Coronary Artery Disease

Coronary Artery Disease 150 150 Tony Guo

Coronary Artery Disease

  • Atherosclerosis
  • Begins as soft deposits of fat that harden with age
  • Referred to as “hardening of arteries”
  • Atheromas (fatty deposits) prefer coronary arteries
  • Etiology and pathophysiology
    • Atherosclerosis is major cause of CAD
      • Characterized by lipid deposits within intima of artery
      • Endothelial injury and inflammation play a major role in development
    • C-reactive protein (CRP)
      • Nonspecific marker of inflammation
      • Increased in many patients with CAD
      • Chronic exposure to CRP linked with unstable plaques and oxidation of LDL cholesterol
    • Collateral circulation
      • Arterial anastomoses (or connections) within coronary circulation
      • Increased with chronic ischemia
      • May be inadequate with rapid-onset CAD
  • Developmental stages
    • Chronic Endothelial Injury due to 
      • Hypertension
      • Tobacco use
      • Hyperlipidemia
      • Hyperhomocysteinemia
      • Diabetes
      • Infections
      • Toxins
    • The stages of atherosclerosis development are
      • Fatty streak
        • Lipids accumulate and migrate into smooth muscle cells
      • Fibrous plaque
        • Collagen covers the fatty streak
        • Vessel lumen is narrowed
        • Blood flow is reduced
        • Fissures can develop
      • Complicated lesion
        • Plaque rupture
        • Thrombus formation
        • Further narrowing or total occlusion of vessel
  • Risk factors of coronary artery disease
    • Non-modifiable risk factors
      • Increasing age 
      • Gender (more common in men than in women until 75 yr of age)
      • Ethnicity (more common in white men than in African Americans)
      • Family history of heart disease
      • Genetic predisposition
    • Major modifiable risk factors
      • Elevated serum lipids
        • Cholesterol >200 mg/dL (5.2 mmol/L)
        • Triglycerides >150 mg/dL (3.7 mmol/L)
        • High-density lipoproteins (HDL)
        • Low-density lipoproteins (LDL)
          • Reduce total fat intake.
          • Reduce animal (saturated) fat intake.
          • Take prescribed drugs for lipid reduction.
          • Adjust total caloric intake to achieve and maintain ideal body weight.
          • Engage in daily physical activity.
          • Increase amount of complex carbohydrates, fiber, and vegetable proteins in diet.
      • Hypertension
        • Monitor home-based BP and obtain regular checkups.
        • Take prescribed drugs for BP control.
        • Reduce salt intake.
        • Stop tobacco use. Avoid exposure to environmental tobacco (secondhand) smoke.
        • Control or reduce weight.
        • Perform physical activity daily.
      • Physical Inactivity
        • Develop and maintain at least 30 min of moderate physical activity daily (minimum 5 days a week). 
        • Increase activities to a fitness level.
      • Obesity: Waist circumference ≥102 cm (≥40 in) in men and ≥88 cm (≥35 in) in women
        • Change eating patterns and habits.
        • Reduce caloric intake to achieve body mass index of 18.5–24.9 kg/m2.
        • Increase physical activity to increase caloric expenditure.
        • Avoid fad and crash diets, which are not effective over time.
        • Avoid large, heavy meals. Consider smaller, more frequent meals.
      • Diabetes
        • Follow the recommended diet.
        • Control or reduce weight.
        • Take prescribed drugs for diabetes.
        • Monitor blood glucose levels regularly. 
      • Psychologic state
        • Increase awareness of behaviors that are harmful to health.
        • Alter patterns that add to stress (e.g., get up 30 min earlier so that breakfast is not eaten on way to work).
        • Set realistic goals for self.
        • Reassess priorities in light of identified risk factors.
        • Learn effective stress management strategies
        • Seek professional help if feeling depressed, angry, and anxious, etc.
        • Plan time for adequate rest and sleep

 

  • Contributing
    • Fasting blood glucose ≥100 mg/dL 
    • Psychosocial risk factors (e.g., depression, hostility, anger, stress)
    • Elevated homocysteine levels

 

