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Coronary Artery Disease Occlusive Disorders Angina Myocardial Infarction.

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Presentation on theme: "Coronary Artery Disease Occlusive Disorders Angina Myocardial Infarction."— Presentation transcript:

1 Coronary Artery Disease Occlusive Disorders Angina Myocardial Infarction

2 Objectives Describe occlusive disorders of the cardiovascular system. Explain the pathophysiology of common occlusive disorders. Describe nursing interventions in caring for clients with occlusive disorders.

3 Arteriosclerosis vs. Atherosclerosis Arteriosclerosis is a general term describing any narrowing (and loss of elasticity) of medium or large arteries Atherosclerosis is a narrowing of blood vessal specifically due to plaque. Atherosclerosis is the most common form of arteriosclerosis.

4 Coronary Artery Disease (CAD) A narrowing or obstruction of one or more coronary arteries as a result of atherosclerosis Decreases the blood flow and therefore the oxygen and nutritional supply to the heart muscle


6 Coronary Artery Disease Blood vessel narrowed by atherosclerosis

7 Coronary Artery Disease When does it become a problem? When enough occlusion occurs to the point where an inadequate blood supply to the myocardium occurs. The resulting effect on the myocardium is called ischemia. Significant CAD is when the Left Main Artery is narrowed more than 50% or any other major branch is narrowed more than 70%.

8 Coronary Arteries


10 Coronary Arteries Collateral Circulation More than one artery that supplies an area of the myocardium with blood When chronic ischemia is present (as in an older adult), additional collateral circulation develops

11 Coronary Artery Disease Collateral Circulation

12 Coronary Artery Disease Complications – Hypertension – Angina – Dysrhythmias – Myocardial Infarction – Heart Failure – DEATH

13 Coronary Artery Disease Blood clot in an atherosclerotic artery

14 Angina Angina = a spasmodic, cramp like, choking,heavy, feeling Pectoris = the breast or chest area Angina Pectoris = paroxysmal (severe, usually episodic) thoracic pain and choking feeling caused by decreased oxygen to the myocardium

15 Angina May develop slowly or quickly Signs and symptoms – Patient may describe as substernal pain, tightness/squeezing or heaviness on chest (mild to moderate) – May think it is heartburn – Pain may radiate to other sites: Left Arm, Right Arm, Epigastric area, Neck, Jaw, Teeth, Shoulders, or the Back  Men and women often experience discomfort in different sites

16 Angina: Data Collection Subjective: Ask patient to describe Chest Pain (CP) in as much detail as possible. Objective: Head to Toe Assessment Signs/symptoms of Decreased Cardiac Output

17 Acute Management of Angina Medications to control platelet aggregation – ASA (325mg (Four 81mg chewable ASA is preferable) Medications to dilate coronary arteries – Nitroglycerin – Morphine Medications to decrease heart workload – Beta Blockers Propanolol Metoprolol Oxygen – 2-4 L/minute

18 Nitroglycerin Nitrates – Dilate Blood Vessels (brain, coronaries, periphery) – Reduces preload to heart – Reduces afterload – Side Effects: Hypotension, headache – Routes: Sublingual, Oral, IV also includes Isosorbide nitrates

19 Acute Management of Angina Diagnostic Tests – EKG – CXR – Cardiac Enzymes, CBC, and BNP – Coronary Angiography – Echocardiogram

20 Angina Surgical Interventions – Coronary Artery Bypass Graft (CABG) – restore blood flow to the affected heart muscle area through grafts which bypass the occluded area Graft sources: saphenous veins in the leg or internal mammary artery – Percutaneous Transluminal Coronary Angioplasty (PTCA) – widens the narrowing in the coronary artery without open heart surgery via a balloon inflation

21 Angina Surgical Interventions (cont.) – Stent Placement – expandable mesh-like structures designed to maintain vessel patency Compresses the arterial walls and resists vasoconstriction Thrombogenic – pt. must take anticoagulants (3+ mo.)

22 Stable Angina Onset usually during exertion or stress Relieved with rest or nitro Usually follows a specific pattern (predictable onset)

23 Nursing Management of Patient with Angina Pectoris Promoting comfort – Chest pain=an oxygen hungry heart Promoting tissue perfusion Promoting activity and rest Promoting relief of anxiety and feeling of well-being Patient and family education

24 Acute Coronary Syndrome Includes – Unstable Angina – Variant Angina – ST Elevation MI – Non ST Elevation MI

25 Unstable Angina Usually unpredictable onset (at rest or with less exertion) May increase in occurrence, duration, and severity over time Not relieved consistently by Nitroglycerin

26 Variant Angina aka Prinzmetal’s or Vasospastic Angina Coronary Artery Spasm – May occur at rest and might last longer than classic angina – ST Elevation may appear on an EKG – Treated with Calcium Channel Blockers Procardia, Diltiazem, Verapamil

27 Myocardial Infarction Necrosis of the myocardium due to atherosclerosis or embolism in the coronary arteries AKA “heart attack” Ability of cardiac muscle to contract and pump is impaired

28 Myocardial Infarction (MI) Abrupt lack of oxygenated blood flow to the myocardium, which results in myocardial necrosis if blood flow is not restored quickly May be ST Elevation MI or Non-ST Elevation MI Troponin I level >around 0.5

