I.

INTRODUCTION Coronary heart disease (CHD) is a narrowing of the small blood vessels that supply blood and oxygen to the heart. CHD is also called coronary artery disease (CAD) and arteriosclerotic heart disease. Coronary heart disease (CHD) is the leading cause of death in the United States for men and women. It is caused by the buildup of plaque in the arteries to the heart. This may also be called hardening of the arteries. Fatty material and other substances form a plaque build-up on the walls of the coronary arteries. The coronary arteries bring blood and oxygen to the heart. This buildup causes the arteries to get narrow. As a result, blood flow to the heart can slow down or stop. A risk factor for heart disease is something that increases the chance of getting it. Some risk factors cannot be changed, but others can be. The risk factors that cannot be changed are age, gender, genes and race. The risk of heart disease increases with age. Men have a higher risk of getting heart disease than women who are still getting their menstrual period. After menopause, the risk for women is closer to the risk for men. If your parents or other close relatives had heart disease, you are at higher risk. African Americans, Mexican Americans, American Indians, Hawaiians, and some Asian Americans also have a higher risk for heart problems. Many things increases this risk factors such as diabetes, high blood pressure, extra cholesterol in the blood that blood builds up inside the walls of blood vessels, smoking, emotional stress, Type A personality (impatient, aggressive, competitive), chronic kidney disease, substance abuse, obesity and sedentary lifestyle. Symptoms may be very noticeable, but sometimes a person can have the disease and not have any symptoms. Chest pain or discomfort (angina) is the most common symptom. The patient may feel this pain when the heart is not getting enough blood or oxygen. How bad the pain is varies from person to

person. It may feel heavy or like someone is squeezing the heart. It may be felt under the breast bone (sternum), but also in the neck, arms, stomach, or upper back. The pain usually occurs with activity or emotion, and goes away with rest or a medicine called nitroglycerin. Other symptoms include shortness of breath and fatigue with activity (exertion). Women, elderly people, and people with diabetes are more likely to have symptoms other than chest pain.

Objectives General Objective: The purpose of this study is to provide deeper theoretical and practical knowledge and information about Coronary Heart Disease (CHD). Specific Objective: 1. To provide information on the related causes of coronary heart disease. 2. To provide information regarding postpartum care for patients who had the similar illness of coronary heart disease. 3. To provide a framework of study regarding the subject that can serve as the foundation of future studies and research.

IX. NURSING MANAGEMENT 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. -Assist in management of symptoms of patients disease to prevent further complications by:

-Checking weight and activity levels. -Checking blood lipid levels, including the bad LDL, the good HDL, and triglycerides, another fat frequently elevated in overweight patients, especially if diabetic - LDL should be less than 100. -Checking blood pressure, which should be less than 130/80 mm Hg. -If diabetic, checking blood sugar and A1C (should be less than 7.0%). -Monitor the effectiveness of treatment regimen. -Monitor side effects of medications. -Ensure patients safety at all times. -Formulate an effective nursing care plan specific for patients condition. -Assist in patients rehabilitation. -Encourage the patient to LIVE A HEALTHY LIFESTYLE by:

Getting plenty of exercise, at least 30 minutes a day on at least 5

days a week (talk to your doctor first).

Maintaining a healthy weight. Men and women should aim for a

body mass index (BMI) between 18.5 and 24.9.

Getting checked and treated for depression. Women who are at high risk for heart disease should take

omega-3 fatty acid supplements.

Choosing a diet rich in fruits, vegetables, and whole grains. Choosing lean proteins, such as chicken, fish, beans, and

legumes.

Eating low-fat dairy products, such as 1% milk and low-fat yogurt.

Avoiding sodium (salt) and fats found in fried foods, processed

foods, and baked goods.

Eating fewer animal products that contain cheese, cream, or

eggs.

Reading labels and staying away from "saturated fat" and

anything that contains "partially-hydrogenated" or "hydrogenated" fats. These products are usually loaded with unhealthy fats.

