Coronary Artery Disease

BY DAISY JANE ANTIPUESTO RN MN JANUARY 13, 2009

336x280, created 7/31/09

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Is characterized by the accumulation of plaque within

coronary arteries, which progressively enlarge, thicken and
calcify. This causes critical narrowing of the coronary artery
lumen (75% occlusion), resulting in a decrease in coronary
blood flow and an inadequate supply of oxygen to the heart
muscle.
Ischemia may be silent (asymptomatic but evidenced by
ST depression of 1 mm or more on electrocardiogram (ECG) or
may be manifested by angina pectoris (chest pain).
Risk factor for Coronary Artery Disease include
dyslipidemia, smoking, hypertension, male gender (women are
protected until menopause), aging, non-white race, family
history, obesity, sedimentary lifestyle, diabetes mellitus,
metabolic syndrome, elevated homocysteine, and stress.
Acute coronary syndrome is a complication of CAD due to
lack of oxygen to the myocardium. Mnaifestations include
unstable angina, non ST-segment elevation infarction, and STsegment elevation infarction.
Other causes of angina include coronary artery spasm,
aortic stenosis, cardiomyopathy, severe anemia, and
thyrotoxicosis.
Assessment:
Chest pain is provoked by exertion or stress and is relieved by
nitroglycerin and rest.

Character. Substernal chest pain, pressure, heaviness, or

discomfort. Other sensations include a squeezing, aching,
burning, choking, strangling, or cramping pain.
Severity. Pain maybe mild or severe and typically present
with a gradual buildup of discomfort and subsequent gradual
fading away.
Location. Behind middle or upper third of sternum; the
patient will generally will make a fist over the site of pain
(positive Levine sign; indicates diffuse deep visceral pain),
rather than point to it with fingers.
Radiation. Usually radiates to neck, jaw, shoulders, arms,
hands, and posterior intrascapular area. Pain occurs more
commonly on the left side than the right; may produce
numbness or weakness in arms, wrist, or hands.
Duration. Usually last 2 to 10 minutes after stopping
activity; nitroglycerin relieves pain within 1 minute.
Precipitating factors. Physical activity, exposure to hot or
cold weather, eating a heavy meal, and sexual intercourse
increase the workload of the heart and, therefore, increase
oxygen demand.
Associated manifestation. Diaphoresis, nausea, indigestion,
dyspnea, tachycardia, and increase in blood pressure.
Signs of unstable angina:
A change in frequency, duration, and intensity of stable
angina symptoms.
Angina pain last longer than 10 minutes, is unrelieved by
rest or sublingual nitroglycerin, and mimics signs and
symptoms of impending myocardial infarction.
Diagnostic Evaluation:
Resting ECG may show left ventricular hypertrophy, ST-T
changes, arrhythmias, and possible Q waves.
Exercise stress testing with or without perfusion studies

shows ischemia.
Cardiac catheterization shows blocked vessels.
Position emission tomography may show small perfusion
defects.
Radionuclide ventriculography shows wall motion
abnormalities and ejection fraction.
Fasting blood levels of cholesterol, low density lipoprotein,
high density lipoprotein, lipoprotein A, homocysteine, and
triglycerides may be abnormal.
Coagulation studies, hemoglobin level, fasting blood sugar
as baseline studies.
Pharmacologic Interventions:
Antianginal medications (nitrates, beta-adrenergic blockers,
calcium channel blockers, and angiotensin converting enzyme
inhibitors) to promote a favorable balance of oxygen supply and
demand.
Antilipid medications to decrease blood cholesterol and
tricglyceride levels in patients with elevated levels.
Antiplatelet agents to inhibit thrombus formation.
Folic acid and B complex vitamins to reduce
homocysteine levels.
Surgical Interventions:
Percutaneous transluminal coronary angioplasty or
intracoronary atherectomy, or placement of intracoronarystent.
Coronary artery bypass grafting.
Transmyocardial revascularization.
Nursing Interventions:
Monitor blood pressure, apical heart rate, and respirations
every 5 minutes during an anginal attack.
Maintain continuous ECG monitoring or obtain a 12-lead
ECG, as directed, monitor for arrhythmias and ST elevation.
Place patient in comfortable position and administer

oxygen, if prescribed, to enhance myocardial oxygen supply.

Identify specific activities patient may engage in that are
below the level at which anginal pain occurs.
Reinforce the importance of notifying nursing staff
whenever angina pain is experienced.
Encourage supine position for dizziness caused by
antianginals.
Be alert to adverse reaction related to abrupt
discontinuation of beta-adrenergic blocker and calcium channel
blocker therapy. These drug must be tapered to prevent a
rebound phenomenon; tachycardia, increase in chest pain,
and hypertension.
Explain to the patient the importance of anxiety reduction
to assist to control angina.
Teach the patient relaxation techniques.
Review specific factors that affect CAD development and
progression; highlight those risk factors that can be modified
and controlled to reduce the risk.