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Coronary Artery
Disease
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Coronary
Atherosclerosisdefnition- abnormalaccumulation of lipids and brous
tissue in the coronary arterieswhich results in decreased bloodow to myocardium
Atheroma comprises the lumen ofthe vessel---clots may form andobstruct the lumen
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Clinical Maniestationsa) narrowing-angina (ischemia)
b) occlusion- AMI (necrosis)
c) other
-E! changes
- aneurysms -dysrhythmias
d) sudden cardiac death
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Angina Pectorisdenition-chest discomfort (pain) due todecreased blood ow resulting in
atheroma or spasmdecreased blood ow results inmyocardial ischemia-nerve endingsaround cells send pain messages to brain
usually transient chest pain ("-#$)%subsides when precipitating factorremoved
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Types o AnginaUnstable- referred to aspreinfarction%&rescendo%unpredicta
ble%or progressive (increase in fre'uency
and duration)
treated with AA and &alcium&hannel loc*ing Agents
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Chronic, Stable Anginareferred to as predictable andconsistent
occurs on e+ertion
relieved with rest
E! changes-, depression
classic type of angina
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Nocturnal Anginareferred to as Angina ecubiti
occurs at night due to lying at
when the wor*load on the heart isincreased (increased venous returnor preload)
relieved by standing or sitting
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Prinzetal!s Anginausually spontaneous andaccompanied by increased ,
elevations on the E! due tocoronary artery spasm
associated with ris* of MI
rare form of angina
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"actors
Precipitating Anginaa) physical e+ertion-increases
wor*load of heart ( se+% e+ercise%
ra*ing leaves %or lifting heavyob.ects)
b) e+posure to heat or cold resulting
in vasoconstriction-elevated bloodpressure-increased demands ofbody for o+ygen
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"actors Precipitating
Anginac) heavy meals-divert blood to !I tract
(/#0of &1)
d) strong emotions-increased release ofcatecholamines
e) cigarette smo*ing
f) se+ual activity
g) stimulants-co2ee or cocaineh) circadian rhythm patterns-early a3m3
after arising
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Description o Paina) substernal-varies in intensity fromdiscomfort to pressure to agoni4ing
painadjectives used to describe pain
heavy feeling% pressure%weight
oppressive or sharp tightness
viseli*e
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Description o Pain crushing
constricting
s'uee4ing
su2ocating
burning
indigestion
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Types o Painb) deep-retrosternal
c) locali4ed but may radiate to
nec*%.aws%shoulder%inner aspects ofeither arm-
usually subsides when causeremoved
relieved by nitrates and rest
duration of pain -appro+imately 5#$or less
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Diagnostic Testsa) E!-changes occur only while having
angina
b) tress tests results-loo* for changes in, segments
c) ,hallium stress test-in.ect dye 5 minutebefore pea* e+ercise% scan immediately
and in /-6 hours3 7oo* for 8cold spots9indicating lac* of ,hallium upta*e orlac* of perfusion
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Diagnostic Testsd) &ardiac &atheteri4ation-
Angiography 7oo*s at o+ygen
levels and pressure readings inheart chambers as well as blood owthrough coronary arteries
e) &hest :-;ay- Identies enlarged
heart% calcication%pulmonarycongestion
f) 7ipids and En4ymes
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Diagnostic Testsg)
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Manageent o Angina#b$ecti%e-decrease the discrepancybetween the o+ygen supply and demand
- ;est-decrease the amount of o+ygenneeded by all tissues of body
-
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&nter%entions or
AnginaAcute AttackAcute Attack-
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Acute Anginal Attac'minute
,a*e ?ital igns
perform E! - loo* for changes in, segments
Administer @itrates or Analgesia
semi-owlers position
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Nursing &nter%entions(
AnginaPre%ent Pain
-Avoid activities that cause pain
- &hange A7 schedules if pain ina3m3
- Bnhurried pace
-Avoid causes
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Nursing &nter%entions(
Angina)educe An*iety
- 8ear of eath9 is common
- tay with an+ious client
- Educate client for discharge
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Nursing &nter%entions(
Angina#b$ecti%es o Client +ducation(oe Care
- reduce fre'uency> severity ofattac*s
- delay disease progression
- protect from complications
- plan activities to minimi4e episodes
- modify ris* factors
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Medications To Treat
Angina5) @itroglycerin-%decreases preload and
afterload by dilating venous and arterialsystem%decreases venous return andarterial pressure
a) wor*s in /-" minutes
b) dose-=3"-=3C mg sl3+" at #-5= minute
intervals c) e2ects last only 5=-5# minute
ma+imum
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Side +-ects o
NitroglycerinIncreased Deart ;ate
1rthostatic Dypotension
,hrobbing Deadache
lushing of face
?ertigo,achycardia
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Nursing &plicationsAssociated .ith
Nitroglycerinresh supply every C- months
,a*e at earliest sign of pain ordiscomfort
eep in brown bottle and cool spot-it is volatile to air
it or lie down when ta*ing;emove cotton from bottle
oes not always sting under tongue
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Nitrate Preparations@itroglycerin sublingual-If no relief from "pills ta*en # minutes apart-see* medicalattention
Long Acting Nitrates
a) ,opical 1intments-duration of e2ect
is 6 hours so client needs 6-Capplications a day
Apply to arms% legs %any unhairy bodyarea
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/ong Acting Nitrate
PreparationsM preparation-long acting
e+amples-
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&ntra%enous
Nitroglycerinrationale-increase collateral bloodow to ischemic area% decrease
myocardial o+ygen demand bydecreasing preload and decreasingafterload
examples- @itrol I?% @itrostat I?%@itrobid or ,ridil I?
