Causes of AP physical exertion stress Other Causes of AP arterial spasm aortic stenosis cardiomyopathy uncontrolled hypertension Non-Cardiac Causes

Causes anemia fever thyrotoxicosis Decreased oxygen due to: Non-obstructive clot on an atherosclerotic plaque coronary vasospasm atherosclerotic obstruction without clot or vasospasm inflammation or infection (sore throat, gingivitis, tonsillitis)

ATHEROSCLEROSIS

CAD
ANGINA PECTORIS

ACS

Risk Factors Modifiable hyperlipidemia obesity smoking DM sedentary lifestyle Non-Modifiable age male race family history Others increased levels of o homocysteine o fibrin o lipoprotein infection inflammation LVH (left ventricular hypertrophy)

UNSTABLE ANGINA

MYOCARDIAL INFARCTION

NON-ST SEGMENT ELEVATION MI

DRUG THERAPY
NITRATES causes generalized vasodilation o Can be administered orally, sublingually, transdermally, or IV o Provide short or long-lasting effects o Short-acting nitrates provide immediate relief or prophylaxis (15 MINUTES EFFECT) o Long-acting nitrates prevent anginal episodes and/or reduce severity and frequency of attacks BETA-ADRENERGIC BLOCKERS inhibit SYMPATHETIC stimulation of receptors of the heart and heart muscle o Non-selective BAB also inhibit stimulation of the lungs. Contraindicated for patients with COPD or ASTHMA because it constricts the large airways in the lungs. CALCIUM CHANNEL BLOCKERS inhibit movement of calcium within the heart muscle and coronary vessels; promote vasodilation and prevent/control CORONARY ARTERY SPASM ACE INHIBITORS have therapeutic effects on the vascular endothelium and have show to REDUCE RISK of worsening angina ANTILIPIDS reduce cholesterol and triglyceride levels ANTIPLATELET AGENTS decrease platelet aggregation to inhibit thrombus formation FOLIC ACID AND B-COMPLEX VITAMINS treat increased homocysteine levels

ST-SEGMENT ELEVATION MI
PERCUTANEOUS CORONARY INTERVENTION
PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY o A balloon tipped catheter is placed in a coronary vessel narrowed by plaque o The balloon is inflated and deflated to stretch the vessel wall and flatten the plaque INTRACORONARY ATHERECTOMY o A blade-tipped catheter is guided into a coronary vessel to the site of the plaque o Plaque is either cut, shaved, or pulverized then removed o Limited larger vessels INTRACORONARY STENT o A diamond mesh tubular device is placed in the coronary vessel o Prevents restenosis o Drug-eluting stents contain an anti-inflammatory drug, which decrease the inflammatory response CABG (CORONARY ARTERY BYPASS GRAFT) SURGERY o A graft is surgically attached to the aorta, and the other end of the graft is attached to a distal portion of the coronary vessel TRANSMYOCARDIAL REVASCULARIZATION o laser beam, small channels are formed in the myocardium

CLINICAL MANIFESTATIONS

CAD

CHRONIC STABLE ANGINA PECTORIS

Chest pain or discomfort provoked by EXERTION or EMOTIONAL STRESS. Relieved by REST or NITROGLYCERIN. Characteristics substernal chest pain, pressure, heaviness or discomfort pain may be mild or severe gradual buildup of discomfort and subsequent gradual fading numbness or weakness in arms, wrists, or hands diaphoresis tachycardia increased BP Location Behind middle or upper third of sternum + Levine Sign Radiation Radiates to neck, jaw, shoulders, arms, hands, and posterior intracapsular area Duration 2-15 minutes (after stopping activities) 1 minute after NITROGLYCERINE Other Precipitating Factor Exposure to hot or cold weather Eating heavy meal Coitus (increase workload of the heart, increase oxygen demand)

UNSTABLE ANGINA PECTORIS (Preinfarction)

Chest pain occurring at REST, no OXYGEN DEMAND is placed on the heart, but an ACUTE LACK of BLOOD FLOW to the HEART occurs because of: Coronary artery spasm Presence of an enlarge plaque Hemorrhage / ulceration of a complicated lesion Critical narrowing of the vessel lumen occurs A change in FREQUENCY, DURATION, and INTENSITY of stable angina symptoms Pain lasts longer than 10 MINUTES Pain UNRELIEVED by rest or Nitroglycerine Mimics S&S of MI CAN CAUSE SUDDEN DEATH OR RESULT IN MI.

