coronary artery disease

The cardiovascular system is composed of the heart, blood, and
vascular system.
The cardiovascular system distributes food, oxygen, and
hormones to all living cells and carries waste products and
carbon dioxide away from the cells.

Types of heart diseases
Congenital Acquired
Coronary artery disease (CAD)
Conduction
problem
Valvular heart disease
Infective heart disease

Coronary artery disease (CAD) also known as atherosclerotic heart
disease, coronary heart disease, or ischemic heart disease (IHD), is
the most common type of heart disease and cause of heart attacks.
The disease is caused by plaque building up along the inner walls of
the arteries of the heart, which narrows the arteries and reduces
blood flow to the heart.

Risk Factors of MI
Non-modifiable: Modifiable:

Modifiable:
Hypercholestorolemia
Habitual diet
Hypertension
Smoking
Obesity
Oral contraceptives
Diabetes mellitus
life style
Psychosocial tension
Lack of exercise

Dyslipidemia Hypertension Smoking Physical inactivity
0
100
200
300
400
500No.ofpatients
Risk factors
Annual incidence of CAD in relation to number of risk factors present

Hypercholesterolemia
Lipoproteins
HDL (“good”) LDL (“bad”)
Protective action on heart Ill effect on heart
Assist in utilization of
total cholesterol
Transport LDL to liver
Biodegraded & excreted
Accelerate the process
of atherosclerosis

Saturated fat
Habitual diet
High in LDL
Animal fat Increases the synthesis of
Cholesterol & triglyceride
Unsaturated fat High in HDL

Hypertension
Increases the risk of heart attack,
stroke, kidney failure and congestive
heart failure.
Increases the heart's workload
Causing the heart to enlarge and
weaken overtime

Smoking
CO Hb + CO HbO2 O2 supply to heart is
limited
Increases workload of heart
Nicotine
HDL
LDL
Catacholamine
Platelet adhesion Higher chance thrombus formation

Obesity
Increases strain on heart
Raises BP Raises cholesterol

Sedentary living pattern
Favorable effects of physical activity
HDL values
Reduction of weight
Increased functional capacity of
heart
Decreased myocardial O2 demand
Decreased platelet adhesiveness
Electrical stability of myocardium

ETIOLOGY
Cause of coronary artery narrowing are:
Atherosclerosis
Thrombosis
Spasm
Coronary dissection
Aneurysm formation

1. The main Cause of coronary artery disease is:
a. Atherosclerosis
b. Thrombosis
c. Spasm
d. Coronary dissection
2. Saturated fat are increases risk for heart disease because its:-
a) High in LDL
b) High in HDL
c) Have both LDH and HDL
d) Non of the above

3. Non-modifiable risk factors for coronary artery
disease are:-
a) Diet
b)Family history
c) Exercise
d)stress
4. modifiable risk factors for coronary artery disease are:-
a) Age
b) Race
c) Gender
d) obesity

5. HDL (“good”) is good for the hear because:-
a) Protective action on heart
b) Assist in utilization of total cholesterol
c) Transport LDL to liver
d) All of the above

CORONARY ATHEROSCLEROSIS
Atherosclerosis is an abnormal
accumulation of lipid, or fatty,
substances and fibrous tissue in
the vessel wall. These substances
create blockages or narrow the
vessel in a way that reduces
blood flow to the myocardium.

Pathophysiology
Progression of Atherosclerosis:
1. Fatty streak:
• Atherosclerosis begins as fatty streaks, lipids are
deposited in the intima of the arterial wall
• The reason why some fatty streaks continue to develop is unknown,
although genetic and environmental factors are involved.
• No obstruction
23

2. Fibrous plaque: Plaque and thrombus formation
• Ruptured plaque or The continued development of atherosclerosis involves
an inflammatory response
• T lymphocytes and monocytes (that become macrophages) infiltrate the area
to ingest the lipids
• this causes smooth muscle cells within the vessel to proliferate and form a
fibrous cap over the dead fatty core. These deposits, called atheromas or
plaques, protrude into the lumen of the vessel, narrowing it and obstructing
blood flow

3. COMPLICATE LESION: TOTAL OCCLUSION
• The thrombus may obstruct blood flow, leading to sudden cardiac
death or an acute myocardial infarction (MI), which is the death
of heart tissue.