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0eta 0loc'ersaction-decrease myocardial o+ygenconsumption by bloc*ing
sympathetic impulses to heart%smooth muscle of bronchi andblood vessels3 It lowers heart rate
and blood pressure and decreasesmyocardial contractility
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0eta 0loc'ersCoon Drugs in Use
- Inderal-F=-"/=mg I or GI
- Atenolol (,enormin)-#=-5==mg>day may ta*e up to /== mg>day
-Metoprolol (7opressor) -#=-
5==mg>day may ta*e up to 6#=mg>day
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0eta 0loc'ers,imolol (locadren5= mg3 I orup to 5==
mg3>day
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Side +-ects o 0eta
0loc'ersMusculos*eletalHea*ness
Dypertensionradycardia
epression
atiguee+ualdysfunction
ronchospasm-watch clients with
history ofAsthma 3&1
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Calciu Channel
0loc'ing Agents&alcium inuences cardiaccontraction and electrical stimulation
Action--dilates smooth muscle ofcoronary arteries thus% increasingo+ygen supply%decreases systemic
arterial pressure and decreaseswor*load of 7? (decreasing peripheralresistance)
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Calciu Channel
0loc'ingAgentsEfects-
- ystemic vasodilatation with
decreased systemic vascularresistance
- ecreased myocardial
contractility
- &oronary vasodilatation
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CoonCalciu
Channel 0loc'ingAgents@ifedipine (
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Side +-ects o Calciu
Channel0loc'ingAgents1rthostatic Dypotension
radycardia
lushing
Deadache
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Coon Nursing
Diagnoses(Anginaa1 Pain rel3to ischemia of
myocardium
b) Acti%ity &ntolerance rel3 tofatigue or wea*ness
c) Altered ealth Maintenance rel
to *nowledge decitd1 An*ietyrel3 to fear of cardiac
disease% future sudden death
P t
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PercutaneousTransluinalCoronary
Angioplasty2PTCA1
rationale- attempts to improve
blood ow within the coronary arteryby crac*ing the pla'ue or atheromathat is interfering with the circulationof blood to the heart
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Ad%antages o PTCAAlternative to surgery
7ocal anesthesia used
Eliminates ,horacotomy Incision&lient is ambulatory within /6 hours
Dospital stay is 5-" days not #-
days as with &A! procedure;apid return to wor*-5wee* insteadof Fwee*s with &A! procedure
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Ad%anceents 3ith
PTCABse of more e+ibleguidewire>catheters
ilates stenosed &A! grafts
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Coplications o PTCA
issection of dilated artery
;upture of artery causing tamponade%
ischemia% infarct% decreased &1%death1cclusion of vessel distal to catheter
&oronary spasm from mechanical orchemical irritation from dye
abrupt closure-/6 hours
;estenosis rates of "=0 within "-C months
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Ne3er Treatents
)adiation 3ith &ntra%ascular StentPlaceents(e+pandable% meshli*estructures to maintain vessel patency
re'uires anticoagulants for " months
Atherectoy(shave pla'ue using
rotating blade when pro+imal ormiddle part of artery involved
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Ne3er Treatents or
Angina/aser Angioplasty(A small laseron tip of catheter welds the area
open or melts the pla'ue areasfacilitating blood ow
Is still a new techni'ue and needs
renement