Coronary Artery Disease

Coronary Artery Disease (CAD)

• Progressive narrowing of coronary arteries occurs due to atherosclerosis.
• It leads to myocardial ischemia, angina, and myocardial infarction (MI).
• Endothelial injury leads to inflammation, which triggers lipid accumulation, forming plaque and narrowing arteries.
• Reduced blood flow and oxygen to the myocardium causes ischemia.

CAD: Risk Factors

• Non-modifiable risk factors include age, gender (higher risk for males until menopause), family history, and ethnicity (increased risk in South Asians and people of African descent).
• Modifiable risk factors include smoking, hypertension, dyslipidemia, diabetes, obesity (especially abdominal), physical inactivity, poor diet, and stress.

CAD: Clinical Manifestations

• Angina presents as chest pain or pressure.
• Stable angina is predictable and relieved by rest or nitroglycerin.
• Unstable angina is new or worsening, not relieved by rest, and requires emergency intervention.
• Variant (Prinzmetal’s) angina is caused by coronary artery spasm.
• Other manifestations include dyspnea, fatigue, diaphoresis, palpitations, dizziness, and nausea.

CAD: Diagnostics

• ECG shows ST changes and T wave inversion.
• Troponin levels are checked to rule out MI.
• A lipid panel is performed.
• Stress testing can be done through exercise or pharmacological means.
• Coronary angiography is the gold standard diagnostic tool.

CAD: Treatment - Medications

• Nitrates cause vasodilation, increasing blood flow.
• Beta-blockers decrease heart rate (HR) and oxygen demand.
• Calcium Channel Blockers (CCBs) cause vasodilation and decrease blood pressure (BP).
• Statins decrease LDL and increase HDL cholesterol.
• Antiplatelets (e.g., ASA, clopidogrel) prevent clot formation.

CAD: Treatment - Procedures

• Percutaneous Coronary Intervention (PCI) involves balloon angioplasty with stent placement.
• Coronary Artery Bypass Grafting (CABG) is a surgical revascularization procedure.

CAD: Nursing Management

• Assess and monitor chest pain using PQRST (Provoking factors, Quality, Region/Radiation, Severity, Timing).
• Administer medications as ordered.
• Educate patients on nitroglycerin use (sit down, wait 5 minutes between doses).
• Educate patients on risk factor management and medication compliance.
• Prepare patients for diagnostics or interventions (e.g., PCI).
• Provide post-PCI care, monitoring for bleeding and arrhythmias.

Valvular Disorders: Definition and Common Issues

• Damage or defect in one of the four heart valves causes either stenosis (narrowed opening), regurgitation (backflow of blood), or prolapse (valve leaflets bulge into atrium).
• Mitral valve problems include stenosis, regurgitation, and prolapse.
• Aortic valve problems include stenosis and regurgitation.

Valvular Disorders: Clinical Manifestations

• Fatigue and dyspnea on exertion are common.
• Orthopnea and paroxysmal nocturnal dyspnea (PND) may occur.
• Murmurs are a key diagnostic clue.
• Other symptoms include chest pain, palpitations, peripheral edema (right-sided involvement), and syncope (aortic stenosis).

Valvular Disorders: Diagnostics

• Echocardiogram is the gold standard for diagnosis.
• ECG can show rhythm changes.
• Chest X-ray can reveal cardiomegaly and pulmonary congestion.
• Cardiac catheterization can confirm the diagnosis before surgery.

Valvular Disorders: Treatment - Medical Management

• Diuretics reduce preload.
• Beta-blockers control heart rate.
• Anticoagulants prevent thromboembolism, especially in atrial fibrillation.
• Afterload reduction is achieved with ACE inhibitors or ARBs.

Valvular Disorders: Treatment - Surgical/Procedural

• Valve repair can be performed.
• Valve replacement can be mechanical (durable, requires lifelong warfarin) or bioprosthetic (shorter lifespan, no long-term anticoagulation).

Valvular Disorders: Nursing Management

• Monitor for signs of heart failure (HF) such as weight gain, crackles, and edema.
• Assess for dysrhythmias, especially atrial fibrillation.
• Monitor INR if the patient is on warfarin (target: 2.0–3.0).
• Teach patients about signs and symptoms of decompensation.
• Teach patients about prophylactic antibiotics for invasive procedures.
• Educate about medication compliance and dietary considerations when taking warfarin.
• Educate about anticoagulant precautions (avoid falls/injury).