SILENT ISCHEMIA
Absence of chest pain with documented evidence of an imbalance between myocardial oxygen supply and demand (ST DEPRESSION of 1mm or more). CIRCADIAN EVENT (occurs during the first few hours after awakening due to an increase in sympathetic nervous system activity) o Increase heart rate o Increase BP o Increase coronary vessel tone o Increase blood viscosity

DIAGNOSTIC EVALUATIONS
Characteristic chest pain and clinical history Nitroglycerin test relief of pain. Blood tests (Hemoglobin, fasting blood glucose, fasting lipid panel, coagulation studies, CRP, homocysteine, lipoprotein). Resting ECG may show LVH, ST-T wave changes, arrhythmias, and Q waves. ECG Stress Testing progressive increases of speed and elevation walking on a treadmill increase the workload of the heart. ST-T wave changes occur if myocardial ischemia is induced. Radionuclide Imaging a radioisotope, thallium 201, injected during exercise is imaged by a camera. Low uptake of the isotope by heart muscle indicates regions of ischemia induced by exercise. Images taken during rest show a reversal of ischemia. Radionuclide Ventriculography (gated blood pool scanning) red blood cells tagged with a radioisotope are imaged by camera during exercise and at rest. Wall motion abnormalities of the heart can be detected and ejection fraction estimated. Cardiac Catheterization coronary angiography performed during the procedure determines the presence, location, and extent of coronary lesion. PET (Positron-Emission Tomography) cardiac perfusion imaging with high resolution to detect very small perfusion differences caused by stenotic arteries. Electron-Beam CT detects coronary calcium, which is found in most, but not all, atherosclerotic plaque. Low specificity.

PRIMARY PREVENTION FOR CAD

STOP SMOKING

IDEAL BODY WEIGHT

NURSING ASSESSMENT
1. Ask patient to DESCRIBE anginal attacks. WHEN do attacks tend to occur? WHERE is the pain located? Does it RADIATE? Was the onset of pain SUDDEN or GRADUAL? How LONG did it LAST? Was the pain STEADY and UNWAVERING in quality? Was the discomfort accompanied by other symptoms? o SWEATING o LIGHT-HEADEDNESS o NAUSEA o PALPITATIONS o SHORTNESS OF BREATH How is the pain RELIEVED? 2. Obtain BASELINE ECG. 3. Assess patient and familys KNOWLEDGE of disease. 4. Identify patient and familys level of anxiety and use appropriate coping mechanism. 5. Gather information about the patients cardiac risk factors. Age Total cholesterol level HDL level Systolic BP Smoking status 10-year risk for development of CHD according to Framingham scoring method 6. Medical history Diabetes Heart failure Previous MI COPD 7. Identify factors that may contribute to NONCOMPLIANCE with prescribed drug therapy. 8. Review RENAL and HEPATIC STUDIES and CBC. 9. Discuss patient current ACTIVITY LEVELS. 10. Discuss patients BELIEFS about modification of risk factors and WILLINGNESS TO CHANGE.

Determine the 10-year risk of development of coronary heart disease (CHD) in men and women based on: AGE CHOLESTEROL HDL BP HYPERTENSION SMOKING

NURSING INTERVENTIONS
RELIEVING PAIN
Determine intensity of patients angina. o Compare pain experienced in the past. o Observe for other signs and symptoms (diaphoresis, sob, protective body posture, dusky facial color, changes in LOC. Position for comfort, FOWLERs promotes ventilation. OXYGEN (PRN) Obtain VS (5-10 min until angina subsides) Obtain 12-Lead ECG Antianginal Drug (PRN) Monitor for relief of pain and note duration of anginal episode Monitor for progression from stable to unstable angina Identify specific activities the patient may engage in that are below the level at which angina pain occurs. Notify staff when angina pain is experienced.