X. MEDICAL MANAGEMENT Coronary heart disease decreases blood supply to the heart from the blocked coronary artery. The lower blood flow may fail to meet the heart's demand for oxygen. Treatment aims to balance blood supply to the heart with heart oxygen demand, and prevent worsening of coronary heart disease. Diagnostic Tests Many tests help diagnose CHD. Usually, your doctor will order more than one test before making a diagnosis. Tests may include:

Coronary angiography/arteriography -- an invasive test that

evaluates the heart arteries under x-ray

CT angiography -- a noninvasive way to perform coronary

angiography

Echocardiogram Electrocardiogram (ECG) Electron-beam computed tomography (EBCT) to look for calcium

in the lining of the arteries -- the more calcium, the higher your chance for CHD

Exercise stress test Heart CT scan Magnetic resonance angiography Nuclear stress test

Pericardiocentesis -- also called a pericardial tap -- means using a needle to get a sample of the fluid in the sac surrounding the heart. Tilt Table Test - the head-up tilt table test is used to help find the cause of fainting spells.

Treatment

Aspirin: When taken daily or every other day, aspirin reduces the risk of developing angina or heart attack by reducing the tendency of your blood to clot.

It reduces the chance that a clot will form over a rupturing plaque in the

coronary artery, a common underlying phenomenon in heart attack (myocardial infarction).

Side effects of aspirin include ulcers or bleeding problems. Talk to your health care provider before starting aspirin.

Beta-blockers: Beta-blockers decrease yourheart rate and blood pressure, thus reducing your heart's demand for oxygen. Clinical trialshave shown prevention of future heart attacks and sudden death. Nitroglycerin: This medication reduces chest pain both by decreasing your heart's oxygen demand and by dilating the coronary arteries, increasing the oxygen supply.

Sprays or tablets placed under your tongue are designed to be taken

when you need instant relief from angina.

Long-acting nitroglycerin tablets or skin patches work slowly over many

hours. Calcium channel blockers: Calcium channel blockers dilate the coronary arteries to improve blood flow. They also reduce blood pressure, and slow heart rate. ACE inhibitors: Angiotensin-converting enzyme (ACE) inhibitors work by dilating blood vessels, increasing blood flow.

They recently have been shown to reduce the numbers of cardiac events,

heart attacks, and deaths in people with coronary heart disease, unrelated to their blood pressure lowering effect. Therefore, additional beneficial tissue effects on blood vessels and heart muscle is thought to occur.

They are immensely useful in people with diabetes and those with

weakened heart muscles. Statins: Statin drugs work by reducing the amounts of lipids (cholesterol and other fats) in your blood.

This changes the inner lining of the blood vessels so plaques are less

likely to form or get large.

They slow or stop the progression of coronary heart disease and also

deter repeat heart attacks.

Recently, clinical trials have shown beneficial effects immediately after a

heart attack or threatened heart attack, even before the fat lowering effect is maximal, meaning they stabilize the plaque.

Examples:atorvastatin (Lipitor), pravastatin (Pravachol), simvastatin(Zoco

r), lovastatin (Mevacor), and rosuvastatin (Crestor). Invasive Procedures When angina symptoms worsen despite medications, the patient may need an invasive procedure in the cardiac catheterization lab to clear the blocked artery. These procedures are performed by a cardiologist, not a cardiac surgeon, and have fewer complications. Coronary angioplasty (PTCA): This procedure is similar to coronary angiography (cardiac catheterization or a dye study to visualize the inside of coronary arteries) but is therapeutic as well as diagnostic.

A similar but sturdier tube (guide catheter) is inserted into an artery in

your groin or arm, and a hair-thin guide wire is threaded through it into your coronary artery.

A much thinner catheter is threaded over the guide wire into the blocked

artery.

