Radheshyam's presentation management of CAD.pptx

Radheshyam's presentation management of CAD.pptx
very use full for nursing students, specially for who pursuing Master of Nursing

1. WELCOME

2. PRESENTATION Management of patient with CAD Radhe shyam Nursing Officer AIIMS,ND 5

3. CONTENT Introduction Definition Epidemiology, Pathophysiology, Clinical manifestations, Medical management, Surgical Nursing management Research inpu t Summary Conclusion

4. Coronary artery disease (CAD) is the most prevalent type of cardiovascular disease. For this reason, it is important for nurses to become familiar with the various types of coronary artery conditions and the methods for assessing, preventing, and treating these disorders medically and surgically. INTRODUCTION

5. DEFINITION Coronary artery disease is the narrowing or blockage of the coronary arteries, usually caused by atherosclerosis.

6. EPIDEMIOLOGY Cardiovascular diseases, especially coronary heart disease (CHD), are epidemic in India. The Registrar General of India reported that CHD led to 17% of total deaths and 26% of adult deaths in 2001- 2003, which increased to 23% of total and 32% of adult deaths in 2010-2013. The annual number of deaths from CVD in India is projected to rise from 2.26 million (1990) to 4.77 million (2020). Coronary heart disease prevalence rates in India have been estimated over the past several decades and have ranged from 1.6% to 7.4% in rural populations and from 1% to 13.2% in urban populations. An estimated 17.9 million people died from CVDs in 2016, representing 31% of all global deaths. Of these deaths, 85% were due to heart attack and stroke

7. Coronary Arteries The left and right coronary arteries and their branches supply arterial blood to the heart. The left coronary artery has three branches The right side of the heart is supplied by the right coronary artery Superficial to the coronary arteries are the coronary veins. Superficial to the coronary arteries are the coronary veins.

8. Ischemic Heart Disease Coronary Heart Disease (CHD) Coronary Occlusive Disease (C.O.D.) Atherosclerotic Heart Disease (A.H.D.) Angina pectoris Acute coronary syndrome a. Unstable angina b. MI (STEMI, NSTEMI) CORONARY ARTERY DISEASE Also called as- CAD Include the disorders Transient Hypoxia: Angina Pectoris Hypoxia with decreased function: Myocardial Ischemia Death and necrosis of myocardium: Myocardial Infarction

9. Risk Factors for Coronary Artery Disease

10. . CAUSE OF CAD

11. PATHOPHYSIOLOGY

12. CLINICAL MANIFESTATIONS

13. These proteins are normally present within the heart cells and are released into the blood after a heart attack. Their presence in the blood can indicate heart damage. However, some of these proteins (CK, CKMB, and myoglobin) are also found in other muscles. Thus, these proteins are not specific to the heart, and elevated levels within the blood can be caused by problems with other muscles in the body. A newer blood test (designed to detect cardiac troponin) is both more sensitive and more specific for heart damage. Cardiac troponins are found only in the heart. Laboratory Tests Creatine kinase (CK) Creatine kinase-MB (CKMB) Myoglobin Cardiac troponin- I or cardiac troponin- T DIAGNOSTIC TESTS : -

14. SIGNIFICANCE

15. DIAGNOSTIC TESTS: - ELECTROCARDIOGRAPH ECG or exercise stress tests, use the ECG to evaluate the electrical activity generated by the heart at rest and with activity . Nuclear Imaging Ultrasound Tests ECHO Radiographic Tests use x-ray

16. DIFFERENTIAL DIAGNOSIS GERD COPD ASTHMA ANEMIA AORTIC STENOSIS

17. MANAGEMENT THE OBJECTIVES Decrease the oxygen demand Increase the oxygen supply Pharmacologic therapy Surgical management Control of risk factors Revascularization procedures to restore the blood supply to the myocardium include (PCI) procedures [PTCA], intracoronary stents and atherectomy CABG, percutaneous transluminal myocardial revascularization (PTMR)

18. Pharmacologic therapy

19. NITRO-GLYCERINE Reduce myocardial oxygen consumption. Nitroglycerin dilates primarily the veins.(  Preload) High dose relax the systemic arteriolar bed &  blood pressure (  Afterload)  blood flow to diseased coronary arteries  M yocardial oxygen requirements  O xygen supply Sublingual tablet Spray Topical agent Intravenous administration. Precaution- It usually is not given if the systolic blood pressure is 90 mm Hg or less.

