Week 3: CAD and ACS Flashcards
Heart Failure
- An abnormal clinical syndrome involving impaired cardiac
pumping and/or filling - Heart is unable to produce an adequate Cardiac Output to meet metabolic needs
Characterized by
- Ventricular dysfunction
- Reduced exercise tolerance
- Deminished quality of life
- Shortened life expectancy
Heart Failure Characterized by
- Ventricular dysfunction
- Reduced exercise tolerance
- Deminished quality of life
- Shortened life expectancy
Coronary Artery Disease
A type of blood vessel disorder that is included in the general category of atherosclerosis:
- Begins as soft deposits of fat that harden with age
- Referred to as “hardening of arteries”
- Can occur in any artery in the body
- Atheromas (fatty deposits) have a preference for the coronary
arteries
Synonyms:
- Arteriosclerotic heart disease (ASHD), cardiovascular heart disease (CVHD), ischemic heart disease (IHD), & coronary heart disease (CHD)
CAD: Eithology & Pathophysology
Atherosclerosis is the major cause of CAD:
- Characterized by a focal deposit of cholesterol & lipid, primarily
within the intimal wall of the artery resulting in reduced or
obstructive blood flow - Endothelial lining is altered as a result of inflammation & injury
- C-reactive protein (CRP) is increased in many clients with CAD
CAD: Etiology and Pathophysiology Developmental stages
Fatty streaks
- Earliest lesions & potentially reversible
- Characterized by lipid-filled smooth muscle cells
Fibrous plaque
- Beginning of progressive changes
- Fatty streak is covered by collagen forming a fibrous plaque
that appears grayish or whitish
- Result = narrowing of vessel lumen
Complicated lesion
- Continued inflammation can result in plaque instability,
ulceration, and rupture
- Thrombus formation
- Increased narrowing or total occlusion of lumen
CAD: Etiology and Pathophysiology Developmental stages
Fatty streaks
- Earliest lesions & potentially reversible
- Characterized by lipid-filled smooth muscle cells
Fibrous plaque
- Beginning of progressive changes
- Fatty streak is covered by collagen forming a fibrous plaque
that appears grayish or whitish
- Result = narrowing of vessel lumen
Complicated lesion
- Continued inflammation can result in plaque instability,
ulceration, and rupture
- Thrombus formation
- Increased narrowing or total occlusion of lumen
CAD: Etiology and Pathophysiology, cont’d
Collateral circulation: Normally some arterial anastomoses (connections) exist within the coronary circulation
Growth and extent of collateral circulation is attributed to two factors
- Inherited predisposition to develop new vessels (angiogenesis)
- Presence of chronic ischemia
CAD: Risk Factors
Non-modifiable:
Increasing age
Sex (men > women until 65 years of age)
Ethnicity
Family history
Genetics – Familial Hypercholesterolemia
Modifiable:
Major:
Elevated serum lipids
Hypertension
Tobacco use
Obesity
Physical inactivity
Contributing:
Diabetes
Metabolic syndrome
Psychological states
Homocysteine levels
Risk Factor: Metabolic Syndrome
Obesity:
- BMI > 30 kg/m2
- *Waist circumference > 102 cm (40”) in males & 88 cm (35”) in
women
Hypertension
Abnormal serum lipid levels
Elevated fasting blood glucose
CAD: Health promotion
Identification of people at high risk:
- Personal & family health histories
- 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
CAD: Health-promoting Behaviours
Physical fitness:
- (FITT )Frequency, Intensity, Time, and Type. It can be prescribed to people to improve health.
Nutritional therapy:
- Omega-3 fatty acids, choose plant-based fats vs saturated fats
Cholesterol-lower drug therapy:
- Restrict lipoprotein production; “Statin” drugs
- Lipoprotein removal; e.g., cholestyramine
Anticoagulant therapy - aspirin/Heparin:
- Prevention of embolus formation & subsequent stroke or MI
2 types of CAD
Chronic Stable Angina
ACS: Acute coronary syndrome
- Unstable Angina NSTEMI
- STEMI
Chronic Stable Angina: Manifestation of CAD
Etiology and Pathophysiology:
- Reversible (temporary) myocardial ischemia = angina (chest
pain); intermittent chest pain
- O2 demand > O2 supply (see Table 36-6)
- Issue is either increased demand or decreased supply
Primary reason for insufficient blood flow is narrowing of coronary arteries by atherosclerosis
- For ischemia to occur, the artery is usually 75% or more stenosed
(obstructed)
NOTE: Chest pain with the same pattern of onset, duration, and intensity of symptoms.
Chronic Stable Angina
Pain usually lasts 3 to 5 minutes
Some patients know their pattern, and will take Nitrospray 0.4mg SL Q5 min x 3 ahead of the precipitating factor
Subsides when the precipitating factor is relieved (see Table 36-8)
Precipitating factors:
- Physical Exertion
- Temperature Extremes
- Strong Emotions
- Consumption of Heavy Meal
- Tobacco Use
- Sexual Activity
- Stimulants
- Circadian Rhythm Patterns
Pain is rarely sharp or stabbing. Often “constrictive, squeezing, heavy, choking”
Usually does not change with position or breathing
Chronic Stable Angina: Collaborative Management
Strategies for the patient with chronic stable angina should address all of the treatment elements in the ABCDEF mnemonic:
A: Antiplatelet agent, Antianginal therapy, ACE inhibitor*
B: β-Adrenergic blocker Blood pressure
C: Cigarette smoking Cholesterol
D: Diet, Diabetes
E: Education, Exercise
F: Flu vaccination*
Other Types of Angina
- Silent ischemia
- Nocturnal Angina
- Angina Decubitus
- Prinzmetal’s (Variant) Angina
Silent ischemia
- Ischemia that is asymptomatic
- Associated with diabetes mellitus
Nocturnal Angina
- Occurs only at night but not necessarily in recumbent position or during sleep
Angina de decubitus
- Chest pain that occurs only while lying down
- Usually relieved by standing or sitting
Prinzmetal’s (Variant) Angina
Occurs at rest usually in response to spasm of major coronary artery
Seen in clients with a history of migraine headaches and Raynaud’s phenomenon
Spasm may occur in the absence of CAD
May be relieved by moderate exercise
ACS: Acute Coronary Syndrome
-when myocardial ischemia is prolonged and not immediately reversible
-ACS is an umbrella term, that covers unstable angina, NSTEMI, and STEMI
----TIME IS MUSCLE----
Unstable Angina (UA)
WHAT IT IS:
Chest pain that is:
- new in onset
- occurs at rest, or
- has a worsening pattern
- Chest pain isn’t sustained
Constitutes a medical emergency
Chest pain results from myocardial ischemia
NSTEMI: non ST elevated MI
WHAT IT IS:
—PARTIAL THICKNESS BLOCKAGE MI—-
Majority of MI’s occur secondary to a thrombus formation
-MI’s take time to damage the heart muscle
-takes 20 mins before cellular death starts to occur
-takes 5-6 hours before the entire thickness of the heart muscle becomes necrosed
-dead muscle DOES NOT rejuvenate
STEMI: ST elevated MI
What it is:
-total occlusion of a cardiac artery
—–FULL THICKNESS BLOCKAGE MI—–
What it looks like:
-can have the same symptoms as a NSTEMI, though usually more rapid onset and progression
-symptoms depend on the location of the blockage
-people usually look “shocky”
-people can have this “impending doom feeling”
-generally look very unwell
GOAL: ANGIOGRAM IN 90 MINS (“Door to balloon time: 90 minutes)
