Coronary Artery Disease (CAD)

Coronary Artery Disease (CAD)

• CAD is caused by the obstruction of blood flow within the coronary arteries.

Health Promotion and Disease Prevention of CAD

• Maintain a BMI of less than 30.
• Follow a diet low in saturated fats and sodium.
• Engage in regular exercise for at least 30 minutes, 5 days a week.
• Avoid smoking and alcohol consumption.

Risk Factors for CAD

• Being a white male.
• Age greater than 45.
• Family history of CAD.
• Post-menopausal status.
• Smoking.
• High cholesterol.
• Hypertension (HTN).
• Diabetes Mellitus (DM).
• Central obesity.
• Sedentary lifestyle.
• Stress.
• Alcohol consumption.

Expected Findings of CAD

• Absence of symptoms until an artery is 40% blocked.
• Angina.
• Syncope.
• Shortness of breath (SOB).
• Fatigue.
• Nausea/Vomiting (N/V).
• Gastrointestinal (GI) upset, which can mimic myocardial infarction (MI) if blocked.
• Men often experience classic exertional chest pain.
• Women may have atypical pain not associated with exertion.

Safety Considerations for CAD

• Cardiac rehabilitation is a supervised program of education, counseling, and activity to rehabilitate the heart.

Lab Tests for CAD

• Lipid levels (lipid profile).
• Total cholesterol levels
• Troponin and creatine kinase levels, indicating a stressed heart.

Diagnostic Procedures for CAD

• Coronary angiography is the gold standard for evaluating blockage in the coronary arteries using left-sided cardiac catheterization.
• Electrocardiogram (EKG) showing ST elevation indicates heart injury; ST inversion indicates ischemia, and ST depression during episodes of angina.
• Stress tests are used to assess heart function during exercise.
  • Goal is to determine if there is reduced oxygen-rich blood flow to the heart.
  • Goal is to identify which parts of the heart are affected by decreased blood flow.

Complications of CAD

• Acute coronary syndrome is caused by an acute decrease in blood flow through the coronaries to myocardial tissues
  • Reporting of unstable chest pain.

Therapeutic Procedures for CAD

• Percutaneous transluminal coronary angioplasty uses a balloon to open the artery.
  • A stent being optional to hold the artery open.
• Coronary Artery Bypass Graft (CABG)

Stable Angina

• Chest pain associated with physical activity
• Linked to fixed plaque formations and is predictable.
• Symptoms are alleviated with rest and/or medication.

Unstable Angina

• Occurs at rest
• Is the initial phase of acute coronary syndrome
• Requires emergency treatment as it is a precursor to MI

Prinzmetals/Variant Angina

• Blockage of blood flow is caused by coronary artery spasm, and NOT plaque formation.
• Occurs at rest and in clusters, typically at night into early morning.

Nursing Assessments for CAD

• Monitor vital signs, as high respiratory rate (RR) and heart rate (HR) can indicate cardiac ischemia, and hypertension (HTN) is a risk factor.
• Perform pain assessment, including provoking factors, quality, region/radiation, severity, and time (PQRST); consider angina or headache from nitroglycerin.
• Continuous cardiac monitoring and EKG to identify depressed ST/inverted T waves, indicating ischemia and dysrhythmias from ischemia and infarction.
• Physical assessments include pallor, clamminess, nausea/vomiting (N/V), shortness of breath (SOB), and diaphoresis which are indicators of cardiac ischemia.
• Evaluate patient history for CAD risk factors, anginal patterns, and non-cardiac causes of chest pain.
• Assess recreational drug use, as drugs like cocaine can cause vasospasm obstructing blood flow.
• Screen for depression, as it can increase morbidity.
• Check lab values, including cardiac biomarkers (CK/CK-MB, troponin), creatinine/BUN, HgbA1c, and lipid profile.

Nursing Actions for CAD

• Administer oxygen (O2) to maintain saturation above 93% for supplemental O2 delivery to the myocardium.
• Obtain an EKG when chest pain occurs.
• Administer nitroglycerin as prescribed to improve blood flow to the heart.
• Administer aspirin as prescribed to prevent platelet aggregation.
• Administer morphine if nitroglycerin doesn't relieve pain to minimize pain and decrease workload of the heart.
• Administer beta-blockers (BBs), calcium channel blockers (CCBs), and statins as prescribed.

Nursing Actions for CAD After Percutaneous Coronary Intervention (PCI)

• Provide cardiac catheterization care.
• Report and treat chest pain immediately.
• Administer anticoagulants (anticoags).
• Maintain fluids through catheterization sheaths if left in place.
• Maintain bedrest and compression devices at the catheter insertion sites.