  • Nursing and Interprofessional care: Chronic Artery Disease
    • Nutritional therapy
      • Decrease saturated fats and cholesterol
      • Increase complex carbohydrates and fiber
      • Increase red meat, egg yolks, whole milk
      • Increase omega-3 fatty acids
        • Strong scientific evidence for reduction of triglyceride levels
    • Lipid-lowering drug therapy
      • If diet and exercise ineffective
      • Statins
        • Inhibit cholesterol synthesis, decrease LDL, increase HDL
        • Monitor for liver damage and myopathy
      • Niacin
        • Lowers LDL and triglyceride by inhibiting synthesis
        • Increases HDL
        • Flushing, pruritus, GI side effects, orthostatic hypotension
      • Fibric acid derivatives (Lopid)
        • Decrease triglycerides and increase HDL
        • GI side effects
    • Increase lipoprotein removal
      • Bile acid sequestrants
        • Increase conversion of cholesterol to bile acids
        • GI side effects; bind with other drugs
      • Decrease cholesterol absorption
        • Ezetimibe (Zetia)
          • Decrease absorption of dietary and biliary cholesterol
    • Antiplatelet therapy 
      • ASA
      • Clopidogrel (Plavix)
  • Cultural and ethnic health disparities
    • Whites
      • White men have the highest incidence of coronary artery disease (CAD).
    • African Americans
      • African Americans have an early age of onset of CAD.
      • Deaths from cardiovascular diseases (e.g., CAD, stroke) are higher for African Americans than for the overall population in the United States.
      • African American women have a higher incidence and death rate related to CAD than white women.
    • Native Americans
      • Native Americans die from heart disease earlier than expected.
      • Mortality rates for those under 65 yr old are twice as high as those of other Americans.
      • Major modifiable cardiovascular risk factors for Native Americans are tobacco use, hypertension, obesity, and diabetes.
    • Hispanics
      • Hispanics have slightly lower rates of CAD than either non-Hispanic whites or African Americans.
      • Hispanics have lower death rates from CAD than non-Hispanic whites
  • Gender differences
    • Coronary Artery disease
      • Men
        • First heart event for men is more often Ml than angina.
        • Men report more typical signs and symptoms of angina and MI.
        • Men receive more evidence-based therapies (e.g., aspirin, statins, diagnostic catheterization, PCI) when acutely ill from CAD (e.g., MI) than women.
        • Mortality rates from CAD have decreased more rapidly for men than women.
      • Women
        • Women experience the onset of heart disease approximately 10 years later than men.
        • CAD is the leading cause of death for women, regardless of race or ethnicity.
        • More women with MI (compared to men with MI) die of sudden cardiac death before reaching the hospital.
        • Before menopause, women have higher HDL cholesterol levels and lower
        • LDL cholesterol levels than men. After menopause LDL levels increase.
    • Acute coronary syndrome
      • Men
        • After age 75, the incidence of MI in men and women equalizes.
        • Men present more frequently than women with an acute MI as the first manifestation of CAD.
        • Men develop greater collateral circulation than women.
        • Men have larger-diameter coronary arteries than women.
        • Vessel diameter is inversely related to risk of restenosis after interventions.
        • Standard screening for risk of sudden cardiac death (e.g., EP studies) is more predictive in men.
      • Women
        • Women are older than men when seen with first MI and often have more co-morbidities.
        • Women seek medical care later in the CAD process and often are more ill on presentation than men.
        • First heart event for women is more often unstable angina than MI.
        • Once a woman reaches menopause, her risk for an MI quadruples.
        • Fewer women than men manifest the “classic” signs and symptoms of UA or MI.
        • Fatigue is often the first symptom of ACS in women.
        • Women experience more “silent” MIs compared with men.
        • Among those who have an MI, women are more likely to suffer a fatal heart event within 1 year than men.
        • Women report more disability after a heart event than men.
        • Women who have coronary artery bypass graft surgery have a higher mortality rate and more complications after surgery than men.

 

  • Clinical manifestation of CAD
    • Angina
      • Chronic and progressive disease
        • O2 demand > O2 supply → myocardial ischemia 
        • Angina = clinical manifestation
          • Occurs when arteries are blocked 70% or more
          • 50% or more for left main coronary artery
      • Locations and patterns of Angina
        • Mid sternum, left shoulder and down both arms, neck and arms
        • Substernal radiating to neck and jaw and substernal radiating down left arm
        • Epigastric and radiating to neck, jaw, and arms
        • Intrascapular
      • PQRST Assessment of Angina
Factor Questions to ask the patient
P Precipitating events What events or activities precipitated the pain or discomfort (e.g., argument, exercise, resting)?
Q Quality of pain  What does the pain or discomfort feel like (e.g., pressure, dull, aching, tight, squeezing, heaviness)?
R Region (location) and radiation of pain Can you point to where the pain or discomfort is located? Does the pain or discomfort radiate to other areas (e.g., back, neck, arms, jaw, shoulder, and elbow)?
S Severity of pain On a scale of 0 to 10, with 0 indicating no pain and 10 being the most severe pain you could imagine, what number would you give the pain or discomfort?
T Timing When did the pain or discomfort begin? Has it changed since this time? Have you had pain/discomfort like this before?
  • Precipitating factors of Angina
    • Physical Exertion
      • Increases HR, reducing the time the heart spends in diastole (the time of greatest coronary blood low), resulting in an increase in myocardial O2 demand.
      • Isometric exercise of the arms (e.g., raking, lifting heavy objects, snow shoveling) can cause exertional angina.
    • Temperature Extremes
      • Increase the workload of the heart.
      • Blood vessels constrict in response to a cold stimulus.
      • Blood vessels dilate and blood pools in the skin in response to a hot stimulus.
    • Strong Emotions
      • Stimulate the sympathetic nervous system, activating the stress response.
      • Increase the workload of the heart.
    • Consumption of Heavy Meal (e.g., holiday meals)
      • Can increase the workload of the heart.
      • During the digestive process, blood is diverted to the GI system, reducing blood low in the coronary arteries.
    • Tobacco Use and Environmental Tobacco Smoke
      • Diminish available O2 by increasing the level of carbon monoxide.
      • Nicotine stimulates catecholamine release, causing vasoconstriction and an increased HR.
    • Sexual Activity
      • Increases the cardiac workload and sympathetic stimulation.
      • In a person with CAD, the extra cardiac workload may precipitate angina.
    • Stimulants (e.g., cocaine, amphetamines)
      • Increase HR and BP and subsequently increases myocardial O2 demand.
      • Stimulate vasoconstriction and subsequently decreases myocardial O2 supply.
      • May precipitate dysrhythmias
    • Circadian Rhythm Patterns
      • Manifestations of CAD tend to occur in the early morning after awakening.

 

  • Chronic stable angina
    • Intermittent chest pain that occurs over a long period with same pattern of onset, duration, and intensity of symptoms
    • Few minutes in duration
    • ST segment depression and/or T-wave inversion
    • Control with drugs
  • Types of Angina
    • Silent ischemia
      • Ischemia that occurs in absence of any subjective symptoms 
      • Associated with diabetic neuropathy
      • Confirmed by ECG changes
    • Prinzmetal’s (variant) angina
      • Rare
      • Occurs at rest
      • Can be seen in patients with a history of migraine headaches, Raynaud’s phenomenon and heavy smoking
      • Spasm of a major coronary artery
      • CAD may or may not be present
    • Microvascular angina
      • Syndrome X (Common in women)
      • Chest pain occurs in the absence of significant CAD or coronary spasm of a major coronary artery
      • Prevention and treatment follows CAD recommendations
  • Interprofessional care
    • Goal: decrease O2 demand and/or increase O2 supply
      • Short-acting nitrates
        • Dilate peripheral and coronary blood vessels 
        • Give sublingually or by spray
        • If no relief in 5 minutes, call EMS; if some relief ,repeat every 5 minutes for maximum 3 doses
        • Patient teaching
        • Can use prophylactically
      • Long-acting nitrates
        • To reduce angina incidence
        • Main side effects: headache, orthostatic hypotension
        • Methods of administration
          • Oral
          • Nitroglycerin (NTG) ointment
          • Transdermal controlled-release NTG
      • Angiotensin-converting enzyme inhibitors (ACE) and angiotensin receptor blockers (ARBs)
      • β-Blockers
      • Calcium channel blockers
      • Lipid lowering drugs
        • Sodium current inhibitor
          • Ranolazine (Ranexa)
    • Diagnostic studies
      • Chest x-ray
      • 12-lead ECG
      • Laboratory studies
      • Echocardiogram 
      • Exercise stress test
      • EBCT
      • CCTA
    • Cardiac catheterization/coronary angiography
      • Visualize blockages (diagnostic)
      • Open blockages (interventional)
        • Percutaneous coronary intervention (PCI)
        • Balloon angioplasty
        • Stent

 

Acute coronary syndrome

  • Etiology and pathophysiology
    • Process
      • Deterioration of once stable plague
      • Rapture
      • Platelet aggregation
      • Thrombus
    • Result
      • Partial occlusion of coronary artery: UA or NSTEMI
      • Total occlusion of coronary artery: STEMI
  • Clinical manifestation of ACS
    • Unstable Angina
      • New in onset
      • Occurs at rest
      • Increase in frequency, duration, or with less effort
      • Pain lasting > 10 minutes
      • Needs immediate treatment
      • Symptoms in women often under-recognized
    • Myocardial infarction (MI)
      • ST-elevation and non-ST-elevation
      • Result of abrupt stoppage of blood flow through a coronary artery, causing irreversible myocardial cell death (necrosis)
        • Pre-existing CAD
        • STEMI – occlusive thrombus
        • NSTEMI – non-occlusive thrombus
      • Pain
        • Severe chest pain not relieved by rest, position change, or nitrate administration
          • Heaviness, pressure, tightness, burning, constriction, crushing
          • Substernal or epigastric
          • May radiate to neck, lower jaw, arms, back
        • Often occurs in early morning
        • Atypical in women, elderly
        • No pain if cardiac neuropathy (diabetes)
      • Catecholamine release and stimulation of SNS
        • Release of glycogen
        • Diaphoresis
        • Increased HR and BP
        • Vasoconstriction of peripheral blood vessels
        • Skin: ashen, clammy, and/or cool to touch
      • Cardiovascular
        • Initially, increase HR and BP, then decrease BP (secondary to decrease in CO) 
        • Crackles 
        • Jugular venous distention
        • Abnormal heart sounds
          • S3 or S4
          • New murmur
      • Nausea and vomiting
        • Reflex stimulation of the vomiting center by severe pain
        • Vasovagal reflex
      • Fever
        • Up to 100.4° F (38° C) in first 24-48 hours
        • Systemic inflammatory process caused by heart cell death

 

Myocardial infarction

  • Healing process
    • Within 24 hours, leukocytes infiltrate the area of cell death
    • Proteolytic enzymes of neutrophils and macrophages begin to remove necrotic tissue by fourth day → thin wall 
    • Necrotic zone identifiable by ECG changes 
    • Collagen matrix laid down
    • 10 to 14 days after MI, scar tissue is still weak 
    • Heart muscle vulnerable to stress
    • Monitor patient carefully as activity level increases
    • By 6 weeks after MI, scar tissue has replaced necrotic tissue
      • Area is said to be healed, but less compliant
    • Ventricular remodeling
      • Normal myocardium will hypertrophy and dilate in an attempt to compensate for infarcted muscle
  • Complications of myocardial infarction
    • Dysrhythmias
      • Most common complication
      • Present in 80% to 90% of MI patients
      • Can be caused by ischemia, electrolyte imbalances, or SNS stimulation
      • VT and VF are most common cause of death in prehospitalization period
    • Heart failure
      • Occurs when pumping power of heart has diminished
      • Left-sided HF
        • Mild dyspnea, restlessness, agitation, slight tachycardia initially
      • Right-sided HF
        • Jugular venous distention, hepatic congestion, lower extremity edema
    • Cardiogenic shock
      • Occurs because of 
        • Severe LV failure, papillary muscle rupture, ventricular septal rupture, LV free wall rupture, right ventricular infarction
      • Requires aggressive management
        • Associated with a high death rate
    • Papillary muscle dysfunction or rupture
      • Causes mitral valve regurgitation
      • Aggravates an already compromised LV → rapid clinical deterioration
    • Left ventricular aneurysm
      • Myocardial wall becomes thinned and bulges out during contraction
      • Leads to HF, dysrhythmias, and angina
    • Ventricular septal wall rupture and left ventricular free wall rupture
      • New, loud systolic murmur
      • HF and cardiogenic shock
      • Emergency repair 
      • Rare condition associated with high death rate
    • Acute pericarditis
      • Inflammation of visceral and/or parietal pericardium
      • Mild to severe chest pain 
        • Increases with inspiration, coughing, movement of upper body
        • Relieved by sitting in forward position 
      • Pericardial friction rub 
      • ECG changes
    • Dressler syndrome
      • Pericarditis and fever that develops 1 to 8 weeks after MI
      • Chest pain, fever, malaise, pericardial friction rub, arthralgia
      • High dose aspirin is treatment of choice

 

  • Unstable Angina and MI
    • Diagnostic studies
      • Detailed health history 
      • 12-lead ECG
        • Compare to previous ECG
        • Changes in QRS complex, ST segment, and T wave 
        • Distinguish between STEMI and NSTEMI
        • Serial ECGs reflect evolution of MI
      • Coronary angiography
        • For patients with a STEMI
        • Not for patients with UA or NSTEMI
      • Pharmacologic stress testing
        • For patients with abnormal but non-diagnostic ECG and negative biomarkers

 

  • Interprofessional care
    • Acute Coronary Syndrome
      • Initial interventions
        • 12-lead ECG
        • Upright position
        • Oxygen – keep O2 sat > 93%
        • IV access 
        • Nitroglycerin (SL) and ASA (chewable)
        • Statin
        • Morphine
      • Ongoing monitoring
        • Treat dysrhythmias
        • Frequent vital sign monitoring
        • Bed rest/limited activity for 12–24 hours
      • UA or NSTEMI 
        • Dual antiplatelet therapy and heparin
        • Cardiac catheterization with PCI once stable
      • NSTEMI 
        • Reperfusion therapy

      • Emergent PCI 
        • Treatment of choice for confirmed STEMI
        • Goal: 90 minutes from door to catheter laboratory
        • Balloon angioplasty + stent(s) 
        • Many advantages over CABG
      • Thrombolytic therapy
        • Only for patients with a STEMI
          • Agencies that do not have cardiac catheterization resources
        • Given IV within 30 minutes of arrival to the ED
        • Patient selection critical
        • Draw blood and start 2–3 IV sites
        • Complete invasive procedures prior
        • Administer according to protocol
        • Monitor closely for signs of bleeding
        • Assess for signs of reperfusion
        • Return of ST segment to baseline best sign
      • IV heparin to prevent reocclusion
      • Coronary surgical revascularization 
        • Failed medical management
        • Presence of left main coronary artery or three-vessel disease 
        • Not a candidate for PCI (e.g., blockages are long or difficult to access)
        • Failed PCI with ongoing chest pain
        • History of diabetes mellitus, LV dysfunction, chronic kidney disease
      • Traditional coronary artery bypass graft (CABG) surgery
        • Requires sternotomy and cardiopulmonary bypass (CPB)
        • Uses arteries and veins for grafts 
          • The internal mammary artery (IMA) is most common artery used for bypass graft
      • Radial Arterty Graft
        • Radial artery is another potential graft 
          • Thick muscular artery that is prone to spasm
          • Perioperative calcium channel blockers and long-acting nitrates can control the spasms
          • Patency rates are not as good as IMA but better than saphenous veins
      • Acute coronary syndrome
        • Minimally invasive direct coronary artery bypass (MIDCAB)
          • For patients with disease of left anterior descending or right coronary artery
          • Does not involve a sternotomy and CPB
        • Off-pump coronary artery bypass (OPCAB)
          • Sternotomy but no CPB
        • Robotic or totally endoscopic coronary artery bypass (TECAB)
        • Transmyocardial laser revascularization
          • Indirect revascularization
          • High-energy laser creates channels in heart to allow blood flow to ischemic areas
        • Drug therapy
          • IV nitroglycerin (NTG)
          • Morphine
          • β-adrenergic blockers
          • ACE inhibitors
          • Antidysrhythmic drugs
          • Lipid-lowering drugs
          • Stool softeners

      Nursing management

      • Nursing Assessment: 
        • Subjective Data
          • Health history
            • CAD/chest pain/angina/ MI
            • Valve disease
            • Heart failure/cardiomyopathy,
            • Hypertension, diabetes, anemia, lung disease, hyperlipidemia
          • Drugs
            • Use of anti-platelets or anticoagulants 
            • Nitrates
            • Angiotensin-converting enzyme inhibitors
            • β-blockers
            • Calcium channel blockers
            • Antihypertensive drugs
            • Lipid-lowering drugs
            • Over-the-counter drugs (e.g., vitamin and herbal supplements)
          • History of present illness
            • Description of events related to current illness
          • Health perception–health management: 
            • Family history of heart disease.
            • Sedentary lifestyle
            • Tobacco use
            • Exposure to environmental smoke
          • Nutritional-metabolic
            • Indigestion/heartburn; nausea/vomiting
          • Elimination
            • Urinary urgency or frequency
            • Straining at stool
          • Activity-exercise
            • Palpitations, dyspnea, dizziness, weakness
          • Cognitive-perceptual
            • Substernal chest pain or pressure (squeezing, constricting, aching, sharp, tingling)
            • Possible radiation to jaw, neck, shoulders, back, or arms
          • Cognitive-stress tolerance
            • Stress, depression, anger, anxiety
        • Objective Data
          • Anxious, fearful, restless, distressed
          • Integumentary effects
            • Cool, clammy, pale skin
          • Cardiovascular 
            • Tachycardia or bradycardia
            • Pulsus alternans
            • Pulse deficit
            • Dysrhythmias  
            • S3, S4, increased or decreased BP, murmur
          • Possible diagnostic findings
            • Positive serum cardiac biomarkers
            • Increased serum lipids; 
              • Increased WBC count. 
            • Positive exercise or pharmacologic stress test and thallium scans. 
            • Pathologic Q wave, ST segment elevation, and/or T wave abnormalities on ECG.
            • Cardiac enlargement, calcifications, or pulmonary congestion on chest x-ray. 
            • Abnormal wall motion with stress echocardiogram. 
            • Positive coronary angiography
        • Psychosocial responses to Acute coronary syndrome
          • Denial
            • May have history of ignoring signs and symptoms related to heart disease
            • Minimizes severity of health condition
            • Ignores activity restrictions
            • Avoids discussing illness or its significance
          • Depression
            • Mourns loss of health, altered body function, and changes in lifestyle
            • Realizes seriousness of situation
            • Begins to worry about future implications of health problem
            • Shows manifestations of withdrawal, crying, apathy
            • May be more evident after discharge
          • Anger and Hostility
            • Is commonly expressed as, “Why did this happen to me?”
            • May be directed at family, staff, or medical regimen
          • Anxiety and Fear
            • Fears long-term disability and death
            • Overtly displays apprehension, restlessness, insomnia, tachycardia
            • Less overtly displays increased verbalization, projection of feelings to others, hypochondriasis
            • Fears activity
            • Fears recurrent chest pain, heart attacks, and sudden death
          • Dependency
            • Is totally reliant on staff
            • Is unwilling to perform tasks or activities unless approved by HCP
            • Wants to be monitored by ECG at all times
            • Is hesitant to leave the intensive care or telemetry unit or hospital
          • Realistic Acceptance
            • Focuses on optimum rehabilitation
            • Plans changes compatible with altered cardiac function
            • Actively engages in lifestyle changes to address modifiable risk factors
      • Nursing diagnoses
        • Decreased cardiac output related to altered contractility and altered heart rate and rhythm
        • Acute pain related to an imbalance between myocardial O2 supply and demand
        • Anxiety related to perceived or actual threat of death, pain, and/or possible lifestyle changes
        • Activity intolerance related to general weakness secondary to decreased cardiac output and poor lung and tissue perfusion
        • Ineffective health management related to lack of knowledge of disease process, risk factor reduction, rehabilitation, home activities, and medications
      • Planning
        • Overall goals
          • Relief of pain
          • Preservation of heart muscle
          • Immediate and appropriate treatment
          • Effective coping with illness-associated anxiety
          • Participation in a rehabilitation plan
          • Reduction of risk factors
      • Acute interventions: Chronic stable angina
        • Upright position
        • Supplemental oxygen
        • Assess vital signs
        • 12-lead ECG
        • Administer NTG followed by an opioid analgesic, if needed
        • Assess heart and breath sounds
      • Acute care: Acute coronary syndrome
        • Pain: nitroglycerin, morphine, oxygen
        • Continuous monitoring
          • ECG
          • ST segment 
          • Heart and breath sounds
          • VS, pulse oximetry, I and O
        • Rest and comfort
          • Balance rest and activity
          • Begin cardiac rehabilitation
        • Anxiety reduction
          • Identify source and alleviate
          • Patient teaching important
        • Emotional and behavioral reaction 
          • Maximize patient’s social support systems
          • Consider open visitation
      • Coronary revascularization: PCI
        • Monitor for recurrent angina
        • Frequent VS, including cardiac rhythm
        • Monitor catheter insertion site for bleeding
        • Neurovascular assessment
        • Bed rest per institutional policy
      • Coronary revascularization: CABG
        • ICU for first 24–36 hours
        • Pulmonary artery catheter
        • Intra-arterial line 
        • Pleural/mediastinal chest tubes 
        • Continuous ECG
        • ET tube with mechanical ventilation
        • Epicardial pacing wires
        • Urinary catheter
        • NG tube
      • Ambulatory Care
        • Resumption of sexual activity
          • Teach when discuss other physical activity
          • Erectile dysfunction drugs contraindicated with nitrates
          • Prophylactic nitrates before sexual activity
          • When to avoid sex
          • Typically 7–10 days post MI or when patient can climb two flights of stairs
      • Evaluation
        • Stable vital signs
        • Relief of pain
        • Decreased anxiety
        • Realistic program of activity
        • Effective management of therapeutic regimen

