Coronary artery disease (CAD)

Coronary artery disease (CAD)

1. PRESENTATION On Topic- Coronary Artery Disease Mentor- Miss Jyoti Sharma, Nursing Tutor, MSN CON, DMC& Hospital Presented By- Haranjan kaur Msc (N) 1 st YEAR Roll N0.- 05

2. WE WILL LEARN ABOUT..

3. INTRODUCTION Coronary circulation- It is the circulation of blood in the blood vessels of the heart muscle (myocardium). The heart muscle needs oxygen-rich blood to function, coronary arteries supply blood to the heart muscle . The coronary arteries wrap around the outside of the heart.

4. CORONARY CIRCULATION

5. WHY ARE THE CORONARY ARTERIES IMPORTANT? Since coronary arteries deliver blood to the heart muscle , any coronary artery disorder or disease can have serious implications by reducing the flow of oxygen and nutrients to the heart muscle. This can lead to a heart attack and possibly death .

6. ATHEROSCLEROSIS Atherosclerosis is a building up of plaque in the inner lining of an artery causing it to narrow or become blocked. Its the most common cause of heart disease.

7. CORONARY ARTERY DISEASE CAD is narrowing or obstruction of one or more coronary arteries because of atherosclerosis which is the accumulation of lipid- containing plaque in the arteries that decreases perfusion to myocardial tissue and inadequate myocardial oxygen supply which leads to hypertension, infarction, arrhythmias , heart failure and death

8. CONTI.. Collateral circulation, more than 1 artery supplying a muscle with blood, is normally present in the coronary arteries, especially in older persons. The development of collateral circulation takes time and develops when chronic ischemia occurs to meet the metabolic demands; therefore, an occlusion of a coronary artery in a younger individual is more likely to be lethal than one in an older individual. Symptoms occur when the coronary artery is occluded to the point that inadequate blood supply to the muscle occurs, causing ischemia.

9. CONTI.. CAD is characterized by the accumulation of plaque within coronary arteries, which progressively enlarge , thicken and calcify . Coronary artery narrowing is significant if the lumen diameter of the left main artery is reduced at least 50%, or if any major branch is reduced at least 75 %. The goal of treatment is to alter the atherosclerotic progression.

10. INCIDENCE AND PREVALENCE The 2016 Heart Disease and Stroke Statistics update of the American Heart Association (AHA) has reported that 15.5 million persons ≥20 years of age in the USA have CHD , prevalence increases with age for both men and women  

11. ETIOLOGY AND RISK FACTORS NON-MODIFIABLE Heredity Race Increasing age Gender MODIFIABLE Cigarette smoking Hypertension Elevated serum cholesterol levels Physical inactivity Obesity Diabetes mellitus Lack of estrogen in women Behavior patterns ( stress, aggressiveness)

12. CONTRIBUTING RISK FACTORS Response to stress Inflammatory response Menopause Homocysteine levels

13. PATHOPHYSIOLOGY Due to etiological factors injury to the endothelial cell Fatty streaks of lipids deposit in arterial wall & Inflammation ,immune reactions start   T lymphocytes & monocytes Infiltrate Release biochemical sub Damage endothelial the area to ingest the lipids & die attract platelets to initiate clotting   Smooth muscle cells proliferation form fibrous cap over dead fatty core (atheroma)   Protrusion of atheroma narrowing & obstruct the lumen of vessel   If cap has thin membrane the lipid core may grow and rupture Hemorrhage into plaque & forming thrombus Thrombus obstruct the blood flow leading to sudden cardiac death of myocardial infarction

