CAD and Angina

Cardiac Conditions: CAD/Angina

• Coronary Artery Disease (CAD) occurs when blood vessels delivering oxygen-rich blood to the heart become obstructed or dysfunctional.
• Males tend to have a higher risk of developing obstructive CAD.
• Risk factors include family history of CAD and aging.
• Other risk factors encompass total cholesterol, hypertension (HTN), diabetes mellitus (DM), obesity, smoking, and physical inactivity.
• Stress and excessive alcohol (ETOH) consumption can also contribute to CAD.
• In obstructive CAD, the heart doesn't receive enough oxygen or nutrients to meet demands, resulting in myocardial ischemia.
• Patients with non-obstructive CAD experience similar symptoms to obstructive CAD but don't have significant plaque buildup. Instead, ischemic symptoms result from decreased blood flow.
• Individuals may not experience manifestations until the artery is approximately 40% blocked by plaque, particularly in obstructive disease.
• Ischemia develops when there is an imbalance between the supply and demand of oxygen-rich blood to the heart.
• The primary complaint is angina which can be stable or unstable.
• Unstable angina can be a precursor to an acute coronary syndrome (ACS).
• Prinzmetal's or variant angina involves blockage of blood flow caused by coronary artery spasm.
• It typically occurs at night, between midnight and 8 AM.
• Angina pain may radiate to the arm, back, neck, and jaw.
• Additional symptoms include chest pressure, shortness of breath (SOB)/dyspnea, fatigue, nausea, vomiting, diaphoresis, weakness, syncope, and epigastric discomfort.
• Non-obstructive CAD involves less plaque.
• With angina, radiation may occur.
• Management involves diet and a healthy lifestyle.

Clinical Manifestations in Women and Diabetics

• Women are more likely to report fatigue, weakness, nausea, and dyspnea.
• Patients with diabetes may not consistently present with chest pain and often have none of the typical signs and symptoms of CAD.

Diagnostic Tests for CAD/Angina

• Lipid profiles evaluate total cholesterol and triglyceride levels.
• LDL and HDL levels, and troponin levels are measured.
• Troponin levels rise when myocardial injury occurs, beginning 2-3 hours after damage and continuing to rise over the next 12-48 hours
• Troponin measured every 6 hours
• An EKG is an initial test.
• ST-segment depression or flat inverted T waves during anginal episodes or signs and symptoms of ACS can indicate ischemia.
• A stress test is performed if troponin and EKG results are normal, assesses the heart during exercise.
• Coronary angiography, a sided-cardiac catheterization, is performed to evaluate coronary arteries for blockage.

Treatment for CAD/Angina

• Aim to stop the aggregation of blood components, manage contributing factors, and relieve symptoms.
• Patients with stable angina at low risk for ACS are prescribed aspirin (ASA) and nitroglycerin (Nitro).
• Medications to manage risk factors include: antihypertensives, antidiabetic agents, and cholesterol-lowering medications.
• ASA prevents thrombus formation.
• Nitroglycerin acts as a vasodilator.
• Sublingual (SL) or IV routes of nitroglycerin is preferred to restore blood flow.
• Monitor blood pressure for hypotension.
• Beta blockers or calcium channel blockers (CCBs) can be administered for ACS.
• ACE inhibitors (ACEIs) or statins can be given for non-obstructive CAD.
• Treatment of ACS may include oxygen for SpO2 ≤93%.
• Morphine can be given for angina pain not responsive to nitroglycerin.
• Coronary artery bypass grafting (CABG) can bypass blockage.

Nursing Management of CAD/Angina

• Assess chest pain and other manifestations of CAD.
• The most common symptom is chest pain.
• Tachycardia/tachypnea can indicate ischemia.
• These indicate the body is compensating for low CO.
• SpO2 ≤93% indicates the need for supplemental oxygen.
• EKG is for continuous monitoring.
• Lab tests include troponin, LDL/HDL, and renal function.
• Administer aspirin and nitroglycerin as ordered.
• Administer morphine if nitroglycerin does not relieve pain.
• Educate patient how to manage angina.
• Educate patient about when to call emergency services.