CLINICAL MANIFESTATIONS
• The most common manifestation of myocardial ischemia is acute onset of chest pain.
However, an epidemiologic study showed that nearly 15% of men and women who had
MIs were totally asymptomatic (Kannel, 1986).
• coronary arteries, which are responsible for bringing oxygenated blood to the heart, can
produce symptoms such as
• Shortness of breath
• Sweating, nausea
• Dizziness or light-headedness
• Breathlessness or palpitations
• Arrhythmias

 Carotid arteries supply blood to the brain and neck. Marked narrowing of
the carotid arteries can present with symptoms such as a feeling of
weakness, not being able to think straight, difficulty speaking, becoming
dizzy and difficulty in walking or standing up straight, blurred vision,
numbness of the face, severe headache and losing consciousness.
 Peripheral arteries, which supply blood to the legs, arms, and pelvis, also
experience marked narrowing due to plaque rupture and clots. Symptoms
for the marked narrowing are numbness within the arms or legs, as well as
pain.

Diagnosis
 HISTORY TAKING AND PHYSICAL EXAMINATION
 BLOOD TEST:- HOMOCYSTEINE, CRP, LIPDPROFILE, SUGAR
 ECG
 CHEST X-RAY
 DOPPLER ULTRASOUND OF RIGHT INTERNAL CAROTID
 STRESS TEST
 ECHOCARDIOGRAM.
 CARDIAC CATHETERIZATION
 CT SCAN HEART
 MYOCARDIAL BIOPSY
 HEART MRI

Angiography – Examination of the blood vessels using x-rays
following the injection of a radiopaque substance.

As these plaques grow, they tend to occlude the artery producing a
“visible” area of stenosis within the arterial lumen. Therefore, they
are typically detected by cardiac stress tests or an angiogram.
Cardiac stress test Angiogram
Area of Stenosis

Treatment for Atherosclerosis
Lifestyle Changes- The changes will focus on weight management,
physical activity and a healthy diet.
Medication (anteplatelets), Other medications such as statins may be
prescribed to lower cholesterol, and Angiotensin-converting enzyme (ACE)
inhibitors to lower blood pressure.
Surgery - Severe cases of atherosclerosis may be treated by surgical
procedures, such as angioplasty , Stents or coronary artery bypass grafting
(CABG).

First, angiography
provides an angiogram
which allows the area of
stenosis to be located.
Angioplasty – a surgical technique for restoring normal blood flow
through an artery narrowed or blocked by atherosclerosis, either by
inserting a balloon into the narrowed section and inflating it or by
stent

The two most common surgical procedures used today are
balloon angioplasty, often accompanied by stent placement, or
coronary artery bypass.
BALLOON ANGIOPLASTY CORONARY ARTERY BYPASS

• A narrow balloon is inserted in
the coronary artery
• The balloon is inflated to press
the plaque against the arterial
wall
• A stent can be inserted to hold
the vessel open
• This opens the lumen and
allows better blood supply
Angioplasty with Stent

Coronary Artery Bypass Graft – open-heart surgery in which the
rib cage is opened and a section of a blood vessel is grafted from the
aorta to the coronary artery to bypass the blocked section of the
coronary artery and improve the blood supply to the heart

Prevention
The best way to prevent atherosclerosis is to eliminate any risk
factors you might have. The best way to do this is by living a
healthy lifestyle.
Diet:-Controlling cholesterol abnormalities
Exercise
Smoking:-Promoting cessation of tobacco use
Managing hypertension
Controlling diabetes mellitus

COMPLICATION
• Coronary artery disease: Stable plaques in the heart's arteries cause angina (chest
pain on exertion). Sudden plaque rupture and clotting causes heart muscle to die.
This is a heart attack, or myocardial infarction.
• Cerebrovascular disease: Ruptured plaques in the brain's arteries causes strokes
with the potential for permanent brain damage. Temporary blockages in an artery
can also cause transient ischemic attacks (TIAs).
• Peripheral artery disease: Narrowing in the arteries of the legs caused by plaque
causes poor circulation. This causes pain on walking and poor wound healing.
Severe disease may lead to amputations.
• Aneurysms

Angina pectoris
Definition:
Angina: Choking or suffocation.
Pectoris: Chest.
Angina pectoris, is the medical term used to describe acute
chest pain or discomfort.
Angina occurs when the heart’s need for oxygen increases beyond
the level of oxygen available from the blood nourishing the heart.

