Ischemic heart disease (IHD) is a significant health concern, with nearly 90% of related deaths occurring in individuals aged 40-70, primarily affecting men due to various risk factors. Clinical manifestations of IHD include symptoms such as angina pectoris and acute myocardial infarction, with medical management focusing on decreasing myocardial oxygen demand and increasing oxygen supply through pharmacologic therapy and revascularization procedures. Prevention strategies include lifestyle modifications such as smoking cessation, managing cholesterol and blood pressure, and maintaining a healthy weight.

2. The magnitude of the health problem presented by IHD can
be illustrated by mortality statistics. Of the 716,215 or 89.7%
due to IHD.
About 90% of the person who develop IHD are between the
age of 40 & 70 years.
The incidence is much higher in men than women

3. i. Family history of coronary
artery disease.
ii. Hypertension.
iii. High level of blood serum
cholesterol.
iv. Diabetes mellitus.
v. Over nutrition or obesity.
vi. Excessive smoking.
vii. Muscular build.
viii.Sedentary existence.

4. I. Angina pectoris (chest
pain on exertion)
II. Acute myocardial
infarction (“heart attack”,
severe chest pain.)
III. Heart failure (difficulty
in breathing or swelling
of the extremities due to
weakness of the heart
muscle.)
CLINICAL MANIFESTION OF
ISCHEMIC HEART DISEASE

5. CAUSE:-
Insufficient
coronary blood flow.
 Angina pectoris is a clinical syndrome usually characterized by
episodes or paroxysms of pain or pressure in the anterior chest.

6. Pain: felt deep in the chest behind the upper or middle third
of sternum.
Feeling of indigestion.
Feel tightness or heaviness.
Feeling of weakness or numbness in the arms, wrists &
hands.
Shortness of breath.
Pallor, diaphoresis.
Dizziness & light headache.
Nausea & vomiting.

7. The objectives of the medical management of angina are to
decrease the o2 demand of the myocardium & to increase the
o2 supply.
The objective are met through
pharmacologic therapy & 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 & atherectomy ), CABG & percutaneous transluminal
mycordial revascularization (PTMR).

8. 1. Nitroglycerin (Nitrates):
 A vasoactive agent, it is administered to reduce
myocardial o2 consumption, which decreases
ischemia & relieves pain.
 It may be given by several routes: sublingual tablets
or spray, topical agent & intravenous.
 The amount of NTG administered is based on the
patient’s symptoms while avoiding side effect such as
hypotension.

9. 2. Beta-Adrenergic Blocking Agents:
 Beta-blockers such as propranolol, mentoprolol &
antenolol appear to reduce myocardial o2
consumption by blocking the beta-adrenergic
sympathetic stimulation to the heart.
3. Calcium channel blocking agents:
 It relax the blood vessels, causing decrease in B.P. &
an increase in coronary artery perfusion. It increase
myocardial o2 supply by dilating the smooth muscle
wall of the coronary arterioles.
 Most commonly used are amlodipine, verapamil &
diltiazem.

10. 4. Antiplatelet and Anticoagulant Medication:-
 Aspirin: It prevents platelets activation & reduces
the incidence of MI & death in patient with CAD. A
160 to 325 mg dose of aspirin should be given to the
patient with angina & continued with 81 to 325 mg
daily.
 Heparin: Unfractionated heparin prevents the
formation of new blood clots. Use of heparin alone
in treating patient with unstable angina reduces the
occurrence of MI.

11.  O2 administration 2 L/min.
 NTG administration sublingually
 Assess the vital signs.
 Advise the patient to stop all activities & sit or
rest in bed in semi-fowler position to reduce the
o2 requirement of ischemic myocardium.
 Reduce the patient anxiety.
 Prevent the pain by minimize the activity.

12. MI refers to the process by which
areas of myocardial cells in the heart are permanently
destroyed.
:-
Reduced blood flow in coronary artery artery due to
atherosclerosis & occlusion of an artery by an embolus or
thrombus.
Vasospasm of coronary artery.
Decreased o2 supply (eg: from acute blood loss, anemia or
low BP.)
Increased demand for o2 (From a rapid heart rate, ingestion
of cocaine etc.)

