Lewis: Medical-Surgical Nursing, 8th Edition

Chapter 34: Nursing Management: Coronary Artery Disease and Acute Coronary
Syndrome
Key Points Printable
CORONARY ARTERY DISEASE

Coronary artery disease (CAD) is a type of blood vessel disorder included in the
general category of atherosclerosis. Atherosclerosis is characterized by the
deposit of cholesterol and lipids within the intimal wall of an artery.

CAD is a progressive disease that develops in stages; when it becomes

symptomatic, the disease process is usually well advanced.

Normally some arterial anastomoses or connections, termed collateral

circulation, exist within the coronary circulation. Their growth and extent is
attributed to the inherited predisposition to develop new blood vessels and the
presence of chronic ischemia.

Many risk factors have been associated with CAD.

o Nonmodifiable risk factors are age, gender, ethnicity, family history, and
genetic inheritance.
o Modifiable risk factors include elevated serum lipids, elevated blood
pressure, tobacco use, physical inactivity, obesity, diabetes, metabolic
syndrome, psychologic states, and homocysteine level.

Elevated serum lipid levels is one of the most firmly established risk
factors for CAD. There are three different types.

High-density lipoproteins (HDLs) carry lipids away from arteries and

to the liver for metabolism. High serum HDL levels are desirable.

HDL levels are increased by physical activity, moderate alcohol

consumption, and estrogen administration.

Elevated low-density lipoprotein (LDL) levels correlate most closely

with an increased incidence of atherosclerosis and CAD.

o Diabetes, metabolic syndrome, elevated homocysteine levels, and certain

psychologic states (e.g., anxiety, anger, depression) have also been found to
be contributing risk factors for CAD.
NURSING AND COLLABORATIVE MANAGEMENT: CORONARY ARTERY
DISEASE

Prevention and early treatment of CAD must involve a multifactorial approach

and needs to be ongoing throughout the life span.

Management of high-risk persons starts with controlling or changing the additive

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effects of modifiable risk factors.

o A regular physical activity program should be implemented.
o Diet that limits saturated fats and cholesterol and emphasizes complex
carbohydrates (e.g., whole grains, fruit, vegetables)

A complete lipid profile is recommended every 5 years beginning at age 20.

Persons with a serum cholesterol level greater than 200 mg/dl are at high risk for
CAD.
o If levels remain elevated despite modifiable changes, drug therapy is
considered.
o The statins are the most widely used drugs. Niacin, fibric acid derivatives,
bile-acid sequestrants, and other agents may also be used.

Antiplatelet therapy with low-dose aspirin is recommended for people at risk for
CAD. For people who are aspirin intolerant, clopidogrel (Plavix) is considered.

GERONTOLOGIC CONSIDERATIONS: CORONARY ARTERY DISEASE

The incidence of cardiac disease is greatly increased as one ages and is the
leading cause of death in older adults. Strategies to reduce CAD risk are
effective in this age group but are often underprescribed.

Aggressive treatment of hypertension and hyperlipidemia will stabilize plaques

in the coronary arteries of older adults, and cessation of tobacco use helps
decrease the risk for CAD at any age.

CHRONIC STABLE ANGINA

Chronic stable angina refers to chest pain that occurs intermittently over a long
period with the same pattern of onset, duration, and intensity of symptoms.
o Angina is rarely sharp or stabbing, and it usually does not change with
position or breathing.
o Anginal pain usually lasts for only a few minutes and commonly subsides
when the precipitating factor is relieved. Pain at rest is unusual.

The treatment of chronic stable angina is aimed at decreasing oxygen demand

and/or increasing oxygen supply and reducing CAD risk factors.

In addition to antiplatelet and cholesterol-lowering drug therapy, the most

common drugs used to manage chronic stable angina are nitrates, -blockers, and
calcium channel blockers.
o Short-acting nitrates are first-line therapy for the treatment of angina.
Nitrates dilate peripheral blood vessels, coronary arteries, and collateral

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vessels.
o -Adrenergic blockers are used in the management of chronic stable angina.
They decrease myocardial contractility, heart rate, systemic vascular
resistance, and blood pressure, which reduce myocardial oxygen demand.

Common diagnostic tests for a patient with a history of CAD include a chest xray, a 12-lead ECG, laboratory tests (e.g., lipid profile), echocardiography,
exercise stress testing, and coronary angiography.

