Coronary artery disease (CAD) refers to a group of diseases caused by narrowing of the coronary arteries due to atherosclerosis. It includes conditions like stable angina, unstable angina, myocardial infarction, and sudden cardiac death. A survey found that residents of public housing in Charlotte had several risk factors for CAD such as high blood pressure, high cholesterol, diabetes, and smoking. Diagnosis involves tests like ECG, cardiac markers, stress echocardiography, and coronary angiography. Treatment includes lifestyle changes, medications, angioplasty, stents, and coronary artery bypass grafting. Nursing management focuses on pre-procedure teaching, post-procedure monitoring for bleeding or other complications, and managing post-surgical

1. CORONARY ARTERY DISEASE
Presented by : Ms Garima
Bhardwaj ( MSc Ist Year )

2. Introduction
 CAD refers to a group of diseases which includes stable angina,
unstable angina, myocardial infarction, and sudden cardiac death.
 Also known as ischemic heart disease
 It is caused by the narrowing of the large blood vessels that supply
the heart with oxygen. fatty deposits called plaque ( Atherosclerosis )
build up inside the coronary arteries.

3. CAD includes :
 Atherosclerosis
 Acute Coronary Syndrome (A spectrum of clinical conditions from unstable
angina to ST-elevation MI and sudden cardiac death )
 Angina Pectoris
 Myocardial Infarction ( STEMI , NSTEMI )

6. Collateral circulation
It is a network of tiny blood vessels, and, under normal conditions, not open.
When the coronary arteries narrow to the point that blood flow to the heart muscle
is limited, collateral vessels may enlarge and become active .
This allows blood to flow around the blocked artery to another artery nearby or to
the same artery past the blockage, protecting the heart tissue from injury.
Two factors contribute to growth and extent of collateral circulation :
•The inherited predisposition of develop new blood vessels ( angiogenesis )
•The presence of chronic ischemia

11. A survey conducted by the Charlotte Housing Authority (CHA) in Charlotte, NC, found
that many public housing residents had risk factors for heart disease, such as high
blood pressure, high cholesterol, diabetes, physical inactivity, overweight/obesity, and
cigarette smoking.

12. Atherosclerosis
 It begins as fatty
streaks, lipids that are
deposited in the intima
of the arterial wall
 plaques, protrude into
the lumen of the vessel,
narrowing it and
obstructing blood flow .

13. Pathophysiology
Injury to endothelial lining due to various factors like (tobacco use ,hypertension ,
hyperlipidaemia etc. )
Accumulation of lipoproteins in the vessel wall – Mainly LDL
Monocyte adhesion to the endothelium – Followed by migration into the intima and
transformation into macrophages and foam cells.

14. Cont.….
Platelets adhesion takes place at the site of injury
smooth muscles cell proliferation occurs
The proliferation results in deposits, called atheroma's or plaques, which protrude
into the lumen of the vessel, narrowing it and obstructing blood flow .

15. Clinical manifestations :

16. Angina Pectoris
 It is a Clinical syndrome characterized by transient episodes of substernal chest
pain or discomfort caused by myocardial ischemia .
 Chronic stable angina is the most common manifestation of CAD .
 Relieved by Nitroglycerine .

17. Types of Angina
Stable angina
Unstable angina
Intractable or refractory angina
Variant angina
Silent ischemia

18. Characteristics of pain
Location : left-sided or Retrosternal
Radiation : radiating to the left arm, neck, jaw, or back
Duration : 30 sec to 15 min

19. Myocardial Infarction

20. Myocardial infarction (MI) refers to tissue death (infarction) of the heart muscle
(myocardium).
It is a type of acute coronary syndrome, which describes a sudden or short-term
change in symptoms related to blood flow to the heart .
It occurs as a result of thrombotic occlusion of the coronary artery and causes
irreversible cell injury and necrosis .
it may be classified as an :
o ST elevation myocardial infarction (STEMI)
o Non-ST elevation myocardial infarction (NSTEMI) based on the results of an ECG .

21. Classification ( based on location )
Anterior myocardial infarction – results from the occlusion of the left
anterior descending coronary artery .
Inferior and posterior MI – occlusion of the right coronary artery that
supplies these regions .
Lateral MI – occlusion of coronary branches supplying the lateral wall of the
left ventricle . Includes left circumflex branch and diagonal branch of the LAD .
Right ventricular MI - occurs in corelation with inferior MI . Results from
occlusion of the RCA proximal to the marginal branches .

