Management of patient with coronary vascular disorders

Mrs. Samia Almusalhi

objectives

1. Patho, ss assessment, diagnosis, risk factor prevention medical and nursing management

2. Athero, angina and MI and acute coronary syndrome

3. Types of angina

4. Identify invasive coronary artery procedure

Acute coronary syndrome

• Includes all heart disease.

atherosclerosis• It is abnormal

Accumulation of fats or

lipids in the arterial of

blood vessels.

atherosclerosis

• Patho: fats deposits in intima (inner layer of blood vessels), ---- monocytes (macrophages) migrate to the site--- it release substance that attracts platelets and initiating clotting----- smooth cells of blood vessels proliferate and for fibrous cape called “ atherosclerosis” or “plaque”– it narrows the blood vessels causing less blood flow.

S&S

• Ischemia

• Angina (chest pain)

• MI

Risk factor

-Non modifiable:• Family history• Increased age• Gender (male more)• Race (more with african americans)-Modifiable:Hyperlipidemia, smoking, DM, obesity,

physical inactivity.

Prevention

1. Controlling cholesterol abnormalities: checking lipid profile p 759,

• Dietary measures: high in vegetables and fruits and less of meat, high fiber reduce fiber diet,

• Physical activity: it reduce LDL

• Medication: as Atrovastatin and simvastatin.

Cont’ prevention

2. Promoting cessation of tobacco: it affect endothelium leads to thrombus formation

3. Managing HTN: elevated BP leads to stiffness of blood vessels walls,

4. Controlling DM:

Coronary artery

Angina pectoris

• Pain or pressure in the anterior chest.

• Patho: when there is increased demand of O2 by cardiac muscle to meet its continous work----- and there is obstruction because of atherosclerosis--- blood flow will be affected----- ischemia result------- chest pain starts which is called angina pertoris

Factors causing angina pain:

• Physical exertion

• Exposure to cold

• Eating heavy meals

• Stress unstable angina is not associated with

pervious factors (at rest even)

Angina pectoris• S&S: severe chest pain

under the sternum impending

to death not relieved by rest

• Chest tightness

• Weakness and numbness in the arms

• Shortness with breathing

• Diaphoresis

• dizziness

• Stable angina relieved with rest or with nitroglycerides.

diagnosis

• Ask the patient: site of pain, if it is radiated, how is the pain, when did it begin, how long it last, what helps to release it, any other symptoms associated with it.

• St wave inversion (ischemia)

• Cardiac biomakers testing (CK mb, Troponin)

• Exercise or stress test (treadmill)

Medical management

1. Pharmacological therapy:

• Nitroglycerin: vasodilator

• Beta-adrenegic blocking agent

To reduce cardiac contractility

• Calcium channel blocking agent:

To slow HR, decrease strength

Of contraction

• Antiplatelet and anticoagulant medication:Prevent platelet aggregation and thrombus

formation.e.g: Aspirin and Heparin or Glycoprotien

2. Oxygen Administration

• Start O2 even if saturation is highat the onset of pain

• Monitor oxygen level

• Assess skin color, mucous membrane (central and peripheral cyanosis)

• Folwler position

• Assess level of pain continuously

• Perform repeated ECG to assess ST segment

• Measure vital signs every 15 minutes or half hour with pain level

• Reduce patient anxiety

• Home care related to ( diet, avoid vigorous exercise like stairs, stress management, follow up appointment, balance rest with activity, stop smoking, take sublingual medication once they feel pain, keep it with him or her all the time and not to stop medication by themselves, ,,,,,,,

MI

• It myocardial ischemia

Result in death of tissues.

• It is called coronary

occlusion, heart attack but proffered to be called MI.

• In MI there is complete occlusion of coronary artery leading to imbalance between demand and supply------ischemia ----infacrtio or tissue death occure.

MI (S&S(

• Severe chest pain

• Shortness of breathing

• Indigestion

• Nausea and anxiety

• Cool, pale skin

Diagnostic finding

• ECG

Diagnostic finding• Cardiac biomarkers (cardiac enzyme( CK

Mb and myoglobin which not specific to heart and Troponin

SGOT (serum glutamic oxaloacetic transaminase( or aspertate aminotransferase (AST)

• 2. Physical examination

• 3. Patient history: of pain and previous attach and family history.

• 4. ECG changes

Treatment guideline for acute MI

• Chart 27-7 page 744:

Transfere to hospital, ECG, blood test, Aspirine, IV heparine,

• MONA treatment

• Careful for side effect of morphin

Types of Angina:

• Stable angina: occurs on exertion and relieved by rest

• Unstable angina: pre-infarction angina is not relieved by rest, it increase in frequency caused by spasm in coronary

• Varient angina (Prinzmetal’s(: pain at rest with reversible st segment elevation caused by coronary artery vasospasm

• Silent ischemia: no pain ECG changes with stress test.

Invasive coronary artery procedure

1. Percutanious transluminal coronary angioplasty (PTCA(:

Is balloon tipped catheter is used to open blocked coronary artery and for blocked CABAG. It compress the atheroma thus improves blood

flow.

Coronary artery stent• After PTCA the area may close off partially

or completely, and the intima of this place has been injured and it might stimulate inflammatory process leading to vasoconstriction and clot formation so----- stent is placed there. Figure 28-8

atherectomy

• Is removal of atheroma by cutting or grinding by a catheter.

• It could be used with PTCA

brachytherapy

• Involves gamma or beta-radiation by catheter to destroy atheroma.

Surgical procedure: coronary artery revascularization

• It is called CABG

1.Traditional Coronary Artery Bypass Graft:

2.Alternative coronary artery bypass graft technique:

Traditional Coronary Artery Bypass Graft:

• The surgeon will do incision sternum and connects patient to cardiopulmonary bypass (CPB), next the blood vessels as saphenous vein is grafted distal to the coronary artery lesion (bypassing the obstruction) then the incision isclosed and patient is admitted

in ICU.

Traditional Coronary Artery Bypass Graft:

Alternative coronary artery bypass graft technique

• It is Off Pump CABG involves median sternotomy incision but without CPB (cardiopulmonary bypass). Beta adrenergic block used to slow HR, then anastomosis of the bypass graft into the coronary artery while the heart continues to beat. p781

complication

• Bleeding, HTN, Hypovolemia,,,,,,,,,,,

Thank You