Cardiovascular disease is the leading cause of death in the United States for

men and women of all racial and ethnic groups. Research related to the identification of
and treatment for cardiovascular disease includes all segments of the population
affected by cardiac conditions, including women, children, and people of diverse racial
and ethnic backgrounds.

At the end of this course packet, the student-nurses can:

1. Describe the pathophysiology, clinical manifestations, and treatment of coronary
atherosclerosis.

2. Use the nursing process as a framework for care of patients with angina pectoris.

3. Describe the pathophysiology, clinical manifestations, and treatment of myocardial

infarction.

Coronary artery disease (CAD) is the most prevalent type of cardiovascular disease in
adults. For this reason, nurses must recognize various manifestations of coronary artery
conditions and evidence-based methods for assessing, preventing, and treating these
disorders.

Stages of Development of Coronary Artery Disease

1. Myocardial Injury: Atherosclerosis
2. Myocardial Ischemia: Angina Pectoris
3. Myocardial Necrosis: Myocardial Infarction
 The most common cause of cardiovascular disease in the United States is
atherosclerosis, an abnormal accumulation of lipid, or fatty substances, and fibrous
tissue in the lining of arterial blood vessel walls. These substances block and narrow the
coronary vessels in a way that reduces blood flow to the myocardium. Atherosclerosis
involves a repetitious inflammatory response to injury of the artery wall and subsequent
alteration in the structural and biochemical properties of the arterial walls.

Plaque buildup, known as atheromas, in the coronary arteries is a result of

atherosclerosis, defined as thickening of the arterial walls’ inner aspect and a loss of
elasticity. As the plaque grows in size, inflammation, necrosis, and fibrosis occur and the
arteries may change in form (remodeling). Plaque accumulation reduces the inner
arterial lumen and leads to wall thickening, calcification, and reduced blood supply.
Complications of CHD include angina, MI, heart failure, stroke, cardiac dysrhythmias,
and sudden death.
Predisposing/Precipitating Factors

● Modifiable risk factors:

o Obesity
o lack of physical activity
o excessive alcohol use
o mental stress.
o Blood levels of cholesterol and low-density lipoproteins (LDLs) have been
associated with increased risk of CAD.
o Hypertension
o Smoking
o High levels of the following: creactive protein; lipoprotein(a);
homocysteine; small, dense LDL cholesterol (LDL-C) particles; and
fibrinogen
● Non-modifiable factors:
o older age
o family history of heart disease
o diabetes mellitus
o race/ethnicity

Signs & Symptoms

● Chest Pain
● Dyspnea
● Tachycardia
● Palpitations
● Diaphoresis

Common Management
● Percutaneous Transluminal
Coronary Angioplasty (PTCA) and
Intravascular Stenting
o Mechanical dilation of the
coronary vessel wall by
compressing the atheromatous
plaque
o Recommended for clients with
single vessel CAD
o Prosthetic intravascular
cylindric stent maintain good
luminal geometry after balloon
is deflated and withdrawn
o Intravascular stenting is done to
prevent stenosis after PTCA

● Coronary Artery Bypass Graft

Surgery (CABG)
o A patent blood vessel from another part of the body is grafted to the
affected coronary artery distal to the lesion. The new vessel bypasses the
obstruction.
o Unless reduction of risks and modification of the lifestyle accompany this
procedure, the grafted vessels will also eventually occlude.
o Vessels commonly used for grafting are the greater or lesser saphenous
veins, basilic veins, and right and left internal mammary arteries.
Objectives of CABG
● Revascularize myocardium
● To prevent angina
● Increase survival rate
● Done to single occluded vessels
● If there is 2 or more occluded blood vessels CABG is done

Complications of CABG
● Pneumonia: encourage to perform deep breathing, coughing exercise and use of
incentive spirometer
● Shock
● Thrombophlebitis

Assessing the Patient

Patients are frequently admitted to the hospital the day of the procedure.
Therefore, most of the preoperative evaluation is completed in the
physician’s office and during preadmission testing.

Reducing Fear and Anxiety

The nurse gives the patient and family time and opportunity to express
their fears. Topics of concern may be pain, changes in body image, fear of
the unknown, and fear of disability or death. It may be helpful to describe
the sensations that the patient can expect, including the preoperative
sedation, surgical anesthesia, and postoperative pain management.

Monitoring and Managing Potential Complications

Angina may occur because of increased stress and anxiety related to the forthcoming
surgery. The patient who develops angina usually responds to typical therapy for
angina, most commonly nitroglycerin.

