Coronary Artery Disease PDF

CORONARY ARTERY DISEASE and HEART FAILURE Facts on Coronary Artery Disease ( WHO,2019) Most common cardiovascular problem world wide. One person dies every 37 seconds in the United States from cardiovascular disease. Onset may start since childhood but become evident in adult hood....

CORONARY ARTERY DISEASE and HEART FAILURE Facts on Coronary Artery Disease ( WHO,2019) Most common cardiovascular problem world wide. One person dies every 37 seconds in the United States from cardiovascular disease. Onset may start since childhood but become evident in adult hood. Facts on Coronary Artery Disease ( WHO,2019) Atherosclerosis or fatty deposition in the walls of arteries is the most common cause of CAD Arteriosclerosis- hardening of the vessels may contribute to coronary artery disease is also a consequence of atherosclerosis aside from aging. What is Coronary Artery Disease ? the narrowing of the major vessels that supply the heart usually from fatty deposits (mostly cholesterol) and plaque formation and buildup in the walls of the arteries that decreases the blood flow or supply to the heart. ( CDC.2020) Lets us review the blood supply of the heart.. Where is the source of blood going to the heart? Blood supply to the heart Oxygenated blood from the aorta flows to the heart via the right and left main coronary arteries. The right coronary artery supplies the right side and partially the anterior portion of the heart muscles. Blood supply to the heart… The left main coronary artery sub divides further into 2 major arteries which are the anterior descending and the left circumflex coronary artery Blood supply to the heart… The anterior descending artery supplies the anterior muscles of the heart while the left circumflex coronary arteries supply the posterior muscles of the heart: Acute Coronary Syndrome ( ACS) an umbrella term for conditions that refers to the sudden, reduced blood flow to the heart. It includes : unstable angina , acute myocardial infarction that is further subdivided into : a. ST segment elevated myocardial infarction( STEMI) b. non St elevated segment myocardial infarction. Extent and prevalence of acute coronary syndrome as a health threat Every year, >780,000 persons will experience an ACS. Approximately 70% of these will have NSTE-ACS. Patients with NSTE-ACS typically have more comorbidities, both cardiac and non cardiac, than patients with STEMI in the United States (Journal of American Cardiology,2018) What makes them get classified as one syndrome ? They all occur suddenly and cause the significant reduction of blood flow to the heart and have similar signs & symptoms Typical Signs and symptoms of Acute Coronary Syndrome : a. Severe chest pain that typically occurs at rest or with minimal exertion lasting ≥10 minutes ;frequently starts in the retrosternal area and can radiate to either or both arms, the neck, or the jaw. Typical Signs and symptoms of Acute Coronary Syndrome : b. Dyspnea /shortness of breath c. Diaphoresis, d. Nausea, e. Abdominal pain, f. Unexplained new-onset or increased exertional dyspnea – most common in unstable angina, g. Syncope Atypical symptom of Acute coronary syndrome Epigastric pain, Indigestion, Stabbing or pleuritic pain Increasing dyspnea in the absence of chest pain (may indicate NSTE-ACS) N.B. *** Psychiatric disorders (e.g., somatoform disorders, panic attack, anxiety disorders) are non cardiac causes of chest pain that can mimic ACS Diagnostics in Acute Coronary Syndrome 1.ECG - Initially done to determine the electrical activity in the heart. - Look for classic ECG changes-ST elevation, ST depression, T wave inversion, pathologic Q wave 2.Blood exam for biomarkers - CK-MB, Troponin Levels 4. Echocardiogram 5. Coronary Angiography 6. Myocardial perfusion imaging 7. Computed tomography (CT) scan – may be done to check calcium buildup and plaque the coronary arteries Management of Acute Coronary Syndrome *** Management in ACS – depends on the specific problem. (STEMI or NSTEMI or Unstable Angina are managed differently) and will be discussed in each problem. Acute myocardial infarction: the presence of myocardial injury ( infarction) or necrosis resulting from the abrupt reduction in coronary blood flow to part of the myocardium. detected by abnormal cardiac biomarkers with evidence of acute myocardial ischemia Acute myocardial infarction… Infarcted tissue may become permanently dysfunctional Infarction according to extent myocardial of injury : 1.Transmural infarction- involve the whole thickness of myocardium from epicardium to endocardium and are usually characterized by abnormal Q waves on ECG Infarction according to extent myocardial of injury 2.Nontransmural (subendocardial): do not extend through the ventricular wall and cause only ST-segment and T-wave (ST-T) abnormalities. Types of Acute myocardial infarction( based on Electrocardiography : 1.ST segment Elevated Myocardial infarction (STEMI)- there