Coronary Artery Disease

1. Gender
   1. men > women until 65 yr of age
2. Ethnicity
   1. Whites > Blacks
      1. South asians
3. Increasing Age
4. Genetic Predisposition
5. Family History

1. Obesity
   1. ↑ hypertension risk
   2. Enlarged heart
      1. ↑ myocardial oxygen consumption
   3. ↑ BMI
2. Physical Inactivity
   1. ↓ HDL levels
   2. No collateral circulation encouragement
      1. atherosclerosis causes chronic ischemia, allowing time for collateral circulation to develop. Well developed collateral circulation might reduce the mortality rate associated with coronary artery disease. Coronary collateral development is negatively related to ejection fracture. (Akgullu, 2014)
3. High homocysteine levels
   1. damaging inner lining of blood vessels
   2. promoting plaque build up
   3. altering clotting mechanism
4. Tobacco use
   1. ↓ estrogen levels
      1. menopausal women ↑ risk
   2. nicotine
      1. ↑ catecholamine release, ↑ HR, ↑ peripheral vasoconstriction, ↑ BP, ↑ platelet adhesion
5. Diabetes
   1. ↑ tendency for CT degeneration and endothelial dysfunction
   2. ↑ cholesterol and triglyceride levels
6. Depression
   1. ↑ circulating catecholamines
      1. endothelial injury, inflammation, ↑ platelet activity
7. BP >/ 140/90
   1. endothelial injury
   2. ↑ rate of atherosclerotic development
8. substance abuse
   1. coronary spasms resulting in myocardial ischemia & chest pain
9. ↑ triglyceride & LDL levels
   1. ↑ mortality rate
10. ↓ HDL levels

1. Atherosclerotic Developmental Stages
   1. 1. Chronic Endothelial Injury
      1. Causes of endothelial lining injury: tobacco use, hyperlipidemia, hypertension, diabetes and infection, leading to inflammation
   2. 2. Fatty Streak & Lipid Core
      1. lipoprotein molecules enter arterial wall & are modified by oxidation. Macrophages then ingest them & form foam cells. reversible, lipid filled smooth muscle w/ yellow tinge
   3. 3. Fibrous Plaque Formation
      1. arterial wall changes, lipoproteins transport cholesterol and other lipids into the arterial intima, fatty streak covered by collagen made by smooth muscle cells, narrowing of vessel lumen. increased accumulation of lipids forms pools causing cell necrosis in the wall.
   4. 4. Complicated Lesion
      1. continued inflammation may result in plaque instability, ulceration and rupture, platelets accumulate and thrombus forms, increased narrowing or complete occlusion of the lumen. lethal ischemia through flow restriction.
   5. (Insull, 2009)
2. ↑ CRP - non-specific marker of inflammation

1. caused by coronary vasospasm
   1. can occur with or without CAD

1. no subjective symptoms

1. Diagnosis
   1. coronary angiography
   2. echocardiogram
   3. stress test
   4. ECG
      1. ST-segment depression and/or T wave insertion
2. Precipitating Factors
   1. emotional stress
      1. ↑ SNS, ↑ Cardiac workload
   2. Tobacco Use
      1. ↑ catecholamine release, ↑ HR
   3. Sexual Activity
      1. ↑ SNS, ↑ Cardiac workload
   4. Stimulants
      1. ↑ HR, ↑ myocardial oxygen demand
   5. Consumption of Heavy Meal
      1. ↑ cardiac workload, more blood to GI, less to coronary arteries
   6. physical activity
3. Features & Symptoms
   1. triggered by physical activity or emotional stress
      1. may still experience angina at rest
   2. promptly relieved by sublingual nitroglycerin
   3. dyspnea
   4. fatigue
   5. chest pain
      1. radiating
   6. nausea
   7. shortness of breath
   8. breathlessness
   9. recurrent belching
   10. anxiety
   11. diaphoresis
4. predictable pattern of chest pain with physical exertion or stress due to atherosclerosis

