Coronary Artery Disease (CAD)

Coronary Artery Disease (CAD)

• Characterized by plaque buildup, caused by increased lipids and triglycerides.
• Treatment options include enterectomy (plaque scraping), stent placement, anti-lipid medications, antiplatelet medications, and surgery (bypass).
• Non-modifiable risk factors include age (males >45, females >55), race (African Americans, Native Americans, South Asians), gender, and family history of CAD at a young age.
• Modifiable risk factors include obesity, smoking, stress, physical inactivity, alcohol/substance abuse, and elevated homocysteine levels (found in red meat; normal range: 4.5-11.9).

CAD Diagnosis

• Diagnosis involves assessing lipid levels, performing an EKG (ST elevation indicates ischemia), conducting a stress test (pharmacological or exercise), and cardiac catheterization (to assess heart chamber/valve structure).
• If a patient receives a stent, percutaneous coronary intervention (PCI) is needed, with Clavix typically administered.

Pre- and Post- PCI Procedure

• Pre-procedure involves gathering medical history, height and weight, medication list, allergies, informed consent, baseline vitals, IV access, site preparation, baseline assessment; patient should be NPO.
• Post-procedure, frequently check vitals, pulses, and the site for bleeding/hematoma; assess LOC; telemetry with pulse oximetry is used; affected extremity is kept straight, HOB elevated to 30 degrees; monitor fluid status (intake/output).
• After discharge, patients should take medications as prescribed, monitor the site for bleeding clean bandage every 2-3 days after removal, and increase fluid intake to flush out kidneys. Cardiac markers are also monitored.

CAD Treatment and Management

• Treatment involves lifestyle changes like diet modifications (limiting fat/cholesterol, increasing fiber/lean meat/low-fat dairy) and lipid-lowering medications and antiplatelet medications. Angioplasty/PCI may also be performed.
• Patients may be asymptomatic until decreased cardiac output.
• Other signs and symptoms: palpitations, dyspnea, syncope, cough/hemoptysis, excessive fatigue, and angina.
• Cholesterol recommendations: total cholesterol (<200 mg/dl), LDL (<100, "bad" cholesterol), VLDL (5-40, "very bad" cholesterol), HDL (>60, "good" cholesterol), and triglycerides (<150).
• Regular cholesterol checks should begin after age 20, every 5 years, with a fasting check.

Angina Types

• Stable angina is "exertional," occurring with exertion or emotional stress, has a predictable pattern, typically lasts 3-5 minutes, and is relieved with nitroglycerin.
• Unstable angina is "periinfarction," indicating worsening cardiac ischemia and a medical emergency. It occurs with unpredictable exertion or at rest, shows a significant change in the usual pattern, typically lasts longer than 15 minutes, and may not be relieved by nitroglycerin.
• Nitrates like Nitroglycerin (NTG) are vasodilators that can be administered sublingually (SL), IV, or transdermally

Nitroglycerin (NTG) Dosing and Cautions

• For acute angina, administer SL tabs x3 doses, five minutes apart.
• For prophylaxis, use a topical application, rotating to a non-hairy area.
• Check blood pressure, note that NTG is light-sensitive, and replace tabs every 3-5 months; wear gloves during application.
• Isosorbide dinitrate and isosorbide mononitrate are scheduled PO nitrates.
• Precautions/contraindications: avoid erectile dysfunction drugs, use caution with glaucoma and inferior MI.

Myocardial Infarction (MI)

• Myocardial Infarction occurs when the heart is deprived of oxygen, with risk factors similar to CAD.
• Signs and symptoms include crushing substernal pain radiating to the jaw and left arm, unrelieved by nitro, lasting 30+ minutes, and accompanied by N/V, diaphoresis, and dyspnea.
• Women may experience fatigue or pain in the upper back, presenting without ST elevation.
• MI Types: LAD (left anterior descending), RAD (right inferior descending), and Circumflex (posterior or lateral).

MI Diagnostics and Markers

• Diagnostics: EKG, cardiac catheterization, myoglobin, and cardiac markers (Troponin, CK-MB).
• Troponin elevates 3-12 hours from onset of pain, peaks at 24-48 hours, and returns to baseline in 7-10 days.
• CK-MB elevates faster than troponin, peaks at 18 hours, and returns to baseline in 48-72 hours.
• Myoglobin elevates fastest at 2 hours and returns to baseline after 7 hours.
• In inferior MI, leads II, III, and AVF are affected. Don't administer Nitro if MI shows in these leads. Administer Morphine to decrease pain, Oxygen above 94, Nitroglycerin for vasodilation and Aspirin.

