D. Safaa eidD. Safaa eid

Medical surgical and critical care nursing Medical surgical and critical care nursing department department

function of the heart

•circulate blood throughout the body

•Pumping blood through the lungs removes carbon dioxide and refreshes the blood with oxygen

•The coronary arteries are the blood vessels that supply blood and oxygen to the heart muscle.

Coronary CirculationCoronary Circulation

Definition: is an abnormal accumulation of lipid, or fatty substances in the vessel wall.

These substances create blockages or narrow the vessel in a way that reduces blood flow to the myocardium.

Risk factors

Risk FactorsUncontrollableUncontrollable

•Sex

•Hereditary

•Age

ControllableControllable

•High blood pressure

•High blood cholesterol

•Smoking

•Physical activity

•Obesity

•Diabetes

•Stress and anger

Pathophysiology :

•Atherosclerosis begins as fatty streaks, lipids that are deposited in the intima of the arterial wall.

• T lymphocytes and monocytes infiltrate the area to ingest the lipids and then die

• a fibrous cap is formed over the dead fatty core.

• These deposits, called atheromas or plaques, protrude into the lumen of the vessel, narrowing it and obstructing blood flow.

• plaques are made up of cholesterol particles, fat, calcium, cellular waste and other substances.

Clinical manifestations

Signs & Symptoms

NoneChestPain

ShortnessOf Breath

HeartAttack

• symptoms similar to those of a heart

attack, such as chest pain (angina).

• If you have atherosclerosis in the arteries leading to your brain, symptoms such as sudden numbness or weakness in your arms or legs, difficulty speaking .

• If you have atherosclerosis in the arteries in your arms and legs, symptoms such as leg pain when walking (intermittent claudication).

Diagnostic studies • ECG

• cardiac enzymes

•Get regular medical checkups.

•Control your blood pressure.

•Check your cholesterol.

•Don’t smoke.

•Exercise regularly.

•Maintain a healthy weight.

•Eat a heart-healthy diet.

•Manage stress.

Treatment

• Lifestyle changes: Reducing the lifestyle risk factors

• Medication: Taking drugs for high cholesterol and high blood pressure

• Anti-platelet medications. such as aspirin, to reduce the likelihood that platelets will clump in narrowed arteries, form a blood clot and cause further blockage.

• Beta blocker medications. They lower heart rate and blood pressure.

• Angiotensin-converting enzyme (ACE) inhibitors

• slow the progression of atherosclerosis by lowering blood pressure and reduce the risk of recurrent heart attacks.

• Calcium channel blockers.

• These medications lower blood pressure

• Diuretics, lower blood pressure.

• Angiography and stenting:- Cardiac catheterization with angiography of the

coronary arteries .

- Using a thin tube inserted into an artery in the leg or arm, doctors can access diseased arteries. Blockages are visible on a live X-ray screen.

• Angioplasty

• (catheters with balloon tips) and stenting can often open up a blocked artery.

• Bypass surgery: Surgeons "harvest" a healthy blood vessel (often from the leg or chest). They use the healthy vessel to bypass a segment blocked by atherosclerosis.

                                                                                                                                                

Treatment (continued)

1) Stenting

• a stent is introduced into a blood vessel on a balloon catheter and advanced into the blocked area of the artery

• the balloon is then inflated and causes the stent to expand until it fits the inner wall of the vessel, conforming to contours as needed

• the balloon is then deflated and drawn back

•The stent stays in place permanently, holding the vessel open and improving the flow of blood.

Treatment (continued)

2) Angioplasty• a balloon catheter is passed through the guiding catheter to the area near the narrowing. A guide wire inside the balloon catheter is then advanced through the artery until the tip is beyond the narrowing.

• the angioplasty catheter is moved over the guide wire until the balloon is within the narrowed segment.

• balloon is inflated, compressing the plaque against the artery wall

• once plaque has been compressed and the artery has been sufficiently opened, the balloon catheter will be deflated and removed.

Treatment (continued)

3) Bypass surgery

• healthy blood vessel is removed from leg, arm or chest

• blood vessel is used to create new blood flow path in your heart

• the “bypass graft” enables blood to reach your heart by flowing

around (bypassing) the blocked portion of the diseased artery. The increased blood flow reduces angina and the risk of heart attack.

Angina Pectoris

• Angina pectoris is a clinical syndrome usually characterized by episodes of pain or pressure in the anterior chest.

Causes

• insufficient coronary blood flow.

• Aortic stenosis

• Pulmonary hypertension

• Congenital disease

Types of Angina

• Stable angina: pain that occurs on exertion and is relieved by rest

• Unstable angina (also called preinfarction angina : symptoms occur more frequently and last longer than stable angina. pain may occur at rest.

• Intractable or refractory angina: severe chest pain

• Variant angina pain at rest with reversible ST-segment elevation; thought to be caused by coronary artery vasospasm

• Silent ischemia: objective evidence of ischemia, but patient reports no symptoms

Clinical Manifestations

• Chest pain

• The patient often feels tightness or a heavy, choking, or strangling sensation.

• The patient with diabetes mellitus may not have severe pain with angina because the neuropathy

• A feeling of weakness or numbness in the arms, wrists, and hands may accompany the pain

• Shortness of breath, pallor, diaphoresis, dizziness , nausea and vomiting.

• Anxiety may accompany angina. An important characteristic of angina is that it subsides with rest or nitroglycerin

Factors are associated with typical angina pain:

• Physical exertion

• Exposure to cold,

• Eating a heavy meal,

• Stress .

Diagnostic Findings

• Noninvasive tests – Chest x-ray – [ECG] – Exercise ECG (stress test) – Echocardiography at rest – Ambulatory ECG (Holter monitor)

Invasive tests

– Coronary arteriography

– Intravascular ultrasound

– Fasting lipid profile including total cholesterol (TC), low density lipoprotein (LDL), high density lipoprotein (HDL), and triglycerides

– C-reactive protein (CRP) is a marker for inflammation of vascular endothelium.

– High CRP is associated with increased coronary artery calcification and risk of an acute cardiovascular event (eg, MI)

Medical Management

A- Pharmacologic Therapy

1-Nitroglycerin reduce myocardial oxygen consumption, which decreases ischemia and relieves pain

2- Beta-Adrenergic Blocking Agents.

• as (Inderal) reduce myocardial oxygen consumption

• Calcium channel blockers relax the blood vessels, causing a decrease in blood pressure and an increase in coronary artery perfusion.

• Antiplatelet medications are administered to prevent platelet aggregation

• Heparin prevents the formation of new blood clots. reduces the occurrence of MI.

B- Oxygen Administration.

• increase the amount of oxygen delivered to the myocardium and to decrease pain.

Nursing Interventions

• Help the patient to sit or rest in bed in a semi-Fowler position .

• Measuring vital signs and observing for signs of respiratory distress.

• The patient is placed on cardiac monitoring .

• a 12-lead ECG is usually obtained, the ST segment is assessed for changes.

• Nitroglycerin is administered sublingually,

• nitroglycerin administration is repeated up to three doses.

• Each time, blood pressure, heart rate, and the ST segment are assessed.

• Assess and document pain characteristics

• The nurse administers oxygen therapy if the patient’s respiratory rate is increased or decreased.

• oxygen is usually administered at 2 L/min by nasal cannula.

• Maintain activity restrictions based on the patient’s activity tolerance to reduce myocardial oxygen demands.

• Begin the patient on a low-cholesterol, low-sodium diet to alleviate the modifiable risk factors

Patient Teaching for Patients with Angina Pectoris

• Activity and Exercise

• Diet

• Smoking

• Cold Weather

• Medications