CAD is a cardiovascular disorder

1. Prepared by ,
Ms .UMA .M ,MSN

2.  Atherosclerosis is a progressive disease that
affects arteries throughout the body
Atherosclerosis ↔ coronary artery disease

3.  Leading cause of death in U.S
 2,40,000 deaths every year / 60 % of total
mortality
 Affects both sex

4.  MODIFIABLE
 Elevated serum lipids
 Hypertension
 Cigarette smoking
 Pre-diabetes /diabetes
 Diet high in fat, cholesterol &
calories
 Elevated homocysteine level
 Metabolic syndrome
 Obesity
 Physical inactivity
 Post menopause ( modification
is controversial )
 NON MODIFIABLE
 Age
 Gender
 Family history
 Race

5.  Age : Middle and old age
average 68.8 for men & 70.4 for women
starting at 75 yrs, prevalence is high in women than
men
 Gender :
Tradition :male disease
Modern : both genders
 Race : white population of similar socio-
economic status
 Family history : close relative with MI/stroke before
age 60 yrs. Genetic or family pre disposition.

6. Types of lipids Target values
Total cholesterol Below 200 mg /dl
HDL cholesterol Above 40mg/dl for men
Above 50mg/dl for women
LDL cholesterol Below 70mg/dl if very high risk
Below 100mg/dl if high risk
Below 130mg/dl if low risk
Triglycerides Below 130mg/dl if low risk
VLDL cholesterol Below 130mg/dl if low risk

7. SYSTOLIC BP DIASTOLIC BP
Normal (optimal) Less than 120 Less than 120
Pre hypertension 120 -139 80- 89
Stage I hypertension
Stage II hypertension
140 – 159
160 or higher
90-99
100 or higher

8. Plasma homocysteine level
Normal 5 – 15 mmol/ L
Moderate risk 16 – 30 mmol/ L
Intermediate risk 30 – 100 mmol/ L
High risk Over 100 mmol/ L
CRP level
Low risk Below 1mg/L
Moderate risk 1-3mg/L
High risk Above 3mg/L

9.  Cigarette smoking :
 decreases HDL cholesterol
 Increases LDL cholesterol
 DM
Fasting plasma glucose
Pre-diabetic 110mg/dl -125mg/dl
Diabetic 126mg/dl or higher

10. BMI WEIGHT STATUS
Under 18.5 Under weight
18.5 – 24.9 Normal
25 – 29.5 Over weight
Over 30 Obese

11.  Chronic kidney disease : ↑ serum creatinine
level
 Metabolic syndrome:
 Waist circumference : › 40 inches in men, › 35 in
women
 Serum triglyceride › 150mg/dl
 High density lipoprotein ‹40mg/dl in men,
‹50mg/dl in men
 Blood pressure 130/85 mmHg or higher
 Fasting glucose 100- 110mg/dl.
 High fat diet
 Physical inactivity

14. 1. Development of atherosclerosis
2. Atherosclerotic plaque rupture
3. Plaque regression
↓ in blood cholesterol
↓ in plaque size
↓ vascular inflammation & less
likely to rupture.

15. High LDL triggers vascular inflammation
↓
Inflammation injures the wall
↓
LDL moves into the vessel wall below the
endothelial cells
↓
Allows lipoprotein to infiltrate the intimal vessel
wall

16. Lipids in blood stream
↓
Extracellular lipid accumulation in the intima of artery
( atheroma)
↓
Evolves to become a fatty – fibrous covered by fibrous cap
↓
Rupture of cap allows the lipid in center is released into
blood stream
↓
Stimulate clot formation ( thrombogenesis )
↓
Fresh clot blocks the vessel

17. Unstable angina
Acute MI

18.  COMMON TYPES:
 Unstable
Change in the level & frequency of
symptoms. Persists for › 5mts,worsening
in intensity & not relieved by NTG.
 Stable
Predictable & caused by similar
precipitating factors, typically exercise
induced. Relieved by rest & sublingual
NTG.

19. Variant
Spasm of coronary artery. Occurs at
rest 7 in same time, cyclic also
associated with ST segment elevation.
Silent ischemia
person does not complaints of
anginal symptoms especially DM
(type II)

20.  Location
• beneath sternum
radiating to neck and jaw
• Upper chest
• Beneath sternum
radiating down left arm
• Epi-gastric
• Epi-gastric radiating to
neck and jaw and arms
• Neck and jaw
• Left shoulder, inner
aspect of both arms and
intracapsular.
 Duration
• Less than 5 mts
• Longer than 5 mts
 Quality
• Sensation of pressure or
heavy wt on chest
• Feeling of tightness
• Visceral quality( deep,
heavy, aching)
• Burning sensation
• Shortness of breath
• Most severe pain ever
experienced

21. • Radiation
• Medial aspect of arms
• Jaw
• Left shoulder
• Right arm
 medication relief
• Usually within 45 seconds
to 5 mts of sublingual
NTG administration.
 Precipitating
factor
• Exertion, cold weather
• Exercising after a heavy
meal
• Walking against the wind
• Emotional upset
• Fright, anger
• Coitus.

