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Coronary Artery Disease, Angina pectoris, Myocardial Infarction


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The prolong complications of coronary artery disease such as angina pectoris, myocardial infarction, cardiac heart failure, its management and surgical mgt.

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  • The heart has four chambers. Blood from the lower extremities go through inferior vene cava and upper extremities go though the superior vene cava into the right atrium, and from the right atrium to right ventricle througn tricuspid valve. Then the blood move from the right ventricle to the pulmonary circulation through pulmonic valve. Oxygen is picked up in the lungs and carbon dioxide is released. Then the oxygen rich blood is moved from pulmonic circulation into the left atrium, then from the left atrium to the left ventricle through mitral valve, from the left ventricle to the Aorta through Aortic valve.
    The heart is a pump, and the left ventricle is the main pump of the heart. When there is any damage to the heart or any arteries, it can cause poor supply of oxygen rich blood to the heart cells, and since the heart requires oxygen to work, poor supply will can ischemia to the area where there is poor supply. High blood pressure and diabetes are the most common medical condition that damages the arteries and arteriole of the body.
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Coronary Artery Disease, Angina pectoris, Myocardial Infarction

  1. 1. CORONARY ARTERY DISEASE ANGINA Pectoris MYOCARDIAL INFARCTION (MI) Presenter Dave Jay S. Manriquez RN. February 21, 2009
  2. 2. Objectives <ul><li>Coronary Artery Diseases </li></ul><ul><ul><li>Angina </li></ul></ul><ul><ul><ul><li>Types </li></ul></ul></ul><ul><ul><ul><li>Mechanism </li></ul></ul></ul><ul><ul><ul><li>Causes </li></ul></ul></ul><ul><ul><ul><li>Clinical manifestation </li></ul></ul></ul><ul><ul><ul><li>Complication </li></ul></ul></ul><ul><ul><ul><li>Nursing care </li></ul></ul></ul>06/08/09
  3. 3. Coronary Artery Disease Definition: CAD is a term that refers to the effect of the accumulation of atherosclerosis plaque in the coronary arteries that obstructs blood flow to the myocardium 06/08/09
  4. 4. Cont. <ul><li>conditions result from CAD </li></ul><ul><li>1 . Angina Pectoris </li></ul><ul><li>2. Myocardial Infarction </li></ul>06/08/09
  5. 5. Angina Pectoris <ul><li>Definition: </li></ul><ul><li>Angina: Choking or suffocation. </li></ul><ul><li>Pectoris: Chest. </li></ul><ul><li>Angina pectoris, is the medical term used to describe acute chest pain or discomfort. </li></ul><ul><li>Angina occurs when the heart’s need for oxygen increases beyond the level of oxygen available from the blood nourishing the heart. </li></ul><ul><li>It has 3 types </li></ul><ul><li>Stable Angina </li></ul><ul><li>Un stable angina & </li></ul><ul><li>Variant Angina (Prinzmetal’s or resting angina) : </li></ul>06/08/09
  6. 6. Cont. <ul><li>Types of Angina </li></ul><ul><li>Stable angina : </li></ul><ul><ul><li>People with stable angina have episodes of chest discomfort that are usually predictable. That occur on exertion or under mental or emotional stress. </li></ul></ul><ul><ul><li>Normally the chest discomfort is relieved with rest, </li></ul></ul><ul><ul><li>  nitroglycerin (GTN) or both. </li></ul></ul><ul><ul><li>It has a stable pattern of onset, duration and intensity of symptoms. </li></ul></ul>06/08/09
  7. 7. Cont. <ul><li>Unstable angina: </li></ul><ul><ul><li>It is triggered by an un predictable degree of exertion or emotion. </li></ul></ul><ul><ul><li>(progressive), more severe than stable. Characterized by increasing frequency & severity. Provoked by less than usual effort, occurring at rest & </li></ul></ul><ul><ul><li>interferes with pt lifestyle. </li></ul></ul>06/08/09
