coronary artery disease

Topic- Coronary Artery Disease

PRESENTATION
On
T
opic- CoronaryArtery Disease
Presented By-
OM VERMA
ASSISTANT PROFESSOR
RELIANCE INSTITUTE OF NURSING

WE WILL LEARNABOUT..
What is coronary circulation?
Why are the coronary arteries important?
What is atherosclerosis?
What is coronary artery disease ?
• Definition
• Incidence and prevalence
• Etiology and risk factors
• Pathophysiology
• Clinical manifestations
• Diagnostic tests
• Medical management
• Health education
• Evidences review

INTRODUCTION
⚫Coronary circulation- It is the circulation of blood
in the blood vessels of the heart muscle
(myocardium).
⚫The heart muscle needs oxygen-rich blood to
function, coronary arteries supply blood to the
heart muscle.
⚫The coronary arteries wrap around the outside of
the heart.

WHY ARE THECORONARY
ARTERIES IMPORTANT?
⚫Since coronary arteries deliver blood to the
heart muscle,
⚫any coronary artery disorder or disease can
have serious implications by reducing the flow
of oxygen and nutrients to the heart muscle.
⚫This can lead to a heart attack and possibly
death.

ATHEROSCLEROSIS
⚫Atherosclerosis is a building up of plaque
in the inner lining of an artery causing it to
narrow or become blocked. Its the most
common cause of heart disease.

CORONARY ARTERY
DISEASE
• CAD is narrowing or obstruction of one or more
coronary arteries because of atherosclerosis
which is the accumulation of lipid- containing
plaque in the arteries.
• According to Lippincott J.B.
• CAD is define as decreases perfusion to
myocardial tissue and inadequate myocardial
oxygen supply which leads to hypertension,
infarction, arrhythmias, heart failure and death.
• According to luckman’s

CAD
Coronary artery disease (CAD) is the
most common type of heart disease. ...
when the arteries that supply blood
to heart muscle become hardened and
narrowed. This is due to the buildup of
cholesterol and other material, called
plaque, on their inner walls. This buildup
is called atherosclerosis.
According to Brunner & Suddarth

CONTI..
⚫ Collateral circulation, more than 1 artery supplying
a muscle with blood, is normally present in the
coronary arteries, especially in older persons.
The development of collateral circulation takes time
and develops when chronic ischemia occurs to meet
the metabolic demands; therefore, an occlusion of a
coronary artery in a younger individual is more
likely to be lethal than one in an older individual.
Symptoms occur when the coronary artery is
occluded to the point that inadequate blood supply to
the muscle occurs, causing ischemia.
⚫According to black J.B.

CONTI..
⚫CAD is characterized by the accumulation of
plaque within coronary arteries, which
progressively enlarge , thicken and calcify.
⚫Coronary artery narrowing is significant if the
lumen diameter of the left main artery is
reduced at least 50%, or if any major branch is
reduced at least 75%.
⚫The goal of treatment is to alter the
atherosclerotic progression.

INCIDENCE AND PREVALENCE
The 2016 Heart Disease and Stroke Statistics
update of the American Heart Association
(AHA) has reported that 15.5 million
persons ≥20 years of age in the USA have
CHD , prevalence increases with age for both
men and women

ETIOLOGY ANDRISK
FACTORS
⚫ Heredity
⚫ Race
⚫ Increasing age
⚫ Gender
NONMODIFIABLE MODIFIABLE
⚫ Cigarette smoking
⚫ Hypertension
⚫ Elevated serum
cholesterol levels
⚫ Physical inactivity
⚫ Obesity
⚫ Diabetes mellitus
⚫ Lack of estrogen in
women
⚫ Behavior patterns (
stress, aggressiveness)

CIGARETTE SMOKING
Smoking increases the formation of plaque in
blood vessels. Coronary Heart Disease
occurs when arteries that carry blood to the
heart muscle are narrowed by plaque or
blocked by clots. Chemicals in cigarette
smoke cause the blood to thicken and form
clots inside veins and arteries.

