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Cardiac CAD
Chapter 38 Interventions for CAD
| Question | Answer |
|---|---|
| CAD | coronary artery disease, leading cause of death. The arteries are partially/completely blocked, ischemia and infartion of the myocardium can result. |
| Ischemia | occurs when insufficient oxygen is supplied to the myocardium |
| Infarction | necrosis--occurs when severe ischemia is prolonged and irreversable damage to tissue |
| Atherosclerosis | leading contributor to CAD and death |
| Process of Athersclerosis | Overgrowth of intimal SM cells with accumulation of macrophages and T cells. Formation of CT matrix in the vessel intima, Accumulation of lipids, esp cholesterol, in the CT |
| What do these processes do? | narrow the vessel lume. Bld flow may be adequate at rest but not with activity. |
| Ischemic Myocardium | o2 deprived myocardium, usually has angina |
| Angina pecotris | "straggling pectoris". It is a temporary imbalance between the cornary arteries ability to supply O2 and the cardiac muscles demand for O2 |
| Ischemia with anginia | does not cause permanent damage of myocardial tissue, it is limited in duration |
| Angina can be two forms | stable and unstable |
| Stable angina | chest discomfort that occurs with moderate to prolonged excertion in a pattern. the freq, duration, and intensity of symtoms hace not inc overthe past several months. Results only slight limitations. Usually relieved with nitro. |
| How is it managed? | medical management Cal Chanel Blockers and Beta blockers, rarely does it require aggressive treatment |
| Women and anginia | atypical, they may describe as chocking sensation that occurs with exertion. Angina is more likely to be the primary presenting symptom of CAD than men. |
| Unstable angina | is CP or discomfort that occurs at rest or with min. exertion and causes marked limitation of act. |
| What characterize unstable anginia? | an increase in the number of attacks and increase in the intensity of the pain. May last longer than 15 min or be poorly relieved by nitro |
| Acute coronary syndromes | describes the disorders that make up unstable angina |
| what happens in Acute coronary sydromes | the plaque in the coronary arteries rupture, resulting inplatelet aggregation, thrombus formation, and vasonconstrition. |
| Progressing to MI | within the first year of unstable angina |
| MI | occurs with mycocardial tissue is abruptly deprived of oxygen. When Bld flow is acutely reduced by 80-90%, ischemia develops. Can lead to necrosis of myocardial if bld is not restored |
| Most causes of MI | atherosclerosis of a coronary artery, rupture of plague, subseq thrombosis, and occlusion of bld flow. |
| Other causes of MI | conary artery spasm. platelet aggregation, and emboli from mural thrombi |
| MI of begin with... | infarction (necrosis) of the subendocardial layer of cardiac muscle. this layer has the longest myofibrils, the greated O2 demand, and the poorest O2 supply |
| Zone of injury | tissue that is injured but not necrotic |
| zone of ischemia | tissue that is oxygen deprived |
| Process of infaction | It evolves over a period of several hrs. |
| Hypoxia from ischemia | leads to local vasodilation of bld vessels and acidosis |
| Imbalances of K+. Ca+, and Mag | may lead to suppresion of normal conduction and contractile functions |
| Automaticity and ectopy | are enhanced |
| catecholamines | released in response to hypoxia and pain may increase HR and force of contractions |
| These factors | Increase O2 demand in tissue that is already O2 deprived |
| The area of infarction may extend | to zones of injury and ischemia |
| Actual extent of the zone of infarction depends on 3 factors: | collateral circulation, anareobic metabolis, and workload demands on the myocardium |
| Physciologic response to infarction | obvious signs do not occur for up to 6hrs. after 48hrs turns gray w/yellow streaks-neutrophils begin remove necrotic cells. 8-10 days, granulation tissue fomrs. 2-3 mo developes into shrunken firm thin scar |
| Scaring after MI | permaently changes the size and shape of the entire left vent. Remodeling may dec the vent function, cause HF and increase M&M |
| Left anterior descending coronary artery perfuses: | Most of the L vent and septum |
| Left circumflex coronary artery perfuses: | Posterior wall of the L vent. SA in 39% AV node in 12%, Left vent muscle in 10% |
| Right coronary artery perfuses | Right ventricle, Inferior portion of the left ventrile, SA node in 59% and 88% the AV node |
| LAD MI | 25% of all MI, and have the hight mortality rate, most likely to have left vent HF and Vent dysrhythmias, because large amount of the Lt vent wall may be damaged |
| RCA MI | 17% of MIs mortality rate of 10%. Have badydysrhymias (because effects of SA node) or AV conduction defects. 1/3 with inferior MIs have a rt vent MI and right Vent failure |