      Sudden cardiac death

      • Nursing/Interprofessional care
        • Diagnostic workup to rule out or confirm MI 
          • Cardiac biomarkers
          • ECGs
          • Treat accordingly
        • Cardiac catheterization
        • PCI or CABG
        • 24-hour Holter monitoring
        • Exercise stress testing
        • Signal-averaged ECG
        • Electrophysiologic study (EPS)
        • Implantable cardioverter-defibrillator (ICD)
        • Antidysrhythmic drugs
        • LifeVest

      Role of Nursing Personnel

      • Registered Nurse (RN)
        • Pre-procedure
          • Assess for allergies, especially to contrast dye. Perform baseline assessment, including vital signs, pulse oximetry, heart and breath sounds, neurovascular assessment of extremities (e.g., distal pulses, skin temperature, skin color, sensation).
          • Assess baseline laboratory values (e.g., cardiac biomarkers, creatinine).
          • Teach patient and caregiver about procedure and post-procedure care.
        • Post-procedure
          • Perform assessment and compare to baseline: vital signs, pulse oximetry, heart and breath sounds, neurovascular assessment of extremity used for procedure, assessment of catheter insertion site for hematoma, bleeding, and bruit.
          • Monitor ECG for dysrhythmias or other changes (e.g., ST segment elevation).
          • Monitor patient for chest pain and other sources of pain or discomfort.
          • Monitor IV infusions of anticoagulants, antiplatelets.
          • Teach patient and caregiver about discharge drugs (e.g., aspirin, clopidogrel, antianginal drugs).
          • Teach patient and caregiver about discharge care including signs and symptoms to report to HCP (e.g., site complications, return of chest pain).
      • Licensed Practical/Vocational Nurse (LPN/LVN)
        • Give drugs before and after the procedure (consider state nurse practice act and agency policy).
        • Assess neurovascular status of involved extremity every 15 min for the first hour, then according to agency policy (consider state nurse practice act and agency policy).
        • Check for bleeding at catheter insertion site every 15 min for the first hour, then according to agency policy.
        • Report changes in neurovascular status of involved extremity or any bleeding to the RN.
      • Unlicensed Assistive Personnel (UAP)
        • Take vital signs and report increases or decreases in HR or BP to RN.
        • Report decreases in pulse oximetry to the RN.
        • Report patient complaints of chest pain, shortness of breath, and/or any other discomfort or distress to RN.
        • Assist with oral hygiene and hydration, meals, and toileting.
        • Record oral intake and urine output as ordered.
        • Perform related skills as ordered (e.g., capillary blood glucose).
      • Role of Other Team Members
        • Respiratory Therapist
          • Provide respiratory therapies (e.g., nebulizer treatments) as ordered and per agency policy.

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