Coronary Artery Disease (CAD)

• Coronary Artery Disease (CAD) involves insufficient oxygenated blood delivery to the myocardium due to atherosclerotic coronary arteries.
• CAD is also known as Atherosclerotic Heart Disease (ASHD), Ischemic Heart Disease (IHD), Coronary Heart Disease (CHD), or Cardiovascular Heart Disease (CVHD).
• CAD is the most common type of Cardiovascular Disease (CVD) and can be asymptomatic, potentially leading to acute coronary syndromes (ACS) or a heart attack.
• The coronary arteries are the arteries that supply blood to the heart

Etiology of CAD

• Atherosclerosis is the primary cause of almost all CAD cases. ="athero" refers to soft, fatty deposits, while "sclerosis" denotes hardening
• Atherosclerosis results in the narrowing of an arterial lumen, leading to lipid plaque formation
• Atherosclerosis can cause thrombus formation, vasospasms, and endothelial cell dysfunction.
• Lipids travel through the blood and, when elevated, can leak through the endothelium into the vessel wall, creating an "atherosclerotic plaque."
• Atherosclerotic plaques are prone to weakness and can erode or rupture, prompting blood clot formation through the inflammatory process

Risk Factors for CAD

• Age greater than 45 for men or 55 for women is a risk factor
• CAD is a leading cause of death in women, with greater mortality if it progresses to myocardial infarction (MI)
• A family history of CHD increases risk
• Hyperlipidemia (HLD) is an elevated level of serum cholesterol, lipids, and/or triglycerides
• HDL molecules transport cholesterol away from plaques to the liver for metabolism and it is considered "Good cholesterol"
• LDL molecules are "bad cholesterol"
• Cholesterol and triglycerides are Primary constituents of natural fats and oils that contribute to atherosclerosis.
• Hypertension (HTN) increases risk
• Tobacco use increases risk
• Diabetes increases risk
• Ethnicity can increase risk
• Obesity increases risk
• Physical inactivity increases risk
• A diet high in fat/cholesterol and sodium increases risk
• Substance abuse increases risk
• Type A personality traits, anxiety, and depression increase risk
• High homocysteine levels increase risk

Pathogenesis of CAD

• Atherosclerosis in heart vessels reduces perfusion.
• Decreased blood flow to the myocardium can cause chest pain due to lactic acid buildup from anaerobic metabolism
• Decreased cardiac output can result from impaired heart contractility, affecting the entire body

Collateral Circulation

• Collateral circulation is the formation of new blood vessels or connections through angiogenesis
• It's a slow process, so rapid-onset CAD does not result in collateral circulation
• Factors contributing to development includes the presence of chronic ischemia and genetic predisposition for angiogenesis

Diagnostics for CAD

• Diagnostic tests include labs like lipid panel and C-reactive protein (CRP).. CRP is elevated w/ inflammation
• Cardiac catheterization involves an angiogram to visualize blockages
• A 12-lead ECG measures heart rhythm
• Cardiac stress tests assess heart function under stress to evaluate how the heart works

Clinical Manifestations of CAD

• Clinical manifestations may include asymptomatic presentation or angina that can radiate to the jaw, neck, arm, or back.
• Other symptoms can include indigestion-like sensation (more common in females), nausea, vomiting, cool, clammy extremities, diaphoresis and fatigue.
• Hypertension is often associated with CAD

Chronic Stable Angina

Chronic stable angina (CSA) involves chest discomfort and/or shortness of breath (SOB) with the following characteristics:

• Occurs with predictable exertion
• The discomfort is familiar in onset, duration, or intensity
• Typically associated with fixed (stable) atherosclerotic plaques
• Does not cause permanent heart damage!.
• Pain may be described as burning, crushing, squeezing, or choking
• The pain can be referred to other locations and may be accompanied by shortness of breath

Assessment of Chest Pain

• Assessment includes identifying the precipitating event, quality (ache, pressure, dull), radiation, severity (0-10 scale), and timing
• Abnormal symptoms more commonly seen in women and patients with DM are epigastric pain/ indigestion, aching chest pain (may be mistaken for a pulled muscle), inactivity, or shortness of breath only
• Patients sometimes wait to seek treatment because of atypical symptoms