22. Characteristics of pain
Severe, immobilizing chest pain.
Usually described as heaviness, pressure, tightness, burning.
Location : Substernal , Retrosternal or Epigastric .
Radiation : It may radiate to neck, jaw, arm or back .
Duration : Lasts for 20 minutes or more.

24. Killip classification
It was published in 1967
categorizes patients with an acute MI based upon the presence or absence
of simple physical examination findings that suggest LV dysfunction.
 The higher the Killip class on presentation, the greater the subsequent
mortality

26. TIMI,S Classification
 The Thrombolysis in Myocardial Infarction (TIMI) Score
 It is used to determine the likelihood of ischemic events or mortality in
patients with angina or myocardial infarction (STEMI).

28. Complications of MI
 Sudden death
 Left ventricular aneurysm
 Left ventricle failure
 Mitral regurgitation
 Ventricular septal rupture
 Arrhythmias
 Heart failure

29. Management of MI
 A 12 lead resting ECG should be obtained immediately in patients with ongoing chest pain as
rapidly as possible with in 10 minutes of presentation
 Morphine - Reduces pain & anxiety, decreases sympathetic tone, systemic vascular resistance
and oxygen demand . 2–4 mg IV every 5–10 minutes until pain is relieved
 Oxygen - 2–4 L/min by nasal cannula to maintain oxygen saturation
 Nitro glycerine - Dilates coronary vessels—increase blood flow & reduces systemic vascular
resistance and preload .
Sublingual: sorbitrate 5-10 mg every 5 min, up to 3 doses (If SBP >100 mmHg)
 Aspirin - Irreversibly inhibits platelet aggregation, stabilizes plaque and arrests thrombus,
reduces mortality in patients with STEMI .
Dosage: 150-300 mg chewed at presentation, then 150 mg PO OD .

30. Cont..…
β-Blocker - oral beta-blocker therapy should be initiated in the first 24 hours (metoprolol 25-50
mg every 12 hours )
ACE inhibitors - Reduces systemic vascular, resistance and cardiac afterload, also reduce
aldosterone release with consequent reduction of circulating fluid load and lower cardiac preload.
low dose oral administration and increase steadily to achieve a full dose within 24 to 48 hours.
(Captopril 6.2 mg TID, Ramipril 2.5-5mg BD)
 Heparin – LMWH , subcutaneous Enoxaparin 1mg/kg BD .

31. Diagnostic Evaluation

32. Physical Examination
 History taking for assessing co morbidity
 General appearance and behavior
 Vital signs
 Skin turgor – cold and clammy
 Auscultate for heart sounds – S3 gallop may be present as well as crackles (indicates LV
failure )
 Assess for level , location of pain .
 Many patients have normal pulse rate and blood pressure within the first hour of STEMI.
 Patients with large infarctions have hypotension (SBP <100 mmHg or sinus tachycardia
>100/min)

33. ECG ( Electrocardiography )
 ST elevation – indicates infarction
 ST depression – indicates ischemia
 Q wave presence
 T wave inversion
 RVMI is diagnosed with ST segment elevation in lead V4R, ST elevation in V1
in the presence of ST elevation in inferior leads .
 Posterior ST depression in V1-V2 ( RCA or LCA )
 Inferior wall MI - II, III, aVF

35. Stress echocardiography
Patient will exercise on a treadmill or stationary bike while doctor monitors the
blood pressure and heart rhythm .
When heart rate reaches peak levels, doctor will take ultrasound images of
the heart to determine whether heart muscles are getting enough blood and
oxygen while patient exercise .
Provides location and extent of MI

36. Nuclear stress test
 It is a nuclear imaging test that shows
how well blood flows into your heart
while you’re exercising or at rest .
 Also known as thallium stress test

37. Lipid profile
 Fasting lipid profile, including total cholesterol, HDL, triglycerides, and calculated
LDL cholesterol .
 A composite of lipid and non lipid risk factors of metabolic origin, called
metabolic syndrome, is another risk factor for CAD.
 Metabolic syndrome includes abdominal obesity, an elevated triglyceride level,
low HDL level, elevated blood pressure, and impaired function of insulin .
 LDL exerts a harmful effect on the arterial wall and accelerates atherosclerosis