Post Cardiac Catheterization Nursing Interventions

• Maintain the patient on flat bedrest for 2-6 hours to prevent stress on the insertion site, which can cause bleeding
  • Immobilize the affected limb for 6-8 hours.
• Observe the catheter insertion site for bleeding or hematoma formation.
• Implement cardiac monitoring and frequent vital sign checks.
• Monitor for chest pain
• Assess for signs and symptoms of stroke, such as confusion, weakness, or slurred speech.
• Monitor peripheral pulses, color, and temperature in the affected extremity.
• Monitor urine output due to the osmotic diuresis caused by contrast dye.
• Maintain sufficient oral/IV fluids to ensure renal clearance of the dye and adequate hydration.
• Obtain blood work to assess renal function (fx), hemoglobin and hematocrit (HandH), and coagulation studies.

Patient Education for CAD

• Adhering to the medication regimen lowers mortality and risk of hospitalization.
• During angina, stop activity and rest, take nitroglycerin dose, and do not exceed three doses in 5 minutes while being cautions of lightheadedness, dizziness/hypotension.
• Take bleeding precautions if on anticoagulants, avoid injury risk activities, use a soft toothbrush and electric razor, and use care with sharp objects.
• Apply risk factor reduction strategies for physical activity, blood pressure (BP) management, a healthy diet/weight loss, smoking cessation, decreased alcohol, and glucose control.
• Know when to contact EMS personnel/provider for unrelieved chest pain, uncontrolled bleeding after PCI, swelling, redness, purulent discharge, pain at the insertion site, or fever.
• Encourage participation in cardiac rehabilitation to reduce mortality and comorbidity.

Heart Failure (HF)

• Myocardial cell dysfunction results in an inability of heart to pump enough to meet the body's demands.
• Myocardial muscles weaken over time due to hypertension (HTN).
  • Cardiac Output (CO) = Stroke Volume (SV) * Heart Rate (HR)

Risk Factors for HF

• CAD
• HTN
• DM
• Metabolic Syndrome
• Obesity
• Smoking
• High sodium diet

Expected Findings for HF

• Fatigue, weight gain, and high heart rate (HR) are common findings.
• Other common findings are hypotension/hypertension and heart murmur (S3 worsening, S4=CHF).
• Additional findings include orthopnea.
• Left-sided: Shortness of breath (SOB), orthopnea, Dyspnea on Exertion (DOE), pulmonary edema, anorexia, poor mentation, weak pulses, less than "<" capillary refill time (CRT).
• Right-sided: Edema, Jugular Vein Distention (JVD), hepatomegaly, cardiac cachexia, muscle wasting, weak pulses, less than "<" CRT.
  • Left causes right

Lab Tests for HF

• Cardiac biomarkers: BNP (overstretching), troponin (stress, MI)
• Complete Blood Count (CBC)
• Urinalysis (UA)
• Glucose
• Lipid profile
• Renal function test
• Electrolytes

Normal Ejection Fraction (EF)

• A normal EF is 55-70%.

Heart Failure Reduced Ejection Fraction (HFrEF)

• Under 45% systolic issue (bad squeeze)

Heart Failure Preserved Ejection Fraction (HFpEF)

• Diastolic issue (relaxation issue, bad fill)

Diagnostic Procedures for HF

• Heavily dependent on history and assessment.
• Diagnostic tests rule out other disorders
• Chest x-ray
• EKG
• Echo tells us EF

Complications of HF

• Pulmonary edema (Left-Sided Heart Failure, LSHF) is caused by the accumulation of fluid in the interstitial and alveolar space of the lung, resulting in increased filling pressures within the heart.
  • Shortness of breath (SOB), chest pain, low oxygen saturation (O2), anxiety/fear, pink frothy sputum, orthopnea, and tachycardia.
    • Treatment includes BiPAP/CPAP, IV diuretics, and oxygen therapy.
• Liver and/or renal failure (Right-Sided Heart Failure, RSHF)

Therapeutic Procedures for HF

• Automatic internal cardiac defibrillator
• Pacemaker
• Cardiac resynchronization therapy
• Mechanical circulatory support
• Ventricular assist device
• Heart transplant or valve

Medications for HF

• Beta-blockers (BB)
• Spironolactone
• Furosemide
• ACE inhibitors/ARBs (Angiotensin II Receptor Blockers)
• ARNIs (Angiotensin Receptor-Neprilysin Inhibitors)
• Digoxin, to increase contractility
• Nitroglycerin

Client Education for HF

• Self-management is critical, including symptom and weight monitoring, medication adherence, and lifestyle changes.