20. Beta-Adrenergic Blocking Agents  M yocardial oxygen consumption by blocking the beta-adrenergic sympathetic stimulation to the heart. Heart rate Blood pressure Myocardial contractility Control chest pain and delays the onset of ischemia  incidence of recurrent angina,  O xygen supply Sublingual tablet Spray Topical agent Intravenous administration. Precaution- Not given if the SBP is < 90 mm Hg Contraindicated in asthmatic patients

21. Calcium Channel Blocking Agents.  Sinoatrial node automaticity . Atrioventricular node conduction These effects decrease the workload of the heart. Calcium channel blockers also relax the blood vessels Blood pressure Prevent and treat vasospasm  incidence of recurrent angina,  O xygen supply Precaution- It usually is not given if BP <90 mm Hg Sublingual tablet Spray Topical agent Intravenous administration.

22. Antiplatelet Aspirin Aspirin prevents platelet activation and reduces conduction A 160- to 325 mg dose of aspirin Cause gastrointestinal upset Clopidogrel and Ticlopidine. -Given to patients who are allergic to aspirin -Given in addition to aspirin in patients at high risk for MI -Take a few days to achieve their antiplatelet effect. -Cause gastrointestinal upset

23. Anticoagulant Medications HEPARIN Unfractionated heparin prevents the formation of new blood clots. The amount of heparin administered is based on the results of the ( aPTT ). aPTT is 1.5 to 2 times the normal aPTT value. UNFRACTIONATED HEPARIN The LMWH enoxaparin binds less avidly to plasma proteins and therefore has increased bioavailability and duration of action Subcutaneous injection of LMWH

24. OXYGEN ADMINISTRATION Oxygen therapy is usually initiated at the onset of chest pain in an attempt to increase the amount of oxygen delivered to the myocardium and to decrease pain. Oxygen inhaled directly increases the amount of oxygen in the blood. The therapeutic effectiveness of oxygen is determined by observing the rate and rhythm of respiration. Blood oxygen saturation is monitored by pulse- oximetry; the normal oxygen saturation (SpO2) level is greater than 93%.

25. INVASIVE INTERVENTIONAL PROCEDURES Invasive interventional procedures to treat angina and CAD are PTCA, Intracoronary stent implantation, Atherectomy, brachytherapy trans myocardial laser revascularization. All of these procedures are classified as percutaneous coronary interventions (PCIs).

26. PERCUTANEOUS TRANSLUMINALCORONARY ANGIOPLASTY (PTCA)

27. PERCUTANEOUS TRANSLUMINALCORONARY ANGIOPLASTY (PTCA) PTCA may be used to treat patients who do not experience angina but are at high risk for a cardiac event. The purpose of PTCA is to improve blood flow within a coronary artery by “cracking” the atheroma.

28. COMPLICATIONS Dissection, Perforation, Abrupt closure Vasospasm of the coronary artery Acute MI, acute dysrhythmias and cardiac arrest. Such as bleeding at the insertion site, Retroperitoneal bleeding, hematoma, pseudoaneurysm arteriovenous fistula, arterial thrombosis Distal embolization.

29. POST PROCEDURAL CARE Observe the catheter access site for bleeding or hematoma Evaluate temperature and color of the affected extremity Monitor for dysrhythmias A vasovagal reaction Encourage fluids to increase output and flush out the dye Ensure safety The patient must remain flat in bed and keep the affected leg straight The nurse teaches the patient to monitor the site for bleeding

30. CORONARY ARTERY STENT

31. CORONARY ARTERY STENT After PTCA, a portion of the plaque that was not removed may block the artery. The coronary artery may recoil (constrict) and the tissue remodels, increasing the risk for restenosis. A coronary artery stent is placed to overcome these risks. A stent is a woven mesh that provides structural support The stent is placed over the angioplasty balloon. The balloon is withdrawn, but the stent is left permanently in place within the artery Endothelium covers the stent and it is incorporated into the vessel wall. The patient receives antiplatelet medications (e.g. clopidogrel) therapy for 2 weeks and lifetime use of aspirin).