is an acute myocardial injury associated with complete coronary artery occlusion that is signified by peaked T waves in the hyper acute phase of infarction-( ST elevation shown in the electrocardiogram) –needs urgent reperfusion. Acute myocardial infarction( based on Electrocardiography 2.Non ST segment Elevated Myocardial Infarction(NSTEMI )- the presence of acute myocardial injury detected by abnormal cardiac biomarkers like elevated cardiac enzymes - Toponin T and I or muscle and brain fraction of creatine kinase [CK-MB ) but with out ST segment elevation ( only ST-segment depression, T-wave inversion, or may not be present in the electrocardiogram.) Management in ST segment elevated Myocardial Infarction 1.Thrombolytics (-fibrinolytics ) - the tissue plasminogen activators - tenecteplase, reteplase, and alteplase. Work by binding to fibrin and converting plasminogen to plasmin, which then breaks cross-links between fibrin molecules of the thrombus. Caution : Fibrinolytics increase the risk of bleeding - contraindicated in patients with bleeding such as recent stroke and active internal bleeding. ( Reilly,2020). Management in ST segment elevated Myocardial Infarction 2.Close monitoring of vital signs and hemodynamic parameters 3.Oxygen therapy 4.Complete bed rest 5.Reperfusion therapy - antiplatelet drugs ( aspirin, Clopidogrel, Ticagrelor), anticoagulants ( Heparin, Enoxaparin, Fondaparinux)and other drugs based on reperfusion strategy when percutaneous coronary intervention is not immediately possible in 90 minutes. 6.Angiography with Percutaneous Coronary intervention or Coronary Artery Bypass Graft ( CABG) for patients with STEMI Management of Non ST segment Elevated MI 1.Close monitoring of vital signs and hemodynamic parameters 2.Oxygen therapy 3.Complete bed rest 4.Vasodilator therapy 5.Anti coagulants therapy 6.Oral beta-blocker therapy 7.Cardiac angiography with PCI or CABG STEMI vs NSTEMI STEMI vs NSTEMI ECG findings Unstable Angina an acute coronary insufficiency marked by severe chest pain (preinfarction angina, intermediate syndrome) caused by worsening of vessel obstruction but no evidence of biochemical myocardial damage or injury. Assessment and Diagnostic findings of Unstable Angina : a. No biomarker can be detected in the bloodstream hours after the initial onset of ischemic chest pain. b. Chest pain or rest angina -usually lasting >20 minutes c. New-onset angina with increasing duration and pain intensity from previous or last occurrence less than 2 months d. ECG changes are transient – (ST-segment depression, ST- segment elevation, or both but disappear after some hours of treatment. Assessment and Diagnostic findings of Unstable Angina :  Signs and symptoms : **It is important to differentiate stable versus unstable angina. Unstable Angina Stable Angina Pain May occur at rest Occurs more with onset strenuous activities or emotional stress Pain Longer than 20 May disappear in duration mins. less than 10 minutes ECG May have Transient Often normal ECG ST depression or elevation Nitrates May not respond to Pain relieved by nitrates nitrates Heart Greater May be vasospasm vessels /progressing lumen with mild to moderate obstruction obstruction Management of Unstable Angina 1.Cardiac monitoring 2.Nitroglycerin (NTG) 3.Supplemental oxygen 4. Morphine sulfate 5.Beta-blockers 6.Non dihydropyridine calcium antagonist (eg, verapamil or diltiazem) 7.Ace inhibitors 8.Cardiac angiography with PCI or CABG if no contraindications Nursing care in patients with Acute Coronary Syndrome ( AMI & Unstable Angina) 1.Close monitoring of vital signs and hemodynamic parameters. 2. Administer Oxygen therapy if SPO2 is below 90% 3. Maintain bed rest to reduce cardiac load and oxygen demand 4.Monitor any chest pain and report immediately. Nursing care in patients with Acute Coronary Syndrome ( AMI & Unstable Angina) 5.Administer prescribed drugs like nitrates ,beta blockers, pain relievers, anti platelets and anti coagulants, Vasodilators, and (thrombolytics in STEMI) with caution, Monitor for the side effects like bradycardia and hypotension and refer as needed. 6. Monitor intake and output- index to renal perfusion ( also patients may develop, heart failure) 7. Monitor for possible bleeding if on anticoagulant /antiplatelet therapy Nursing care in patients with Acute Coronary Syndrome ( AMI & Unstable Angina) 8.Check capillary blood glucose levels should be regularly checked if diabetic 9.Check femoral or radial pulses if post angiography 10.Check intravenous lines are patent for any emergency. 