Angina is temporary chest discomfort or pain caused by
coronary artery disease. It is caused by a partial blockage in the
coronary artery(s). Angina is the heart’s way of telling you that there is
not enough blood and oxygen supply to the heart. The usual
symptom of angina is discomfort/pain (ache, pressure, heaviness,
tightness, burning feeling, numbness) in the chest or the neck, jaw,
arms, or back.

• Angina pectoris is a clinical
syndrome usually characterized by
episodes or paroxysms of pain or
pressure in the anterior chest. The
cause is usually insufficient
coronary blood flow.
• Constricting chest pain, often
radiating to the left shoulder and
down the left arm, caused by an
insufficient supply of blood to the
heart. Coronary artery disease is a
common cause of angina pectoris.

Types of Angina
Stable angina:
 People with stable angina have episodes of chest discomfort that are
usually predictable.
 It triggered by:
 activity
 eating a very large meal
 emotional stress
 exposure to extreme hot or cold weather.
 Normally the chest discomfort is relieved with rest, nitroglycerin
(GTN) or both. Occurs in a regular pattern, usually lasts 5 minutes or
less, and is easily relieved by medications
 It has a stable pattern of onset, duration and intensity of symptoms.

Unstable
May be new onset of pain with exertion or at rest, or recent acceleration
in severity of pain
Occurs in no regular pattern, usually lasts longer (30 min-), not generally
relieved with rest or medications
Sometimes grouped with myocardial infarction (MI) under the diagnosis
of acute coronary syndrome (ACS)

Silent ischemia: objective evidence of ischemia (such as
electrocardiographic changes with a stress test), but patient
reports no symptoms
Variant Angina (Prinzmetal’s or resting angina) :
• occur spontaneously with no relationship to activity. Occurs at rest due
to spasm.
• Appears to by cyclic & often occurs at about the same time each day
(usually at night). Thought to be caused by coronary artery spasm
• Electrocardiogram (ECG) changes due to coronary artery spasm

SIGNS AND SYMPTOMS
 Retrosternal chest discomfort (pressure, heaviness, squeezing, burning,
or choking sensation) as opposed to frank pain
 Pain localized primarily in the epigastrium, back, may radiate to the
neck, jaw, shoulders, and inner aspects of the upper arms, usually the
left arm
 Pain precipitated by exertion, eating, exposure to cold, or emotional
stress, lasting for about 1-5 minutes and relieved by rest or
nitroglycerin
 A feeling of weakness or numbness in the arms, wrists, and hands may
accompany the pain, as may shortness of breath, pallor, diaphoresis,
dizziness or lightheadedness, and nausea and vomiting.

DIAGNOSTIC EVALUATION
 HISTORY TAKING AND PHYSICAL EXAMINATION
 BLOOD TEST:- HOMOCYSTEINE, CRP, LIPDPROFILE, SUGAR
 CHANGES IN THE CARDIAC MARKER
 ECG
 CHEST X-RAY
 DOPPLER ULTRASOUND OF RIGHT INTERNAL CAROTID
 STRESS TEST
 ECHOCARDIOGRAM.
 CARDIAC CATHETERIZATION
 CT SCAN HEART
 MYOCARDIAL BIOPSY
 HEART MRI

Medical Management
 The objectives of the medical management of angina are to decrease
the oxygen demand of the myocardium and to increase the oxygen
supply. Medically, these objectives are met through pharmacologic
therapy and control of risk factors.
 Revascularization procedures to restore the blood supply to the
myocardium include percutaneous coronary interventional (PCI)
procedures (eg, percutaneous transluminal coronary
angioplasty [PTCA], intracoronary stents, and atherectomy),
CABG, and percutaneous transluminal myocardial revascularization
(PTMR).
 Oxygen Administration.