14. CLINICAL MANIFESTATIONS Chest pain (Angina pectoris ) Palpitations

15. CLINICAL MANIFESTATIONS Dyspnea

16. CLINICAL MANIFESTATIONS Syncope

17. CLINICAL MANIFESTATIONS Cough/ hemoptysis

18. CLINICAL MANIFESTATIONS Dysarrythmias

19. CLINICAL MANIFESTATIONS Chest heaviness

20. CLINICAL MANIFESTATIONS Dizziness

21. CLINICAL MANIFESTATIONS Sweating

22. CLINICAL MANIFESTATIONS Feeling of Anxiety

23. CLINICAL MANIFESTATIONS Excessive Fatigue

24. DIAGNOSTIC TESTS History collection

25. DIAGNOSTIC TESTS Physical examination

26. DIAGNOSTIC TESTS Cardiac Enzymes

27. DIAGNOSTIC TESTS Cardiac Enzymes CARDIAC MARKER INCREASES PEAK RETURN TO BASELINE COMMENTS Myoglobin 1–4 h 4–12 h 24–36 h Earliest marker, but non-specific with negative predictive value. CK-MB 4–9 h 24 h 48–72 h Gold standard before troponin was introduced. Mostly found in cytosol but may increase in non-MI situation. Troponin I/T 4–9 h 12–24 h 7–14 days Most specific marker. Found in small amounts in cytosol, but mostly in sarcomere of cardiac myocytes (both early and late marker). Troponin T is less specific than troponin I because troponin T is also found in muscle.

28. DIAGNOSTIC TESTS Cardiac Enzymes

29. DIAGNOSTIC TESTS Cardiac Enzymes

30. DIAGNOSTIC TESTS Serum cholesterol levels

31. DIAGNOSTIC TESTS Electrocardiograms

32. DIAGNOSTIC TESTS Echocardiograms

33. DIAGNOSTIC TESTS Treadmill Test (TMT)

34. DIAGNOSTIC TESTS Cardiac catheterization or Angiography

35. MEDICAL MANAGEMENT Goal- Decrease myocardial oxygen demand Increase oxygen supply It include- Pharmacological Therapy Surgical Management Nursing Management Lifestyle Changes

36. PHARMACOLOGICAL THERAPY Nitrates(nitroglycerine ) – to dilate coronary arteries and decrease preload and afterload. These actions help relieve chest pain. SUBLINGUAL TABLET : 0.3 to 0.6 mg sublingually or in the buccal pouch every 5 minutes as needed, up to 3 doses in 15 minutes; if pain persists after maximum dose, prompt medical attention is recommended. EXTENDED RELEASE CAPSULE : 2.5 to 6 mg orally 3 to 4 times a day; titrate as needed and tolerated. 5 mcg/min continuous IV infusion via non-absorptive tubing; increase by 5 mcg/min every 3 to 5 minutes as needed up to 20 mcg/min, then by 10 or 20 mcg/min if needed.

37. PHARMACOLOGICAL THERAPY Beta-Adrenergic Blockers (Atenolol, Metroprolol ) - decrease myocardial oxygen consumption, decrease heart rate. Increasing the amount of oxygen delivered to the heart increases the chances of survival of individuals having a heart attack . These actions help relieve chest pain . DOSAGE- Atenolol- 25 milligrams (mg), 50 mg, and 100 mg . Metoprolol - 25, 50 and 100 mg. IV begins with a 5 mg injection.

38. PHARMACOLOGICAL THERAPY Calcium channel blockers- Calcium channel blockers help lower blood pressure by relaxing the blood vessels throughout your body. As a result, less pressure is built up and your heart does not have to work as hard to pump blood . Nifedipine - Oral capsule- 10 mg, 20 mg. Oral extended-release tablet- 30 mg, 60 mg, 90 mg. Amlodipine- 2.5 mg, 5mg, 10mg.

39. PHARMACOLOGICAL THERAPY Antiplatelet and anticoagulant agents- to inhibit thrombus formation. Aspirin- Immediate-release: 50 to 325 mg orally once a day Extended-release (ER): 162.5 mg orally once a day. Clopdidogrel - 75 mg orally once a day.

40. Conti.. Antilipid medications (atorvastatin) to decrease blood cholesterol and triglyceride levels. Atorvastatin- Initial dose: 10 mg or 20 mg orally once a day Maintenance dose: 10 mg to 80 mg orally once a day.

41. Conti.. Angiotensin converting enzyme inhibitors (captopril) to promote a favorable balance of oxygen supply and demand. Captopril- Initial dose: 25 mg orally 2 to 3 times a day one hour before meals. Maintenance dose: May increase every 1 to 2 weeks up to 50 mg orally three times a day . Maximum dose: 450 mg/day.

42. Conti.. Imipramine, morphine sulphate for analgesia. Dose- imipramine- 100 mg and 150 mg daily. Morphine- 10mg, 15 mg.   Folic acid and B complex vitamins to reduce homocysteine levels.

