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Pathophysiology > Coronary Artery Disease > Flashcards

Coronary Artery Disease Flashcards

1
Q

Cardiovascular Disease

A
  • leading cause of death in Canada
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2
Q

Coronary Artery Disease

A

A type of blood vessel disorder that is included in the general category of atherosclerosis

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3
Q

Progression of Atherosclerosis

A
  • begins as soft deposits of fat that harden with age (hardening of arteries)
  • Atheromas (fatty deposits) have a preference for the coronary arteries
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4
Q

Synonyms for Coronary Artery Disease

A
  • Arteriosclerotic heart disease (ASHD)
  • Cardiovascular heart disease (CVHD)
  • Ischemic heart disease (HD)
  • Coronary heart disease (CHD)
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5
Q

Major cause of CAD

A
  • atherosclerosis
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6
Q

Atherosclerosis

A
  • focal deposits of cholesterol & lipid, primarily within the intimal wall of the artery resulting in reduced or obstructed blood flow
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7
Q

Developmental stages of Atherosclerosis

A
  • Fatty streaks (earliest lesion, possible reversible). lipid-filled smooth muscle cells
  • Fibrous plaque (beginning of progressive changes) fatty streak covered with collagen
  • Complicated lesion (continuous inflammation results in plaque instability, ulceration, and rupture and thrombus formation. total occlusion)
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8
Q

Collateral circulation

A

normally some arterial anastomoses exist within coronary circulation

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9
Q

Growth and extent of collateral circulation is attributed to two factors…

A
  • inherited predisposition to develop new vessels (angiogenesis)
  • presence of chronic ischemia
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10
Q

Non-modifiable Risk Factors

A
  • increased age
  • sex (men>women until 65 years of age)
  • ethnicity
  • family history
  • genetics
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11
Q

Modifiable Risk factors (9)

A
  • elevated serum lipids
  • hypertension
  • tobacco use
  • obesity
  • physical inactivity
  • diabetes
  • metabolic syndrom
  • psychological stress
  • homocysteine levels
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12
Q

Metabolic Syndrome

A
  • obesity
  • BMI > 30 kg/m2
  • Waist circumference > 102 cm in males and 88 cm in women
  • HTN
  • abnormal serum lipid levels
  • elevated fasting glucose
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13
Q

Health Promotion in CAD

A
  • identification of people at high risk
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14
Q

People at High Risk of CAD

A
  • personal & family history
  • Presence of cardiovascular symptoms
  • Environmental patterns: eating habits, type of diet, activity
  • Psychosocial history: smoking, alcohol, type A behaviours, recent stressful life events, sleeping, presence of anxiety or depression
  • Attitudes and beliefs about health and illness
  • Educational background
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15
Q

Health-Promoting Behaviours: CAD

A
  • physical fitness
  • nutritional therapy (omega-3 fatty acids, choose plant-based fats vs saturated fats) (cholesterol lowering drug therapy - statins restrict lipoprotein production)
  • anticoagulant therapy - apsirin/heparin - prevention of embolus formation & subsequent stroke or MI
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16
Q

Chronic Stable Angina: Manifestation of CAD

- etiology and pathophysiology

A
  • reversible
  • myocardial ischemia = angina
  • intermittent chest pain
  • issue is either increased demand or decreased supply
  • primary reason for insufficient blood flow is narrowing of coronary arteries by atherosclerosis
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17
Q

At what percentage of occlusion will ischemia occur?

A
  • 75% or more is stenosed (obstructed)
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18
Q

Chronic Stable Angina (type of pain?)

A
  • chest pain with the same pattern of onset, duration, and intensity of symptoms
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19
Q

Chronic Stable Angina characteristics

A
  • pain usually lasts 3-5 min
  • patient knows pattern of pain and will take Nitrospray (0.4 mg SL Q5 min 3x ahead of precipitating factor
  • subsides when precipitating factor is relieved
  • pain is constrictive, squeezing, heavy, choking
  • Predictable
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20
Q

Precipitating Factors for Chronic Stable Angina

A

things that increase O2 demand, physical exertion, temperature extremes, strong emotion, consumption of heavy metals, tobacco use, sexual activity, circadian rhythm patterns