PRINZMETALS ANGINA

Prinzmetals angina is a rare form of angina that often occurs at rest, usually in
response to spasm of a major coronary artery. When spasms occur, the patient
experiences angina and transient ST segment elevation.
Smoking and tobacco use may precipitate coronary artery spasms. Prinzmetals
angina may also be seen in patients with a history of migraine headaches and
Raynauds phenomenon.
The pain may be relieved by moderate exercise or it may disappear
spontaneously. Calcium channel blockers and/or nitrates are used to control the
angina.

ACUTE CORONARY SYNDROME

Acute coronary syndrome (ACS) develops when ischemia is prolonged and not
immediately reversible. ACS encompasses the spectrum of unstable angina, non
ST-segment-elevation myocardial infarction (NSTEMI), and ST-segment-elevation
myocardial infarction (STEMI).

Unstable angina (UA) is chest pain that is new in onset, occurs at rest, or has a
worsening pattern. UA is unpredictable and represents an emergency.

MYOCARDIAL INFARCTION

Myocardial infarction (MI) occurs as a result of sustained ischemia, causing

irreversible myocardial cell death. Contractile function of the heart stops in the
infarcted area(s).

The acute MI process takes time, evolving over a period of up to 12 hours.

Infarctions are described based on the location of damage.

Severe, immobilizing chest pain not relieved by rest, position change, or nitrate
administration is the hallmark of an MI. The pain is usually described as a
heaviness, pressure, tightness, burning, constriction, or crushing.

Complications after MI

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o Dysrhythmias are the most common complication and the most common
cause of death in patients in the prehospital period.
o Other complications include heart failure, cardiogenic shock, papillary
muscle dysfunction or rupture, ventricular aneurysm, and pericarditis.

Primary diagnostic studies used to determine whether a person has UA or an MI

includes an ECG and serum cardiac markers.

COLLABORATIVE CARE: ACUTE CORONARY SYNDROME

Rapid diagnosis and treatment for a patient with ACS is necessary to preserve
cardiac function.

For patients with STEMI or NSTEMI with positive cardiac markers, reperfusion
therapy is the recommended treatment of choice. This can include emergent PCI
or fibrinolytic (thrombolytic) therapy.
o Cardiac catheterization is used to locate and assess blockage and implement
treatment modalities if needed.
o Fibrinolytic therapy aims to stop infarction process by dissolving the
thrombus in the coronary artery to reperfuse the myocardium.

Coronary revascularization with coronary artery bypass graft (CABG) surgery is

recommended for patients who fail medical management, have left main coronary
artery or three-vessel disease, are not candidates for PCI, have failed PCI with
ongoing chest pain, or have diabetes.
o Minimally invasive direct CABG surgery can be used for patients requiring
one or two bypasses in one or two coronary arteries on the anterior surface
of the heart.
o Off-pump coronary artery bypass procedure uses full or partial sternotomy to
enable access to all coronary vessels.
o Transmyocardial laser revascularization is an indirect revascularization
procedure used for patients with advanced CAD who are not candidates for
traditional bypass surgery and who have persistent angina after maximum
medical therapy.

Drug Therapy

Initial management of the patient with chest pain includes aspirin, IV

nitroglycerin, systemic anticoagulation, morphine sulfate for pain unrelieved by
nitroglycerin, and oxygen.

IV antiplatelet agents may also be used if PCI is anticipated.

-Adrenergic blockers are administered IV initially or orally within 24 hours if

there are no contraindications.
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ACE inhibitors, calcium channel blockers, angiotensin receptor blockers, and

long-acting nitrates are also used in select situations.

Stool softeners are given to facilitate and promote the comfort of bowel
evacuation.

NURSING MANAGEMENT: CHRONIC STABLE ANGINA AND ACUTE

CORONARY SYNDROME

The following nursing measures should be instituted for a patient experiencing

angina: (1) administer supplemental oxygen and position patient in upright
position unless contraindicated, (2) determine vital signs, (3) obtain a 12-lead
ECG, (4) provide prompt pain relief first with a nitrate followed by an opioid
analgesic if needed, and (5) auscultate heart sounds.

Teaching for a patient with angina should include information regarding ACS,
managing angina, risk factor reduction, and medication.