  8. 8. Cont. <ul><li>Variant Angina (Prinzmetal’s or resting angina) : </li></ul><ul><li>occur spontaneously with no relationship to activity. Occurs at rest due to spasm. Pt discomfort that occurs rest usually of longer duration. Appears to by cyclic & often occurs at about the same time each day (usually at night). Thought to be caused by coronary artery spasm </li></ul>06/08/09
  9. 9. <ul><li>Mechanism Of Angina </li></ul>06/08/09
  10. 10. 06/08/09
  11. 11. Causes <ul><li>Coronary atherosclerosis (atheroma ) </li></ul><ul><li>Factors increasing preload : </li></ul><ul><ul><li>Hyperthyroidism </li></ul></ul><ul><ul><li>Exercise </li></ul></ul><ul><ul><li>Anemia </li></ul></ul><ul><li>Factors increasing after load: </li></ul><ul><li>Hypertension </li></ul><ul><li>Aortic stenosis </li></ul><ul><li>Obstructive cardio myopathy </li></ul><ul><li>Coronary artery spasm </li></ul>06/08/09
  12. 12. Clinical Manifestations <ul><ul><li>Characteristics: Squeezing, burning, pressing, choking, or bursting pressure. </li></ul></ul><ul><ul><li>Onset: Quickly or slowly </li></ul></ul><ul><ul><li>Location: Chest, right or left arms, shoulder, or neck, jaw. </li></ul></ul><ul><ul><li>Duration: Less then 5 minutes. </li></ul></ul><ul><ul><li>Associated: Dyspnea, Sweating, faintness, palpitation, dizziness ect. </li></ul></ul><ul><ul><li>Relieving: GTN and rest. </li></ul></ul><ul><ul><li>Aggravating: exertion, exercise, heavy meal, emotional upset, and anger. </li></ul></ul>06/08/09
  13. 13. Investigations <ul><li>Electrocardiogram ( ECG) </li></ul><ul><li>Coronary angiography </li></ul><ul><li>Exercise Electrocardiogram (Stress test). </li></ul><ul><li>Complications: </li></ul><ul><li>Myocardial infarction </li></ul><ul><li>Cardiac Arrhythmias </li></ul>06/08/09
  14. 14. Myocardium Infarction <ul><li>Myo means muscle, “Cardiac” heart, infarction means “death of tissues due to lack of blood supply”. </li></ul><ul><li>It is also called heart attack. It occurs when coronary arteries become blocked and the part of myocardial muscles become dead due to prolonged lack of oxygen supply to the muscle cells. </li></ul>06/08/09
  15. 15. PATHOPHYSIOLOGY <ul><li>Coronary artery cannot supply enough blood to the heart in response to the demand due to CAD </li></ul><ul><li>Within 10 seconds myocardial cells experience ischemia </li></ul><ul><li>Ischemic cells cannot get enough oxygen or glucose </li></ul><ul><li> Ischemic myocardial cells may have decreased electrical & muscular function </li></ul><ul><li>Cells convert to anaerobic metabolism. </li></ul><ul><li>Cells produce lactic acid as waste </li></ul><ul><li>Pain develops from lactic acid accumulation </li></ul><ul><li>Pt feels anginal symptoms until receiving demand increase 02 requirements of myocardial cells </li></ul>06/08/09
  16. 16. ECG changes in Angina & MI <ul><li>Zone of Ischemia: T wave inversion </li></ul><ul><li>Zone of Injury: ST elevation </li></ul><ul><li>Zone of Necrosis: Abnormal Q wave </li></ul>06/08/09
  17. 17. Sign and Symptom <ul><li>Classic symptom of heart attack are chest pain radiating to neck, jaws, back of shoulder, or left arm </li></ul><ul><li>The pain can be felt like: </li></ul><ul><li>Squeezing or heavy pressure </li></ul><ul><li>A tight band on the chest </li></ul><ul><li>An elephant sitting on the chest </li></ul>06/08/09
  18. 18. Cont <ul><li>Other symptoms include: </li></ul><ul><li>Shortness of breath (SOB) </li></ul><ul><li>Weakness and tiredness </li></ul><ul><li>Anxiety </li></ul><ul><li>Lightheadedness </li></ul><ul><li>Dizziness </li></ul><ul><li>Nausea vomiting </li></ul><ul><li>Sweating, which may be profuse </li></ul>06/08/09
  19. 19. Collaborative Management <ul><li>Assessment: </li></ul><ul><li>History </li></ul><ul><li>Clinical manifestation </li></ul><ul><li>Cardiovascular assessment </li></ul><ul><li>Laboratory assessment </li></ul><ul><li>Troponin T & I </li></ul><ul><li>CK-MB </li></ul>06/08/09