11.Provide psycho emotional care as patients experiences are life threatening 12.Assist to prepare for surgical interventions as ordered Cardiomyopathies : refers to weakening of the heart muscles from many causes that lead to decreased muscle tone and capacity to contract adequately. They can be acquired or congenital. The most common types are the hypertrophic ,dilated, restrictive ,and ischemic cardiomyopathies. Dilated Cardiomyopathy(DCM)- The heart muscle in ventricles and atria are abnormally dilated or thinned out leading to weakened walls of the ventricles causing systolic dysfunction. May occur at any age but affects more people below 60 years. Viral infections ( Coxsakie) causing myocarditis are often the cause of dilated cardiomyopathy Assessment and Diagnosis in DCM 1.Medical history and physical exams to check : History of Cardiovascular or thyroid problems Exposure to toxic substances like lead or heavy metals, chemotherapy Use of alcohol or recreational drugs Infections affecting the heart muscles Assessment and Diagnosis in DCM a. Laboratory work up Chest x-ray,-provides an image of the heart b. Echocardiography c. Magnetic Resonance imaging (MRI d. Blood exam e. Myocardial biopsy f. Genetic testing ( in familial idiopathic dilated cardiomyopathy) g. Stress test. ( walking on a treadmill) Treatment of DCM : a. Drug therapy – Ace inhibitors , ARBs, betablockers, anticoagulants, diuretics, anti-arrhythmics as indicated b. Pace maker c. Implantable cardioverter-defibrillator d. Repair of moderate to severe valvular regurgitation, e. Left ventricular assist device,- helps to pump blood into the body f. Heart transplantation if the other treatment have failed. Other Myopathies Nursing care in Dilated Cardiomyopathy Heart Failure : Learning Objectives : After completing this module the student is expected to : 1. Describe what is heart failure. 2. Differentiate or the types of heart failure 3. Identify and explain the risks for heart failure 4. Explain the pathophysiology of heart failure 5. Develop a care plan to help patients with heart failure Heart Failure A. Heart failure defined: - A state when the heart is unable to meet the oxygenation needs of the body from pump failure ( Black & Hawks , 2009). Pathophysiology of Heart Failure A. Types of Heart Failure 1. Left-sided HF 2. Right-sided HF Summary of Heart Failure Causes of Heart Failure a. Coronary heart disease (&complications like myocardial infarction) b. Untreated high blood pressure c. Cardiomyopathy and valvular diseases d. Dysrhythmias e. Congenital heart disease f. Severe anemia g. Alcohol and drug abuse ( cocaine ,amphetamine) h. Some chemotherapeutic drugs i. Hyperthyroiditis j.pulmonary hypertension Assessment and Diagnosis of Heart failure 1.Physical exams to check for vital signs 2.Chest X-ray 3.Arterial blood gases 4.Echocardiography 5.Liver function tests- checks involvement of the liver 6.Blood culture-checks for infections that may be one cause of the problem. Complications of heart failure The reduced blood flow to the body causes cumulative damage to major organs leading to the following: 1. Kidney failure 2. Heart valve problems 3. Liver damage 4. Encephalopathy Treatment /Management of heart failure 1.Medications – commonly used include : a. ACE inhibitors, angiotensin-2 receptor blockers (ARBs), beta blockers- b. Diuretics c. Digoxin d. Ivabradine e. Dopamine/amrinone f.Hydralazine 2.Lifestyle changes a. Reduction of salt intake to limit water retention b. Low fat ,more fiber diet- vegetables and fruits c. Maintaining controlled physical activities- help in cardiotoning ( mild exercises like walking / doing home chores- keeps patient moving-decreases edema from prolonged sitting) d. Smoking /alcohol recreational drug cessation e. Weight reduction if overweight Treatment /Management of heart failure 3.Implantable cardioverter devices - to control abnormal heart rhythm Treatment /Management of heart failure 4.Surgery- valvular repairs if it’s the prime cause - Heart transplant *in people with severe or advanced heart failure Nursing care of Heart Failure… Nursing care of Heart Failure… 5. Patient teaching on home care a. Split long activities to maintain cardiac reserve ( controls fatigue ) b. What food to eat – low salt – avoid canned /preserved food c. Deep breathing exercises - improves oxygenation d. Weight taking at same time before breakfast- weight gain indicates more retention or progress of heart failure e. Explain disease process to increase compliance to therapy requirement f. Review medications- their actions and side effects -increases patient’s capacity for medication compliance g. Teach need for regular follow up -prevents recurrent hospital admissions Summary of latest practice guidelines on Acute Coronary Syndrome). A. Community health center or Clinic or Out Patient 1. Assess vital signs and chest pain and identification of possible cardiac ischemia 2. Aspirin 300 mgs 3. Oxygenation if hypoxic ( SPO2- below 94% 4. ECG to know where to refer ( Secondary of tertiary) 5. Notify Cardiac Cath lab if available 6. Pain Control if in severe pain ( 2019 ACS guidelines (https://www.acls.net/acute-coronary-syndromes- algorithm.htm B. Hospital Emergency department 1.Check vital signs 2. IV access 3. Physical Exams 4. Notify /activate cardiac cath lab 5. Cardiac Biomarkers 6. 12 lead ECG 7. Chest Xray