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21
Q

Collaborative Management (ABCDEF) of Chronic Stable Angina

A

A. antiplatelet, anti-anginal, ACE inhibitors
B. Beta-blockers, management of BP
C. Cigarette smoking, cessation, Management of cholesterol
D. Diet and diabetes
E. Education and exercise.
F. Flu vaccination

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22
Q

Silent Ischemia

A

ischemia is asymptomatic

associated with diabetes mellitus

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23
Q

Nocturnal angina

A

occurs only at night but not necessarily in recumbent position or during sleep

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24
Q

Angina decubitus

A

chest pain that occurs only while lying down

usually relieved by standing or sitting down

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25
Q

Prinzmetal’s angina

A
  • occurs at rest usually in response to spasm of major coronary artery
  • seen in clients with a history of migraine headaches and Raynauds phenomenon
  • Spasm may occur in the absence of CAD
  • May be relieved by moderate exercise
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26
Q

Acute Coronary Syndrom (ACS)

A
  • when myocardial ischemia is prolonged and not immediately reversible
  • ACS is umbrella term, covers unstable angina, NSTEMI, STEMI
27
Q

Unstable Angina (UA)

A
  • chest pain that is new in onset, occurs at rest, or has a worsening pattern
  • chest pain isnt sustained. constitutes a medical emergency
    chest pain results form myocardial ischemia
28
Q

NSTEMI

A

(non-ST elevated MI)

  • partial-thickness blockage MI - blockage of only part of the thickness of the heart muscle. Part of the heart can still be living and functional.
  • Takes time to damage heart muscle
  • 20 minutes before cell death
  • takes 5-6 hr before the entire thickness of the heart muscle becomes necrosed
29
Q

Symptoms of NSTEMI

A
  • diaphoresis, crackles, SOB, increased HR
30
Q

STEMI

A
  • total occlusion of a cardiac artery
  • full thickness blockage MI
  • can have same symptoms as NSTEMI (more rapid onset and progression)
  • Symptoms depend on the location of the blockage
31
Q

Symptoms of STEMI

A
  • shocky
  • tachycardic, nauseous, vomiting, crushing chest pain
  • impending doom feeling
  • generally look very unwell
32
Q

Goal in STEMI

A

angiogram in 90 min (door to balloon time: 90 min)

ECG 10 min from onset of chest pain

33
Q

ECG (electrocardiogram)

A
  • electrical conduction in the heart
  • electrical depolarization proceeds electrical conduction
  • electrical abnormalities = mechanical abnormalities
  • 12-lead
34
Q

P-wave

A

little one that proceeds the QRS complex - atrial depolarization

35
Q

QRS complex

A

ventricular depolarization

36
Q

T-wave

A

repolarization of ventricles

37
Q

ST segment

A

following QRS complex and before the T wave.

- in STEMI, the ST segment does not return to isoelectric line. important when it happens in two or more vectors.

38
Q

Clinical Manifestations of CAD

A
  • midsternal left shoulder and down both arms
  • neck and arms
  • substernal radiating to neck and jaw
  • substernal radiating down left arm
  • epigastric
  • epigastric radiating to neck, jaw, and arms
  • intrascapular
  • women - nausea, right shoulder or bilateral
39
Q

Assessment of Angina (PQRST)

A 
P: precipitating events
Q: quality of pain 
R: radiation of pain 
S: severity of pain 
T: timing
40
Q

Subjective Data: CAD

A
  • health history: hypertension, diabetes, smoking, obesity, history of stroke
  • symptoms: ask questions. chest pain.
41
Q

Objective data:

A

General: anxiety, fear, restlessness
Integumentary: cool, clammy, diaphoretic, pale/gray
Cardiovascular: tachy/bradycardia/dysrhthmias, BP, changes, quality of pulses, listen to heart sounds, look for changes in baseline vitals, listen for crackles in lungs

42
Q

Goals of Care for all ACS patients

A
  • same as it was for stable angina patients
  • decrease demand for oxygen
  • increase oxygen supply/blood flow to the cardiac arteries. - deliver supplemental O2, keep SpO2 over 90%. 2L/min
43
Q

ACS Diagnostic Studies

A
  • 12-lead ECG - need to happen within 10 min of onset of chest pain.
  • lab studies
  • chest x-ray
  • echocardiogram - more important in heart failure
  • exercise stress test.
44
Q

