Elsevier items and derived items © 2006 by Elsevier Inc. Coronary Artery Disease Includes stable angina pectoris and acute coronary syndromes Ischemia:

Elsevier items and derived items © 2006 by Elsevier Inc.

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

• 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


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

• 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


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.

• 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.

4

Hospitalizations in the U.S. Due to Acute Coronary Syndromes (ACS)

Acute Coronary Syndromes*

1.57 Million Hospital Admissions - ACS

UA/NSTEMI†

STEMI

1.24 million Admissions per

year

.33 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.

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Class I Benefit >>> Risk

Procedure/ Treatment SHOULD be performed/ administered

Class IIa Benefit >> RiskAdditional studies with focused objectives needed

IT IS REASONABLE to perform procedure/administer treatment

Class IIb Benefit ≥ RiskAdditional studies with broad objectives needed; Additional registry data would be helpful

Procedure/Treatment MAY BE CONSIDERED

Class III Risk ≥ BenefitNo additional studies needed

Procedure/Treatment should NOT be performed/administered SINCE IT IS NOT HELPFUL AND MAY BE HARMFUL

shouldis recommendedis indicatedis useful/effective/

beneficial

is reasonablecan be useful/effective/

beneficialis probably recommended

or indicated

may/might be consideredmay/might be reasonableusefulness/effectiveness is

unknown /unclear/uncertain or not well established

is not recommendedis not indicatedshould notis not

useful/effective/beneficialmay be harmful

Applying Classification of Recommendations and Level of Evidence


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

• 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


Nonmodifiable Risk Factors

• Age

• Gender

• Family history

• Ethnic background

• Age

• Gender

• Family history

• Ethnic background


Modifiable Risk Factors

• Elevated serum cholesterol

• Cigarette smoking

• Hypertension

• Impaired glucose tolerance

• Obesity

• Physical inactivity

• Stress

• Elevated serum cholesterol

• Cigarette smoking

• Hypertension

• Impaired glucose tolerance

• Obesity

• Physical inactivity

• Stress


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)

• 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)


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?

• 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?

What else will you assess?



Diagnostic Assessment

• Electrocardiogram

• Stress test

• Myocardial perfusion imaging

• Magnetic response imaging

• Cardiac catheterization

• Electrocardiogram

• Stress test

• Myocardial perfusion imaging

• Magnetic response imaging

• Cardiac catheterization

Lab Test

• CK

• CK-MB

• Tropopnin

• CBC

• Chem 7

• CK

• CK-MB

• Tropopnin

• CBC

• Chem 7



Acute Pain

• Interventions include:

– Provide pain relief modalities.

– Decrease myocardial oxygen demand.

– Increase myocardial oxygen supply.


– Provide pain relief modalities.

– Decrease myocardial oxygen demand.

– Increase myocardial oxygen supply.


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

• Morphine sulfate

• Nitroglycerine

• Oxygen

• ASA

• Position of comfort; semi-Fowler’s position

• Quiet and calm environment

• Deep breaths to increase oxygenation



Ineffective Tissue Perfusion (Cardiopulmonary)


– 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.



– 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.



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

• Abrupt cessation of pain or discomfort

• Sudden onset of ventricular dysrhythmias

• A peak at 12 hours of markers of myocardial damage


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)

• 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)


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.

• 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.


Potential for Dysrhythmias

• Dysrhythmias are the leading cause of death in most clients with MI who die before they can be hospitalized.


– Identify the dysrhythmias.

– Assess hemodynamic status.

– Evaluate for discomfort.

• Dysrhythmias are the leading cause of death in most clients with MI who die before they can be hospitalized.


– Identify the dysrhythmias.

– Assess hemodynamic status.

– Evaluate for discomfort.


Potential for Heart Failure Interventions

• Assessment

• Monitoring for signs of poor organ perfusion

• Hemodynamic monitoring

• Assessment

• Monitoring for signs of poor organ perfusion

• Hemodynamic monitoring


Care of the patient going for PTCA/Stent

• Percutaneous transluminal coronary angioplasty (PTCA)

• Assessment

• Plan

• Goals

• Interventions

• Evaluations


• Assessment

• Plan

• Goals

• Interventions

• Evaluations


Care of the patient Post PTCA/Stent


• Assessment

• Plan

• Goals

• Interventions

• Evaluations


• Assessment

• Plan

• Goals

• Interventions

• Evaluations


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

• 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


Health Teaching

• Smoking cessation

• Diet control

• Complementary and alternative therapies

• Physical activity

• Sexual activity

(Continued)

• Smoking cessation

• Diet control

• Complementary and alternative therapies

• Physical activity

• Sexual activity

(Continued)


Health Teaching (Continued)

• Blood pressure, blood glucose control

• Cardiac medications

• Self-monitoring; seeking medical assistance if needed

• Blood pressure, blood glucose control

• Cardiac medications

• Self-monitoring; seeking medical assistance if needed

Documents

Elsevier items and derived items © 2006 by Elsevier Inc. Coronary Artery Disease Includes stable angina pectoris and acute coronary syndromes Ischemia: