PATHOPHYSIOLOGY Incidence/prevalence of the disease/what age range is most susceptible? The average age of a person having a first MI is 64.

5 years for men and 70.4 years for women. A person in the U.S. has a major coronary event every 26 seconds. A person dies from this every minute. Premenopausal women have a lower incidence of MI than men, however, for postmenopausal women in their 70s or older, the incidence of MI equals that of men. Coronary artery disease (CAD) is the leading cause of premature, permanent disability in the U.S., accounting for more than 20% of disability allowances from social security. Pathophysiology (describe what happens in the body initially and what happens as the condition worsens) What causes the condition? Angina means strangling of the chest, it is caused by a temporary imbalance between the coronary arteries ability to supply oxygen and the cardiac muscles demand for oxygen. Ischemia that occurs with angina is limited in duration and does not cause permanent damage of myocardial tissue. Causes include obstruction of coronary blood flow resulting from atherosclerosis, coronary artery spasm, or conditions increasing myocardial oxygen consumption. Chronic Stable Angina (CSA)- Chest discomfort that occurs with moderate to prolonged exertion in a pattern that is familiar to the patient. The frequency, duration and intensity of symptoms remain the same over several months. CSA results in only slight limitation of activity and is usually associated with a fixed atherosclerotic plaque. It is usually relieved by nitro and managed with drug therapy. Unstable Angina- chest pain or discomfort that occurs at rest or with exertion and causes severe activity limitation. An increase in the number of attacks and in the intensity of the pain indicates unstable angina. The pain may last longer than 15 minutes or may be poorly relieved by rest or nitro. Variant angina- Also called Prinzmetals angina, results from a coronary artery spasm, may occur at rest, and may be associated with ST segment elevation on ECG. What other conditions are related to this disease and how are they related? Angina is a form of acute coronary syndrome. People who have angina can be described as having ACS. In ACS, it is believed that the atherosclerotic plaque in the coronary artery ruptures, resulting in platelet aggregation, thrombus formation, and vasoconstriction. Atherosclerosis is the primary factor in the development of CAD. Between 10 and 30% of patients with unstable angina progress to having an MI in 1 year, and 29% die of MI in 5 years.

GENETICS What genetic component is associated with this condition? Family history is a factor for developing coronary artery disease and angina. Those with a family hx are more susceptible. HEALTH PROMOTION AND MAINTENANCE What risk factors are related to this disease? Non modifiable risk factors: age, gender, family hx, and ethnic background. Modifiable risk factors: elevated serum lipid levels, tobacco use, limited physical activity, hypertension, DM, obesity, excessive alcohol, stress. Describe the physical assessment findings related to this disease Question the pt about the chest pain using OLDCARTS. Ask the pt if the pain is in the chest, epigastric area, jaw, back, shoulder, or arm. Some pts describe it as tightness, a burning sensation, pressure, or indigestion. Atypical angina manifests as indigestion, pain between the shoulders, an aching jaw, or a chocking sensation that occurs with exertion. Chart 40-2 Angina MI Substernal chest discomfort: Pain or discomfort: -radiating to the left arm -substernal chest pain radiating to the left -precipitated by exertion or stress (or arm rest in variant angina) -pain or discomfort in jaw, back, shoulder, -relieved by nitroglycerin or rest or abdomen -lasting <15 mins -occurring without cause, usually in the -few, if any, associated symptoms morning -relieved only by opioids -lasting 30 mins or more frequent associated symptoms: -nausea/vomiting -diaphoresis -dyspnea -feelings of fear and anxiety -dysrhythmias -fatigue -palpitations -epigastric distress -anxiety -dizziness -disorientation/acute confusion -feeling SOB

Describe the psychosocial and cultural assessment related to this disease Age is the most important risk factor for developing CAD. African Americans and Hispanic women have higher CAD risk factors than white women of the same socioeconomic status. American Indians, Alaskan Natives, and Euro-American population are also at risk. Patients need to be aware of their cultural lifestyles, such as diet, and if it is contributing to the risk factors for coronary heart disease. Further assessment of stress, alcohol use, and tobacco use with a behavioral and psychological support may help stop behaviors. Also culture considerations for hypertension such as African Americans and whites in the southeastern U.S. have higher risk for HTN. Assess for denial, fear, depression, anxiety, and anger, in patient and family. Describe the laboratory findings and other diagnostic procedures related to this disease 12-lead ECGs: ST-elevation MI (STEMI) (traditional) and non-ST-elevation MI (NSTEMI) (common in women). Increase in the number of attacks and in the intensity of the pain indicates unstable angina. The pain may last longer than 15 minutes or may be poorly relieved by rest or nitroglycerine. Elevated serum lipid levels: risk of CAD rises as serum cholesterol and triglyceride levels increase. High blood pressure 130/85 or higher, increased fasting blood glucose 110 mg/dL or higher, increased fibrinogen or plasma activator inhibitor (blood clotting factors) and increased C-reactive protein (marker for inflammation). Elevated levels of serum homocysteine. Troponins T and I and myoglobin rise quickly. CK-MB is the most specific marker for MI but does not peak until 24 hours after the onset of pain. Thallium scans use radioisotope imaging to assess for ischemia or necrotic muscle tissue. Contrast-enhanced cardiovascular magnetic resonance, computed tomography coronary angiography, stress test, cardiac catheterization. What screening can be done to detect this disease in an early stage? new-onset angina describes the patient who has his or her first angina symptoms, usually after exertion of other increased demands on the heart. Diagnosis of metabolic syndrome, syndrome X , elevated levels of serum homocysteine, screened for hypertension and diabetes mellitus, and possible imaging assessments. What interventions will alleviate this disease? percutaneous tranluminal coronary angioplasty, drug therapy (vasopressors, positive inotropes, nitrates, sympathomimetics), intra-aortic balloon pump, atherectomy (excise and retrieve plaque or emulsify it). What are the nutritional implications of this disease? - There are modifiable risk factors like obesity, hypertension, diabetes mellitus, and hyperlipidemia. - Approaches can include diet, exercise, and drug therapy to lower cholesterol and triglyceride levels.