43. Procedures for CAD

44. PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY

45. DIRECTIONAL CORONARY ATHERECTOMY

46. INTRACORONARY STENTS

47. LASER ABLATION

48. TRANSMYOCARDIAL REVASCULARIZATION

49. SURGICAL MANAGEMENT

50. OPEN HEART SURGERY Cardiopulmonary bypass is used during cardiac surgery to divert the client’s unoxygenated blood to a machine in which oxygenation & circulation occurs . This technique called extracorporeal circulation (ECC) allows the surgeon to stop the heart during time of surgery . The heart lung machine does the following:

51. CORONARY ARTERY BYPASS GRAFTING It involves the bypass of a blockage in one or more of the coronary arteries using the saphenous veins, mammary artery or radial artery.

52. Typically, the left internal thoracic artery (LITA ) (previously referred to as left internal mammary artery or LIMA ) is grafted to the left anterior descending artery and a combination of other arteries and veins is used for other coronary arteries . The great saphenous vein from the leg is used approximately in 80% of all grafts for CABG . The right internal thoracic (mammary) artery (RITA or RIMA) and the radial artery from the forearm are frequently used as well; these vessels are usually harvested either endoscopically , using a technique known as endoscopic vessel harvesting (EVH), or with the open-bridging technique, employing two or three small incisions. The right gastroepiploic artery from the stomach is infrequently used given the difficult mobilization from the abdomen . GRAFTS FOR CABG

53. LIFESTYLE CHANGES Weight control Smoking cessation Exercise Healthy diet

54. NURSING MANAGEMENT ASSESSMENT Gather information about patient present signs and symptoms. Assess patients risk factors for CAD Perform the physical examination Obtain and assess ECG Check vital signs and report lab investigations Evaluate patients past health history such as DM2, heart failure, previous MI, obstructive lung disease that may influence choice of drug therapy Identify patient and family’s knowledge about diagnosis, their level of anxiety and use of appropriate coping mechanisms

55. NURSING DIAGNOSIS Acute Pain related to decreased myocardial blood flow or increased cardiac workload/oxygen consumption as evidenced by reports of pain varying in frequency, duration, and intensity. Ineffective tissue perfusion related to decreased cardiac output as evidenced by dyspnea. Decreased cardiac output related to alteration in heart rate Impaired gas exchange related to decreased cardiac output as evidenced by dyspnea and decreased SpO2 Activity intolerance related to decreased cardiac output Anxiety related to hospital admission evidenced by patients verbal response Risk to constipation related to bed rest as evidenced by subjective feeling of fullness .

56. Acute Pain Instruct patient to notify nurse immediately when chest pain occurs . Assess and document patient response to medication . Identify precipitating event, if any: frequency, duration, intensity, and location of pain . Observe for associated symptoms: dyspnea, nausea and vomiting, dizziness, palpitations, desire to micturate . Evaluate reports of pain in jaw, neck, shoulder, arm, or hand (typically on left side ). Place patient at complete rest during anginal episodes . Elevate head of bed if patient is short of breath .

57. Acute Pain Monitor heart rate and rhythm . Monitor vital signs every 5 min during initial anginal attack . Stay with patient who is experiencing pain or appears anxious . Maintain quiet, comfortable environment. Restrict visitors as necessary . Provide supplemental oxygen as indicated . Administer antianginal medication(s) promptly as indicated : Nitroglycerin :  sublingual , atenolol, nifedipine , Analgesics, Morphine sulphate (MS ).

58. INEFFECTIVE TISSUE PERFUSION Assess V/S. Assess spO 2 of patient. Review laboratory data (ABGs, BUN, creatinine , electrolytes , international normalized ratio, and prothrombin time or partial thromboplastin time. Check respirations and absence of work of breathing . Check Hgb levels Check for pallor, cyanosis, mottling, cool or clammy skin. Assess quality of every pulse . Check for optimal fluid balance. Administer IV fluids as ordered . Maintain optimal cardiac output . Administer nitroglycerin (NTG) sublingually for complaints of angina . Maintain oxygen therapy as ordered.