1. Unstable Angina
   1. Diagnosis
      1. stress test
      2. serum cardiac markers
      3. echocardiogram
      4. ECG
      5. coronary angiography
   2. Features & Symptoms
      1. easily provoked by minimal or no exertion
      2. unpredictable emergency
      3. unexplained fatigue from chronic stable angina or first clinical manifestation
      4. nausea
      5. anxiety
      6. diaphoresis
      7. chest pain, new onset
         1. occurs at rest
         2. radiates to upper extremities (left side) or back
      8. shortness of breath
      9. nitroglycerine may not help
      10. worse over time
   3. unexpected chest pain at rest due to a thrombotic occlusion secondary to atherosclerosis
2. Myocardial Infarction
   1. Clinical Manifestations
      1. severe immobilizing chest pain
         1. activity or at rest
         2. substernal, retrosternal & epigastric (radiating)
         3. unrelieved by Nitroglycerine
      2. SNS stimluation
         1. catecholamine release
         2. clammy cool skin
      3. fever 38°C, 24 hours - 1 week
      4. nausea and vomitting
      5. diaphoresis
      6. denial
      7. fatigue & extreme weakness
      8. Cardiovascular changes
         1. initial BP/HR elevation
         2. BP later drops because of decreased CO
      9. necrotic zone formation
      10. at 6 weeks, scar tissue replaces necrotic tissue
      11. anxiety
      12. dyspnea
      13. hiccuping
      14. belching
      15. tinnitus
   2. Complications
      1. Cardiogenic Shock
         1. severe left ventricular failure causing inadequate oxygen & nutrient supply to tissues. Not pumping enough blood for body needs.
      2. Dressler's syndrome
         1. pleuritic pain, fever, pericarditis, pericardial effusion
      3. Dysrhythmias
         1. fast HR, slow HR, irregular beat
      4. Papillary muscle dysfunction
         1. mitral valve regurgitation leading to ↓ CO
      5. heart failure
      6. Post-infarction Pericarditis
         1. pericardium inflammation causing pain
      7. Ventricular aneurysms
         1. can rupture ventricle & harbour thrombi
   3. Diagnosis
      1. stress test
         1. treadmill exercise test. to check heart response, chest discomfort, BP & ECG changes
      2. serum cardiac markers
         1. MB isoenzyme of creatine kinase (CK-MB)
         2. cardiac specific troponin C (cTnT)
         3. cardiac specific troponin I (cTnI)
      3. echocardiogram
         1. Provides info about left ventricular function. Identify non-working areas of the heart
      4. ECG
         1. NSTEMI
            1. partial blockage of coronary artery
            2. No pathological Q wave
            3. depressed ST wave or T wave inversion
         2. STEMI
            1. elevated ST wave
            2. pathological Q wave
            3. full blockage of coronary artery
      5. coronary angiography
         1. X-ray test with special dye to locate blockage
   4. results from sustained ischemia leading to myocardial necrosis

1. Subjective Data
   1. Risk factors
   2. Current health history
   3. Past Health History
   4. Current medications
   5. Pain
      1. exercise vs rest
      2. squeezing, tight, pressure
      3. upper chest, neck & jaw, epigastric, epigastric radiating to neck, jaw & arms, left shoulder, arms, intrascapular
      4. 0-10, 10 being the most severe pain you could imagine
      5. onset, duration, changes
2. Objective Data
   1. General
      1. anxiety
      2. fear
      3. restlessness
      4. fatigue
   2. Integumentary
      1. cool skin
      2. diaphoresis
      3. pale skin
   3. Cardiovascular
      1. tachycardia
      2. arrhythmias
      3. ↑ levels of serum lipids
      4. ↑ WBC count
      5. ↑ or ↓ levels of serum cardiac markers
   4. Respiratory
      1. shortness of breath
         1. exercise intolerance

1. Patient-centred care
   1. involvement of family
   2. respect for patients' preferences
   3. goal priority is patient directed
2. Nursing Goals
   1. relief of pain
   2. ↓ risk factors
   3. ↓ anxiety
   4. ↑ rehabilitation plan involvement
   5. preserve myocardium
   6. appropriate ischemia treatment
3. Nursing Diagnosis
   1. acute pain (angina)
   2. anxiety
   3. activity intolerance
   4. risk for ↓ Cardiac Output
   5. deficient knowledge
      1. ineffective self-health management
   6. risk for altered tissue perfusion