22.  Asssessment of
chest pain
 12 lead ECG
 Cardiac
catheterization
 PHARMACOLOGIC
 Aspirin
 NTG
 Anti platelet agent
( glycoprotein II-b, III a
inhibitors) IV
 Unfractioned heparin IV
 LMWH combined with
fibrinolysis under 75 yrs
with serum creatinine
below 2.5mg/dl in men &
‹ 2mg/dl for women.

23.  Components:
1. Smoking cessation
2. Blood pressure control
3. Lipid management
4. Physical activity
5. Weight management
6. Diabetes management

24.  Enquire about tobacco use status
 Assess willingness to quit
 Assist in developing a plan to smoking
cessation
 Arrange follow up, referral program
 Pharmacotherapy:
nicotine replacement
bupropion

25.  Life style modification
 Weight control
 Increased physical activity
 Alcohol moderation
 Sodium reduction
 Emphasis on increased consumption of fresh
fruits & vegetables, low fat dietary products
 β- blockers & ACEI in addition with
thiazides.

26.  Dietary therapy:
 reduce intake of saturated fat to <7% of total
calories, trans fatty acids & cholesterol to
<200mg/dl.
 Adding plant stanol/sterol (2g/d)& viscous
fiber (› 10 g/d) will reduce LDL-C
 Encouraged increased consumption of
omega-3 fatty acids in the form of fish or
capsule form(1g/d) for risk reduction.
 LDC-C lowering therapy, niacin & fibrate
therapy.

27.  Risk identification
 Encourage 30- 60 mts of moderate intensity
aerobic activity such as brisk walking,
lifestyle changes
 Achieve a BMI between 18.5-24.9 kg/m²
 Waist circumference ≥35 inches in women &
≥40 inches in men, initiate life style changes.

28.  Goal : HbA1c< 7%
 Vigorous modification of other risk factors (
physical activity, weight management, Bp
control, life style changes )
 pharmacotherapy:
 Aspirin 75-162 mg/d continued indefinitely
 Clopidogrel 75mg/d in combination with aspirin
continued for up to 12 months after PCI with
stent placement.
 ACEI if LV ejection fraction ≤ 40 % in
HTN,DM.
 β- blockers is also given.

29.  Total fat consumption=25 – 35%
 Saturated fat =<7%
 Total cholesterol =< 200mg
 Viscous fiber = 5 – 10 g

30.  β- carotene supplements (vit-A) :
 Omega – 3 fatty acids: 7g /day
 Soluble /viscous fiber: 5 – 10g /day
 vegetables and fruits, fish, less meat,
plant oils.

31.  Fried oily food items, animal fats, brown
rice, peas, beans, barley, oats etc.
 Butter, cheese.

32.  Psychological and social support
recommendations:
 Offer stress management within the context
of cardiac rehabilitation
 Use vicarious experiences to alleviate
anxiety
 Provide cognitive psychological intervention
such as cognitive behavioral therapy
 Sexual activity
 Presents no greater risk of triggering a
subsequent MI
 Resume activity after 4 weeks of recovery.

33.  Recognize MI
 Oxygen: 90% saturation, emergency
intubation, mechanical ventilation
 Nitrates :IV, sublingual NTG. Avoid if
systolic Bp‹ 90mmHg
 Analgesia : morphine 2-4 mg IV.
s/e:hypotension & respiratory depression.
 Aspirin : chewing non enteric coated aspirin
(162 – 325 mg) at beginning reduces
mortality.

34.  Relieve chest pain
 Maintain calm environment
 Patient education

35. 1. Acute pain r/t transmission & perception of
cutaneous, visceral, muscular or ischemia
2. Ineffective tissue perfusion r/t decreased
myocardial oxygen supply / demand
increased
3. Activity intolerence r/t cardio pulmonary
dysfunction
4. Knowledge deficit regarding discharge
regimen

36. Intensive statin regimen for 2
years produced a highly
significant (15%) further
reduction in major vascular
events .

37.  lynda urden.et.al., “critical care nursing”
 Madhavi, “secondary prevention strategies
in acute MI” NNT, july’11.
 JPS Sawhney,” cardiology today”, efficacy&
safety of more intensive lowering of LDL
cholesterol”,may-june’11