32. ATHERECTOMY Atherectomy is an invasive interventional procedure that involves the removal of the atheroma, or plaque, from a coronary artery. Directional (DCA) and transluminal extraction (TEC) coronary atherectomy procedures involve the use of a catheter that removes the lesion and its fragments. Rotational atherectomy uses a catheter with diamond chips impregnated on the tip) that rotates like a dentist’s drill at 130,000 to 180,000 rpm, pulverizing the lesion. Usually, several passes of these catheters are needed to achieve satisfactory results.

33. BRACHYTHERAPY PTCA and stent implantation cause a cellular reaction in the coronary artery that promotes proliferation of the intima of the artery, which also increases the possibility of arterial obstruction. Brachytherapy reduces the recurrence of obstruction, preventing vessel restenosis by inhibiting smooth muscle cell proliferation. Brachytherapy (from the Greek word, brachys , meaning short) involves the delivery of gamma or beta radiation by placing a radioisotope close to the lesion. The radioisotope may be delivered by a catheter or implanted with the stent.

34. BRACHYTHERAPY

35. TRANS MYOCARDIAL REVASCULARIZATION Patients who have cardiac ischemia and who are not candidates for CABG may benefit from trans myocardial laser revascularization The procedure may be performed percutaneously The tip of a fiberoptic catheter is held firmly against the ischemic area of the heart while a laser burns a channel Each procedure usually involves making 20 to 40 channels. It is thought that some blood flows into the channels. The channels close as a result of the body’s inflammatory process of healing a wound. The long-term result is the formation of new blood vessels (angiogenesis) The new blood vessels provide enough blood to decrease the symptoms of cardiac ischemia.

36. TRANS MYOCARDIAL REVASCULARIZATION

37. COMPLICATIONS OF CAD

38. SURGICAL PROCEDURES Coronary Artery Revascularization-CABG CAD has been treated by some form of myocardial revascularization since the 1960s; CABG is a surgical procedure in which a blood vessel from another part of the body is grafted Candidates for CABG are usually patients with the following conditions . Angina that cannot be controlled by medical therapies Unstable angina A positive exercise tolerance test and lesions A left main coronary artery lesion or blockage of more than 60% Blockage of two or three coronary arteries Left ventricular dysfunction with blockages in two or more coronary arteries The vessel most commonly used for CABG is the greater saphenous vein, then lesser saphenous vein Cephalic and basilic veins are used also. The right and left internal mammary arteries and, occasionally, radial arteries are also used for CABG.

39. Coronary Artery Revascularization-CABG

40. TRADITIONAL CORONARY ARTERY BYPASS GRAFT The traditional CABG procedure is performed with the patient under GA. A median sternotomy incision & connects the patient to the CPB machine. A blood vessel from another part of the patient’s body is grafted distal to the coronary artery lesion, bypassing the obstruction The vessel most commonly used for CABG is the greater saphenous vein, then lesser saphenous vein. Cephalic and basilic veins are used also. CPB is then discontinued and the incision is closed. The patient then is admitted to a critical care unit.

41. Cardiopulmonary Bypass (CPB).

42. Cardiopulmonary Bypass (CPB).

43. MINIMALLY INVASIVE DIRECT CABG (MIDCAB) For patients with single coronary artery blockages who cannot be treated by PTCA or with contraindications for CPB, an alternative to traditional CABG. One or more 2- to 4-inch (5- to 10-cm) incisions in the chest wall for a left or right anterior thoracotomy or for a midsternal or midline upper laparotomy. The graft is prepared for the bypass myocardial stabilizer, is put around the site. The stabilizer holds the graft site still for the surgeon while the heart continues to beat. Temporarily collapse the lung on the side of the chest Decrease the respiratory rate and the volume of each breath, Give medications to cause bradycardia or up to 20 seconds of asystole.