HYPERTENTION
high blood pressure are more likely to develop coronary
artery disease, because high blood pressure puts added force
against the artery walls. Over time, this extra pressure can
damage the arteries, making them more vulnerable to the
narrowing and plaque buildup associated with atherosclerosis.
ELEVATED SERUM CHOLESTEROLLEVELS
When there is too much cholesterol in your blood, it builds
up in the walls of your arteries, causing a process called
atherosclerosis, a form of heart disease

PHYSICAL INACTIVE
lack of physical activity comes with great risks
including blood clots, high blood pressure, heart
attack, stroke and other heart related problems.
OBECITY
Obese individuals require more blood to supply oxygen
and nutrients to their bodies which causes an increase in
blood pressure. body will also require more pressure to
move this blood around. High blood pressure is also a
common cause of heart attack, which are sadly more
common for obese individuals.

D.M
Over time, high blood glucose from diabetes can damage your
blood vessels and the nerves that control your heart
and blood vessels. The longer you have diabetes, the higher
the chances that you will develop coronary heart disease.
.. In adults with diabetes, the most common causes of death
are heart disease and stroke.
LACK OF ESTROGEN IN WOMEN
A decline in the natural hormone estrogen may be a factor
in coronary heart disease increase among ….
post-menopausal women. Estrogen is believed to have a
positive effect on the inner layer of artery wall, helping to
keep blood vessels flexible.

STRESS
Studies suggest that the high levels of cortisol from long-
term stress can increase release of Catecholamine blood
cholesterol, triglycerides, blood sugar, and blood pressure.
These are common risk factors for heart disease.
This stress can also cause changes that promote the
buildup of plaque deposits in the arteries.

CONTRIBUTING RISK FACTORS
⚫Response to stress
⚫Inflammatory response
⚫Menopause
⚫Homocysteine levels

PATHOPHYSIOLOGY
Due to etiological factors injury to the endothelial cell
Fatty streaks of lipids deposit in arterial wall & Inflammation ,immune reactions start
T lymphocytes & monocytes Infiltrate
the area to ingest the lipids & die
Release biochemical sub Damage endothelial
attract platelets to initiate clotting
Smooth muscle cells proliferation form fibrous cap over dead fatty core (atheroma)
Protrusion of atheroma narrowing & obstruct the lumen of vessel
If cap has thin membrane the lipid core may grow and rupture
Hemorrhage into plaque & forming thrombus
Thrombus obstruct the blood flow leading to sudden cardiac death of myocardial infarction

CLINICALMANIFESTATIONS
⚫ Chest pain (Angina pectoris)
⚫ Palpitations

Dyspnea

Syncope

Cough/ hemoptysis

Dysarrythmias

Chest heaviness

Dizziness

Sweating

Feeling ofAnxiety

SCREENING TESTS FOR CAD
TMT
Radionuclide
stress test
Stress
echocardiography
Pharmacologic
stress test CTscanning
Coronary
angiography

Excessive Fatigue

DIAGNOSTIC TESTS
History collection

DIAGNOSTIC TESTS
Physical examination

DIAGNOSTIC TESTS
Cardiac Enzymes

DIAGNOSTIC TESTS
Cardiac Enzymes
CARDIAC
MARKER
INCREASESPEAK
RETURN
TO
BASELINE
COMMENTS
Myoglobin 1–4h 4–12h 24–36h
Earliest marker, but non-specific with
negative predictive value.
CK-MB 4–9 h 24 h 48–72h
Gold standard before troponin was
introduced. Mostly found in cytosol but
may increase in non-MI situation.
TroponinI/T 4–9 h 12–24h 7–14days
Most specific marker. Found in small
amounts in cytosol, but mostly in
sarcomere of cardiac myocytes (both
early and late marker). Troponin T is less
specific than troponin I because troponin
T is also found in muscle.

MYOGLOBIN
This test measures the amount of a protein called myoglobin in
your blood. It's done to help diagnose conditions caused by
muscle damage. Myoglobin is found in your heart and skeletal
muscles. There it captures oxygen that muscle cells use for
energy.
CK-MB CRDIAC ENZYMES This test
measures the amount of an isoenzyme of creatine kinase
(CK) in your blood. It is called CK-MB.
Your body makes 3 forms of CK, including CK-MB.
CK is found in the heart, muscles, and other organs.
These include the small intestine, brain, and uterus. If
you have a heart attack, injured heart muscle cells
release CK-MB into your blood.

