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Coronary Artery Disease Risk factors Age Gender Ethnicity Family history Genes Hyperlipidemia Hypertension Tobacco products

bacco products Inactivity Obesity Diabetes Metabolic syndrome Homocysteine level Type A

Usual medical treatment Control Blood pressure Blood glucose Lipid levels

Life style changes Exercise Weight loss Stress reduction Smoking cessation

Angina Reversible ischemia Types Chronic stable Intermittent

Silent

Same pattern, onset, duration, intensity

Diabetics

Nocturnal Decubitus Variant (Prinzmetals) At rest With or without CAD

Diagnostic tests 12 lead ECG Cardiac enzymes CXR Stress test Coronary angiogram

Usual medical treatment Nitrates Nitroglycerin Sublingual onset 3 min; duration 30-60 min Spray same Ointment duration 3-6h Patch onset 2h; duration 24h Isosorbide Beta blockers CCB Decrease: contractility, HR, SVR, BP Decrease morbidity & mortality esp after MI Oral Long acting Wear 12-14h to decrease tolerance Rest Medications

ACEI

Vasodilation, decrease contractility

Prevent vasoconstriction

Ranolozine Preventative action unknown

Unstable angina Prolonged not immediately reversible ischemia

Clinical manifestations Chest pain Women Fatique, SOB, indigestion, anxiety Feeling not quite right New onset, at rest, worsening pattern

Diabetics

Myocardial infarction Necrosis Irreversible myocardial cell death Cellular death in 20min in subendocardium 4-6h for transmural

Clinical manifestations Severe, immobilizing chest pain Not relieved by rest, nitrates, or position change Often early in the morning

Diagnostic tests 12 lead ECG Cardiac enzymes Myoglobin CK CK-MB Troponin

Other tests

CXR PT PTT INR Metabolic profile

Usual medical treatment UA & NSTEMI Aspirin Heparin Glycoprotein IIb/IIa inhibitor STEMI PCI Fibrinolytics 1-6h from onset 60 min ideal 30 min from ED arrival Heparin to prevent reocculusion Success

Other medications PTCA 90 min door to balloon time if STEMI IV nitro Morphine Beta blockers ACEI Antidysrhythmics Lipid lowering agents Stool softeners

Pre procedure nursing care Obtain consent Check allergies

Explain flush & flutter Explain post procedure course NPO 6-8h if not emergent 2 IV sites

Procedural nursing care Monitor - ECG rhythm, vs, conscious sedation, pt tolerance Emotional support

Post procedure nursing care Bed rest 4-6h Leg straight 1-2h, then 30 degrees Pressure dressing Distal pulse, color, temp, bleeding & vs CABG Reasons Types Sternotomy Cardiopulmonary bypass Off pump Minimally invasive Transmyocardial laser revascularization >50% occlusion left main Severe blockage in several Failed medical management Not a candidate for PCI Failed PCI .q15min x4, q30min x2, q1h x4

Pressure if bleeding IV fluids I&O

Donor sites Internal mammary

Saphenous 2 time Gastroepiglotic, Inferior epigastric


nd

Pre op nursing care Obtain consent Demonstrate/ return demonstrate Teaching ICU 24-36h 3-5 day hospitalization Devices Post op care Monitor and tend to devices Monitor ECG I&O Lung & hear sounds Pain CO Resp status ET tube, vent, restraints extubated in 12h Pulmonary artery catheter Art line IV central or peripheral Pacer wires NG tube Urinary catheter Pleural, mediastinal chest tubes Incentive spirometry Leg exercises Deep breath Do not cough

Emotional response

Cardiac rehab Phase I In hospital, self care, ROM, walk, 3-4 stairs

Phase II Outpatient, 2-12 weeks, gradually increase, monitored, can be in home

Phase III Long term program In home, gym, or rehab facility

Return to sexual activity 7-10d after uncomplicated MI Able to climb 2 flights of stairs Inability common returns after several attempts Prophylactic nitro Orogenital no stress No rectal No ED Rx with nitrates