Cardiac Conditions: Heart Failure

• Men have a higher rate of Heart Failure (HF).
• Risk factors include CAD, hypertension, diabetes, metabolic syndrome, obesity, smoking, high dietary sodium intake, and sleep apnea.
• Other conditions that can cause HF are valvular dysfunction, cardiomyopathy, pericarditis, endocarditis, dysrhythmias, anemia, thyroid disease, chemotherapy, and illicit drug use.
• Respiratory issues, such as COPD, pulmonary artery hypertension, and obstructive sleep apnea, can lead to right-sided HF (cor pulmonale).
• In response to decreased stroke volume (SV) and cardiac output (CO), compensatory mechanisms are activated.
• The sympathetic nervous system (SNS) releases epinephrine/norepinephrine, increasing myocardial contractility and vasoconstriction, to increase CO.
• This can result in hypertrophy and stiffening of ventricular walls, resulting in increased cardiac workload and cardiac oxygen consumption, worsening HF.
• HF is classified based on ejection fraction, which the percentage of blood that is ejected from the ventricle with each contraction.
• Normal ranges: 55%-70%.
• Patients with reduced EF (HFrEF) have a weakened contraction, with an EF of ≤40%.
• Patients with EF >50% are defined as having HF with preserved EF (HFpEF).
• HFpEF= inability of the ventricles to fill.
• These patients tend to be older women.
• Clinical manifestations vary depending on the type, onset, and severity of heart failure.
• Acute HF has a sudden onset of symptoms.
• Chronic HF describes baseline set of symptoms.
• Congestion is an important sign of HF to recognize.
• Findings of congestion include orthopnea, bendopnea, and jugular venous distension (JVD).
• Other common signs and symptoms are fatigue, weight gain, increased heart rate, and hypertension/hypotension.
• Heart murmurs may be present if the cause of heart failure is valve dysfunction.
• An S3 heart sound can indicate worsening HF.
• S4 is common in chronic HF.

Right sided vs Left Sided HF

• Right-Sided HF symptoms: JVD, peripheral edema, hepatomegaly, ascites
• Left-Sided HF symptoms: SOB/dyspnea/orthopnea, lung crackles, fatigue/weakness, pale/weak pulses, decreased temperature, delayed capillary refill

Diagnostic Tests for HF

• CBC, UA, glucose, LFTs, lipid profile, electrolytes, renal function, BNP, troponin can be used. Can to rule out ischemic event, but also indicate if if chronically elevated, electrolytes are also seen due to ↓ kidney perfusion
• Look for poor mentation, anorexia, exercise intolerance, and other signs and symptoms.
• Impaired oxygenation may be present.
• Hypertension may be present due to increased afterload.
• Hypotension may be caused by acute HF or adverse effects of medications.
• Tachycardia may be present as a compensatory mechanism.
• Tachypnea and decreased SpO2 may be present due to fluid accumulation in left-sided HF.

Nursing Management of HF

• Primary interventions include elevating the head of the bed (HOB).
• Non-pharmacological interventions should be prioritized before pharmacological interventions.
• Educate patients diet, medications, activity tolerance, evaluation of fluid retention and signs/symptoms of worsening HF.
• Instruct patients monitor daily weight.

Cardiac Conditions: Valvular Disease

• Risk factors encompass infectious diseases, IE, rheumatic fever, MI, HF, congenital defects, and degenerative changes.
• Pregnancy can increase the risk of valvular disease due to increased workload.
• CAD is also a risk factor.
• The most common valvular disorder is aortic stenosis and mitral regurgitation.
• The least commonly affected valves are the tricuspid and pulmonic valves.
• Types of valvular disease include stenosis, insufficiency or regurgitation, and prolapse.
• Mitral valve regurgitation causes backward flow of blood into the left atrium.
• Auscultation of a murmur.
• Systolic murmurs can be heard during S1 when the ventricles are contracting.
• Diastolic murmurs can be heard during S2 when the ventricles are relaxing.
• Most of the clinical manifestations of valvular disease resemble those of HF.
• Diagnostic tests include echocardiogram, CXR, EKG, and stress test.

Nursing Management of Valvular Disease

• Assess vital signs.
• Administer oxygen and ensure proper positioning.
• Possible anti-coagulation therapy.
• Restrict sodium and fluids to reduce overload.
• Maintain a consistent intake of green leafy vegetables.
• Valvular disorders can result in HF, cardiogenic shock, thromboembolism, bleeding, endocarditis, and dysrhythmias.