39. Cardiac Markers
CK-MB - increases 3-6 hrs after onset of chest pain, peaks in 12-18 hrs & return
to normal within 3-4 days.
LDH - it increases 14-24 hrs after onset of MI, peak within 48-72 hrs & slowly
return to normal over next 7-14 days .
Cardiac troponin T/ I - increases 7-14 hrs after MI & persists for 5-7 days

41. Trop T kit

42. Coronary Angiography
 coronary catheterization is a minimally invasive procedure to access the
coronary circulation and blood filled chambers of the heart using a catheter .
 It is performed for both diagnostic and interventional (treatment) purposes
 Done under local anaesthesia

44. Nursing Management
Pre procedure :
 Before the patient undergoes cardiac catheterization a pre cardiac
catheterization patient teaching plan must be established and initiated .
 Explain the procedure to the patient
 Alleviate anxiety of the patient
 Assess for allergies
 complete pre procedure checklist before shifting the patient to lab
 check and document the status of peripheral pulses.

45. Post procedure :
Assess the peripheral vascularity of the lower extremities.
monitor vital signs, and distal pulses every 15 min
Maintain the patient on hourly intake and output
Check the puncture site for any signs of bleeding

47. Regular exercise Quit smoking
Healthy diet

48. Pharmacological Management
 Statins - to help lower cholesterol E. g - Lovastatin , simvastatin block cholesterol
synthesis, lower LDL and triglyceride levels, and increase HDL levels
 ACE inhibitors - Reduces systemic vascular, resistance and cardiac afterload .
Captopril 6.25 mg TID.
 Nitrates – Nitroglycerine sublingually 5-10 mg every 5 minutes, up to 3 doses (If
SBP > 100 mmHg)
 Thrombolytics - The purpose of thrombolytic is to dissolve and lyse the thrombus
allowing blood to flow through the coronary artery again (reperfusion) . E. g -
Aspirin , Clopidogrel , streptokinase

49. Chest pain for longer than 20 minutes, unrelieved by nitroglycerin
 ST-segment elevation in at least two leads that face the same area of the heart
 Less than 24 hours from onset of pain
Absolute Contraindications
 Active bleeding
 Known bleeding disorder
 History of haemorrhagic stroke
 History of intracranial vessel malformation
 Recent major surgery or trauma
 Uncontrolled hypertension
 Pregnancy
Indications for thrombolytics

50. Nursing Considerations
 Avoid intramuscular injections.
 Monitor for acute dysrhythmias, hypotension, and allergic reaction.
 Check for signs and symptoms of bleeding
 Treat major bleeding by discontinuing thrombolytic therapy
 Treat minor bleeding by applying direct pressure if accessible

51. Surgical Management
 PTCA ( Percutaneous transluminal coronary angioplasty )
 CABG (Coronary artery bypass grafting )

52. PTCA
 Coronary balloon angioplasty, also referred to as percutaneous
(through the skin) coronary intervention (PCI) .
 The purpose of PTCA is to improve blood flow within a coronary
artery by “cracking” the atheroma .
 The coronary arteries are examined by angiography

54. Risk and complications :
 Embolization
 Arterial rupture
 Hematoma or pseudo aneurysm formation at the access site
 Radiation Injuries Radiation induced injuries (burns) from the X-Rays used .

55. Coronary Artery Bypass Grafting
It is a surgical procedure to restore normal blood flow to an obstructed
coronary artery .
The 2004 AHA CABG guidelines state CABG is the preferred treatment for:
• Disease of the left main coronary artery (LMCA).
• Disease of all three coronary arteries (LAD, LCX and RCA).
• Diffuse disease not amenable to treatment with a PCI .

57. Nursing Management
 Acute Pain related to Decreased myocardial blood flow Increased cardiac
workload/oxygen consumption .
 Risk for Decreased Cardiac Output
 Impaired gas exchange related to trauma of extensive chest surgery
 Risk for deficient fluid volume and electrolyte imbalance related to alterations
in blood volume
 Acute pain related to surgical trauma and pleural irritation caused by chest
tubes and/or internal mammary artery dissection