Con……
Because many tissues contain CK, high levels of CK
can be a sign of a variety of problems. Higher CK-
MB may point more directly to heart damage.
Measuring CK-MB used to be a common tool for
diagnosing heart attacks, but healthcare providers use
it less often today. Cardiac troponin is now the test of
choice for finding a heart attack. This is because
cardiac troponin is more specific and more sensitive
than CK-MB.

TROPONIN TEST I/T
A troponin test measures the levels of troponin T
or troponin I proteins in the blood. These proteins are
released when the heart muscle has been damaged, such as
occurs with a heart attack. The more damage there is to the
heart, the greater the amount of troponin T and I there will
be in the blood.

DIAGNOSTIC TESTS
Serum cholesterol levels
When there is too much cholesterol in your blood, it builds
up in the walls of your arteries, causing a process called
atherosclerosis, a form of Coronary heart disease.
The arteries become narrowed and blood flow to
the heart muscle is slowed down or blocked.

DIAGNOSTIC TESTS
Electrocardiograms

An electrocardiogram (ECG or EKG) is
a test that checks how your heart is
functioning by measuring the electrical
activity of the heart. With each heart
beat, an electrical impulse (or wave)
travels through your heart. This wave
causes the muscle to squeeze and pump
blood from the heart.

DIAGNOSTIC TESTS
Echocardiograms

ECHOCARDIOGRAM checks how your
heart's chambers and valves are pumping
blood through your heart.
An echocardiogram uses electrodes to
check your heart rhythm and ultrasound
technology to see how blood moves
through your heart.
An echocardiogram can help your doctor
diagnose heart conditions.

DIAGNOSTIC TESTS
Treadmill T
est (TMT)

TREADMILL / STRESS TEST
ST Before you begin exercising, you’ll be hooked up to the
EKG machine. Several sticky pads electrode will be
attached to patient chest and electrode connected to the
macjine for monitoring heart electrical activity . doctor or
nurse will check heart rate and breathing before you begin
exercising. doctor may also have you breathe into a tube to
test the strength of lungs.
You’ll start off by walking slowly on a treadmill. The
speed and grade of the treadmill will be increased as the
test continues. EKG machine is recorded heart condition .
If you experience any difficulties — especially, chest
pains, weakness, or fatigue — you may ask to stop the test.
When your doctor is satisfied with your results, you’ll be
able to stop exercising. Your heart rate and breathing will
continue to be monitored for a short while afterward.

DIAGNOSTIC TESTS
Cardiac catheterization orAngiography

CARDIAC CATHETERIZATION OR ANGIOGRAPHY
The catheterization involves placing small IV tubes in the vein and
artery of a leg, arm or the neck. Through the special IV tubes the
cardiologist can pass thinner tubes (called catheters) into the
circulation. Catheters are small, hollow plastic tubes that are the size
of spaghetti noodles. The catheter is slowly moved through the
circulation until it reaches the heart. From there it can be passed to
different chambers of the heart and to the veins and arteries
connected to the heart. Your cardiologist can learn very important
information about your heart condition from the blood samples and
blood pressures measured through the catheter at different places in
the circulation. During the catheterization an angiogram is usually
performed. This is done by injecting special fluid (called dye or
contrast) through the catheter into a blood vessel or a chamber of the
heart. Since the dye is visible by X-ray, an X-ray movie of the
circulation can be recorded.

MEDICAL MANAGEMENT
Goal-
⚫Decrease myocardial oxygen demand
⚫Increase oxygen supply
It include-
⚫Pharmacological Therapy
⚫Surgical Management
⚫Nursing Management
⚫Lifestyle Changes

PHARMACOLOGICAL
THERAPY
⚫ Nitrates(nitroglycerine) – to dilate coronary arteries and decrease
preload and afterload.These actions help relieve chest pain.
⚫ SUBLINGUALTABLET:
0.3 to 0.6 mg sublingually or in the buccal pouch every 5 minutes as
needed, up to 3 doses in 15 minutes; if pain persists after maximum
dose, prompt medical attention is recommended.
⚫ EXTENDED RELEASE CAPSULE:
2.5 to 6 mg orally 3 to 4 times a day; titrate as needed and tolerated.
⚫ 5 mcg/min continuous IV infusion via non-absorptive tubing;
increase by 5 mcg/min every 3 to 5 minutes as needed up to 20
mcg/min, then by 10 or 20 mcg/min if needed.

