REVIEW OF ANATOMY AND PHYSIOLOGY

Arteries are the blood vessels that transport blood away from the heart. They vary
considerably in size and their walls consist of three layers of tissue.

1. Innermost- tunica intima:

● Made up of a smooth muscle layer contains one layer of endothelial cells,
and the rest is smooth muscle and elastin
● creates a tube for the oxygen-rich blood to move through to reach the
appropriate site of perfusion

2. Middle layer- tunica media:

● Made up of more smooth muscle that can dilate or constrict, which
adjusts the pressures on the arterial walls during systolic pumping.
● this layer of muscle lets arteries handle the high pressures from the heart.

3. Outermost layer- tunica adventitia:

● Connective tissue anchoring arteries to nearby tissues.
● Crucial for connecting the arteries to other tissues in the body, including
the vascular nerves, which control the smooth muscles in the arteries.

Coronary arteries supply blood to the heart muscle. Like all other tissues in the body,
the heart muscle needs oxygen-rich blood to function. Also, oxygen-depleted blood
must be carried away. The coronary arteries wrap around the outside of the heart. Small
branches dive into the heart muscle to bring it blood.
The 2 main coronary arteries are the left main and right coronary arteries.

Left main coronary artery (LMCA): supplies blood to the left side of the heart muscle
(the left ventricle and left atrium). The left main coronary divides into branches:
The left anterior descending artery branches off the left coronary artery and
supplies blood to the front of the left side of the heart.
The circumflex artery branches off the left coronary artery and encircles the
heart muscle. This artery supplies blood to the outer side and back of the
heart.

Right coronary artery (RCA): supplies blood to the right ventricle, the right atrium,
and the SA (sinoatrial) and AV (atrioventricular) nodes, which regulate the heart
rhythm.
The right coronary artery divides into smaller branches, including the right posterior
descending artery and the acute marginal artery. Together with the left anterior
descending artery, the right coronary artery helps supply blood to the middle or
septum of the heart.

Since coronary arteries deliver blood to the heart muscle, any coronary artery disorder
or disease can have serious implications by reducing the flow of oxygen and nutrients to
the heart muscle. This can lead to a heart attack and possibly death. Atherosclerosis (a
buildup of plaque in the inner lining of an artery causing it to narrow or become blocked)
is the most common cause of heart disease.
DEFINITION

Coronary artery disease is the narrowing or blockage of the coronary arteries, usually
caused by atherosclerosis which is an abnormal accumulation of lipid, or fatty
substances, and fibrous tissue, that leads to reduced blood flow to the myocardium.

RISK FACTORS

Modifiable:
● Dyslipidemia (LDL directly related to CAD, HDL inversely related to CAD, VLDL
directly related to CAD in patients with DM)
● Cigarette smoking,tobacco use
● Hypertension
● Diabetes mellitus
● Metabolic syndrome
● Obesity
● Physical inactivity

Non-modifiable:
● Family history of CAD
● Increasing age (more than 45 years for men; more than 55 years for women)
● Gender (men develop CAD at an earlier age than women)
● Race (higher incidence of heart disease in African Americans than in
Caucasians)

Risk enhancing factors

● Premature menopause
● Preeclampsia
● Chronic inflammatory conditions (for example rheumatoid arthritis, HIV, psoriasis)
● Persistently elevated triglycerides
● Stress

CAUSES
Coronary artery disease is thought to begin with damage or injury to the inner layer of a
coronary artery. The damage may be caused by various factors, including:
● Smoking
● High blood pressure
 ● High cholesterol
● Diabetes or insulin resistance
● Sedentary lifestyle

PATHOPHYSIOLOGY
CLINICAL MANIFESTATIONS

CARDIOVASCULAR
● Angina pectoris refers to chest pain (that is brought about by myocardial
ischemia) coinciding with increased exertion or stress. Pain described as
pressure, squeezing, burning, or tightness, can also radiate to arms, shoulders,
jaw, throat, or back.
● Low cardiac output- Bradycardia, hypertension
● MI
● Diaphoresis (cold sweats)
● ECG changes - ST segment and T wave changes, tachycardia.
● Dysrhythmias

RESPIRATORY
● Dyspnea, shortness of breath
● Pulmonary edema
● Chest tightness
● Fatigue

GENITOURINARY
● Decreased urinary output

GASTROINTESTINAL
● Nausea
● Vomiting

SKIN
● Cool, clammy skin
● Diaphoretic
● Pale appearance

DIAGNOSTIC EVALUATION
➢ History Taking
➢ Physical Examination (Tachycardia, hypertension, S4 gallop, heart murmurs,
pulmonary congestion)
➢ Blood investigations (Lipid profile, CRP)
 ➢ Urine analysis
➢ Serum markers (Troponins (I or T), Creatine kinase with MB isozymes, Lactate
dehydrogenase and lactate dehydrogenase isozymes, Serum aspartate
aminotransferase)
➢ Exercise stress test- treadmill test
➢ Chest X-ray
➢ ECG
➢ Echocardiography
➢ PET
➢ Nuclear imaging studies
➢ CT scan
➢ Coronary Angiography
➢ Doppler velocity probes

MEDICAL MANAGEMENT
PRIMARY PREVENTION
The primary goal of management of patients with CAD is reducing and controlling risk
factors.

1. Diet - According to ACC/AHA 2019, the plant-based Mediterranean diet (high in

vegetables, fruits, legumes, nuts, whole grains, and fish) is highly recommended.
2. Exercise, physical activity, and weight loss, Physical activity is also equally
beneficial for CAD risk reduction. At least 150 minutes per week of moderate-
intensity activities and greater than 75 minutes a week of vigorous-intensity
physical activities are helpful.
3. Smoking cessation - Using tobacco is a significant risk factor of CAD.
4. Hypertension management
○ Non-pharmacological interventions are lifestyle modifications that include
changes in diet and exercise.
○ Weight loss also has a positive impact on lowering blood pressure.
○ Reducing alcohol consumption also has blood-pressure-lowering effects.
5. Type 2 Diabetes mellitus (DM) - Initially, dietary modifications using a heart-
healthy diet (like Mediterranean and DASH diet) and physical activities (at least
150 minutes/week of moderate to vigorous) are encouraged. Weight loss is
recommended if the individual is overweight or obese.

PHARMACOLOGIC MANAGEMENT
● Nitrates and vasodilators
Nitrates treat immediate pain
 Vasodilator causes venodilation, which decreases preload, reducing oxygen
demand of the heart
Examples: Nitroglycerin, Isosorbide Mononitrate

● Beta blockers
Reduce myocardial oxygen demand by reducing heart rate and contractility
Examples: Propranolol, Timolol
● Calcium channel blockers
Reduce the total coronary flow by blocking beta 2 receptors
Examples: Nifedipine, Amlodipine

● Antiplatelet agent - Aspirin

Prevents thrombosis by blocking platelet activation

● Statins
Lowers low density lipoproteins, improves dyslipidemia

PERCUTANEOUS CORONARY INTERVENTIONS

Invasive interventional procedures to open up blood vessels and restore blood flow
through the coronary arteries.
It includes:
● PTCA
● Intracoronary Stent Implantation
● Atherectomy
● Brachytherapy

Percutaneous Transluminal Coronary Angioplasty:

In PTCA, a balloon-tipped catheter is used to open blocked coronary vessels and
resolve ischemia.
The purpose of PTCA is to improve blood flow within a coronary artery by compressing
and “cracking” the atheroma.
PTCA is carried out in the cardiac catheterization laboratory.
Hollow catheters called sheaths are inserted, usually in the femoral artery (and
sometimes femoral vein), providing a conduit for other catheters. Catheters are then
threaded through the femoral artery, up through the aorta, and into the coronary
arteries.
Angiography is performed using injected radiopaque contrast agents (commonly called
dye) to identify the location and extent of the blockage.
A balloon-tipped dilation catheter is passed through the sheath and positioned over the
lesion.
The physician determines the catheter position by examining markers on the balloon
that can be seen with fluoroscopy.
When the catheter is properly positioned, the balloon is inflated with high pressure for
several seconds and then deflated.
The pressure compresses and often “cracks” the atheroma.The media and adventitia of
the coronary artery are also stretched.

Coronary artery stent:

A stent is a metal mesh that provides structural support to a vessel at risk of acute
closure.
The stent is positioned over the angioplasty balloon.
When the balloon is inflated, the mesh expands and presses against the vessel wall,
holding the artery open.
The balloon is withdrawn, but the stent is left permanently in place within the artery.