44. MINIMALLY INVASIVE DIRECT CABG (MIDCAB)

45. COMPLICATIONS MI, dysrhythmias, and hemorrhage Bleeding during or after the surgery. Blood clots that can cause heart attack, stroke, or lung problems. Infection at the incision site Pneumonia Breathing problems Pancreatitis Kidney failure Abnormal heart rhythms.

46. NURSING PROCESS Health History Medical history- Functional status of the cardiovascular system patient’s symptoms, including past and present experiences with chest pain, hypertension, palpitations, cyanosis, breathing difficulty (dyspnoea), leg pain that occurs with walking (intermittent claudication), orthopnoea, paroxysmal nocturnal dyspnoea, and peripheral oedema. Surgical History- Habits - use of drugs, alcohol, and tobacco are also obtained.

47. Assessment A history and physical examination A chest x-ray, ECG, laboratory tests. The health assessment focuses on obtaining baseline physiologic, psychological, and social information. The patient’s and family’s learning needs are identified and addressed as necessary. patient’s usual functional level, coping mechanisms, and support systems. Nutritional and fluid status, weight, and height

48. Vital signs Inspection and palpation of the heart, noting the point of maximal impulse, abnormal pulsations, and thrills Auscultation of the heart, noting pulse rate, rhythm, and quality; S3 and S4, snaps, clicks, murmurs, and friction rub Jugular venous pressure Peripheral pulses Peripheral oedema

49. ASSESSMENT OF ANGINA

50. Nursing Diagnosis 1.Ineffective cardiopulmonary tissue perfusion related to reduced coronary blood flow Goal: Relief of chest pain/discomfort Interventions Initially assess Obtain a 12-lead ECG recording Administer oxygen as prescribed. Administer medication therapy as prescribed and evaluate the patient’s response. Ensure physical rest Provide a restful environment, and allay fears and anxiety by being supportive, calm, and competent.

51. 2.Potential ineffective air exchange related to fluid overload Goal: Absence of respiratory difficulties Interventions Initially assess- chest discomfort or symptoms, assess, document, and report to the physician abnormal heart sounds (particularly S3 and S4 gallops and the holosystolic murmur of left ventricular papillary muscle dysfunction), abnormal breath sounds (particularly crackles), and patient intolerance to specific activities Teach patient: To adhere to the diet prescribed (for example, explain low-sodium, low calorie diet) To adhere to activity prescription

52. 3. Risk for deficient fluid volume and electrolyte imbalance related to alterations in blood volume Goal: Fluid and electrolyte balance Interventions Assess the following parameters: pulmonary artery pressures, left atrial pressures, BP ,CVP, PAWP, weight, electrolyte levels, hematocrit, tissue turgor, breath sounds, Maintain fluid and electrolyte balance Keep intake and output Measure postoperative chest drainage Be alert to changes in serum electrolyte levels Manage electrolytes Hypokalemia, Hyperkalemia, Hypomagnesemia

53. 4.Potential ineffective peripheral tissue perfusion related to decreased cardiac output Goal: Maintenance/attainment of adequate tissue perfusion Interventions Initially, every 4 hours, and with chest discomfort, assess, document, • Hypotension • Tachycardia and other dysrhythmia • Activity intolerance • Mentation changes (use family input) • Reduced urine output (less than 200 mL per 8 hours) • Cool, moist, cyanotic extremities And report to physician

54. 5. Anxiety related to fear of death, change in health status Goal: Reduction of anxiety Interventions Assess and document the patient’s level of anxiety and coping mechanisms Assess the need for spiritual counseling and refer as appropriate. Allow patient (and family) to express anxiety and fear: By showing genuine interest and concern By facilitating communication (listening, reflecting, guiding) By answering questions Use of flexible visiting hours allows the presence of a supportive family Encourage active participation in a cardiac rehabilitation program. Teach stress reduction techniques