1. Health Promotion
   1. Physical activity
      1. participate in exercise programs
         1. ↑ exercise capacity
      2. ↑ endothelium-dependent vasodilation
      3. reduced rehospitalizations
      4. ↑ event-free survival
      5. 2.5 hours of exercise/week
   2. Manage stress
   3. Stop smoking
      1. ↓ blood clot formation
   4. ↑ social & emotional support
   5. Health Education
      1. teaching good health practices
      2. lifestyle habits can be positively influenced at an early age
   6. Nutritional Therapy
      1. ↓ saturated fat and cholesterol
         1. 30% of total calories from fat
      2. ↑ complex carbohydrates
      3. ↓ red meats, eggs and whole milk products
      4. ↓ alcohol and simple sugars
         1. ↓ serum triglyceride levels
      5. ↑ fatty fish
         1. x2/week
            1. ↑ omega-3 fatty acids
      6. ↑ garlic
         1. ↓ hypertension
      7. ↑ soy & fiber
         1. ↓ cholesterol and LDL levels
      8. niacin
         1. ↓ LDL, ↑ HDL
      9. ↑ steaming, grilling, roasting
2. Acute Intervention
   1. administer supplemental oxygen
   2. vital signs
   3. 12-lead ECG
   4. teach relaxation techniques
   5. position the patient comfortably
   6. pain assessment
      1. prompt relief w/ medication
   7. reduce anxiety
   8. patient education
   9. maintain awareness to adverse reactions to treatment
   10. heart auscultation
3. Collaborative Care
   1. Drug Therapy
      1. Chronic Stable Angina
         1. Short-acting Nitrates
            1. vasodilators, resulting in ↓ pressures & ↓ wall stress
         2. Sublingual Nitroglycerin
            1. onset 3 mins, duration 30-60 mins
               1. rapid relief
         3. Long-acting Nitrates
            1. vasodilators to reduce incidents of anginal attacks
               1. ↑ exercise tolerance
         4. β-Adrenergic Blockers
            1. ↓ myocardial oxygen demand by decreasing HR, SVR, BP & myocardial contractility
               1. thus ↑ exercise tolerance
                  1. first line therapy
         5. Calcium Channel Blockers
            1. systemic vasodilation w/ ↓ SVR
               1. ↓ myocardial contractility
                  1. coronary vasodilation
                     1. indicated for those who can't tolerate or do not respond enough to β-Adrenergic Blockers
         6. ACE Inhibitors
            1. ↓ BP
      2. Acute Coronary Syndrome
         1. IV Nitroglycerin
            1. ↓ preload and afterload & ↑ the myocardial oxygen supply
         2. Morphine Sulphate
            1. vasodilator
               1. ↓ anxiety & fear
         3. IV β-Adrenergic Blockers
            1. ↓myocardial oxygen demand by decreasing HR, SVR, BP & myocardial contractility
         4. Ace Inhibitors
            1. ↓ BP
               1. slows progression of heart failure
                  1. ↓ CV death, stroke & revascularization
                     1. if intolerant use Angiotensin II blockers
         5. Cholesterol lowering drugs
   2. Surgical Interventions
      1. Percutaneous Coronary Intervention
         1. non-surgical procedure
            1. catheter with stent mounted on balloon
               1. stent with balloon inflated
                  1. stent in place & balloon withdrawn
                     1. plaque compressed & blocked coronary artery opened
                        1. symptom relief is immediate & of greater magnitude compared to medical therapy
                           1. restenosis occurs 20-40% requiring reintervention
      2. Coronary Artery Bypass Graft Surgery
         1. bypass blocked portion of coronary artery with a healthy blood vessel from somewhere else in the body
            1. most commonly used are the left internal mammary artery & saphenous vein
               1. arterial conduits preferred to reduce subsequent development of obstructive lesions
                  1. blood reaches the heart muscle through new pathway
   3. Interprofessional Collaboration
      1. primary care physician
      2. cardiologist
      3. nurse educator
      4. rehabilitation nurse
      5. physical therapist
      6. psychiatrist
      7. social worker
      8. dietitian
      9. cardiovascular surgeon
      10. geriatrician
      11. heart failure nurse