What If Chest Pain Isn't Relieved

• It may be Prinzmetal's angina, where chest pain occurs primarily at rest due to coronary vasospasm and the potential trigger is smoking
• Microvascular angina is where chest pain occurs from myocardial ischemia due to presence of small coronary arteries and the trigger is exertion (but can be minimal
• It may be unstable angina (UA) or myocardial infarction (MI) also known as heart attack. Myocardial Infarction may cause death and is is defined as Infarction of the myocardium due to sudden blockage of a coronary artery secondary to Atherosclerosis, thrombus, or vasospasm

CAD & Stable Angina- Interprofessional Care

• Risk factor reduction (Primary and Tertiary Prevention) is needed.
• Reduction includes managing hyperlipidemia (HLD), reducing LDL, VLDL, triglyceride, and total cholesterol levels, managing HTN and may need to prevent it, and managing DM with insulin or other antidiabetic drugs
• Risk factor reduction includes smoking cessation, diet changes (DASH, Low Sodium, low fat/cholesterol), weight loss and increasing physical activity

CAD & CSA- Pharmacological Care

• Aspirin: An 81 mg daily dose prevents platelet aggregation
• Lipid-Lowering Drugs: Used lifelong. Omega-3 fatty acids reduce triglycerides
• HMG-CoA Reductase Inhibitors (Statins) decrease cholesterol synthesis in the liver. Watch forrhabdomyolysis which is muscle breakdown, muscle pain, etc.
• Niacin reduces lipid synthesis
• Fibric acid derivatives remove VLDLs
• Ezetimibe inhibits absorption of cholesterol
• ACE-Inhibitors & ARBs cause vasodilation and decreased blood volume
• Beta Blockers & Calcium Channel Blockers reduces heart workload by reducing HR, SVR, and BP and it needs to be taken every day.

Nitrates

• Short Acting Nitrates dilate peripheral blood vessels and coronary arteries to increase blood flow to ischemic areas of heart. Can be given sublingually in 5 minute intervals and stored away from light
• Common effects include headache, flushing, dizziness, tingling under tonuge
• Long Acting Nitrates: Reduces frequency of angina. common effects includeheadache
• Should be daily: should be used daily, changing location each time. Remov overnight to prevent tolerance.

CAD & Stable Angina- Diagnostic & Surgical Care

• Coronary Artery Bypass Grafting (CABG) involves surgery
• 12-Lead ECG evaluates heart rhythm and electrical disturbances caused by ischemia
• Cardiac Biomarkers (Troponin, CK-MB, Myoglobin) evaluates damage to heart muscle
• Coronary CT Angiography looks for blockages
• Exercise Stress test monitors the rhythm while someone is working out
• Cardiac Catheterization is the GOLD STANDARD in the form of Left heart catheterization (LHC), coronary cath, coronary/cardiac angiogram
• Coronary revascularization with percutaneous coronary intervention (PCI) is a procedure that allows radiographic visualization &/ordiilation of obstructed coronary arteries
• Coronary artery procedures can use balloons and stenting (Bare Metal (BMS), or Drug-eluding stent (DES)
• Contrat dyes are utilized with anti-coagulants to prevent platelets. Watch Iodinge Allergy.

Dangers of Contrast Dye

• Shell Fish relates allergies and it can be difficult to get rid system,
• Increase fluid after procedure to limit damage

Cardiac Catheterization

• To keep blockage of the coronary arteries under 50%
• Follow the appropriate Post Care by monitoring Kidney Function, heart functions, encouraging fluid intake, giving anti-coagulation
• Femoral Approach monitors pressure, while Radial restricts movement
• Assess peripheral perfusion for signs of bleeding
• Coronary Artery Bypass Grafting (CABG): Bypass of occluded coronary arteries through use of patient's own arteries and veins within chest wall, arm(s), or leg(s)
• Accomplished through open heart surgery: Sternotomy
• Indications for open heart include: ineffective meds, progression of vessel disease and left main cornary
• Post Op Compilations: hypo/hypertension, bleeding, tamponade impaired and surgial side infection
• Risk Factors For infection: the vent and painful brething. Perform anti septic lung exercis

Cardiac Nursing Actions

• Post operation is ICU level with invasive montering, monitoring complications and rhythm
• wound/infection/pain management
• Perform Cadiac Rehabilitation the the different phases and educat

First Case Study

• Client has CSA Stable and shoudl take short actigin nitrate
• Client undergoes angipolsty and should modify lifestyle. Should have better education and take meds

NCLEX setion

• Hypertention who Smokes
• the fat to fish rather then lamp