CORONARY HEART DISEASEHNI 455

Impact of CVD in the US2012 UpdateCardiovascular disease (CVD) caused 811,940 deaths in 2008 (more than one in three) and is the single leading cause of death in America today (more than cancer, trauma and chronic respiratory disease combined).More than 2200 Americans die from CVD each day1 death every 39 secondsCoronary Heart Disease responsible for 405,309 of these deathsCHD=coronary heart disease.American Heart Association. Heart Disease and Stroke Statistics2012 Update.

Impact of CVD in the US2012 UpdateHypertension (HTN)33.5% of US adults 20 y.o. have HTN (SBP 140)Equal in men and womenAfrican Americans make up 44%Smoking21.2% men, 17.5% women smoke19.5% students in grades 9-12 report smokingCholesterol15% of Americans 20 y.o. have total cholesterol 240 mg/dL

CHD=coronary heart disease.American Heart Association. Heart Disease and Stroke Statistics2012 Update.

Impact of CVD in the US2012 UpdateObesity33.7% of US Adults are obese (BMI 30 kg/m2)33% adults report no physical activity31.7% children aged 2-19 are overweight or obese29.9% girls and 17% boys in grades 9-12 report not engaging in 60 mins of moderate physical activity once a weekCHD=coronary heart disease.American Heart Association. Heart Disease and Stroke Statistics2012 Update.

Impact of CVD in the US2012 Update

Angina pectoris (chest pain or discomfort caused by reduced blood supply to the heart muscle)9,000,000 Myocardial infarction 610,000 new 325,000 recurrentEvery 34 secondsabout one fourth of these will die in an emergency department or before reaching a hospital.*From 1998 to 2008 the death rate from coronary heart disease decreased 30.6 percent CHD=coronary heart disease.American Heart Association. Heart Disease and Stroke Statistics2012 Update.

Cardiac OutputThe amount of blood ejected from the heart in one minute. (4-8 L/min)CO=SV X HRStroke volume is the amount of blood pumped with each contraction

Factors Affecting Cardiac OutputPreload volume of blood in the LV at the end of diastole. Starlings Law

Afterload The resistance against which the LV must pump.

Contractility Refers to the intensity with which the cardiac fibers contract.

Hemodynamic monitoringSpecial indwelling catheters that provide information about blood volume and perfusion, fluid status and how well the heart is pumping.Central venous pressure (CVP)Pulmonary artery catheters (PA)Intra-arterial pressure (a-line)

Atherosclerotic Progression

3 stages of atherosclerotic plaque development

Fatty streaks earliest lesions age 15. LDL lowering agents may reverse.Fibrous plaque phase endothelial damage cholesterol deposition in intimaComplicated lesion stage continuation of inflammation leads to an unstable plaque lesion. Rupture platelets thrombus!

Hemodynamic effects of CADDisturbance in the delicate balance between myocardial oxygen supply and demand

Vessels become stiff and lose ability to dilate

Decreased O2 is supplied to myocardium; resulting in tissue hypoxia or ischemia

Review - Risk factors for CADAge, gender, ethnicityFamily history and genetic*Elevated serum lipids Mayo clinic- most people should aim for an LDL below 130mg/dl*Hypertension Normal is

Treatment of CADHEALTH PROMOTION** IDENTIFY PEOPLE AT RISK EDUCATE!HEALTHY PEOPLE BOX ON P. 766 AND PT GUIDE ON P. 767 ASSESS WHEN READY TO LEARN!GIVE CONTINUED SUPPORT TO ENCOURAGE LIFE-LONG BEHAVIORSNUTRITIONAL THERAPY BOX ON PAGE 768

Drug therapy usually lifetimeStatins (Lipitor - atorvastatin) block cholesterol synthesis by blocking HMG-CoA reductase. Lower LDL and triglycerides and small rise HDL. Used for initial therapy. Serious adverse effects Liver damage & myopathy (monitor liver enzymes (ALT, AST) and complaints of muscle aches) Niacin Increases HDL Flushing, pruritusFibric acid derivatives (lopid Gemfibrozil) accelerate elimination of VLDLs and increases production of apoproteins A-I and A-II. Effect is increasing HDL and lowering triglycerides.