PHARMACOLOGICAL
THERAPY
⚫ Beta-Adrenergic Blockers (Atenolol, Metroprolol) - decrease
myocardial oxygen consumption,
Increasing the amount of oxygen
decrease heart
delivered to the
rate.
heart
increases the chances of survival of individuals having a heart
attack. These actions help relieve chest pain.
⚫ DOSAGE-
 Atenolol- 25 milligrams (mg), 50 mg, and 100 mg.
 Metoprolol- 25, 50 and 100 mg. IV begins with a 5 mg
injection.

PHARMACOLOGICAL
THERAPY
⚫ Calcium channel blockers- Calcium channel blockers help
lower blood pressure by relaxing the blood vessels throughout
your body. As a result, less pressure is built up and your heart
does not have to work as hard to pump blood.
⚫ Nifedipine- Oral capsule- 10 mg, 20 mg. Oral extended-
release tablet- 30 mg, 60 mg, 90 mg.
⚫ Amlodipine- 2.5 mg, 5mg, 10mg.

PHARMACOLOGICAL
THERAPY
⚫ Antiplatelet and anticoagulant agents- to inhibit thrombus
formation.
⚫ Aspirin- Immediate-release: 50 to 325 mg orally once a day
Extended-release (ER): 162.5 mg orally once a day.
⚫ Clopdidogrel- 75 mg orally once a day.

Conti..
⚫Antilipid medications (atorvastatin) to decrease
blood cholesterol and triglyceride levels.
⚫Atorvastatin-
 Initial dose: 10 mg or 20 mg orally once a day
 Maintenance dose: 10 mg to 80 mg orally once a
day.

Conti..
⚫Angiotensin converting enzyme inhibitors
(captopril) to promote a favorable balance of
oxygen supply and demand.
⚫Captopril-
Initial dose: 25 mg orally 2 to 3 times a day
one hour before meals.
Maintenance dose: May increase every 1 to 2
weeks up to 50 mg orally three times a day.
Maximum dose: 450 mg/day.

Conti..
⚫Imipramine, morphine sulphate for
analgesia. Dose- imipramine- 100 mg and
150 mg daily. Morphine- 10mg, 15 mg.
⚫
⚫Folic acid and B complex vitamins to
reduce homocysteine levels.

THROMBOLYTICS : Medications administered
directly to the coronary artery through cardiac catheter.
Its purpose is to dissolve & lyse the thrombus in a
coronary artery allowing blood to flow through the
coronary artery again , minimizing the size of infarction
& prerving ventricular function. Streptokinase & tissue
type plasminogen activator is used.
Streptokinase : it increase the amount of plasminogenactivator which
than increases the amount of both circulating and clot bound
plasminogen.
Tissue type plasminogen activator : t-PA activates the plasminogen on
the clot more than the circulating plasminogen. Because it does not
decrease the clotting factors as much as streptokinase does, heparin is
used with t-PA to prevent another clot from forming at the same
location. Naturally occurring enzyme so allergic reactions are minimized.

PERCUTANEOUS TRANSLUMINAL
CORONARY ANGIOPLASTY

PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY
(PTCA)
is a minimally invasive procedure to open up blocked
coronary arteries, allowing blood to circulate unobstructed to
the heart muscle.
The procedure begins with the doctor injecting some local
anesthesia into the groin area and putting a needle into the
femoral artery, the blood vessel that runs down the leg.
Next, a long narrow tube called a diagnostic catheter is
advanced through the introducer over the guide wire, into the
blood vessel. This catheter is then guided to the aorta and the
guide wire is removed. Once the catheter is placed in the
opening one the coronary arteries, the doctor injects dye and
takes an x-ray.

If a treatable blockage is noted, the first
catheter is exchanged for a guiding
catheter. Once the guiding catheter is in
place, a guide wire is advanced across
the blockage, then a balloon catheter is
advanced to the blockage site. The
balloon is inflated for a few seconds to
compress the blockage against the artery
wall. Then the balloon is deflated.

The doctor may repeat this a few times, each time
pumping up the balloon a little more to widen the
passage for the blood to flow through. This
treatment may be repeated at each blocked site in
the coronary arteries. A device called a stent may
be placed within the coronary artery to keep the
vessel open. Once the compression has been
performed, contrast media is injected and an x-ray
is taken to check for any change in the arteries.
Following this, the catheter is removed and the
procedure is completed.

