the same pattern of onset, duration, and intensity of symptoms Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations of CAD Chronic Stable Angina • Pain usually lasts minutes • Subsides when the precipitating factor is relieved • Pain at rest is unusual • ECG may reveal ST segment depression Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Location of Chest Pain (Angina) Fig. 34-7 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Stable Angina Types of Angina • Prinzmetal’s (variant) angina • Occurs at rest usually in response to spasm of major coronary artery • Seen in patients with a history of migraine headaches and Raynaud’s phenomenon • Spasm may occur in the absence of CAD Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Stable Angina Types of Angina • Prinzmetal’s (variant) angina • When spasm occurs • Chest pain • Marked, transient ST segment elevation • May occur during REM sleep • May be relieved by moderate exercise Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Stable Angina Nursing and Collaborative Management • Drug therapy: Goal: and/or O2 supply O2 demand • Short-acting nitrates: Sublingual • Long-acting nitrates • Nitroglycerin ointment • Transdermal controlled-release nitroglycerin Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Stable Angina Nursing and Collaborative Management • Drug therapy: Goal: O2 demand and/or O2 supply • β-Adrenergic blockers • Calcium channel blockers • If β-adrenergic blockers are poorly tolerated, contraindicated, or do not control anginal symptoms • Used to manage Prinzmetal’s angina • Angiotensin-converting enzyme inhibitors Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Stable Angina Nursing and Collaborative Management • Diagnostic Studies • Health history/physical examination • Laboratory studies • 12-lead ECG • Chest x-ray • Echocardiogram • Exercise stress test Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Chronic Stable Angina Nursing and Collaborative Management • Diagnostic Studies • Cardiac catheterization • Diagnostic • Coronary revascularization: Percutaneous coronary intervention • Balloon angioplasty • Stent Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Placement of a Coronary Artery Stent Fig. 34-9 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Pre- and Post-PCI with Stent Placement Fig. 34-10 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Acute Coronary Syndrome • When ischemia is prolonged and not immediately reversible, acute coronary syndrome (ACS) develops • ACS encompasses: • Unstable angina (UA) • Non–ST-segment-elevation myocardial infarction (NSTEMI) • ST-segment-elevation (STEMI) Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Relationship Between CAD, Chronic Stable Angina, and ACS Fig. 34-11 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Acute Coronary Syndrome Etiology and Pathophysiology • Deterioration of a once stable plaque rupture aggregation • Result platelet thrombus • Partial occlusion of coronary artery: UA or NSTEMI • Total occlusion of coronary artery: STEMI Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Coronary Thrombogenesis Secondary to Plaque Deterioration Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations of ACS Unstable Angina • Unstable angina • New in onset • Occurs at rest • Has a worsening pattern • UA is unpredictable and represents a medical emergency Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations of ACS Myocardial Infarction (MI) • Result of sustained ischemia (>20 minutes), causing irreversible myocardial cell death (necrosis) • Necrosis of entire thickness of myocardium takes 4 to 6 hours Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Acute Myocardial Infarction Fig. 34-13 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations of ACS Myocardial Infarction • The degree of altered function depends on the area of the heart involved and the size of the infarct • Contractile function of the heart is disrupted in areas of myocardial necrosis) Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Occlusion of the Left Anterior Descending Coronary Artery, Resulting in MI Fig. 34-12 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations of ACS Myocardial Infarction • Pain • Total occlusion → anaerobic metabolism and lactic acid accumulation Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations of ACS Myocardial Infarction • Pain • Described as heaviness, constriction, tightness, burning, pressure, or crushing • Common locations: substernal, retrosternal, or epigastric areas; pain may radiate Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations of ACS Myocardial Infarction • Sympathetic nervous system stimulation results in • Release of glycogen • Diaphoresis • Vasoconstriction of peripheral blood vessels • Skin: ashen, clammy, and/or cool to touch Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations of ACS Myocardial Infarction • Cardiovascular • Initially, ↑ HR and BP, then ↓ BP (secondary to ↓ in CO) • Crackles • Jugular venous distention • Abnormal heart sounds • S3 or S 4 • New murmur Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Clinical Manifestations of ACS Myocardial Infarction • Nausea and vomiting • Can result from reflex stimulation of the vomiting center by the severe pain • Fever • Systemic manifestation of the inflammatory process caused by cell death Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Myocardial Infarction Healing Process • Development of collateral circulation improves areas of poor perfusion • Necrotic zone identifiable by ECG changes and nuclear scanning • 10 to 14 days after MI, scar tissue is still weak and vulnerable to stress Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Complications of Myocardial Infarction • Dysrhythmias • Most common complication • Present in 80% of MI patients • Life-threatening dysrhythmias seen most often with anterior MI, heart failure, or shock Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Complications of Myocardial Infarction • Heart failure • A complication that occurs when the pumping power of the heart has diminished Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Complications of Myocardial Infarction • Cardiogenic shock • Occurs when inadequate oxygen and nutrients are supplied to the tissues because of severe LV failure • Requires aggressive management Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Complications of Myocardial Infarction • Papillary muscle dysfunction • Causes mitral valve regurgitation • Condition aggravates an already compromised LV • Ventricular aneurysm • Results when the infarcted myocardial wall becomes thinned and bulges out during contraction Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Complications of Myocardial Infarction • Acute pericarditis • An inflammation of visceral and/or parietal pericardium • May result in cardiac compression, ↓ LV filling and emptying, heart failure • Pericardial friction rub may be heard auscultation on Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Diagnostic Studies Unstable Angina and Myocardial Infarction • Detailed health history and physical • 12-lead ECG: Changes in QRS complex, ST segment, and T wave can rule out or confirm UA or MI • Serum cardiac markers • Coronary angiography • Others: Exercise stress testing, echocardiogram Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Serum Cardiac Markers After MI Fig. 34-15 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Acute Coronary Syndrome • Emergency management • Initial interventions • Ongoing monitoring • Emergent PCI • Treatment of choice for confirmed MI • Balloon angioplasty + drug-eluting stent(s) • Ambulatory 24 hours after the procedure Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Acute Coronary Syndrome • Fibrinolytic therapy • Indications and contraindications • Marker of reperfusion: Return of ST segment to baseline • Rescue PCI if thrombolysis fails • Major complication: Bleeding Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Acute Coronary Syndrome • Drug therapy • • • • • • • IV nitroglycerin Morphine sulfate β-adrenergic blockers Angiotensin-converting enzyme inhibitors Antidysrhythmia drugs Cholesterol-lowering drugs Stool softeners Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Acute Coronary Syndrome • Nutritional therapy Progress to low-salt, low saturated fat, low-cholesterol diet Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Acute Coronary Syndrome • Coronary surgical revascularization • Fail medical management • Presence of left main coronary artery or three-vessel disease • Not a candidate for PCI (e.g., lesions are long or difficult to access) • Failed PCI with ongoing chest pain Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Collaborative Care Acute Coronary Syndrome • Coronary surgical revascularization • Coronary artery bypass graft (CABG) surgery • Requires cardiopulmonary bypass • Uses arteries and veins for grafts Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. CABG Surgery Fig. 34-16 Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Chronic Stable Angina and ACS • Nursing Assessment • Subjective Data • Health history • Functional health patterns • Objective Data Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Chronic Stable Angina and ACS • Nursing Diagnoses • Acute pain • Ineffective tissue perfusion (cardiac) • Anxiety • Activity intolerance Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Chronic Stable Angina and ACS • Planning: Overall goals • • • • Relief of pain Preservation of myocardium Immediate and appropriate treatment Effective coping with illness-associated anxiety • Participation in a rehabilitation plan • Reduction of risk factors Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Chronic Stable Angina • Health Promotion • Therapeutic lifestyle changes to reduce cardiac risk factors Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Chronic Stable Angina • Acute Interventions for anginal attack • Rest • Administration of supplemental oxygen • 12-lead ECG • Prompt pain relief first with a nitrate followed by an opioid analgesic if needed • Auscultation of heart sounds • Comfortable positioning of the patient Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management Chronic Stable Angina • Ambulatory and Home Care • Patient teaching • CAD and angina • Precipitating factors for angina • Risk factor reduction • Medications Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management ACS • Acute Intervention • Pain: Nitroglycerin, morphine, oxygen • Continuous monitoring • ECG • VS, pulse oximetry • Heart and lung sounds • Rest and comfort • Balance rest and activity • Begin cardiac rehabilitation Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management ACS • Acute Intervention • Anxiety • Emotional and behavioral reaction • Maximize patient’s social support systems • Consider open visitation Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management ACS • Coronary revascularization: ICU for first 24 to 36 hours • Pulmonary artery catheter for measuring CO, other hemodynamic parameters • Intraarterial line for continuous BP monitoring • Pleural/mediastinal chest tubes for chest drainage • Continuous ECG monitoring to detect dysrhythmias (esp. atrial dysrhythmias) Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management ACS • Coronary revascularization: ICU for first 24 to 36 hours • Endotracheal tube connected to mechanical ventilation • Extubation within 12 hours • Epicardial pacing wires for emergency pacing of the heart • Urinary catheter to monitor urine output • NG tube for gastric decompression Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management ACS • Coronary revascularization: Care is focused on • Assessing the patient for bleeding (e.g., chest tube drainage, incision sites) • Monitoring fluid status • Replacing electrolytes PRN • Restoring temperature (e.g., warming blankets) Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management ACS • Ambulatory and Home Care • Patient teaching • Physical exercise • Resumption of sexual activity • Emotional readiness of patient and partner • Physical expenditure Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Nursing Management ACS • Evaluation • Relief of pain • Preservation of myocardium • Immediate and appropriate treatment • Effective coping with illness-associated anxiety • Participation in a rehabilitation plan • Reduction of risk factors Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Sudden Cardiac Death (SCD) • Unexpected death from cardiac causes • Most deaths occur outside of hospital • CAD accounts for about 80% of all SCDs Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.