Bile acid sequestering agents (cholestyramine -Questran) bind cholesterol in intestine. Cholesterol absorption inhibitor (ezetimibe Zetia)Aspirin low dose 81mg

3 Manifestations of CAD

Angina - symptoms when 70% occludedStable AnginaUnstable angina Acute coronary syndrome, preinfarction anginaSilent ischemia

M.I.

Sudden cardiac death

Angina Pectoris pain in the chestSymptom of CAD; indicates myocardial ischemia

Oxygen demand exceeds supply

Precipitating factors:Physical exertionTemperature ExtremesStrong emotionsEating heavy meal

Types of Angina

Stable angina (exertional angina) Lack of O2 is temporary and reversible. Predictable, usually occurs with exertion.

Unstable angina Acute coronary syndrome or ACS - more prolonged lack of O2, unpredictable and represents an emergency, occurs during rest, sleep and increasing frequency.

Variant Prinzmetalss angina coronary spasm

Atypical Women Fatigue, SOB, indigestion and anxiety.

Care of patient with Chronic Stable AnginaGoal is to decrease O2 demand or increase O2 supplyNitrates use short acting (sublingual) for treatment of angina. Long acting (isosorbide mononitrate) to reduce incidence. SE headache, complication orthostatic hypotension. B-blockers decrease contractility, HR, SVR and BP. SE bradycardia, hypotension, wheezing, sexual dysfunction, depressionCalcium channel blockers Used if pt cant tolerate B-blockers and for Prinzmetals angina

Patient teaching for Response to chest pain and sublingual NTGStop activity and rest.Place NTG under tongue and let dissolve. Should feel tingling under tongue. Spray on tongue.Can take up to 3 NTG tablets 5 min apart; then go to ER/call 911.Replace NTG after 6 monthsProtect from light and heat sources.Caution against quickly rising to a standing position orthostatic hypotensionSide Effect pounding headache, flushingMay be taken prophylactically before activity

Acute Coronary SyndromeBecause unstable angina and acute MI are considered to be the same process but different points along a continuum The term Acute coronary syndrome (ACS) is used.Pain unrelieved by rest or nitroglycerin and lasting for more than 15 min differentiates MI from angina.

Manifestations of ACSChest pain that is new in onset, occurs at rest or has a worsening pattern is called unstable angina.As the cells are deprived of O2, ischemia develops, cellular injury occurs, and the lack of O2 results in infarction or the death of cells. Myocardial infarction (MI).MI is associated with nausea, epigastric distress, dyspnea, anxiety, diaphoresis

SLIDTA Assessment of AnginaS 1-10 scaleL Where is the pain and where does it go? Substernal radiating to neck and jaw, left shoulder and down both arms, epigastric radiating to neck, jaw and arms.I What initiated and relieved? Argument, exercise, resting and what relieved? Sitting down, NTGD How long? Have you had pain like this before?T What does it feel like? Pressure, dull, aching, tight, squeezing, heavinessA Other symptoms? diaphoresis, nausea, vomiting, anxiety, feeling of doom. Women?

PathophysiologyIschemia occurs within 20 minutes; necrosis occurs within 6 hours. Time is muscle!!

Zone of ischemia inverted T waves; ST depression Zone of injury (ST elevations)Zone of infarction Q waves

Myocardial InfarctionChest pain unrelieved by rest and NTG

Deficiency of coronary artery blood supply resulting in NECROSIS of myocardial tissue

25 % die before reaching hospital

Eighty to 90% of all acute MIs are secondary to thrombus formation Interventions (emergent PCIs or fibrinolytic therapy) have greatly reduced mortality rates.

Anatomical Location of MIInferior wall RCA; also perfuses SA node and conduction system look for conduction disturbances

Lateral wall left circumflex -LCX

Anterior wall - LAD; large portion of LV; look for problems with mechanical pumping ability of heart

Assessment and Diagnostic Findings of MIHistory Presenting symptoms:Pain unrelieved by rest and NTG (described as severe and immobilizing, heaviness, pressure, tightness, burning, constriction or crushing.)Associated symptoms - diaphoresis, nausea, vomiting

12 lead EKG changes (Q waves, ST elevation or depression)

Assessment and Diagnostic Findings of MI

Serum cardiac markers: These tests are based on the release of cellular contents in the circulation when myocardial cells die.Troponin I (marker of choice) norm