Using a catheter, the coronary
artery stent and angioplasty balloon are
guided to the site of the narrowed vessel.
The balloon is inflated to expand
the stent and then removed from the artery.
The expanded stents remains in place,
keeping the artery open. Tissue will
completely grow over it within two to three
weeks.

Laser ablation or photoablation
is the process of removing material
from a solid (or occasionally liquid)
lipid accumulation surface by
irradiating it with a laser beam. At
low laser flux, the material is heated by
the absorbed laser energy and
evaporates or sublimates then remove
blockage of artery .

CORONARY ARTERYBYPASS
GRAFTING
⚫It involves the bypass of a blockage in one
or more of the coronary arteries using the
saphenous veins, mammary artery or
radial artery.

Coronary artery bypass graft
surgery (CABG) is
a procedure used to treat coronary
artery disease. Coronary artery
disease (CAD) is the narrowing of the
coronary arteries – the blood vessels
that supply oxygen and nutrients to
the heart muscle.

LIFESTYLE CHANGES
⚫Weight control
⚫Smoking cessation
⚫Exercise
⚫Healthy diet

NURSING MANAGEMENT
ASSESSMENT
⚫ Gather information about patient present signs and
symptoms.
⚫ Assess patients risk factors for CAD
⚫ Perform the physical examination
⚫ Obtain and assess ECG
⚫ Check vital signs and report lab investigations
⚫ Evaluate patients past health history such as DM2, heart
failure, previous MI, obstructive lung disease that may
influence choice of drug therapy
⚫ Identify patient and family’s knowledge about diagnosis,
their level of anxiety and use of appropriate coping
mechanisms

NURSING DIAGNOSIS
⚫ Acute Pain related to decreased myocardial blood flow
or increased cardiac workload/oxygen consumption as
evidenced by reports of pain varying in frequency,
duration, and intensity.
⚫ Ineffective tissue perfusion related to decreased cardiac
output as evidenced by dyspnea.
⚫ Decreased cardiac output related to alteration in heart
rate
⚫ Impaired gas exchange related to decreased cardiac
output as evidenced by dyspnea and decreased SpO2
⚫ Activity intolerance related to decreased cardiac output
⚫ Anxiety related to hospital admission evidenced by
patients verbal response
⚫ Risk to constipation related to bed rest as evidenced by
subjective feeling of fullness.

Acute Pain
⚫ Instruct patient to notify nurse immediately when
chest pain occurs.
⚫ Assess and document patient response to medication.
⚫ Identify precipitating event, if any: frequency,
duration, intensity, and location of pain. Observe for
associated symptoms: dyspnea, nausea and vomiting,
dizziness, palpitations, desire to micturate.
⚫ Evaluate reports of pain in jaw, neck, shoulder, arm,
or hand (typically on left side).
⚫ Place patient at complete rest during anginal
episodes.
⚫ Elevate head of bed if patient is short of breath.

Acute Pain
⚫ Monitor heart rate and rhythm.
⚫ Monitor vital signs every 5 min during initial
anginal attack.
⚫ Stay with patient who is experiencing pain or
appears anxious.
⚫ Maintain quiet, comfortable environment. Restrict
visitors as necessary.
⚫ Provide supplemental oxygen as indicated.
⚫ Administer antianginal medication(s) promptly as
indicated: Nitroglycerin: sublingual , atenolol,
nifedipine, Analgesics, Morphine sulphate(MS).

INEFFECTIVE TISSUE PERFUSION
⚫ Assess V/S.
⚫ Assess spO2 of patient.
⚫ Review laboratory data (ABGs, BUN, creatinine,
electrolytes, international normalized ratio, and
prothrombin time or partial thromboplastin time.
⚫ Check respirations and absence of work of breathing.
⚫ Check Hgb levels
⚫ Check for pallor, cyanosis, mottling, cool or clammy
skin. Assess quality of every pulse.
⚫ Check for optimal fluid balance. Administer IV fluids as
ordered.
⚫ Maintain optimal cardiac output.
⚫ Administer nitroglycerin (NTG) sublingually for
complaints of angina.
⚫ Maintain oxygen therapy as ordered.