Nursing Assessments for HF

• Vital signs: Hypertension (HTN) related to increased afterload, hypotension related to acute HF or adverse effects (AE) of medication, high heart rate (HR) compensation for low cardiac output (CO), and high respiratory rate (RR) and low oxygen saturation (O2) if fluid accumulation in lungs related to left-sided HF.
• Breath sounds indicating pulmonary congestion (crackles LSHF).
• Monitor for irregular heart rhythm or dysrhythmias.
  • Common adverse effect (AE) of HF and medications that treat HF
• Perform skin assessment for color and temperature, check peripheral pulses, and capillary refill time (CRT) related to low cardiac output (CO).
• Dry persistent cough: common adverse effect (AE) of ARBs.
• Monitor for activity intolerance: DOE, weakness, fatigue related to CO and worsening HF.
• Measure urine output, decreased with low renal perfusion where a provider should be called if diuretic therapy is at less than 30mL/hr.
• Eval fluid retention and diuretic efficiency with daily weights.
• Assess lab data for high BNP indicating overstretching of heart tissue, high BUN indicating prerenal failure related to decreased kidney perfusion, elevated LFTs indicating hepatomegaly and low erythropoietin indicating the patient has anemia.
• Perform depression screening and identify social support.

Nursing Actions for HF

• Administer oxygen therapy, elevate the head of the bed (HOB), and provide a fan for dyspnea.
• Administer medications as ordered.
• Restrict sodium and fluids.

Patient Education for HF

• Medication management for understanding and adhering to medication treatment plan.
• Maintain activity as tolerated to reduce muscle wasting and functional losses to decrease cardiac workload.
• Follow a low salt diet to prevent fluid retention.
• Monitor daily weight every morning after voiding (+2lb/day or +5lb/wk) to prevent symptoms from worsening.
• Implement a s/s worsening HF checklist (edema, sob, fatigue, orthopnea).
• Encourage cardiac rehab.

AHA Classification of HF Stages

• Stage A: Compensating with no symptoms.
• Stage B: Compensating with symptoms.
• Stage C: Symptomatic.
• Stage D: Requires a heart transplant with a 5-10% EF.

NYHA Classification of HF Stages

• Class I: No symptoms.
• Class II: Shortness of breath (SOB) during Dyspnea on Exertion (DOE).
• Class III: Dyspnea on Exertion (DOE) is severe, but okay at rest.
• Class IV: At rest, struggling.

Valvular Disease

• The pathophysiology related to valvular disease is in response to backward flow through the valve or resistance to forward flow through the constricted or stenosed valve.

Risk Factors for Valvular Disease

• Age
• Aortic stenosis
• Pregnancy, which increases workload
• Infectious diseases such as IE, rheumatic fever, MI, HF, and congenital defects.

Expected Findings for Valvular Disease

• Presence of a murmur
• Shortness of breath (SOB)
• Dyspnea
• Orthopnea
• Crackles
• Dysrhythmias
• Palpitations
• Fatigue
• Weight gain
• Edema
• Cool, pale extremities
• Weak pulses

Diagnostic Procedures for Valvular Disease

• Echocardiogram (ECHO)
• Chest x-ray to identify left/right hypertrophy and pulmonary edema
• Stress testing to ID functional capacity
• Heart catheterization as a definitive test for stenosis
• Computer Tomography/Magnetic Resonance Imagine (CT/MRI)

Nursing Care for Valvular Disease

• Administer supplemental oxygen and raise the head of the bed (HOB)
• Administer medications
• Restrict sodium and fluids

Therapeutic Procedures for Valvular Disease

• Valve replacement by means of open heart surgery or transcatheter aortic valve replacement (TAVR)
• Repairative surgery

Client Education for Valvular Disease

• Medication teaching
• Prophylactic antibiotics (abx) before dentist appointments
• Adherence to anticoagulants
• Bleeding precautions
• Maintain a consistent diet if taking warfarin

Complications of Valvular Disease

• HF
• Cardiogenic shock
• Thromboembolism
• Bleeding
• Dysrhythmias

Stenosis

• Stiffening and thickening of valve leaflets caused by calcium deposits and scarring, which narrow the opening and obstruct flow.

Regurgitation

• Blood flows/leads backwards due to the incomplete closing of the valve.

Prolapse

• Valve leaflets bulge backwards and do not close, causing regurgitation.

Nursing Assessments for Valvular Disease

• Monitor vital signs, as hypertension (HTN), high HR, and high RR are indicators of HF due to increased resistance to flow and backflow of blood into the pulmonary system.
• Assess pain.
• Chest pain and palpitations are usually with murmurs.
• Monitor for irregular heart rhythm because atrial fibrillation (Afib) is common with this disease.
• Perform a peripheral vascular assessment for pallor and cool extremities, weak peripheral pulses, delayed capillary refill time (CRT), and edema related to weak CO.
• Listen to breath sounds for crackles and orthopnea related to pulmonary congestion.
• Check for activity intolerance.
  • Dyspnea on exertion (DOE), weakness, fatigue related to worsening heart failure (HF).
• Auscultate heart sounds to assess for a murmur, an initial manifestation of valvular disease.
• Monitor INR if the patient is on warfarin.