ED-CCU or telemetry unit nursing care- ACSAssess subjective complaints, pain scaleEstablish IV 12 lead ECG and continuous ECG monitoringO2 2 to 4 L/minIV Nitroglycerin (Tridil), Morphine Sulfate, beta blockers, aspirin, ACE are first line. Frequent VS and pulse oximetry - q1-2hrs Maintain patent venous access and monitor I & OStool softeners Initially bedrest for 12-24 hours then activity progression Initially the pt is NPO

Collaborative care- ACSGoals: limit infarct sizePrevent and manage complicationsPreserve myocardial function

Gold standard Evaluate for indications for reperfusion therapy - Percutaneous coronary intervention (PCI - stents and angioplasty) and Fibrinolytic therapy.PCI should be performed less than 90 minutes from the arrival time in the ED. Door-to balloon time

Care of the patient with acute coronary syndromeAnxiety related to perceived or actual threat of death, pain and possible lifestyle changes.Nursing interventionsObserve for verbal and nonverbal signs of anxiety. Use a calm reassuring approach so as not to increase a patients anxiety.Assess need for further emotional support (relaxation techniques, individualized visiting, spiritual support) Encourage verbalization of feelings and concernsProvide factual information concerning diagnosis so as to decrease fear of the unknown.

Complications of MIArrhythmias

Acute LV failure (HF)

Cardiogenic shock

Cardiac Rehabilitation for the patient after an MIGoal restoration of person to an optimal state of function: physiologic/psychologic/spiritual/economic and vocational.

Topics S&S of angina/MI, and reasons they occur. Anxiety, use of SL NTG (and other meds), lifestyle changes, includes diet (low in sodium and sat fats), sexual matters, exercise program.

CCUStepdown unitHome rehab most patients in our areaCommunity rehab program

Geriatric considerationsOlder adults often do not feel the intense crushing pain.Arteries are less elastic, less distensible. Systolic HTNCO decreases by 1% per year after age 70Antianginal agents that cause postural hypotension and decrease preload may not be tolerated.More complications. After MI > afib.However, they do have well established collaterals

ANEURYSMS and VASCULAR DISEASEHNI 455Professor Patricia VoelpelRevised 2014

THORACIC ANEURYSMSecondary to atherosclerosisMen ages 40-70Most common site for dissectionPain is prominent symptomDyspnea, cough, hoarseness, and dysphagiaSurgically repaired

ABDOMINAL AORTIC ANEURYSM (A.K.A. AAA)Secondary to atherosclerosisMore common in Caucasians Men >60 yoaComplain they can feel their heart beating in their abdomen80 % are palpable with bruit over massSurgically repaired

ARTERIAL OCCLUSIVE DISEASE

Arterial vs Venous Disease

ArterialVenousPulsesWeak, threadyBoundingColorPale, mottledRedTemperatureCoolWarmOptimal PositioningDependentElevated

DIAGNOSTICSDoppler studiesAngiographyThrombolyticsExercise testing

DEEP VEIN THROMBOSISSymptoms are edema, swelling of the extremity because outflow of blood is obstructed, can be warm and tenderManagement

**Coronary heart disease includes MI, angina, CVA and HFIf CVD eliminated, would gain 7 years in life expectancy. If all forms of cancer eliminated, would only gain 3 years*Coronary heart disease includes MI, angina, CVA and HFIf CVD eliminated, would gain 7 years in life expectancy. If all forms of cancer eliminated, would only gain 3 years*Coronary heart disease includes MI, angina, CVA and HF*Coronary heart disease includes MI, angina, CVA and HF*Cardiac index is the CO divided by the body surface area and is the preferred value because it reflects the CO related to patient size. (norm 2.8 to 4.2 l/min/m2)*Preload is a reflection of the pressure exerted by blood volume in the ventricle at the end of diastole. Preload is often called filling pressure.Afterload is primarily a reflection of vascular tone, but it is also a reflection of the stress or tension generated in the ventricle during systoleContractility refers to an alteration in the force of contraction that occurs at the cellular level and is related to changes in myocardial fiber length and CA levels. Contractility is affected by the sympathetic nervous system stimulation as well as injury, acidosis, electrolyte imbalance and hypoxia..***p. 761 - 762**Page 763******Nitrate free period 8 hour period usually at night to reduce the orthostatic complication****************About 1/3 of post MI men and women do not resume sexual activity or reduce activity for fear of sexual inadequacy, death during coitus and impotence. It is our role to correct misconceptions.*