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Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

Focus onFocus onCoronary Artery DiseaseCoronary Artery Disease

(Relates to Chapter 34, (Relates to Chapter 34, “Nursing Management: Coronary “Nursing Management: Coronary

Artery Disease in the textbook)Artery Disease in the textbook)

By Esmeralda Garza, MSN, RNBy Esmeralda Garza, MSN, RN


Coronary Artery Disease

• A type of blood vessel disorder that A type of blood vessel disorder that is included in the general category is included in the general category of atherosclerosisof atherosclerosis• Begins as soft deposits of fat that Begins as soft deposits of fat that

harden with ageharden with age• Referred to as “hardening of Referred to as “hardening of

arteries”arteries”


• Atherosclerosis (cont’d)Atherosclerosis (cont’d)• Can occur in any artery in the bodyCan occur in any artery in the body• Atheromas (fatty deposits)Atheromas (fatty deposits)

• Preference for the coronary arteriesPreference for the coronary arteries



• Atherosclerosis (cont’d)Atherosclerosis (cont’d)• Terms to describe the disease processTerms to describe the disease process

• Arteriosclerotic heart diseaseArteriosclerotic heart disease• Cardiovascular heart diseaseCardiovascular heart disease• Coronary artery disease (CAD)Coronary artery disease (CAD)



• Cardiovascular diseases are the Cardiovascular diseases are the major cause of death in the major cause of death in the United StatesUnited States

• Heart attacks are still the leading Heart attacks are still the leading cause of all cardiovascular disease cause of all cardiovascular disease deaths and deaths in generaldeaths and deaths in general



CAD Gender Differences

• Men tend to manifest CAD 10-15 yr Men tend to manifest CAD 10-15 yr earlier than womenearlier than women

• Initial cardiac event for men is more Initial cardiac event for men is more often MI rather than anginaoften MI rather than angina

• Left ventricular hypertrophyLeft ventricular hypertrophy


Women

• CAD causes more deaths in women CAD causes more deaths in women than in menthan in men

• Initial cardiac event is anginaInitial cardiac event is angina• Women complain of palpitations Women complain of palpitations

more frequently than menmore frequently than men• After menopause LDL increases.After menopause LDL increases.


Coronary Artery Disease Etiology and Pathophysiology

• Atherosclerosis is the major cause Atherosclerosis is the major cause of CADof CAD• Characterized by a focal deposit of Characterized by a focal deposit of

cholesterol and lipid, primarily within cholesterol and lipid, primarily within the intimal wall of the arterythe intimal wall of the artery

• Endothelial lining altered as a result of Endothelial lining altered as a result of inflammation and injuryinflammation and injury



• C-reactive protein (CRP)C-reactive protein (CRP)• Nonspecific marker of inflammationNonspecific marker of inflammation• Increased in many patients with CADIncreased in many patients with CAD• Chronic exposure to CRP triggers the Chronic exposure to CRP triggers the

rupture of plaquesrupture of plaques


Progression of Atherosclerosis

Fig. 34-2Fig. 34-2



• Developmental stages: Developmental stages: Fatty streaksFatty streaks• Earliest lesionsEarliest lesions• Characterized by lipid-filled Characterized by lipid-filled

smooth muscle cellssmooth muscle cells• Potentially reversiblePotentially reversible



• Developmental stages: Developmental stages: Fibrous plaqueFibrous plaque • Beginning of progressive changes in the Beginning of progressive changes in the

arterial wallarterial wall• Lipoproteins transport cholesterol and

other lipids into the arterial intima • Fatty streak is covered by collagen

forming a fibrous plaque that appears grayish or whitish

• Result = narrowing of vessel lumen



• Developmental stages: Developmental stages: Complicated lesionComplicated lesion

• Continued inflammation can result in plaque instability, ulceration, and rupture

• Platelets accumulate and thrombus forms

• Increased narrowing or total occlusion Increased narrowing or total occlusion of lumenof lumen



• Collateral circulation: Normally Collateral circulation: Normally

some arterial anastomoses some arterial anastomoses

(or connections) exist within the (or connections) exist within the

coronary circulationcoronary circulation



• Growth and extent of collateral Growth and extent of collateral circulation is attributed to two factorscirculation is attributed to two factors• Inherited predisposition to develop Inherited predisposition to develop

new vessels (angiogenesis) new vessels (angiogenesis)• Presence of chronic ischemiaPresence of chronic ischemia



• When occlusion of the coronary When occlusion of the coronary arteries occurs slowly over a long arteries occurs slowly over a long period, there is a greater chance of period, there is a greater chance of adequate collateral circulation adequate collateral circulation developingdeveloping