DECREASED CARDIAC OUTPUT
RELA
TED TO AL
TERA
TION IN
HEART RATE
⚫Assess cardiac output, pulse, arterial BP,
ECG
⚫Assess heart rhythm and treat dysthymias
⚫Auscultate heart sounds and lung sounds
⚫Administer vasodilators
⚫Administer calcium channel blockers
⚫Administer antiarryrthmatics

IMPAIRED GAS EXCHANGE
DECREASED CARDIAC
RELATED TO
OUTPUT AS
EVIDENCED BY DYSPNEA AND DECREASED
SPO2
⚫ Assess respiratory rate, SpO2 andABG
⚫ Assess capillary refill, LOC, dyspnea
⚫ Auscultate chest for breath sounds
⚫ Provide high fowlers position
⚫ Administer oxygen as ordered
⚫ Administer nebulization
⚫ Encourage the use of spirometry and deep
breathing exercise.
⚫ Perform chest physiotherapy

ACTIVITY INTOLERANCE R/T
DECREASED CARDIAC OUTPUT
⚫Assess the general condition of patient
⚫Assess the vitals before and after activity
⚫Monitor the clients response to activities
⚫Space the nursing activities
⚫Schedule the rest periods
⚫Increase activity as ordered
⚫Instruct the client to avoid activity that
increase cardiac workload

ANXIETY RELATED TO HOSPITAL
ADMISSION EVIDENCED BY PATIENTS
VERBALRESPONSE
⚫Assess the level of anxiety
⚫Allow and encourage the client and family to
ask questions
⚫Allow the patient to verbalize the feelings
⚫Provide comfortable and quiet environment
⚫Administer anti anxiety drugs.

RISK TO CONSTIPATION RELATED TO
BED REST AS EVIDENCED BY
SUBJECTIVE FEELING OF FULLNESS
⚫Assess the intake output of patient
⚫Ensure that patient has adequate bulk in
diet and fluid intake
⚫Monitor the effectiveness of softeners or
laxatives
⚫Encourage the client to use beside
commodate rather than bedpan

What are the complications of coronary
artery disease?
Heart failure. Over time, CAD can lead
to heart failure. ...
Abnormal heartbeat. An abnormal
heartbeat is called an arrhythmia. ...
Chest pain. ...
Heart attack. ...
Sudden death. ...
Related arterial diseases.

HEALTH EDUCATION
Physical exercise

HEALTH EDUCATION
Decreasing obesity

HEALTH EDUCATION
Treating high blood pressure

HEALTH EDUCATION
Eating a healthy diet

HEALTH EDUCATION
Adequate rest

HEALTH EDUCATION
Controlling blood sugar

HEALTH EDUCATION
Decreasing cholesterol levels

HEALTH EDUCATION
Decrease psychosocial stress

HEALTH EDUCATION
Regular follow-ups

HEALTH EDUCATION
⚫Decreasing cholesterol levels
⚫Stopping smoking
⚫Decrease psychosocial stress.
⚫Regular follow-ups
⚫Exercise.Aerobic exercise, like walking,
jogging, or swimming, can reduce the
risk of mortality from coronary artery
disease.

RECAPTUALIZATION
1. Which of the following illness is the leading cause of
death in the world?
a) Cancer
b) CoronaryArtery Disease
c) Liver Failure
d) Renal Failure
Answer: b.
2. There are number of risk factors associated with CAD.
Which of the following is a modifiable risk factor?
a) Obesity
b) Heredity
c) Gender
d) Age
Answer: a.

RECAPTUALIZATION
3. Which of the following conditions most commonly
results in CAD?
a) Atherosclerosis
b) Diabetes mellitus
c) Myocardial Infarction
d) Renal Failure
Answer: a.
4. Atherosclerosis impedes coronary blood flow by which
of the following mechanisms?
a) Plaques obstruct the vein
b) Plaques obstructs the artery
c) Blood clots from outside the vessel wall
d) Hardened vessels dilate to allow the blood flow through
Answer: b.

BIBLIOGRAPHY
⚫ Brunner & Suddarth. Text book of
medical & surgical nursing, edition 8th,
28th chapter; (859-64).
⚫ Lippincott J.B. Text book of medical&
surgical nursing. 4th ed.; (1347-48).
⚫ Black J.M. Text book of medical&
surgical nursing, 7th ed; 56 chapter;
(1410-1415).

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