| Primary factory of CAD? | atherosclerosis |
| Nonmodifiable risk factors | age, gender, family hx, and ethnic background. Increases with age. Premenopausal have lower incidence of MI then men. Postmenopausal women in 70s the risk is equal to men. |
| Modifialble risk factors | elevated cholesterol, smoking, HTN, impaired glucose tolerance, obesity, physical inactivity and stress. |
| Choesterol Levels | should be less than 200 |
| Smoking | 2x the risk than nonsmokers and have 2-4x the risk of sudden cardiac death. Reducing the tar and nicotine content does not reduce the risk of CAD |
| Physical inactivity | one of the most important risk factor becuase between 40-60% are sedentary |
| Stress and Type A | increase incidence with left vent hypertrophy |
| HTN | increases the workload, which increases the risk of MI |
| Impaired glucose tolerance (diabetes) | seriously inc the risk of esp in women |
| Obesity | is associated with inc cholestrol, elevated B/P and abnormal glucose tolerance |
| Distrubution of adipose tissue | women with fat deposited about the waist rather than the hips oftern unfavorable lipid profiles and higher rates of CAD |
| Cultural considerations | Afican Americans: incidence of HTN at earlier age and diabetes increases the rate. Hispanics have lower death rates, higher obesity rate. Native americans obesity and HTN |
| Incidence/Prevalence | Single largest cause of death for both men and women. 1/2 of the deaths from MI occur within the first hour before reaching the hospital. |
| Education: Smoking | if you smoke quiet, if you dont, dont start |
| Education: Diet | Follow a prudent diet, consume sufficent calories for your body. Limit cholesterol intake to less than 300/day. Limit sodium intake to less than 130 per day |
| Education: Cholesterol | Have cholesterol and LDL checked regulary. If your cholesterol and LDL levels are high, follow MD advice |
| Education: Physical Activity | If => middle aged or hx of medical problems seek MD advice before starting program. Appropriate exercise should be enjoyable; burn 120-150 cal per session, and sustain a HR of 120-150, depending on your age. Perform 3-5 times per week. Preferably 5 Xs. |
| Education: Physical Activity | Exercise should be at least 20-30 min long with a 10 min warmup and 5 min cool down period. If unable to exercise-walk daily for 30 min at comfortable pace. If unable to walk 30 min then walk any distance you can. |
| Education: Diabetes | Manage your diabetes with your HC provider |
| Education: B/P | Check b/p regularly. If elevated, follow MD advice. Continue to monitor at regular intervals |
| Education: Obesity | Avoid severely restricted or fad diets. Consider a restriction in intake of saturated fats, simple sugars, and cholesterol-rich foods. Increase physical activity |
| Obtaining Hx | defer historical hx until stable. Whenpain free, info can be obtianed |
| Pain: ask to explain the immidiate concern | Presence of chest, epigastric jaw, back, or arm discomfort is noted. Asked to rate the discomfort. Often discribe as tightness, buring sensations, pressure or indegestion. Ask what they have done to try to relieve the pain. |
| Pain assessment | rapid and completely assess chest pain. Important to differentiate among the types of CP and to identify the source. Include Onset, Location, Radiation, Intensity, Duration, and precipitating and relieveing factors. |
| Pain: anginal | because it is ischemic it usually improves when the disparity between O2 supply and demand is resolved. For example, rest reduces tissue demands and nitro improves O2 demands and nitro improves O2 supply. Discomfort from an MI does not usually resolved |
| Associated symptoms that should be noted | N&V, diaphoresis, dizziness, weakness, palpitations, and SOB |
| Pain: women | chest discomfort is often not the initial symptom reported by women experiencing MI. Usually c/o atypical symptoms such as heart "flutters" without pain, SOB, fatigue, depression. As progesses, chest discomfort, arm/shoulder/back pain, jaw, neck tooth |
| Pain: culteral considerations | African Americans longer delays in seeking tx with higher mortality rate. Greater incidence of dyspnea as an acute symptom of MI rather than CP |
| Pain: older adults | CP or discomfort may be mild or absent and complain primarily of associated symptoms. Indigestion, disorientation or confusion, d/t poor cardiac output. |
| Angina: Key features | Substuranl chest discomfort: Radiating to Lt arm. Precipitated by exertion or stress. Relieved by nitro or rest. Last <15 m. Few associated symptoms |
| MI: Key features | Substernal chest pressure. Raidating to Lt arm, back, or jaw. Occuring without cause, primarily early in am, relieved only by opioids. Lasting =>30 m. Frequent associated symptoms. N&V. Diaphoris, SOB, fear, anxiety, dysrhytmias. |
Created by:
sbrown
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