Development of Collateral Circulation

Fig. 34-3Fig. 34-3


Risk Factors for CAD

• Risk factors can be categorized asRisk factors can be categorized as• Nonmodifiable risk factorsNonmodifiable risk factors

• Age Age • GenderGender• EthnicityEthnicity• Family historyFamily history• Genetic predispositionGenetic predisposition


Risk Factors for CAD

• Modifiable risk factorsModifiable risk factors• Elevated serum lipidsElevated serum lipids• HypertensionHypertension• Tobacco useTobacco use• Physical inactivity• Obesity• Diabetes

• Metabolic syndrome

• Psychologic states

• Homocysteine level

• Risk factors can be categorized asRisk factors can be categorized as


Risk Factors for CAD Health Promotion

• Identification of people at high riskIdentification of people at high risk• Health history, including use of Health history, including use of

prescription/nonprescription medicationsprescription/nonprescription medications• Presence of cardiovascular symptomsPresence of cardiovascular symptoms• Environmental patterns: diet, activityEnvironmental patterns: diet, activity• Values and beliefs about health and Values and beliefs about health and

illnessillness



• Health-promoting behaviorsHealth-promoting behaviors• Nutritional therapyNutritional therapy

• Therapeutic Lifestyle Changes

• Omega-3 fatty acidsOmega-3 fatty acids



• Health-promoting behaviorsHealth-promoting behaviors• Cholesterol-lowering drug therapyCholesterol-lowering drug therapy

• Drugs that restrict lipoprotein Drugs that restrict lipoprotein production: Statins, niacinproduction: Statins, niacin

• Drugs that increase lipoprotein removal: Drugs that increase lipoprotein removal: Bile acid sequestrantsBile acid sequestrants

• Drugs that decrease cholesterol Drugs that decrease cholesterol absorption: absorption: Ezetimibe (Zetia)



• Health-promoting behaviorsHealth-promoting behaviors• Antiplatelet therapy Antiplatelet therapy

• ASAASA

• Clopidogrel (Plavix)


Gerontologic ConsiderationsCoronary Artery Disease

• Strategies to reduce risk factors are Strategies to reduce risk factors are effective but often underprescribedeffective but often underprescribed

• Necessary to modify guidelines for Necessary to modify guidelines for physical activityphysical activity

• Two points when elderly may consider lifestyle change(s)• When hospitalized • When symptoms result from CAD

and not normal aging


Clinical Manifestations of CAD Chronic Stable Angina

• Etiology and PathophysiologyEtiology and Pathophysiology• Reversible (temporary) myocardial Reversible (temporary) myocardial

ischemia = angina (chest pain)ischemia = angina (chest pain)• OO22 demand > O demand > O22 supply supply



• Etiology and PathophysiologyEtiology and Pathophysiology• Primary reason for insufficient blood Primary reason for insufficient blood

flow is narrowing of coronary arteries flow is narrowing of coronary arteries by atherosclerosisby atherosclerosis

• For ischemia to occur, the artery is For ischemia to occur, the artery is usually 75% or more stenosedusually 75% or more stenosed



• Intermittent chest pain that occurs Intermittent chest pain that occurs over a long period with the same over a long period with the same pattern of onset, duration, and pattern of onset, duration, and intensity of symptomsintensity of symptoms



• Pain usually lasts 3 to 5 minutesPain usually lasts 3 to 5 minutes• Subsides when the precipitating factor Subsides when the precipitating factor

is relievedis relieved• Pain at rest is unusualPain at rest is unusual• ECG reveals ST segment depressionECG reveals ST segment depression


Location of Chest Pain (Angina)

Fig. 34-7


Chronic Stable Angina Types of Angina

• Silent ischemiaSilent ischemia• Up to 80% of patients with myocardial Up to 80% of patients with myocardial

ischemia are asymptomaticischemia are asymptomatic• Associated with diabetes mellitus and Associated with diabetes mellitus and

hypertensionhypertension• Confirmed by ECG changesConfirmed by ECG changes



• Nocturnal anginaNocturnal angina• Occurs only at night but not Occurs only at night but not

necessarily during sleepnecessarily during sleep

• Angina decubitusAngina decubitus• Chest pain that occurs only while Chest pain that occurs only while

lying downlying down• Relieved by standing or sittingRelieved by standing or sitting


Chronic Stable AnginaTypes of Angina

• Prinzmetal’s (variant) anginaPrinzmetal’s (variant) angina• Occurs at rest usually in response to Occurs at rest usually in response to

spasm of major coronary arteryspasm of major coronary artery• Seen in patients with a history of Seen in patients with a history of

migraine headaches and Raynaud’s migraine headaches and Raynaud’s phenomenonphenomenon

• Spasm may occur in the absence of CADSpasm may occur in the absence of CAD



• Prinzmetal’s (variant) anginaPrinzmetal’s (variant) angina• When spasm occursWhen spasm occurs