Nursing Implementation: Acute Coronary Syndrome

Initial treatment of a patient with ACS includes pain assessment and relief,
physiologic monitoring, promotion of rest and comfort, alleviation of stress and
anxiety, and understanding of the patients emotional and behavioral reactions.
o Nitroglycerin, morphine sulfate, and supplemental oxygen should be
provided as needed to eliminate or reduce chest pain.
o Continuous ECG monitoring, frequent vital signs, intake and output, and
physical assessment should be done. Included is an assessment of heart and
lung sounds and inspection for evidence of early heart failure.
o Bed rest may be ordered for the first few days after an MI involving a large
portion of the ventricle. A patient with an uncomplicated MI may rest in a
chair within 8 to 12 hours after the event.
o Anxiety is common following ACS. Your role is to identify the source of
anxiety, assist the patient in reducing it, and provide appropriate patient
teaching.
o It is important to ensure adequate rest periods free from interruption.
Comfort measures that can promote rest include frequent oral care, adequate
warmth, a quiet atmosphere, use of relaxation therapy (e.g., guided imagery),
and assurance that personnel are nearby and responsive to the patients
needs.

After PCI, your major responsibilities involve monitoring for signs of recurrent
angina; frequent assessment of vital signs, including HR and rhythm; evaluation
of the groin site for signs of bleeding; and maintenance of bed rest per institution
policy.

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For patients having CABG surgery, care is provided in the intensive care unit
(ICU) for the first 24 to 36 hours, where ongoing monitoring of the patients ECG
and hemodynamic status is critical.
o Following transfer from the ICU, postoperative care focuses on monitoring
for dysrhythmias, providing wound care, managing pain, and preventing
complications (e.g., venous thromboembolism).

Ambulatory and Home Care

Many patients will be referred to an outpatient or home-based cardiac

rehabilitation program. Maintaining contact with the patient appears to be the
key to the success of these programs.

Cardiac rehabilitation restores a person to an optimal state of function in six

areas: physiologic, psychologic, mental, spiritual, economic, and vocational.

Patient teaching begins with you and continues at every stage of the patients
hospitalization and recovery. Careful assessment of the patients learning needs
helps you set goals and objectives that are realistic.

In the hospital, activity level is gradually increased so that the patient can
achieve a discharge activity level adequate for home care. Physical activity then
becomes part of a rehabilitation program. A regular schedule of physical activity,
even after many years of sedentary living, is beneficial.

Post-MI depression is common; it should resolve in 1 to 4 months.

Sexual counseling for cardiac patients and their partners should be provided. The
patients concern about resumption of sexual activity often produces more stress
than the physiologic act itself.
o The inability to perform sexually after MI is common and sexual dysfunction
usually disappears after several attempts.
o Patients should know that drugs used for erectile dysfunction should not be
used with nitrates as severe hypotension may occur.
o Typically, it is safe to resume sexual activity 7 to 10 days after an
uncomplicated MI.

SUDDEN CARDIAC DEATH

Sudden cardiac death (SCD) is unexpected death from cardiac causes, producing
an abrupt loss of cardiac output and cerebral blood flow. Death usually occurs
within 1 hour of the onset of acute symptoms (e.g., angina, palpitations).

The majority of cases of SCD are caused by acute ventricular dysrhythmias (e.g.,
ventricular tachycardia, ventricular fibrillation) and may have been accompanied
by an acute MI.

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Patients who survive are at risk for recurrent SCD caused by the continued
electrical instability of the myocardium that caused the initial event to occur.

Risk factors for SCD include left ventricular dysfunction (EF <30%), ventricular
dysrhythmias following MI, male gender (especially African American men),
family history of premature atherosclerosis, tobacco use, diabetes mellitus,
hypercholesterolemia, hypertension, and cardiomyopathy.

Most SCD patients have a lethal ventricular dysrhythmia and require 24-hour
Holter monitoring or other type of event recorder, exercise stress testing, signalaveraged ECG, and electrophysiologic study (EPS).

The most common approach to preventing a recurrence and improving survival is

the use of an implantable cardioverter-defibrillator (ICD) in conjunction with
drug therapy.

Survivors of SCD develop a time bomb mentality, fearing the recurrence of

cardiopulmonary arrest. They and their caregivers may become anxious, angry,
and depressed and may need to deal with additional issues such as possible
driving restrictions and change in occupation.

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