Atherectomy:
Invasive interventional procedure that involves the removal of the atheroma, or plaque,
from a coronary artery by cutting, shaving, or grinding.
It may be used in conjunction with PTCA.

Brachytherapy:
Reduces the recurrence of obstruction, preventing vessel restenosis by inhibiting
smooth muscle cell proliferation.
Brachytherapy involves the delivery of gamma or beta radiation by placing a
radioisotope close to the lesion.
The radioisotope may be delivered by a catheter or implanted with the stent.
SURGICAL INTERVENTIONS
CABG
CABG is a surgical procedure in which a blood vessel is grafted to an occluded
coronary artery so that blood can flow beyond the occlusion; it is also called a bypass
graft.
In the traditional CABG procedure, the surgeon performs a median sternotomy and
connects the patient to the cardiopulmonary bypass (CPB) machine.
Next, a blood vessel from another part of the patient’s body (eg, saphenous vein, left
internal mammary artery) is grafted distal to the coronary artery lesion, bypassing the
obstruction.

NURSING MANAGEMENT

1. Managing Acute Chest Pain and Discomfort

● Perform pain assessment: Identify precipitating events, if any, as well as

frequency, duration, intensity, and location of the pain.
● Assess and document the client’s response to medication.
● Elevate the head of the bed if the client is short of breath or during nitrates
administration.
● Encourage immediate reporting of pain for prompt administration of medications
as indicated.
● Monitor and document effects or adverse responses to medications, noting BP,
heart rate, and rhythm.

2. Managing Decreased Cardiac Output and Oxygen demand

● Provide supplemental oxygen as indicated.

● Observe associated symptoms such as dyspnea, nausea, vomiting, dizziness,
palpitations, and desire to micturate.
● Provide light meals with decreased saturated fats, decreased cholesterol,
decreased sodium, and refined sugar. Have the client rest for one hour after
meals.
● Monitor vital signs and cardiac rhythm.
● Auscultate breath sounds and heart sounds. Listen for murmurs.
● Note skin color and the presence and quality of pulses.
● Stress the importance of avoiding straining down, especially during defecation.

3. Monitoring and Preventing Potential Myocardial Complications

● Evaluate reports of pain in the jaw, neck, shoulder, arm, or hand (typically
on the left side).
● Closely monitor alterations in the cardiac monitor.
● Prepare for surgical intervention, angioplasty with/without intracoronary
stent placement, valve replacement, and CABG, if indicated.

4. Providing Emotional Support and Reducing Anxiety

● Maintain a calm environment and stay with the client who is experiencing pain or
appears anxious.
● Evaluate the client’s and family member’s level of understanding of the
diagnosis.
● Observe and monitor physical responses, such as restlessness, changes in vital
signs, and repetitive movements.
● Promote the expression of feelings and fears. Let the client or family member
know these are normal reactions.
● Encourage the client to perform stress reduction or relaxation techniques.

5. Providing Patient Education and Teachings for Lifestyle Changes

● Assess the client’s readiness and ability to learn, their culture, and identify any
culturally specific information needs.
● Review the significance of cholesterol levels and differentiate between LDL and
HDL factors. Emphasize the importance of periodic laboratory measurements.
● Encourage avoidance of situations that may precipitate episodes of angina
(stress, intense physical exertion, large heavy meals especially during bedtime,
exposure to extreme temperatures).
● Review the importance of weight control, cessation of smoking, dietary changes,
and exercise.
 ● Discuss the impact of illness on desired lifestyle and activities, including work,
driving, sexual activity, and hobbies.

NURSING DIAGNOSIS

➢ Acute pain related to increased cardiac workload, decreased blood flow to the
myocardium as evidenced by reports of chest pain, facial grimace, guarding
behavior
➢ Decreased cardiac output related to transient or prolonged myocardial ischemia,
altered heart rate and rhythm as evidenced by tachycardia, ecg changes
➢ Ineffective tissue perfusion related to inadequate blood supply to the heart,
obstructed arteries as evidenced by pallor, prolonged capillary refill time,
tachycardia, dyspnea.
➢ Anxiety related to situational crisis, threat of change in health status as
evidenced by expression of distress and insecurity.
➢ Activity intolerance related to fatigue secondary to decreased cardiac output.