PHARMACOLOGIC THERAPY
1. Nitroglycerin:-It helps to increase coronary blood flow by
preventing vasospasm and increasing perfusion through the
collateral vessels.
2. Beta-Adrenergic Blocking Agents
3. Calcium Channel Blocking Agents
4. Antiplatelet and Anticoagulant Medications

• Ischemic heart disease is also known as coronary artery disease or
“hardening of the arteries.” Cholesterol plaque can build up in the arteries
of the heart and cause “ischemia,” which means the heart is not getting
enough blood flow and oxygen. If the plaque blocks an artery, a heart
attack can result.
• " Ischaemia " refers to an insufficient amount of blood. The
coronary arteries are the only source of blood for the heart muscle.
If this coronary arteries are blocked, the blood supply will reduce.
Ischemic Heart Disease

Definition of acute Myocardial Infarction
Myocardial O2
demand
Myocardial O2
supply
Irreversible myocardial necrosis

MI refers to a dynamic process by which one or more regions of the heart
experience a severe and prolonged decrease in oxygen supply because of
insufficient coronary blood flow; subsequently, necrosis or death to the
myocardial tissue occurs. The onset of the MI process may be sudden or
gradual, and the progression of the event to completion takes approximately
3 to 6 hours. MI is one manifestation of ACS.
MI refers to the process by which areas of myocardial cells in the heart are
permanently destroyed. Like unstable angina, MI is usually caused by reduced
blood flow in a coronary artery due to atherosclerosis and occlusion of an
artery by an embolus or thrombus.

How does the infarcted area look?

Atherosclerosis,
1Lumen (opening)
2  Plaque
3  Artery wall

Etiology of myocardial infarction
Coronary artery disorders:
Atheroscelorosis
Coronary artery spasm
Coronary arteritis
Circulatory disorders:
Hypovolemia
Hypertension
Left ventricular failure
Blood disorders:
Polycythemia
Anaemia
Hypoxemia

Pathophysiology of Myocardial Infarction
Stages of atherosclerosis formation

How can MI occur??
Luminal narrowing of coronary blood vessel
Reduced blood flow & O2 supply to myocardium
Leads to ischemia
If not treated leads to injury
If continues for prolonged time
Myocardial infarction

Acute inferior myocardial infarction

Acute anterior myocardial infarction
ST elevation in the anterior leads V1 - 6, I and aVL
Reciprocal ST depression in the inferior leads

Acute posterior myocardial infarction
(hyperacute) the mirror image of acute injury in leads V1 – 3
(fully evolved) tall R wave, tall upright T wave in leads V1 -3
usually associated with inferior and/or lateral wall MI

Anteroseptal MI
Note QS waves in V1-2, qrS complex in V3, plus ST-T wave changes)

Anterior MI (similar changes, but usually V1 is spared; if V4-6 involved call it
"anterolateral”
note Q's V2-6 plus hyperacute ST-T changes)

Clinical manifestation of MI
duration
location
radiating
Any relieving
factors????

Characteristic chest pain
ECG changes
Elevated cardiac
enzymes
Diagnosis of coronary artery disease
Echocardiogram
Radionuclide imaging
Angiography

Study of cardiac enzyme …….most reliable
Graphical representation
of the enzyme activity in
plasma following a
myocardial infarction

CARDIAC ENZYME
Normal
3hrs
Peak
Myoglobin
EARLIEST INCREASE (HR)
4-24 hr 1-3 wkTroponin T or I
1–3 hr 4–12 12 hr
CK-MB 4-8 hr
12-24
3–4 days

Goals of medical management of patient with MI
Management of MI
Pain Control
Pharmacological Therapy
Thrombolytic therapy
PTCA
CABG

Administration of Thrombolytic Therapy
Indications
• 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 hemorrhagic stroke
• History of intracranial vessel
malformation
• Recent major surgery or trauma
• Uncontrolled hypertension
• Pregnancy

Nursing Considerations
• Minimize the number of times the
patient’s skin is punctured.
• Avoid intramuscular injections.
• Draw blood for laboratory tests when
starting the IV line.
• Start IV lines before thrombolytic
therapy; designate one line
to use for blood draws.
• Avoid continual use of noninvasive
blood pressure cuff.
• Monitor for acute dysrhythmias,
hypotension, and allergic reaction.
• Monitor for reperfusion: resolution of
angina or acute ST-segment changes.
• Check for signs and symptoms of
bleeding: decrease in hematocrit and
hemoglobin values, decrease in blood
pressure, increase in heart rate, oozing or
bulging at invasive procedure sites, back
pain, muscle weakness, changes in level
of consciousness, complaints of
headache
• Treat major bleeding by discontinuing
thrombolytic therapy and any
anticoagulants; apply direct pressure and
notify the physician immediately.
• Treat minor bleeding by applying direct
pressure if accessible and appropriate;
continue to monitor.