Heart Failure (HF)

• Right-sided HF (cor pulmonale): right side of the heart back flows to the body. S/S: edema, ascites, JVD, hepatomegaly, abdominal pain, anorexia, nausea, bloating, dependent edema, anasarca, JVD, and weight gain.
• Left-sided HF: Left ventricle issues back up into the lungs. Pulmonary edema, blood accumulates in left side of heart and pulmonary circulates. S/S: pulmonary edema/ congestion, SOB, orthopnea, cough, crackles, Cheyne-Stokes respirations, renal failure, cerebral hypoxia. S3 and S4 heart sounds can be heard

Preload and Afterload in HF

• Preload is the volume of blood in ventricles at the end of diastole, it's elevated in hypervolemia, regurgitation of cardiac valves, and heart failure.
• Afterload is the resistance the left ventricle must overcome to circulate blood; increased in HTN and Vasoconstriction.
• HF can be acute or chronic, with risk factors including CAD, HTN, MI, heart valve disorders, diabetes, cardiomyopathy, heart infections, and Afib.

HF Diagnosis and Treatment

• Diagnostic tests include chest x-ray, EKG, echocardiogram (measures ejection fraction; normal: 50-70%, borderline: 40-49%, low: <40%), BNP measurement, ABGs, BUN and creatinine check, elevated liver enzymes (LFT), and electrolyte monitoring (K, Mg).
• Treatment involves placing the patient in high Fowler's position, administering oxygen, assessing lung sounds (crackles), and medications.

HF Medications

• Medications: diuretics (Spironolactone - potassium-sparing diuretic and aldosterone blocker), beta-blockers (slow down heart; for chronic HF, not acute), ACE inhibitors or ARBs (cause vasodilation and decrease mortality), nitrates (dilate vessels), digoxin (makes heart pump stronger)
• Patients with EF <40 must be on Digoxin, aldosterone blocker (Spironolactone) and a beta blocker (metoprolol, carvedilol). Strict I&Os and fluid restriction is necessary.

HF Education and Management

• Patient education includes diet (low sodium) and daily weights.
• Patients may get an AICD, as they are more likely to go into lethal rhythm, which increases ejection fraction.

Pulmonary Edema

• Pulmonary Edema is a medical emergency, exhibiting signs and symptoms such as pink, frothy sputum, SOB, increased HR and RR, accessory muscle use/nasal flaring, wheezing, crackles, gurgling, anxiety, diaphoresis, and cyanosis.
• Treatment involves high Fowler's position, oxygen administration, quick assessment, ensuring a working IV line, preparing for IV diuretic and IV morphine, inserting a Foley catheter, strict I&Os, preparing for possible intubation, and staying with the patient.

Pulmonary Embolism (PE)

• PE is a condition where one or more arteries in the lung become occluded. Risk factors include obesity, smoking, blood stasis, and birth control.
• Diagnosis involves chest XR (to rule out other things) and VQ scan. A VQ scan matches up ventilation & oxygen, if mismatched its indicative of a clot
• Other diagnostic tests include ABGs, CT angiogram, Doppler US, and D-dimer (tells us if there is a clot; >50 is normal).
• Signs/Symptoms: SOB, blood-tinged sputum, chest pain (exacerbated by inspiration), cough, crackles, cyanosis, hypotension, petechiae over chest and axilla, shallow respirations, tachypnea, and tachycardia.

PE Interventions and Treatments

• Interventions: notify HCP, elevate HOB, administer oxygen, monitor vitals, assess lung sounds, obtain ABGs, anticipate anticoagulation, and document interventions.
• Treatments include heparin drip (prevents clot from getting bigger), inferior vena cava (IVC) filter, thrombolysis (clot-breaking medications), and thrombectomy (surgical clot removal).

Cerebral Vascular Accident (CVA/ Stroke)

• Transient ischemic attack (TIA): lasts less than 24 hours and serves as a warning sign for impending CVA.
• Symptoms: stroke-like, but shorter duration.
• Diagnostics: CT (no contrast), MRI (takes longer than CT), carotid ultrasound, EKG, and Holter monitor during home stay and lifestyle changes.
• Treatment involves lifestyle changes (low fat/salt/red meat, high fiber/lean meat, stop smoking, increase activity, limit alcohol), antiplatelet medications, and antihypertensive medications.