This thinner catheter has a tiny balloon at the end. Once the balloon is positioned at the blockage, the balloon is inflated to

widen your artery and improve blood flow. The plaque is still there, just flattened against the wall of the artery.

The balloon catheter is then withdrawn. This procedure is sometimes referred to as PTCA, which stands for its full

formal name: percutaneous (through the skin) transluminal (through the hollow center of the blood vessel) coronary angioplasty. Stent: A stent is a small, sieved, coil-like metallic tube or scaffold mounted over a balloon.

The balloon is inflated at the blockage, which expands the stent. The balloon is then withdrawn, but the stent stays in place, keeping the

artery from narrowing again.

Like arteries treated with angioplasty alone, arteries treated with a stent

can eventually close up again.

The stent is a longer lasting solution for many people.

Atherectomy: Sometimes the plaques become too rigid, bulky, or calcified to be treated with angioplasty or a stent.

In such cases, the plaques must be removed by cutting with a drill-like

device.

This works only if the narrowing or blockage is limited to a relatively small

and self-contained portion of an artery.

Devices commonly used for atherectomy include directional atherectomy

(DCA) catheter, rotational atherectomy or rotablator (PTRA), transluminal extraction catheter (TEC), or AngioJet.

Plaques also may be burned away with an excimer laser atherectomy

(ELCA). Brachytherapy: Radiation is applied to the blockage to clear it.

The radiation comes from a very tiny source placed inside or near the

artery.

This procedure is used to treat arteries that have undergone angioplasty

or stenting but have blockage that keeps coming back (restenosis). Surgery Surgery in coronary heart disease is reserved for people whose disease is either severe or is not improved or stabilized by medication and other less invasive therapies. Coronary artery bypass grafting (CABG): This is the standard operation for blockages of coronary arteries.

If multiple coronary arteries are blocked, or if the left main artery shows

significant blockage, bypass surgeryis usually the best treatment choice.

The blocked parts of the arteries are detoured or bypassedwith blood

vessels "harvested" from your chest (internal mammary), arm (radial artery),or a leg (saphenous vein).

During the surgery, the heart is stopped temporarily and you are

connected to a machine called a bypass pump that takes over the functions of the heart.

These operations are very successful and have a low rate of

complications. Off-pump bypass surgery: Sometimes surgeons can perform open heart surgerywithout using a bypass pump and while the heart is beating. The procedure causes fewer side effects than the standard procedure, but it is not feasible in all situations. Minimally invasive coronary bypass (MINI-CABS): If just your front or right coronary arteries need bypass, a surgeon may replace the blocked artery with an artery from the chest via a small keyhole incision, without opening your chest, to detour the blockage Transmyocardial laser revascularization (TMR): TMR offers an alternative for people who are not good candidates for either angioplasty or bypass surgery.

A surgeon uses a laser catheter to create multiple pinholes in your heart

muscle.

The holes encourage growth of new vessels into the diseased heart

muscle.

This procedure can be done by itself or in conjunction with coronary

bypass surgery. Expectations (Prognosis) Everyone recovers differently. Some people can maintain a healthy life by changing their diet, stopping smoking, and taking medications exactly as the doctor prescribes. Others may need medical procedures such as angioplasty or surgery. Although everyone is different, early detection of CHD generally results in a better outcome.

Follow-up Regular follow-up visits with health care provider are essential. Coronary heart disease is a chronic (long-term, ongoing), relentlessly progressive disease.

Reducing risk factors may only slow its pace. Even angioplasty or bypass surgery only reduces the severity of the

disease. It does not cure the disease.

It often comes back and gets worse, requiring further treatment for people

with previous heart attacks or bypass, especially if the patient has not corrected the abnormal risk factors. The health care provider will usually monitor the patient for the following conditions:

New symptoms or signs of disease progression (periodic physical exams

and ECGs or stress tests)

Silent ischemia (periodic treadmill or radionuclide stress tests or stress

echocardiography)