• Chest painChest pain• Marked, transient ST segment Marked, transient ST segment

elevationelevation• May occur during REM sleepMay occur during REM sleep• May be relieved by moderate May be relieved by moderate

exerciseexercise


Chronic Stable Angina Nursing and Collaborative Management

• Drug therapy: Goal: Drug therapy: Goal: O2 demand and/or O2 supply• Short-acting nitrates: SublingualShort-acting nitrates: Sublingual• Long-acting nitratesLong-acting nitrates

• Nitroglycerin ointmentNitroglycerin ointment• Transdermal controlled-release Transdermal controlled-release

nitroglycerinnitroglycerin


Chronic Stable Angina Nursing and Collaborative Management

• Drug therapy: Goal: Drug therapy: Goal: O2 demand and/or O2 supply• ββ-Adrenergic blockers-Adrenergic blockers• Calcium channel blockersCalcium channel blockers

• If If ββ-adrenergic blockers are poorly tolerated, -adrenergic blockers are poorly tolerated, contraindicated, contraindicated, or do not control anginal symptoms

• Used to manage Prinzmetal’s anginaUsed to manage Prinzmetal’s angina• Angiotensin-converting enzyme inhibitorsAngiotensin-converting enzyme inhibitors


Chronic Stable AnginaNursing and Collaborative Management

• Diagnostic StudiesDiagnostic Studies• Health history/physical examinationHealth history/physical examination• Laboratory studiesLaboratory studies• 12-lead ECG12-lead ECG• Chest x-rayChest x-ray• Echocardiogram Echocardiogram • Exercise stress testExercise stress test


Chronic Stable AnginaNursing and Collaborative Management

• Diagnostic StudiesDiagnostic Studies• Cardiac catheterization Cardiac catheterization

• DiagnosticDiagnostic• Coronary revascularization: Coronary revascularization:

Percutaneous coronary interventionPercutaneous coronary intervention

• Balloon angioplastyBalloon angioplasty

• StentStent


Placement of aCoronary Artery Stent

Fig. 34-9Fig. 34-9


Pre- and Post-PCIwith Stent Placement

Fig. 34-10Fig. 34-10


Relationship Between CAD, Chronic Stable Angina, and ACS

Fig. 34-11Fig. 34-11


Acute Coronary Syndrome Etiology and Pathophysiology

• Deterioration of a once stable plaqueDeterioration of a once stable plaque

rupture platelet rupture platelet aggregation thrombus aggregation thrombus

• Result Result • Partial occlusion of coronary artery: UA Partial occlusion of coronary artery: UA

or NSTEMIor NSTEMI• Total occlusion of coronary artery: STEMITotal occlusion of coronary artery: STEMI


Coronary Thrombogenesis Secondary to Plaque Deterioration


Clinical Manifestations of ACS Unstable Angina

• Unstable anginaUnstable angina• New in onsetNew in onset• Occurs at restOccurs at rest• Has a worsening patternHas a worsening pattern

• UA is unpredictable and represents UA is unpredictable and represents a medical emergencya medical emergency


CABG Surgery

Fig. 34-16Fig. 34-16


Nursing ManagementChronic Stable Angina and ACS

• Nursing AssessmentNursing Assessment• Subjective DataSubjective Data

• Health historyHealth history• Functional health patternsFunctional health patterns

• Objective DataObjective Data



• Nursing DiagnosesNursing Diagnoses• Acute painAcute pain• Ineffective tissue perfusion Ineffective tissue perfusion

(cardiac)(cardiac)• AnxietyAnxiety• Activity intoleranceActivity intolerance



• Planning: Overall goalsPlanning: Overall goals• Relief of pain• Preservation of myocardium• Immediate and appropriate treatment• Effective coping with illness-associated

anxiety• Participation in a rehabilitation plan• Reduction of risk factors


Nursing ManagementChronic Stable Angina

• Health PromotionHealth Promotion• Therapeutic lifestyle changes to reduce Therapeutic lifestyle changes to reduce

cardiac risk factorscardiac risk factors



• Acute Interventions for anginal attackAcute Interventions for anginal attack• Administration of supplemental oxygen• 12-lead ECG• Prompt pain relief first with a nitrate

followed by an opioid analgesic if needed• Auscultation of heart sounds• Comfortable positioning of the patient



• Ambulatory and Home CareAmbulatory and Home Care• Patient teaching Patient teaching

• CAD and angina

• Precipitating factors for angina

• Risk factor reduction

• Medications

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Documents

coronary circulation

cad risk factors

cad modifiable risk

cad health promotion

women cad

artery endothelial lining

cardiovascular disease

high risk health history