Lab Studies for ACS

A
  • serial troponins (urgent)

- CBC, CP7, fasting lipids and glucose, LFTs, BNPs, TSH

45
Q

Troponin

A

cardiac cell monocytes has to be damaged, strained, or have died to release the enzyme - it is a specific cardiac marker.
- repeat test in 3 hr to capture the rise in troponin that may not be captured in the first test + ECG

46
Q

Nursing Management of ACS

A
  • relief of pain
  • preservation of myocardium
  • immediate and appropriate treatment
  • effective patient coping and illness-associated anxiety
  • prevention of further angina or MI by reducing risk factors
47
Q

Acute interventions for angina attack

A
  • REST
  • Give supplemental oxygen is spO2 < 92% (due to risk for oxygen toxicity)
  • Determine vital signs and do routinely
  • Do a 12-lead ECG
  • Provide prompt pain relief with a nitrate followed by an opioid analgesic if needed
  • auscultate heart sounds
  • position client comfortably
48
Q

Broad interventions for ACS

A
  • provide pain relief
  • preserve myocardium (cardiac monitoring and diagnostics)
  • maintain signs of effective cardiac perfusion
  • provide immediate and ongoing treatment
  • ensure comprehensive discharge plan
49
Q

Discharge plan for those with ACS

A

Encourage cardiac rehabilitation
Encourage reduction of risk factors
Teach regarding medications

50
Q

Beta-adrenergic blockers

A
  • reduce workload of heart, decrease myocardial oxygen demand. slow heart rate and can drop BP
51
Q

Calcium channel blockers

A
  • dilate coronary arteries
  • used if B-adrenergic blockers are poorly tolerated, contraindicated, or do not control anginal symptoms
  • Reduce heart rate
52
Q

Nitrates - first line of therapy for angina

A
  • vasodilator
  • short-acting nitrates - SL or TL (spray) nitroglycerin
  • transdermal nitrates (nitropatch)
  • Nursing considerations; lowers BP, and headache. monitor VS and give again after 5 min if doesn’t help
53
Q

Angiotensin converting enzyme inhibitors

A
  • dilate blood vessels and decrease BP

- need to check BP before administering

54
Q

Opioids - morphine/fentanyl

A
  • reduce pain
  • may lower HR and reduce need for O2
  • nursing consideration: monitor resp rate. do not five to patient with RR < 12
55
Q

ASA/antiplatelet agents

A
  • inhibits platelet aggregation
  • is there blood in stool or vomit (GI bleed)
  • chewable so if can be absorbed faster
  • reduces platelet stickiness so the thrombus that forms at atherosclerotic plaque does not fully occlude artery
56
Q

What to do if suspected MI

A
  • order troponin to determine ACS or NSTEMI. tells degree of heart strain
  • start IV incase they stop breathing and need Epi quickly
  • left-arm because angiogram goes in rt arm
  • five blood thinners
  • if near cath lab, give ASA and heparin then communicate with hospital they are going to and send the ASAP
57
Q

Discharge Planning

A
  • ambulatory and home care
  • client teaching (CAD and angina, precipitating factors for angina, educate regarding energy preservation strategies, risk factor reduction, medications.
58
Q

Unstable Angina/NSTEMI

A
  • ECG
  • Serial troponins
  • Stress test
  • Urgent angiogram/-plasty
59
Q

STEMI treatment

A
  • ECG
  • serial troponins
  • emergent angioplasty and stenting
60
Q

Restoration of Blood Supply

A
  • angioplasty
  • stenting
  • CABG
61
Q

Angiogram

A

part of cardiac catheterization. A procedure that uses contrast dye and fluoroscopy to examine blockage in coronary arteries. A diagnostic piece

62
Q

Angioplasty

A

the balloon that is inflated to push the blockages out of the way. Temporary. inflation of the balloon right at the narrowing of the artery.

63
Q

Stenting

A

a small wire, mesh tube angioplasty is often combined with placement of stent. maintains patency.

64
Q

CABG

A
  • coronary artery bypass graft surgery
  • not a cure. long-standing smoking patients or long-standing diabetics.
  • uses arteria and veins for grafts

Pathophysiology (8 decks)

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