55. 6. Deficient knowledge about post-MI self-care Goal: Adheres to the home health care program, Chooses lifestyle consistent with heart-healthy recommendations Interventions Changing lifestyle during Convalescence and Healing Avoiding any activity that produces chest pain, extreme dyspnea, fatigue Stopping smoking and use of tobacco Developing heart-healthy eating patterns Dietary Approaches to Stopping Hypertension (DASH) diet Adhering to medical regimen, especially in taking medications Use of flexible visiting hours allows the presence of a supportive family Encourage active participation in a cardiac rehabilitation program. Teach stress reduction techniques

56. ADOPTING AN ACTIVITY PROGRAM Physical conditioning with a gradual increase in activity duration & intensity Walking daily, increasing distance and time as prescribed Monitoring pulse rate during physical activity Avoiding activities that tense the muscles Avoiding physical exercise immediately after a meal Alternating activity with rest periods Participating in a daily program of exercise

57. RESEARCH INPUT-1 &2

58. Development of Smartphone Educational Application for Patients with Coronary Artery Disease Objective The aims of this study were to determine This study was conducted to develop a smartphone application (app) as an educational learning instrument for coronary artery disease (CAD) patients and to assess the users' level of satisfaction. Methods This methodological research involves elicited learning content for CAD patients to develop a learning instrument using the smartphone app The levels of satisfaction with the developed smartphone app among 30 outpatients with CAD were assessed via a questionnaire during their visits to a cardiology outpatient department. Results A smartphone app 'Strong Heart' was developed through reviewing the literature associated with education for CAD patients under professional supervision and searching for medical smartphone apps that are already available. The learning contents include six main sections containing essential learning issues in managing CAD and additional information to attract the user's attention, such as patient cases and quizzes. After modification with feedback from experts, the app was finally developed and evaluated by patients who reported that they were satisfied with the usefulness of the app. . Conclusion The developed smartphone app is available on both the iPhone App Store and the Android Play Store. Patients with CAD may utilize the app for supporting educational material without limitations of time and space. .  

59. Prevalence of risk factors for coronary artery disease in an urban Indian population. Aim The objective of this study was to assess the prevalence of risk factors for coronary artery disease (CAD) in government employees across India. . Methods The study population consisted of government employees in different parts of India ({n=10 642 men and n=1966 women; age 20–60 years}) and comprised various ethnic groups living in different environmental conditions. Recruitment was carried out in 20 cities across 14 states, and in one union territory. All selected individuals were subjected to a detailed questionnaire, medical examinations and anthropometric measurements. Blood samples were collected for blood glucose and serum lipid profile estimation, and resting ECG was recorded. Results were analyzed using appropriate statistical tools. . Results The study revealed that 4.6% of the study population had a family history of premature CAD. The overall prevalence of diabetes was 16% (5.6% diagnosed during the study and the remaining 10.4% already on medication). Hypertension was present in 21% of subjects. The prevalence of dyslipidaemia was significantly high, with 45.6% of study subjects having a high total cholesterol/high density lipoprotein ratio. Overall, 78.6% subjects had two or more risk factors for CAD. Conclusions The present study demonstrates a high prevalence of CAD risk factors in the Indian urban population. Therefore, there is an immediate need to initiate measures to raise awareness of these risk factors so that individuals at high risk for future CAD can be managed.  

60. SUMMARY AND CONCLUSION Today we have discussed about coronary artery disease, definition, epidemiology, types pathophysiology, clinical manifestations, medical management, surgical and nursing management and research input. Coronary artery disease now days more common because of changes in the life style of people, sedentary life, diet pattern. Knowledge of management of CAD is very important to save the life of patients

61. Que. 1 What are the risk factors of CAD? ANS. Modifiable and Non Modifiable Que.2 Nursing Diagnoses for CAD patients on a priority basis? Ans . Ineffective cardiopulmonary tissue perfusion related to reduced coronary blood flow. Que.3 what is CABG? Ans. CABG is a surgical procedure in which a blood vessel from another part of the body is grafted in the place of blocked coronary artery EVALUATION

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