1. evaluate whether nursing care was effective
2. conduct evaluation measures to determine if expected outcomes are met

Annotations:

•    References   Akgullu, C., Ufuk, E., Ok, I., Gungor, H., Avcil, M., Dagli, B., Omurlu I.K., Zencir, C. (2014). Predictors of well developed coronary collateral circulation in patients with stable angina pectoris. J Clin Exp Cardiolog, 5(4); 1-7.   Cassar, A., Holmes, D.R. Jr., Rihal, C.S., Gersh, B.J. (2009). Chronic coronary artery disease: diagnosis and management. Mayo Clinic Proceedings, 84(12): 1130-46.   Coronary Artery Disease: How Your Diet Can Help. (2003). Am Fam Physician, 67(8); 1769-1770.   Hajar, R. (2017). Risk Factors for Coronary Artery Disease: Historical and Perspectives. Heart Views, 18(3): 109-114.   Health Canada. (2011). Eating well with Canada’s food guide. Retrieved from https://www.canada.ca/content/dam/hc-sc/migration/hc-sc/fn-an/alt_formats/hpfb-dgpsa/pdf/food-guide-aliment/print_eatwell_bienmang-eng.pdf   Hembrecht, R., Wolf, A., Gielen, S., Linke, A., Hofer, J. (2000). Effect of exercise on coronary endothelial function in patients with coronary artery disease. N Engl J Med, 342; 454-460.   Hillis, G.S. (2002) Management of stable angina and unstable angina/non-st-elevation myocardial infarction. Medicine, 30(4); 64-70.   Hombach, V., Grebe, O., Merkle, N., Waldenmaier, S., Hoher, M., Kochs, M., Wohrle, J., Kestler HA. (2005). Sequelae of acute myocardial infarction regarding cardiac structure and function and their prognostic significance as assessed by magnetic resonance imaging. Europaean Heart Journal, 26(6); 549-557.   Insull, W Jr. (2009). The pathology of atherosclerosis: plaque development and plaque responses to medical treatment. The American Journal of Medicine, 122(1 Suppl; S3-S14.   Jaarsma, T. (2005). Inter-professional team approach to patients with heart failure. Heart, 91(6); 832-838.   Kimble, L.P., Dunbar, S.B., Weintraub, W.S., McGuire, D.B., Manzo, S.F., Strickland, O.L. (2011). Symptom clusters and health-related quality of life in people with chronic stable angina. Journal of Advanced Nursing, 67(5); 1000-1011.   Kumar, A. Cannon, C.P. (2009) Acute Coronary Syndromes: Diagnosis and Management, Part 1. Mayo Clinic Proceedings, 84(10); 917-938.   Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Camera, I. M.(Eds.). (2014). Medical-surgical nursing in Canada: Assessment and management of clinical problems (3rd Cdn. ed.) (M. A. Barry, S. Goldsworthy & D. Goodridge, Cdn. Adapt.). Toronto: Elsevier Canada.   Taghipour, B., Nia, H.S., Kaveh, H., Heideranlu, E., Far, S.S., Zeydi A.E., Soleimani, M.A. (2014) Clinical manifestations of myocardial infarction in diabetic and non-diabetic patients. Iran J Crit Care Nurs, 7(2); 116-123.  Registered Nurses’ Association of Ontario. (2013). Assessment and Management of Pain. Toronto, Canada: Registered Nurses’ Association of Ontario.   Thadani, U. (2004). Current medical management of chronic stable angina. J Cardiovasc Pharamacol Therapeut, 9(Supplement 1); S11-S29.   Thompson, E.G., McPherson, J.A., (2010) Coronary artery disease: roles of different doctors. Heallthwise. Retrieved from https://www.uofmhealth.org/node/652182.               Wee, Y., Burns, K., Bett, N. (2015). Medical management of chronic stable angina. Aust Prescr, 38(4): 131-136.   Zaman, M.J., Philipson, P., Chen, R., Farag, A., Shipley, M., Marmot, M.G., Timmis, A.D., Hemingway, H. South Asians and coronary artery disease: is there discordance between effects on incidence and prognosis? Epidemiology, 99(10); 729-736.