59. DECREASED CARDIAC OUTPUT RELATED TO ALTERATION IN HEART RATE Assess cardiac output, pulse, arterial BP, ECG Assess heart rhythm and treat dysthymias Auscultate heart sounds and lung sounds Administer vasodilators Administer calcium channel blockers Administer antiarryrthmatics

60. IMPAIRED GAS EXCHANGE RELATED TO DECREASED CARDIAC OUTPUT AS EVIDENCED BY DYSPNEA AND DECREASED SPO2 Assess respiratory rate, SpO2 and ABG Assess capillary refill, LOC, dyspnea Auscultate chest for breath sounds Provide high fowlers position Administer oxygen as ordered Administer nebulization Encourage the use of spirometry and deep breathing exercise. Perform chest physiotherapy

61. ACTIVITY INTOLERANCE R/T DECREASED CARDIAC OUTPUT Assess the general condition of patient Assess the vitals before and after activity Monitor the clients response to activities Space the nursing activities Schedule the rest periods Increase activity as ordered Instruct the client to avoid activity that increase cardiac workload

62. ANXIETY RELATED TO HOSPITAL ADMISSION EVIDENCED BY PATIENTS VERBAL RESPONSE Assess the level of anxiety Allow and encourage the client and family to ask questions Allow the patient to verbalize the feelings Provide comfortable and quiet environment Administer anti anxiety drugs.

63. RISK TO CONSTIPATION RELATED TO BED REST AS EVIDENCED BY SUBJECTIVE FEELING OF FULLNESS Assess the intake output of patient Ensure that patient has adequate bulk in diet and fluid intake Monitor the effectiveness of softeners or laxatives Encourage the client to use beside commodate rather than bedpan

64. SCREENING TESTS FOR CAD

65. HEALTH EDUCATION P hysical exercise

66. HEALTH EDUCATION Decreasing obesity

67. HEALTH EDUCATION Treating high blood pressure

68. HEALTH EDUCATION Eating a healthy diet

69. HEALTH EDUCATION Adequate rest

70. HEALTH EDUCATION Controlling blood sugar

71. HEALTH EDUCATION Decreasing cholesterol levels

72. HEALTH EDUCATION Stop smoking

73. HEALTH EDUCATION Decrease psychosocial stress

74. HEALTH EDUCATION Regular follow-ups

75. HEALTH EDUCATION Walk

76. HEALTH EDUCATION Swimming

77. HEALTH EDUCATION Decreasing cholesterol levels Stopping smoking Decrease psychosocial stress . Regular follow-ups Exercise. Aerobic exercise, like walking, jogging, or swimming, can reduce the risk of mortality from coronary artery disease .

78. EVIDENCES REVIEW Evidence also suggests that the Mediterranean diet and a high fiber diet lower the risk . The World Health Organization (WHO) recommends " low to moderate alcohol intake" to reduce risk of coronary artery disease while high intake increases the risk Evidence does not support a beneficial role for omega-3 fatty acid supplementation in preventing cardiovascular disease (including myocardial infarction and sudden cardiac death).

79. Conti.. High levels of physical activity reduce the risk of coronary artery disease by about 25 %. In diabetes mellitus, there is little evidence that very tight blood sugar control improves cardiac risk although improved sugar control appears to decrease other problems such as kidney failure and blindness.

80. RECAPTUALIZATION Which of the following illness is the leading cause of death in the world? Cancer Coronary Artery Disease Liver Failure Renal Failure Answer: b. There are number of risk factors associated with CAD. Which of the following is a modifiable risk factor? Obesity Heredity Gender Age Answer: a.

81. RECAPTUALIZATION Which of the following conditions most commonly results in CAD? Atherosclerosis Diabetes mellitus Myocardial Infarction Renal Failure Answer: a. Atherosclerosis impedes coronary blood flow by which of the following mechanisms? Plaques obstruct the vein Plaques obstructs the artery Blood clots from outside the vessel wall Hardened vessels dilate to allow the blood flow through Answer: b .

82. BIBLIOGRAPHY Brunner & Suddarth . Text book of medical & surgical nursing, edition 8 th , 28 th chapter; ( 859-64 ). Lippincott J.B . Text book of medical& surgical nursing . 4 th ed.; ( 1347-48 ). Black J.M . Text book of medical & surgical nursing, 7 th ed ; 56 chapter ; ( 1410-1415 ).