Ischemic Stroke

• Ischemic Stroke: something blocks blood flow.
• Risk factors: alcohol/drug use, diabetes, hyperlipidemia/atherosclerosis, HTN, sickle cell disease, age >65, male gender, and oral contraceptives.
• Hemorrhagic Stroke: bleeding in the brain.
• Risk factors: hemophilia, anticoagulant use, pancytopenia, HTN, and aneurysm (weak blood vessel).
• Clinical manifestations of stroke: facial drooping, arm weakness, speech difficulty, time to call 911.
• Other symptoms: headaches, vomiting, seizures, and altered mental status.

Stroke Manifestations, Lobes, and Symptoms

• Manifestations of stroke are related to the area of injury. Cushing's triad (increased ICP) involves high systolic BP, low pulse, and low RR.
• Frontal lobe: speech production (Broca's area).
• Temporal lobe: speech comprehension (Wernicke's area).
• Damage to the right side of the brain results in symptoms appearing on the left side of the body, left-sided neglect, special/perceptual deficits, and impulsivity/judgment issues.
• Damage to the left side of the brain results in symptoms appearing on the right side of the body, right-sided neglect, patients being more anxious and aware of deficits, and impaired math/language comprehension.

Stroke Symptoms

• Apraxia: inability to perform purposeful movements.
• Dysarthria: difficulty articulating.
• Dysphasia: difficulty speaking or comprehending.
• Aphasia: loss of ability to speak or comprehend; expressive (Broca's area damage) and receptive (Wernicke's area damage).
• Agraphia: Loss of ability to write.
• Alexia: Loss of ability to read.
• Dysphagia: difficulty swallowing.
• Hemianopsia: Visual field cut.

Stroke Treatment

• Treatment: clot busters
• Fibrinolytic therapy is administered within 3 hours of symptom onset (up to 4.5 hours in some instances).
• Contraindications: age over 80, current anticoagulant use, history of stroke/diabetes, or current/recent bleeding.
• Before administration: obtain EKG, platelet count, pT, PTT, blood glucose, and assess BP.

tPA Dosing

• The recommended dose of Activase is 0.9 mg/kg infused over 60 minutes (do not exceed 90 mg total dose); administer 10% as initial bolus over 1 minute, and infuse the remaining dose intravenously over 60 minutes.

Stroke Treatment Options

• Priority treatments include getting a CT scan, neuro-assessment, and transferring to a stroke center.
• Treatment options are endovascular for ischemic strokes such as thrombectomy or endovascular treatment of stroke, or thrombolysis
• Other treatments: corticosteroids (decrease cerebral edema), H2 inhibitors/PPI (prevent gastric ulcers), aspirin/clopidogrel, CCB (lower BP and vasodilation), and stool softeners.

Stroke Medications

• Analgesics and anxiolytics may be administered.
• Mannitol: osmotic diuretic that prevent kidney injury, decrease ICP, and induces diuresis with chemo.
• Side effects: F&E imbalance, pulmonary edema, N/V, hyponatremia, and dehydration.
• Actions: monitor VS, weight, UOP, electrolytes, lung and heart sounds; administer via IV infusion with a filter and monitor for crystal formation.

Nursing Actions for Stroke and ICP

• Maintain airway patency (assess swallowing) and perform neuro checks.
• Monitor vitals frequently, monitor for seizure activity, cardiac rhythm with telemetry, urine output/retention, mobility/strength, and electrolytes.
• Watch for signs of increased ICP: decreased LOC, restlessness/agitation, headache, changes in speech, N/V, seizures within 24 hours, and vital sign changes (increased systolic BP, decreased HR and RR).
• Provide supportive care to patient in Decorticate posture (arms adducted and flexed) and Decerebrate posture (arms extended)

Managing ICP, Preventing Clots and Nursing Actions

• Elevate HOB to 30 degrees or more, keep head midline, avoid coughing/deep breathing, suction only when necessary, avoid clustering care, maintain a calm environment, and use sedatives cautiously (may mask neuro symptoms).
• Monitor for VTE, place SCDs on the patient.
• Implement fall precautions, turn the patient every 2 hours, avoid lifting or turning the patient using the flaccid arm, and perform ROM exercises.