MAINTAINING CARDIAC OUTPUT

Monitor response to therapy. o BP and PR (provides baseline data for orthostatic hypotension) Recheck VS as indicated by ONSET of action of drug and at time of drugs PEAK effect. Note changes in BP of more than 10 mmHg and changes in heart rate of more than 10 beats/min. Note complaints of headache (esp. use of Nitrates) and dizziness. o Analgesics for headache o Supine position to relieve dizziness (associated with hypotension, PRELOAD is enhanced, thereby increasing BP) Institute continuous or PRN ECG. o Beta-adrenergic blockers and calcium channel blockers can cause significant bradycardia and varying degrees of heart block. Evaluate for development of heart failure. o Beta adrenergic blockers and calcium channel blockers DECREASE CONTRACTILITY, increasing the likelihood of heart failure. o Obtain daily weight and IO. o Auscultate lung fields for CRACKLES. o Monitor for presence of EDEMA. Remove previous nitrate patch or paste before applying new paste or patch. o Prevents HYPOTENSION. o To decrease nitrate tolerance transdermal nitroglycerin may be worn only in the daytime hours and taken off at night when physical exertion is decreased. Be alert to ADVERSE REACTION related to ABRUPT DISCONTINUATION of betaadrenergic blockers and calcium channel blockers. o Prevent rebound phenomenon. Tachycardia Hypertension Chest pain Discuss use of CHROMOTHERAPEUTIC therapy with health care provider. o Tailoring of anginal drug therapy to the timing of circadian events. Report adverse drug effects.

DECREASNG ANXIETY
Rule out physiologic etiologies for increasing anxiety before administering PRN sedatives. Auscultate patient for signs of HYPOPERFUSION. o Auscultate heart and lung sounds o Obtain a rhythm strip o Administer Oxygen PRN o Notify physician immediately Document all assessment findings, health care provider notification and response, and interventions and response. Explain reasons for hospitalization, diagnostic tests, and therapies. Encourage patient to verbalize fears and concerns about illness through frequent conversations. Answer patients questions. Administer anti-anxiety medication (PRN). Explain the importance of anxiety reduction to assist in control of angina. o Anxiety and fear put an increased stress on the heart, requiring the heart to use more oxygen. o Teach relaxation technique. Discuss measures to be taken when an anginal episode occurs. o Preparing client can decrease anxiety. o Allow patient to accurately describe angina.

ANTI-ANGINA MEDICATIONS AND ADVERSE EFFECTS

NITROGLCERIN o Carry it at all times. o Keep in original dark container. o Should cause a slight burning or stinging sensation under the tongue when potent. o Place under tongue at first sign of chest discomfort. o Stop all effort or activity, sit and take tabletrelief should be after a few minutes. o Bite tablet between front teeth and slip under tongue for quick action. o Repeat dosage in a few minutes (3x) if relief is not obtained. o Take prophylactically to avoid pain known to occur with certain activities. o Remove previous paste before applying new one (same with patch). o Do not remove patch when swimming or bathing. VERAPAMIL (CALAN) constipation NIFEDIPINE (PROCARDIA) ankle edema BEETA-ADRENERGIC BLOCKERS / CALCIUM CHANNEL BLOCKERS heart failure, shortness of breath, weight gain, REBOUND EFFECT (angina, tachycardia, hypertension) VASODILATORS, ANTIHYPERTENSIVES dizziness

Others: CAFFEINE increases heart rate and produce angina DIET PILLS, NASAL DECONGESTANTS increases heart rate and stimulate high BP ALCOHOL increase hypotensive adverse effect of drugs