29 Signs and Symptoms of MI Similar to angina, but more intense pain, longer in duration “silent MI” may occur with no initial symptoms Patient may experience nausea, dizziness, DOE,SOB, weakness, pallor, ashen color, impending sense of doom

30 Necrotic Heart Tissue can’t be seen

31 Medical Management of MI Morphine Oxygen Nitrates Aspirin

32 Treatment of MI Once MI is apparent: – Heparin gtt may be started or Lovenox injections – Decision needs to be made how to treat: Cath Lab (PCI) – PTCA – Coronary Stent Placement Fibrinolytics (thrombolytics )

33 Heparin Heparin Sodium – Prevents Thrombin from being converted to Fibrinogen to Fibrin and forming a clot – Dosing is dependant on aPTT levels and the patient’s weight – Therapeutic Levels measured by activated partial thromboplastin time (aPTT) Goal of heparin is to prolong the clotting time from 8-15 minutes to 15-20 minutes  This is verified by an aPTT that is 1.5 to 2.5 times normal Serum aPTT levels are drawn every 4-8 hours Heparin gtt will be increased or decreased based on aPTT levels * Antidote is Protamine Sulfate

34 Lovenox Low molecular weight heparin aPTT levels do not need to be measured, as the effect of Lovenox is more predictable

35 Nursing

36 Heparin and Lovenox Monitor for signs and symptoms of bleeding (including Hemoglobin and Hematocrit) Lovenox is potentially nephrotoxic, adjustments in dosing should be considered for someone with renal impairment. Monitor BUN and Creatinine levels Monitor Platelet count (Possible Heparin Induced Thrombocytopenia)

37 Fibrinolytics ( Incorrectly known as Thrombolytics ) Activates plasminogen, which generates plasmin Plasmin breaks down clots Must be started within 6 hours Monitor for signs of bleeding – Coagulation Studies – Hypotension, Tachycardia – Neurological Changes – All excretions should be tested for blood

38 Fibrinolytics Should not be given if: – Recent CPR – Uncontrolled HTN – Signs of active internal bleeding – History of CVA – Hepatic or Renal Disease – Recent trauma or surgery – Known intracranial problems AV malformations Aneurysms

39 Fibrinolytics Once given and for the next 24-48 hours – Avoid injections and blood draws if possible – Hold direct pressure over puncture site for 20-30 minutes – Extreme caution when moving the patient – Bedrest – Electric Razors only *Antidote is Aminocaproic Acid (Amicar)

40 Percutaneous Coronary Intervention Balloon Angioplasty, Stent Placement

41 Post-Procedure PLAVIX! ASA! – Clopidogrel! Acetylsalicylic Acid – Also includes Ticlopidine (Ticlid), Tirofiban (Aggrastat) IV Meds – Abciximab (ReoPro) – Eptifibatide (Integrelin) Antiplatelet medications- Inhibit aggregation of platelets Indications- to prevent future MI and/or in-stent thrombosis Side Effects- Bleeding/Bruising Client Teaching- Do not stop taking oral medications unless instructed to do so by a cardiologist

42 Post-MI Medications ASA Plavix Beta- Blockers Nitrates Ace-Inhibitors

43 Nursing Management of MI Administration of medications to control pain, dilate coronary vessels, and to decrease the workload on the heart is paramount in preventing further injury Patient needs to be on a cardiac monitor Prevention of overexertion, including anything involving the valsalva maneuver Education is a large component of post-MI recovery

44 Prognosis ?

45 Risk Factors Non-modifiable: Family History Age – Reduced efficiency and strength of contractions leading to disorientation, syncope, decreased tissue perfusion, may develop collateral circulation, may experience dyspnea more than chest pain, Heart failure, edema, venous stasis and ulcers, require lower doses of medications, Gender - males more at risk than females until menopause Culture and Ethnicity - Black men have higher incidence of HPT, Black women have more CAD with increased severity and death Elevated CRP

46 Modifiable Risk Factors Smoking – catecholamine release, tachy, vasoconstriction, HPT, platelet aggregation Hyperlipidemia Hypertension Diabetes Obesity Sedentary lifestyle Stress Psychosocial factors

47 Cholesterol Levels Total cholesterol : desirable <200 Borderline – 200-230 High – 240 or greater HDL Cholesterol: Low less than 40 High > 60 LDLCholesterol: Optimal <100 Near to above optimal - 100 – 129 Borderline High 130 – 150 High – 160-189 Very High >190

48 Treatment No heart disease, less than 2 risk factors – start tx if chol 160 or more, goal,< 160 No heart disease 2 or more risk factors – Start tx if Chol 130 or more, goal less than 100 Definite heart disease – start tx if Chol 100 or more, goal less than 130

49 Treatment Weight loss Exercise Medications: – Bile acid sequestrants - Locholest, Prevalite, Welchol, Colestid – Nicotinic acid – niacin – Statins – simvastatin(zocor), pravastatin ( pravachol), resuvastatin ( crestor) – Fibric acid derivatives – gemfribrozol (lopid), probucol (lorelco) – Cholesterol absorption inhibitor ezeltimibe (zetial) – Combination drugs - Vitorin

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