14. Due to any cause
Necrosis develop in affected
Part of the muscle
Completely occlusive artery thrombus &
Full muscle thickness
Complete absence of flow
Infarction
(> 20 min)
(Reduction in coronary blood flow >2
hrs.)

15. CLINICAL MANIFESTATION:-
Chest pain or discomfort, palpitation
Tachycardia, bradycardia & dysrhythmias
 ST-segment & T-wave change in ECG
Shortness of breath
Dyspnea & tachypnea
Pulmonary edema may be present
Nausea & vomiting
Decrease urine output
Cool, clammy & pale skin
Anxiety , restlessness & light headache
Visual disturbance & altered speech

17. ASSESSMENT & DIAGNOSTIC FINDING:-
 Patient history
 ECG
 Echocardiogram
 Laboratory test -
creatine
kinase(ck), lactic
dehydrogenize
etc.

18. MEDICAL MANAGEMENT:-
Goal: i. To minimize myocardial damage
ii. ToPreserve myocardial function
iii. To prevent complication
 This goals are achieve by
- use of thrombolytic agents
- PTCA
- O2 administration
- Bed rest

19. PHARMACOLOGICAL THERAPY:-
1. Thrombolytic :-
 The purpose of trombolytics is to dissolve & lyse the
thrombus in a coronary artery (Thrombolysis), allowing
blood to flow through the coronary artery again
(reperfusion), minimizing the size of the infarction &
preserving ventricular functions.
 The thrombolytic agents used most often are streptokinase,
alteplase & reteplase
2. Analgesics:-
 The analgesic of choice for acute MI is morphine sulphate
administered in intravenous boluses.
 Morphine reduces pain & anxiety. It reduces preload, which
decreased the work load of the heart.

20. 3. Angiotensin-Converting Enzyme Inhibitor:-
 Angiotensin-I is formed when the kidneys release renin
in response to decreased blood flow.
 ACE inhibitors prevent the conversion of angiotensin
from I to II. In the absence of angiotensin II,the BP
decreases & the kidney excrete sodium, fluid ,
decreasing the O2 demand of the heart.
4. Emergent Percutaneous Coronary
Intervention(PCI)
 PCI may be used to open the occluded coronary artery in
an acute MI & promote reperfusion to the area that has
been deprived of O2.
 PCI is performed should be less than 60 minutes.

21. NURSING MANAGEMENT:-
1. Reliving pain & other singn & symptoms of ischemia:
 Balancing the cardiac O2 supply with it’s O2 demand.
 Administration of thrombolytic therapy & emergent PCI
 Administer the morphine for relief of pain.
 Assess the vital signs frequently.
2. Improving respiratory function:
 Regular & carefull assessment of respiratory function can
help the nurse detect early sign of pulmonary complication.
 Encouraging the client to breath deeply & change position
frequently, help keep fluid from pooling in the bases of the
lungs.

22. 3. Promoting adequate tissue perfusion:
 Limiting the client to bed or chair rest during the
initial phase of treatment is particularly helpful in
reducing in myocardial O2 consumption.
 Checking vital signs frequently for ensuring
adequate tissue perfusion.
4. Reducing Anxiety:
 Developing a trusting & coping relationship.
 Providing adequate information.
 Provide a quiet environment.

23. 5. Monitoring & Managing potential complications:
 The nurse monitors the client closely for changes in
cardiac rate & rhythm, heart sound, BP, chest pain,
respiratory status, urinary out put, skin colour, &
temperature, ECG changes.
 Any changes in the client’s condition are reported to
the physicians & emergency measures are provide
when necessary.

24. INVESTIGATION & DIAGNOSIS FOR IHD
Clinical diagnosis based on characteristc & complaint of
chest pain or discomfort.
1. ECG- During the episodes of pain there may be
depression of ST-segment & a T-way inversion in
several leads.
2. Echocardiogram- help in showing any functional
abnormality in various cardiac chambers & in assessing
the pumping efficiency of the heart.
3. Treadmill test (TMT exercise testing)- indicated in
patient who have symptoms but normal ECG patterns.