Diet: o Reduce intake of saturated fats to less than 7% total calories per day o Avoid trans fats o Take in less than 200mg cholesterol per day o Decrease sodium intake <2mg/day o Restrict intake of simple sugars o Manage diabetes o Alcohol may prevent CAD (moderate amount) Excess consumption >3oz day can lead to increased heart disease, HTN, and metabolic syndrome. - Exercise: o Moderate-intensity like walking associated with major reduction in CAD risk. 30 min/day to reduce HTN increase secretions of endorphins Improved metabolism Decreased smoking and eating Decreased blood clotting Higher plasma HDL Increased heart volume Increased cardiac capillary blood flow Decreased heart rate Does NOT increase collateral circulation or reduce size of existing plaques o However, intense exercising may contribute to plaque rupture and increase number of cardiac episodes. What drug therapy is effective? - Nitroglycerin for episodic angina pain o Increases collateral blood flow o Redistributes blood flow toard the subendocardium o Dilates the coronary arteries o Decreases myocardial oxygen demand o Angina usually responds to NTG o If 3 dont relieve pain, then patient may be experiencing MI Immediately notify HCP Prepare pt for transfer to specialized unit If at home, 911 - Morphine sulfate relieve discomfort that is unresponsive to NTG - Supplemental oxygen 2-4L titrated to maintain arterial saturation of 95%. - Aspirin 325mg antiplatelet, to prevent clots that further block coronary arteries - Thrombolytic therapy using fibrinolytics that dissolve thrombi and restores myocardial blood flow. o Tissue plasminogen activator (t-PA, alteplase [Activase]) -

o Reteplase (Retavase) o Tenecteplase (TNK) o Glycoprotein (GP) IIb/IIIa inhibitors target the platelet component of the thrombus (Abciximab, Eptifibatide, Tirofiban) - Beta-adrenergic blockers (metoprolol, carvedilol) - ACE inhibitors or Angiotensin receptor blockers given within 48 hrs of MI to prevent ventricular remodeling and dev of heart failure. - Calcium-channel blockers for chronic stable angina (CSA) - ranolazine [Ranexa] anti-angina and anti-ischemic properties; effective in relieving pain with CSA What complementary or alternative therapies are associated with this disease? - Add omega-3 fatty acids from fish and plant sources o These have been effective in reducing lipid levels, stabilizing atherosclerotic plaque, and reducing sudden death from an MI. - Garlic supplements may also have small effect on reducing lipid levels, but may not prevent an MI. - Vitamin E, coenzyme Q10, Pantesin, and Vitamin B complex can decrease risk of heart disease, but not helpful in reducing CAD. COMMUNITY BASED CARE Describe the home management for this condition - Patient should not be discharged home alone. - May need home care nurse - Cardiac rehabilitation - Assessment o Cardiovascular fn o Coping skills o Functional ability o Nutritional status o Patients understanding of illness and tratment Describe the health teaching for this condition - Normal A&P of heart - Pathophysiology of angina and MI - Risk factor modification - Activity and exercise protocols - Cardiac drugs - When to seek medical assistance - Smoking cessation - Reducing anxiety - Health care resources like AHA. ANALYSIS Name at least one nursing diagnosis and expected outcome for this disease - Acute pain r/t imbalance between myocardial oxygen supply and demand o Expected outcome: Pt with CAD is expected to state that pain is relieved.

Ineffective tissue perfusion r/t interruption of arterial blood flow o Expected outcome: Pt to have adequate blood flow through the coronary vasculature to maintain heart function. Baseline ejection fraction, pulmonary wedge pressure, cardiac biomarkers, apical heart rate, systolic and diastolic blood pressure - Activity intolerance r/t fatigue caused by imbalance between oxygen supply and demand - Ineffective coping r/t effects of acute illness and major changes in lifestyle EVALUATION - How will you know the patient is getting better? - Patient states that discomfort or other symptoms alleviated - Baseline VS - Have adequate blood flow through coronary vasculature to ensure heart function - Walk 200 ft four times a day without discomfort, shortness of breath, other symptoms of CAD - Take personal actions to manage stressors related to CAD -