Coronary Heart Disease

Pathophysiology: Atherogenesis
Risk Factors NONMODIFIABLE

MODIFIABLE
Stress diet sedentary living smoking/alcohol HPN/DM/obesity hyperlipidemia/ hypercholesterolemia behavioral factors contraceptive pills

age gender race heredity

A.Nonspecific Injury to Arterial Wall(endothelial injury) Desquamation of endothelial lining

Increased permeability/ adhesion molecules

B. lipids(LDL, VLDL) and platelets assimilate into the area C. Oxydized LDL attracts monocytes and macrophages to the site D. Plaques begin to form from cells to which imbed into the indothelium

Lipids are engulfed by the cells(foam cells) and smooth muscles cells develop

Coronary atherosclerotic heart disease

Decrease coronary tissue perfusion Coronary ischemia

Decrease myocardial oxygenation Angina Pectoris MI

Self management education guide: decreasing risk for coronary heart disease
Daily management of HPN. Take meds at regular basis.

Dont stop Stop smoking ASAP. Smoking reduces available oxygen to the heart and can precipitate angina. Smoking increase HR and BP Avoid passive smoke. Two hrs of passive smoke decreases oxygen to the heart and increases HR and BP. Plan a regular exercise under medical supervision. If over weight, lose wt. seek help from professionals Follow a healthy heart diet. Reduce cholesterol and increase fiber Reduce stress Allow adequate time for rest and relaxation These are life-long life-style changes

Angina Pectoris(Myocardial Ischemia)

Transient chest pain caused by insufficient blood flow to

the myocardium resulting in myocardial ischemia. It results when myocardial oxygen demand exceeds myocardial oxygen supply. Pathophysiology: CAUSES: Atherosclerosis, HPN, DM, Thromboangitis obliterans Polycythemia vera, aortic regurgitation

Reduces coronary tissue perfusion

Diminished myocardial oxygenation

Anaerobic metabolism

Increase lactic acid formation(lactic acidosis)

Chest pain

Clinical Manifestation Of Angina Pectoris

Pain: transient, paroxysmal substernal or precordial pain - Describe as heaviness or tightness of the chest,

indigestion, crushing - Radiates down one or both arms, left shoulder, jaw, neck and back - Precipitate by activity or exertion - Relieve by rest or nitroglycerine
S-ubsternal A-nterior chest V-ague(radiates) E-xertion related R-elieve by rest or nitroglycerine S-hort duration(less than 30minutes)

Clinical Manifestation Of Angina Pectoris

Pallor Diaphoresis

Dyspnea
Faintness

Palpitations
Dizziness Digestive disturbances

Clinical Manifestation Of Angina Pectoris

Angina: PQRST pain assessment - P-rovocative:what act. Causes the pain - Q-uality:what does the pain feel like - R-egion/radiation:where is the pain/does it

radiat elsewhere - S-everity:how does the pain rate on the scale of 1-10? - T-iming/treatment:when did the pain begin?;how long does it last?; what do you do to relieve the pain?; are these measures effective

Types of Angina Pectoris

Stable Angina - Chest pain last for less than 15 minutes - Recurrence is less frequent Unstable Angina(Preinfarction Angina,

Cresendo Angina, Intermittent Coronary Syndrome) - Chest pain last for more than 15minutes but less than 30 minutes - Recurrence is more frequent, may occur at night - Intensity of pain increases

Types of Angina Pectoris

Variant Angina(Prinzmetals Angina) - Chest pain is of longer duration and may occur at rest - The attacks tend to occur in the early hours of the day - May result from coronary artery spasm Nocturnal Angina - Occur only during the nightand is possibly associated with -

REM sleep Angina Decubitus Paroxysmal chest pain that occurs when the pt sits/stand up Intractable Angina Chronic incapacitating angina unresponsive to intervention Postinfarction Angina Occurs after MI, when residual ischemia may cause episodes of angina

Precipitating Events Of Angina Pectoris

Exertion: vigorous exercise done very

sporadically Emotions: excitement, sexual activity Eating a heavy meal Environment: exposure to cold These events increases myocardial oxygen demands. Further disequilibrium between oxygen supply and oxygen demand occurs

Collaborative Management of Angina Pectoris

Medications: Vasodilators: Nitroglycerine/ Amyl Nitrate/ Isosorbide Effects: - Direct relaxing effect on vascular smooth muscle, resulting in generalized vasodilation - Decrease peripheral resistance, decrease systolic pressure, produce venous pooling and decrease preload - Coronary vasodilation redistributes myocardial blood flow more effeciently

Collaborative Management of Angina Pectoris

Medications: Beta-adrenergic blocking agents - Propranolol(Inderal) - Metoprolol(lopressor) - Nadolol(Corgard) - Atenolol(Tenormin) - Piendolol(Visken) - Esmolol(Brevibloc) Effects: decrease myocardial O2 demand by decreasing HR, BP, myocrdial contractility and calcium output

Collaborative Management of Angina Pectoris

Medications:
Calcium-channel blockers

- Verapamil(Isoptin, Calan)
- Nifedipine(Precardia, Adalat, Calcibloc) - Diltiazem(Cardizem)

- Amlodipine(Norvasc)
- Nicardipine(cardene) Effects: inhibit Ca ion transportation into

myocardial cell to depress inotropic and chronotropic activity, decreasing cardiac workload - Vasodilation - Reduce coronary vasospasm

Collaborative Management of Angina Pectoris

Medications: other meds
Platelet Aggregation inhibitors - ASA(Aspirin) - Dipyridamole(Persantin) - Clopidogrel(Plavix) - Ticlopidine(Ticid) - Effects: inhibit platelet aggregation

Anticoagulants
- Heparin Na(Clexane, Fragmin, Lovenox, Innohep) - Effects: inactivates thrombin and other clotting factors

inhibiting conversion of fibrinogen to fibrin, fibrin clot formation is prevented - Warfarin Na(Coumadin) - Dicumarol - Effects: inhibit hepatic synthesis of vit. K

Nursing Interventions In Drug Therapy

Nitroglycerine therapy - Assume sitting/supine rationale - Prevent hypostatic

position when taking the drug Take maximum of 3 doses at five minutes interval Practice gradual change of position If taken sublingual, the medication causes burning/stinging sensation under the tongue Sublingual route produces onset of action within 1-2 min. duration of action is 30min

hypotension

- Prevent orthostatic

hypotension - Indicate that the meds is potent

Nursing Interventions In Drug Therapy

Nitroglycerine therapy - Offer sips of water before rationale - Dryness of mouth may

giving sublingual nitrates Instruct pt to avoid drinking alcohol Advice pt to always carry 3 tablet in his pocket Store nitroglycerine in cool dry place; use dark/ambercolored air-tight container. Do not refrigerate Change stock every 3 months

inhibit drug absorption - to avoid hypotension, weakness and faintness

- May destroyed by heat,

light/moisture

Nursing Interventions In Drug Therapy

Nitroglycerine therapy - Observe for side effects: rationale - These are common during

HA, flushed face, dizziness/faintness, tachycardia - Transderm-Nitropatch: applied once a day usually in the morning. Rotation of the skin site is necessary, usually on the chest wall - Evaluate effectiveness

the first few doses. Do not discontinue the drug

- Remove the patch during

the night to prevent tolerance

- Relief of chest pain