Chronic Heart Failure (CHF): Pathophysiology

• The heart cannot pump effectively, leading to decreased perfusion and oxygenation.
• Left-sided HF affects the lungs (backward flow into pulmonary circulation).
• Right-sided HF affects the body/systemic circulation.

CHF: Clinical Manifestations

• Left-sided HF symptoms include dyspnea, orthopnea, PND, pulmonary crackles, fatigue, confusion, and S3 heart sound.
• Right-sided HF symptoms include peripheral edema, jugular vein distension (JVD), hepatomegaly, ascites, nausea, and anorexia.
• Both types can cause weight gain and nocturia.

CHF: Diagnostics

• BNP >100 pg/mL is a key marker of HF.
• Chest X-ray can show cardiomegaly and congestion.
• ECG may show ischemia or arrhythmias.
• Echocardiogram shows decreased ejection fraction.
• Labs may show increased creatinine, liver enzymes, and troponin.

CHF: Nursing Assessments

• Monitor daily weights (1 kg = 1 L fluid).
• Monitor intake and output (I&O).
• Assess lung sounds and respiratory effort.
• Observe edema and skin integrity.
• Check vital signs and mental status.

CHF: Nursing Interventions

• Administer medications such as ACE inhibitors, beta-blockers, loop diuretics, and digoxin.
• Position the patient in High Fowler’s position.
• Administer oxygen as needed.
• Provide a low-sodium diet.
• Implement fluid restriction if ordered.
• Monitor for digoxin toxicity (nausea, vision changes, bradycardia).

CHF: Client Education

• Instruct patients to weigh themselves daily and report a gain of >2 kg in 2 days.
• Educate on a low-sodium diet.
• Emphasize taking medications as prescribed.
• Advise avoiding NSAIDs (worsen fluid retention).
• Teach energy conservation techniques.
• Instruct patients to report worsening symptoms like fatigue, shortness of breath (SOB), and swelling.

Peripheral Artery Disease (PAD): Pathophysiology

• Atherosclerosis leads to narrowed arteries and decreased blood flow to the limbs.

PAD: Clinical Manifestations

• Intermittent claudication is a key symptom.
• Other signs include pale, cool skin; shiny, hairless legs; weak/absent pulses; delayed capillary refill; pain at rest (late stage); and ulcers on the toes that are round, dry, and have well-defined edges.

PAD: Diagnostics

• Ankle-brachial index (ABI) < 0.9 indicates PAD.
• Doppler ultrasound is used.
• Arteriography/angiography can be performed.

PAD: Nursing Assessments

• Assess peripheral pulses and capillary refill.
• Evaluate skin color and temperature.
• Assess pain (rest vs exertion).
• Assess any ulcers present.

PAD: Nursing Interventions

• Promote circulation by dangling legs and encouraging walking to build collateral circulation.
• Administer antiplatelets (ASA, clopidogrel) and statins.
• Focus on skin care and foot protection.
• Advise avoiding cold exposure and tight shoes.

PAD: Client Education

• Emphasize smoking cessation.
• Instruct patients to inspect feet daily and keep them clean and dry.
• Advise patients to walk to the point of pain, rest, and repeat.
• Instruct them to avoid crossing legs or wearing tight garments.
• Urge them to seek help for non-healing wounds.

Chronic Venous Insufficiency (CVI): Pathophysiology

• Valve dysfunction leads to blood pooling in the legs, increased pressure, edema, and skin breakdown.

CVI: Clinical Manifestations

• Brown pigmentation (hemosiderin) occurs.
• Edema is present, especially at the end of the day.
• Skin thickening (lipodermatosclerosis) may occur.
• Ulcers typically appear on the medial ankle, have irregular edges, and are wet/exudative.

CVI: Diagnostics

• Duplex ultrasound assesses venous flow.

CVI: Nursing Assessments

• Assess skin color, moisture, and integrity.
• Note the presence and location of edema.
• Evaluate ulcer characteristics.
• Look for signs of infection (odor, exudate, redness).

CVI: Nursing Interventions

• Use compression therapy (unless ABI < 0.8).
• Elevate legs to reduce edema.
• Apply moist dressings (hydrocolloid, alginate).
• Apply emollients to dry skin.
• Encourage ambulation.

CVI: Client Education

• Advise wearing compression stockings daily.
• Instruct patients to elevate legs above the heart 4-5 times a day.
• Teach skin hygiene and daily moisturizing.
• Advise avoiding prolonged sitting/standing.
• Educate on nutrition: increase protein, vitamin C, and zinc to promote healing.