26. 4. Coronary Angiogram- provides accurate information about
actual site & extent of the stenosis.
5. Blood study- to measure total fat, cholesterol & lipoproteins
6. Chest X-ray

27. PREVENTION OF IHD

29. GENERAL MEASURES
Stop smoking
Treat elevated cholesterol level with low fat, low
cholesterol diet, exercise & cholesterol lowering
medication.
Treat elevated BP
Reduce stress
Maintain ideal body weight

30. 1. Beta-blocker:-
Reduce the resting heart rate & so
reduce the demand for 02. beta-blockers &
nitrates have been proven to reduce the
incidence of heart attacks & sudden deaths in
people with coronary artery disease. eg :
propranol, metoprolol & antenolol etc.

31. 2. Nitrates:-
 Such as Nitroglycerin, cause dilatation of the blood vessels.
There are short-acting & long-acting nitrates. NTG is available
as a Tablet(sublingual) or an oral spray.
 A tablets of NTG placed under the tongue or inhalation of the
oral spray usually relieves an episode of angina in 1 to 3 minute-
the effect of these short-acting nitrate lasts 30 minutes. Anyone
with chronic stable angina must keep NTG tablets or spray with
them at all times.
 Long-acting nitrate are available as tablets, skin patches or
paste. Tablets are taken 1 to 4 time daily. Nitro paste & skin
patches,in which the drug is absorbed through skin over many
hour, are also effective.

32. 3. Calcium channel antagonist:-
Prevent the blood vessels from
constricting & thus prevent coronary artery spasms.
Certain calcium antagonists, such as varapamil &
diltiazem, also show the heart rate & in some patients
this drugs are used in conjunction with beta-blockers
to prevent episodes of tachycardia.
4. Anti-platelet drugs:-
Such as aspirin is recommended for
patient with coronary artery disease. Aspirin binds
irreversibly to platelets & prevents them from
clumping on blood vessels-walls-thus preventing
platelets from forming a clot on the fatty plaoues
which could block an artery & result in heart attack.

33. General Surgical Measures:-
•Balloon angioplasty- treatment for obstructed
arteries, specially those supplying blood to heart &
brain. A small uninflated balloon is passed up the
artery to the obstruction & than expanded to
release the obstruction.
•Surgery to Bypass Arteries (In severe cases)
•Heart transplant (In rare cases)- end stage
coronary artery disease, event when no simple
procedure will help.

34. Assessment:-
It is establishes the baseline for the patient so
that any deviation may be identified, systematically
identifies the patient’s need & helps determine the
priority of those needs. Systematic assessment includes a
careful history, particularly as it relates to symptoms:
chest pain or discomfort, difficulty breathing,
palpitation, unusual fatigue, faintness or sweating. Each
symptoms must be evaluated with regard to time,
duration, the factors that precipitate the symptoms &
relieve it. IV sites are examined frequently.

35.  Ineffective cardiopulmonary tissue perfusion R/t
reduced coronary blood flow from coronary
thrombus & atherosclerotic plaque.
 Potential impaired gas exchange R/t fluid
overload from left ventricular dysfunction.
 Potential altered peripheral tissue perfusion R/t
decreased cardiac output from left ventricular
dysfunction.
 Anxiety R/t fear of death.
 Deficient knowledge about post MI-self care.

36. A 40 years old male patient came in your ward with
complain of chest pain, he diagnose the IHD.
Answer the following Question:
Q. What are the nursing care you will provide for
this patient?

37. Richard Hatchett & David thompson.cardiac nursing.first
edition(2002); publish by churchil Livingstone sydney P.N
152-160.
Shaffer’s.Medical-Surgical.seven editions. BI publications
New Delhi (2002). P.N. 439-444.
Brunner & Suddarth’s.Medical-Surgical nursing.10th
edition.Lippincott williams & wilkins publication (2004). P.N.
649-656.
www.google.com.
www.pubmed.com.