CORONARY ARTERY DISEASE (CAD)

Nota:

• - most common form of heart disease - narrowing of coronary arteries caused by plaque build-up

1. Etiology/Pathophysology
   1. Atherosclerosis: fat and cholesterol plaque deposits in arterial walls causing narrowing

      Nota:

      •    Endothelial lining altered by injury. Platelets are activated and smooth muscle proliferation occurs which traps lipids. Lipids calcify over time. This irritant causes platelets to adhere and aggregate = Thrombin and fibrin formation.      
      1. Developmental stages
         1. 1. Damaged Endothelium- injury (chemical or high-shear stress) promotess build-up of plaque
            1. Smoking
            2. HTN
            3. Diabetes
            4. hyperlipidemia
            5. Infection
         2. 2. Fatty Streak and Lipid core formation - Lipid filled smooth muscle cells
         3. 3. Fibrous Plaque - platelets stimulate smooth muscle proliferation and thickening of arterial wall. Fatty streak covered by collagen = fibrous plaque
            1. Narrowing of vessels. Reduced flow of O2 and nutrients to tissues.
            2. Collateral Circulation. Due to chronic ischemia, re-routing of blood circulation around a blocked artery via minor vessels.
         4. 4. Complicated lesion- thrombus formation
            1. Plaque growth can lead to plaque instability, ulceration and rupture
            2. Further narrowing
            3. Can lead to total occulsion
      2. Takes years to develop
2. Diagnosis
   1. Health History
   2. Physical Exam
      1. Exercise Stress Testing
   3. Lab tests
      1. Cholesterol Levels: LDL,, HDL, Triglycerides
   4. Diagnostic Tests
      1. Chest Radiograph
         1. Cardiac Enlargement
         2. Aortic Calcification
         3. Pulmonary Congestion
      2. 12-lead ECG
      3. Echocardiogram
      4. Holter Test
      5. Pharmacological nuclear imaging
      6. Coronary Angiogram
      7. Arteriogram
3. Clinical Manifestation
   1. 1. Can be asymptomatic for many years
   2. 2. Chronic Coronary Syndromes
      1. Chronic Stable Angina: Chest pain with increase in work of the heart due to insufficient oxygen (O2 demand > supply)
      2. Stable ischemic heart disease: years of damage from ischemia have weakened the heart, gradually causing it to fail
   3. 3. Acute Coronary Syndrome: acute disruption of plaques causing severe schema
      1. Sudden Cardiac Death
      2. Myocardial Infarction (MI): atherosclerotic plaque or vasospasm completed blocks coronary artery causing tissue damage
      3. Unstable Angina
4. Collaborative & Nursing Care
   1. 1. Assessment
      1. Subjective Data
         1. Pain:: Angina caused by low oxygen and nutrient flow to myocardial tissue
            1. Location/Radiation : Midsternal, arms, jaw, abdomen, back
            2. Onset/Duration: more than 3 minutes
            3. Quality: Heaviness, tightness
            4. Intensity: rating of 1-10 on a verbal rating scale (1 being no pain, 10 being the worst pain ever experienced)
            5. Provocation: activity or rest
         2. Health History
         3. Risk Factors
      2. Objective Data
         1. Vital signs: tachycardia, hypoxemia
         2. Skin: cool, pale
         3. Arrhythmic Heart Sounds: S3 or S4, cradles
         4. Exercise Intolerance
         5. Peripheral Pulses: diminished
         6. Anxiety: concern, apprehension, restlessness
         7. Diaphoresis
         8. Shortness of Breath
         9. High serum lipids
      3. Determine severity
   2. 2. Planning/ Implementation
      1. Drug Therapy
         1. 1. Short/Long - Acting Nitrates: artery vasodilators
         2. 2. Beta-Adrenergic Blockers: reduce stimulation of the heart, reducing heart rate and contractility
         3. 3. Ca2+ Channel Blockers: promote peripheral vasodilation and reduce heart rate and contractility
         4. 4. ACE Inhibitors: recent renin production
         5. 5. Antiplatelet: Aspirin and PLavix to prevent thrombocytosis
         6. 6. Analgesia/ Ntroglycerine: angina pain relief
         7. 7. Statins: LDL lowering drug
      2. Nutrition Therapy: Eating habits can affect other controllable risk factors such as cholesterol, blood pressure, diabetes, and weight
         1. DASH diet: daily fruits, vegetables, nuts, Omega-3 fish, decrease saturated fats, complex carbs
      3. Surgical Interventions
         1. Coronary Artery Bypass Graft
         2. Percutaneous Coronary Intervention
   3. 3. Evaluation
      1. Are pt goals met: Relief of pain, preservation of heart muscles, response to treatment, coping with illness, patient participation in care, pscyhosocial status, reduction of risk/ lifestyles changes
   4. Health Promotion
      1. Lifestyle changes
         2. 30 mins exercise 5days/week
         3. Healthy Eating / Weight Management
         4. Smoking cessation
      2. Disease screening and Prevention:
      3. Stress Menagement
      4. Emotional / social support
5. Risk Factor
   1. Modifiable
      1. High Blood Cholesterol: diet age or gender
      2. Homocysteine Level
      3. Psychological Syndrome
      4. Metabolic Syndrome
      5. Diabetes
      6. Obesity
      7. Physical Inactivity
      8. Hypertension: causes arterial damage increasing fatty deposits
      9. Smoking: nicotine increases BP and contracts arteries
      10. Elevated Serum Lipids
   2. Non-Modifiable
      1. Gender
      2. Genetics & Family History
      3. Race & Ethnicity
      4. Age