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CORONARY ARTERYDISEASE
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Coronary Artery Disease
Definition:CAD is a term that refers to the effect of theaccumulation of atherosclerosis plaque in thecoronary arteries that obstructs blood flow to the
myocardium
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Cont.
Conditions result from CAD
1. Angina Pectoris
2. 2. Myocardial Infarction
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Angina Pectoris
Definition:
Angina pectoris, is the medical term usedto describe acute chest pain ordiscomfort.
Angina occurs when the hearts need foroxygen increases beyond the level ofoxygen available from the blood nourishingthe heart.
It has 3 types
Stable Angina Un stable angina & Variant Angina (Prinzmetals or resting
angina) :
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Mechanism Of Angina
5/12/2013
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Causes
Coronary atherosclerosis (atheroma )
Factors increasing preload :
Hyperthyroidism
Exercise Anemia
Factors increasing after load:
Hypertension
Aortic stenosis Obstructive cardio myopathy
Coronary artery spasm
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Clinical Manifestations
Characteristics: Squeezing, burning, pressing,choking, or bursting pressure.
Onset: Quickly or slowly
Location: Chest, right or left arms,shoulder, or neck, jaw.
Duration: Less then 5 minutes.
Associated: Dyspnea, Sweating, faintness,
palpitation, dizziness ect. Relieving: GTN and rest.
Aggravating: exertion, exercise, heavy meal,emotional upset, and anger.
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Investigations
Electrocardiogram ( ECG)
Coronary angiography
Exercise Electrocardiogram (Stresstest).
Complications: Myocardial infarction
Cardiac Arrhythmias
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Myocardium Infarction
Myo means muscle, Cardiac
heart, infarction means death of
tissues due to lack of blood
supply.
It is also called heart attack. It
occurs when coronary arteries
become blocked and the part of
myocardial muscles become dead
due to prolonged lack of oxygen
supply to the muscle cells.
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PATHOPHYSIOLOGY
Coronary artery cannot supply enough blood to the heart inresponse to the demand due to CAD
Within 10 seconds myocardial cells experience ischemia
Ischemic cells cannot get enough oxygen or glucose
Ischemic myocardial cells may have decreased electrical &muscular function
Cells convert to anaerobic metabolism.
Cells produce lactic acid as waste
Pain develops from lactic acid accumulation
Pt feels anginal symptoms until receiving demand increase 02
requirements of myocardial cells
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ECG changes in Angina & MI
Zone of Ischemia: T wave inversion
Zone of Injury: ST elevation
Zone of Necrosis: Abnormal Q wave
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Sign and Symptom
Classic symptom of heart attack are
chest pain radiating to neck, jaws,
back of shoulder, or left arm
The pain can be felt like:
Squeezing or heavy pressure
A tight band on the chest
An elephant sitting on the chest
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Cont
Other symptoms include:
Shortness of breath(SOB)
Weakness andtiredness
Anxiety
Lightheadedness
Dizziness
Nausea vomiting
Sweating, which maybe profuse
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Radiographic Assessment
ECG
Stress Test
Myocardial perfusion imaging
MRI
Cardiac Catheterization
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Drug therapy
Analgesic for relief of pain, this is a priority. Pain may cause shock.Examples, morphine sulfate, lidocaine, Nitroglycerine IV
Thrombolytic Therapy to disintegrate blood clot by activating thefibrinolytic processes.
Ex. Streptokinase, urokinase and tissue plasminogen activator (TPA).
Administration is most crucial between 3-6 hours after the initial infarction hasoccurred.
Detect for occult bleeding during and after thrombolytic therapy.
Assess neurologic status changes which may indicate GI bleeding or cardiactamponade.
Anticoagulant and antiplatelet medications are administered afterthrombolytic therapy to maintain arterial patency.
Other Medications:
Beta-adrenergic blocking agents
Diazepam
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Surgical management
PTCA (Percutaneous TransluminalCoronary Angioplasty
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Coronary Artery Bypass Graft
surgery (CABG)
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Coronary
revascularization with coronary
artery bypass
graft (CABG)
surgery is
recommended
for patients who
(1) fail medical
management, (2)
have left maincoronary artery
or three-vessel
disease
Surgical Therapy
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CABG is performed to restore blood flow to your heart by bypassing
coronary (heart) arteries that have been narrowed or blocked by
the build-up of plaque. In CABG, a surgeon uses a piece of anartery or vein from another part of your body to reroute blood
around the blocked or narrowed portion of your coronary artery or
arteries.
Your surgeon will perform a physical examination and review your
medical history before your procedure. Be sure to bring a list ofany medications, dietary supplements, allergies any other problem
with anesthesia or herbal supplements that you take with you to
your doctor's appointment.
You also may undergo several pre-operative imaging tests, in which
the arteries that deliver blood to your heart are evaluated. Eg. 2D
Echo & CAG
The day before your procedure, you will get admitted to complete
paperwork, have a blood sample taken, be weighed, and have a
chest x-ray. You have to undergo complete body preparation as
body bath with antiseptic solution , full body shaving & hair to be
shampooed. You will be in fast for 8-10 hours.
PRE-OPERATIVE
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Take a shower or bath again on the day of surgery with the
anti-septic solution we gave you.
At the hospital, you will change into a gown. You willreceive an IV, and when its time to go to the operating
room, medications will be given to you as ordered.
As a part of your pre-operative preparation respiratory
preparation & post operative exercises will be taught to you
by physiotherapist.
You & your close relative have to give surgical & anesthesia
consent for medico-legal aspects.
Post operatively you will be kept in ICU and on fasting for
24 hrs & nutritional needs will be met by administration ofIV fluids & medication. You will have drain tubes and
catheter for
Minimum 2days
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Half an hour back to your scheduled time you will be shifted to
operation theatre along with nursing staff.
In OT you will be received in pre-op area & your file will be
verified for completion of documentation.
As soon as surgical team is ready you will be shifted to the
specified OT & you will be on your supine position & you will be
anaesthetized. Midline sternotomy incision will be taken on you
INTRA-
OPERATIVE
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ICU Stay:
You will have to stay 12-24 hrs post operatively
in ICU or as recommended by the
Surgeon/Anaesthetist.
Exercise:
Deep Breathing exercises
Chest ExercisesSpirometry
Limb Exercises( Active & Passive ROM , -
Flexion,
Extension, Circumduction)
POST-OPERATIVE
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Early Ambulation:
Sitting at the edge of the bed with feet
dangling (1-2nd day)
Bed side ambulation ( 2nd3rd day)
Pace walking
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Diet:
Low Fat diet
Not more than 12 - 15% of total calories shouldcome from fat.
Plenty of vegetables & fruits ( High Fibre).
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The off-pump coronaryartery bypass (OPCAB)
procedure uses full or
partial sternotomy to
enable access to all
coronary vessels. OPCAB is
also performed on a
beating heart using
mechanical stabilizers and
without cardiopulmonarybypass (CPB).
Surgical Therapy
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Transmyocardial laser revascularization (TMR) is an indirectrevascularization procedure used for patients with advancedCAD who are not candidates for traditional bypass surgeryand who have persistent angina after maximum medicaltherapy.
Surgical Therapy
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PTCA (Percutaneous Transluminal Coronary Angioplasty
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Balloon Angioplasty involves insertion of a special catheter through
fluoroscopy into the site of occlusion. The balloon tip of the
catheter is inflated to compress and rupture the atheromatousplaque.
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Stent involves use of rigid but flexible structure that
maintains the integrity of the vascular wall and patency ofthe artery.
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Thank you
5/12/2013
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