Pain control
Administer morphine sulphate
Mode of action :
Bind the opiate receptor in CNS
Inhibit the ascending pain pathway

Other pharmacological therapy
Anticoagulant
Betablockers
Calcium channel blockers
Vasodilators
Antiplatelet

POPULATION
/PROBLEM INTERVENTION RESULT CONCLUSION
LEVEL OF
EVIDENCE
Low serum testosterone and
myocardial infarction
A survey of
serum Testosteronetlevels and a
range of medical and behavioral
factors was conducted on 71 males
aged 46 to 89 years in an extended
care medical facility. Histories
of M.I or heavy drinking were
separately associated with
diminished Testosteronelevels No
other factor was associated
with Testosteron level, including age
and mobility.
Histories of M.I or heavy drinking were separately
associated with diminished Testosteronetllevels (P less
than.002 and P less than.006, respectively). No other
factor was associated with Testosteronetl level,
including age and mobility. A Testosteronetllevel of no
more than 438 ng/dl best discriminated patients
with M.I (P less than.005, sensitivity 86.2%, and
selectivity 50%). Increased incidence of M.I appeared
to be influenced by Testosteronein a threshold manner,
since the incidence did not rise further with
lesserTestosterone levels once the level was below 438
ng/dl. The incidence of M.I among patients
withTestosterone levels below this threshold was
unaffected by their exposure to alcohol. Among the
21 formerly heavy drinkers, many (62%)
showed tTestosteronelevels less than or equal to 300
ng/dl.
Increased incidence
of M.I appeared to be
influenced by Testosteronein a
threshold manner.
3

1) The nurse, discussing coronary heart disease risk factors with a group of
factory employees, would include which option(s) as modifiable risk
factors? Select all that apply.
1. hypertension
2. diabetes mellitus
3. obesity
4. age
5. heredity
2) Which diagnostic test would the nurse anticipate as priority for a pt
admitted with chest pain to determine coronary heart disease status?
1. coronary angiography
2. stress electrocardiography
3. echocardiography
4. radionuclide testing

3) Aspirin has been prescribed for a pt following a myocardial infarction. What should the
nurse include in teaching about this drug?
1. Check with your healthcare provider before taking any herbal remedies.
2. Report any itching that develops after seven days of taking the drug.
3. Take at a different time of day than warfarin (Coumadin).
4. Do not skip any scheduled appointments to have blood drawn for labs.
4) The nurse is assessing a pt who is six hours postoperative from coronary artery bypass
graft (CABG) surgery. The pt's heart rate is 120, bp is 90/50, urine output is decreased,
chest tube output is decreased, heart sounds are muffled, & peripheral pulses are
diminished. What action should be taken by the nurse first?
1. Notify the physician immediately.
2. Recheck vital signs in 15 minutes.
3. Reposition the pt.
4. Increase the intravenous fluids.

5) During an office visit, a 55-yr-old female pt asks why she has not been prescribed a
daily dose of aspirin. Her 56-yr-old husband has been advised by the physician to
take a daily aspirin. What can the nurse explain is the most likely reason for this?
1. The benefit of aspirin in women under age 65 is not clear.
2. Aspirin is not recommended for women.
3. This must have been an oversight.
4. She has other meds that could interfere
6) During pt teaching about cardiac risk factors, the nurse knows that which laboratory
test, if abnormal, requires further instruction due to the risk for the development of
coronary artery disease?
1. elevated homocysteine
2. elevated creatinine
3. elevated high density lipoprotein (HDL)
4. elevated INR

7) The nurse, caring for a pt admitted w/ chest pain, realizes that which factor
places the pt at the highest risk for heart disease?
1. overweight & carries the weight around the waist
2. mother died at age 70 of an acute myocardial infarction
3. a single mother of four young children with a low income
4. has a desk job & works long hours
8) The nurse, assessing a middle-aged pt experiencing chest pain, realizes that
presence of which symptoms would be most characteristic of an acute
myocardial infarction?
1. substernal pressure type pain, radiating down the left arm
2. colic-like epigastric pain
3. sharp, well-localized unilateral chest & left arm pain
4. sharp, burning chest pain moving from place to place

9) The nurse, caring for a pt diagnosed with Prinzmetal's or variant angina, realizes this is a
serious type of chest pain. Why is this so?
1. It indicates presence of coronary artery spasm.
2. It indicates there is associated renal disease.
3. It indicates there is associated pulmonary disease.
4. It indicates the presence of a myocardial infarction.
10) A pt enters the ER complaining of chest pain that is radiating down the left arm. The
emergent treatment plan for this pt includes which nursing actions? Select all that apply.
1. morphine intravenously & oxygen
2. aspirin 325 mg orally
3. open heart surgery
4. heparin drip at 100 units per hour
5. Foley catheter insertion

11) Following a transmural myocardial infarction, which ECG change stays with the
pt for life?
1. Q wave deepening
2. ST segment elevation
3. ST segment depression
4. P wave inversion
12) A pt reports chest pain, nausea, & vomiting off & on for the last 4 days, which
the pt interpreted as the flu. Which lab tests will provide info about acute cardiac
damage for this pt?
1. Troponin I & T
2. Red blood cells
3. CPK-MB
4. Homocysteine & platelets

13) Coronary heart disease (CHD) is a major problem in the United States. Pts with
which history may require closer evaluation for CHD? Select all that apply.
1. diabetes
2. hyperlipidemia
3. positive family history
4. a premenopausal woman
5. hypotension
14) A nurse is conducting teaching about risk factor management for cardiovascular
disease (CVD) at a senior center. What is the most important info for the nurse
to include?
1. Stop smoking.
2. Eat in moderation.
3. Exercise when able.
4. Reduce saturated fats in the diet.

15) Which is the priority nursing intervention for a pt with a junctional escape
rhythm?
1. Assess the pt for symptoms associated with this rhythm.
2. Contact the physician immediately for emergency orders.
3. Eliminate caffeine from the diet.
4. Prepare for a pacemaker insertion.
16) The nurse is reviewing a new prescription for propranolol (Inderal) for a pt
with coronary heart disease (CHD). The nurse would call the physician &
question this prescription if the pt has which history?
1. has a history of asthma & chronic obstructive pulmonary disease (COPD)
2. is also taking antioxidants
3. is also taking simvastatin (Zocor)
4. has a history of bleeding disorders

17) Angina that is characterized as atypical, occurs unpredictably & often at night
& is associated with coronary artery spasm would be labeled as which type of
angina?
1. Prinzmetal's (variant) angina
2. stable angina
3. unstable angina
4. ischemic angina
18) Premature ventricular contractions (PVCs) are best characterized by which
statement?
1. They are insignificant in people with no history of heart disease.
2. PVCs typically have no pattern.
3. The frequency of PVCs is not associated with specific events.
4. Their incidence & significance has no relevance to the pt having had a
myocardial infarction.

19) A pt reports the following symptoms to the nurse: nausea, loss of appetite,
blurred & double vision, green yellow halos, vomiting & "feeling uneasy."." What
situation should the nurse suspect?
1. digoxin toxicity
2. lidocaine toxicity
3. amiodarone toxicity
4. procainamide toxicity
20) the nurse is admitting a patient who is complaining of chest pain to the
emergency department (ED). Which information collected by the nurse suggests
that the pain is caused by an acute myocardial infarction (AMI)?
1. The pain worsens when the patient raises the arms.
2. The pain increases with deep breathing.
3. The pain is relieved after the patient takes nitroglycerin.
4. The pain has persisted longer than 30 minutes.

Answer key:-
1) 1, 2, 3
2) 1
3) 1
4) 1
5) 1
6) 1
7) 1
8) 1
9) 1
10) 1, 2
11) 1
12) 1

13) 1, 2, 3
14) 1
15) 1
16) 1
17) 1
18) 1
19) 1
20) 4

coronary artery disease

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