  20. 20. Radiographic Assessment <ul><li>ECG </li></ul><ul><li>Stress Test </li></ul><ul><li>Myocardial perfusion imaging </li></ul><ul><li>MRI </li></ul><ul><li>Cardiac Catheterization </li></ul>06/08/09
  21. 21. IMPORTANT INFORMATION TO REMEMBER Increase supply of Oxygen <ul><li>Decreasing the demand of Oxygen: </li></ul><ul><li>Stop activity and lie down (CBR) </li></ul><ul><li>Take Tab. Angisid sublingually and wait till it dissolves. </li></ul><ul><li>If pain continues take up to 03 Tab. Angisid one every five minutes. If pain is not relieved yet take another tab. and rush to EMERGENCY services. </li></ul>06/08/09
  22. 22. IMMEDIATE MANAGEMENT OF MI: <ul><li>GOALS: </li></ul><ul><li>To prolong life. </li></ul><ul><li>Minimize infarct size. </li></ul><ul><li>Reverse ischemia. </li></ul><ul><li>Reduce cardiac work. </li></ul><ul><li>Prevent and treat complications. </li></ul><ul><li>A) INITIAL TREATMENT: </li></ul><ul><li>Rapid triage. </li></ul><ul><li>OMI (oxygen, monitor and I/V line). </li></ul><ul><li>Check vital signs and O2 saturation. </li></ul><ul><li>ECG within 10 minutes and repeat ECG. </li></ul><ul><li>Blood samples for enymes, CBC, lytes, and lipid profile. </li></ul>06/08/09
  23. 23. Intervention <ul><li>Medication: </li></ul><ul><li>Morphine Sulphate </li></ul><ul><li>Nitrates (GTN) </li></ul><ul><li>Beta blockers </li></ul><ul><li>Calcium Channel Blocker </li></ul><ul><li>Anti platelets / Anti coagulant </li></ul><ul><li>Thrombolytic therapy </li></ul>06/08/09
  24. 24. Surgical management <ul><li>PTCA (Percutaneous Transluminal Coronary Angioplasty </li></ul>06/08/09
  25. 25. Coronary Artery Bypass Graft surgery (CABG) 06/08/09
  26. 26. Nursing Diagnosis <ul><li>Acute pain R/T imbalance between myocardial oxygen supply and demand </li></ul><ul><li>Ineffective tissue perfusion R/T interruption of arterial blood flow </li></ul><ul><li>Ineffective coping R/T effects of acute illness and major changes in life style </li></ul><ul><li>Impaired gas exchange related to ineffective breathing pattern and decreased systemic tissue perfusion. </li></ul><ul><li>Anxiety related to present status and unknown future, possible lifestyle changes, pain, and perceived threat of death. </li></ul><ul><li>Activity intolerance related to fatigue </li></ul>06/08/09
  27. 27. Prevention <ul><li>Recognize the symptoms </li></ul><ul><li>Reduce your risk factors: </li></ul><ul><li>Lose weight </li></ul><ul><li>Quit Smoking </li></ul><ul><li>Keep your cholesterol at a normal level. </li></ul><ul><li>Keep your blood pressure under control. </li></ul><ul><li>Use techniques to ease stress. </li></ul><ul><li>Control blood sugar level. </li></ul><ul><li>Eat Right </li></ul><ul><li>REGULER EXERCISE </li></ul>06/08/09
  28. 28. COMPLICATIONS OF MI: <ul><li>Arrhythmias </li></ul><ul><ul><li>Atrial arrhythmias. </li></ul></ul><ul><ul><li>Ventricular arrhythmias. </li></ul></ul><ul><ul><li>Bradycardia and heart block. </li></ul></ul><ul><ul><li>Asystol. </li></ul></ul><ul><li>Hypertension. </li></ul><ul><li>LV failure. </li></ul><ul><li>Cardiogenic shock. </li></ul>06/08/09
  29. 29. CARDIAC REHABILITATION: <ul><li>Cardiac rehabilitation provides a venue for continued education, re-enforcement of lifestyle modification, and adherence to a comprehensive prescription of therapies for recovery from MI, which includes exercise training </li></ul><ul><li>Goals of Rehabilitation program : </li></ul><ul><li>Develop a program for progressive physical activity </li></ul><ul><li>Lives as full, vital and productive life </li></ul><ul><li>Remain within the limits of the heart’s ability to respond to increases in activity and stress. </li></ul>06/08/09
  30. 30. FOLLOW UP 06/08/09