Intraoperative Management
In assisting with the surgical procedure, perioperative nurses are responsible for the
comfort and safety of the patient. Possible intraoperative complications include low
cardiac output, dysrhythmias, hemorrhage, MI, organ failure from shock, and
thromboembolic events including stroke.

Postoperative Nursing Management

Initial postoperative care focuses on achieving or maintaining hemodynamic stability
and recovery from general anesthesia. Care may be provided in the postanesthesia
care unit (PACU) or ICU.
 ● Nitroglycerine: Drug of Choice for pain from acute ischemic attacks; Check BP
prior to giving of medication
● Instruct to avoid over fatigue
● Plan regular activity program
● For saphenous vein site:
o Wear support stocking 4-6 weeks post-op
o Apply pressure dressing or sand bag on the site
o Keep leg elevated when sitting

Angina pectoris is a clinical syndrome usually characterized by episodes or paroxysms

of pain or pressure in the anterior chest.

Clinical syndrome characterized by paroxysmal chest pain that is usually relieved by

rest or nitroglycerine due to temporary myocardial ischemia

The cause is insufficient coronary blood flow, resulting in a decreased oxygen supply
when there is increased myocardial demand for oxygen in response to physical exertion
or emotional stress. In other words, the need for oxygen exceeds the supply.

Types of Angina

● Stable angina
o Predictable and consistent pain that occurs on exertion and is relieved by
rest and/or nitroglycerin.
o Pain less than 15 minutes, recurrence is less frequent
● Unstable Angina
o Pain is more than 15 minutes, but less than 30 minutes
o also called preinfarction angina or crescendo angina
o symptoms increase in frequency and severity; may not be relieved with
rest or nitroglycerin
● Prinzmetal’s angina
o Intractable or refractory angina
o severe incapacitating chest pain Variant angina
o pain at rest with reversible ST-segment elevation;
o thought to be caused by coronary artery vasospasm
● Angina Decubitus
o Paroxysmal chest pain that occur when the client sits or stands
Predisposing/Precipitating Factors
● Obesity
● lack of physical activity
● excessive alcohol use
● mental stress.
● Blood levels of cholesterol and low-density lipoproteins (LDLs) have been
associated with increased risk of CAD.
● Hypertension
● Smoking
● Thromboangitis Obliterans
● Severe Anemia
● Aortic Insufficiency: Heart Valve that fails to pen & close efficiently
● Diet: Increased saturated fats
● Type A personality

Signs & Symptoms

● Levine’s Sign: initial sign that shows the hand clutching the chest
● Chest pain: characterized by sharp stabbing pain located at sub sternal. Usually
radiates from neck, back, arms, shoulder and jaw muscles usually relieved by
rest or taking nitroglycerine
● Dyspnea
● Tachycardia
● Palpitations
● Diaphoresis

Diagnostic Highlights
● History Taking and physical examination
● ECG: may reveal ST segment depression & T wave inversion during chest pain
● Stress test/treadmill test: reveal abnormal ECG during exercise
● Increase serum lipid levels
● Serum cholesterol & uric acid is increased

Common Management
● Drug Therapy: if cholesterol is elevated
o Nitrates: nitroglycerine
o Beta adrenergic blocking agent: Propranolol
o Calcium channel blocking agent: nifedipine
o Ace inhibitors: enalapril
o Antiplatelet and Anticoagulants: Aspirin, Clopidogrel, IV Heparin
● Modification of diet & other risk factors
● Surgery: CABG
● PTCA
● Oxygen inhalation
TREATING ANGINA
If the patient reports pain (or cardiac ischemia is suggested by prodromal symptoms,
which may include sensations of indigestion or nausea, choking, heaviness, weakness
or numbness in the upper extremities, dyspnea, or dizziness), the nurse takes
immediate action.

REDUCING ANXIETY
Patients with angina often fear loss of their roles within society and the family. They may
also fear that the pain (or the prodromal symptoms) may lead to an MI or death.
Exploring the implications that the diagnosis has for the patient and providing
information about the illness, its treatment, and methods of preventing its progression
are important nursing interventions.

PREVENTING PAIN
The nurse reviews the assessment findings, identifies the level of activity that causes
the patient’s pain or prodromal symptoms, and plans the patient’s activities accordingly.

Myocardial Infarction (MI) is the death of myocardial cells from inadequate oxygenation,
often caused by sudden complete blockage of coronary artery.

Blood supply to the myocardium is interrupted for a prolonged time due to the blockage
of coronary arteries. This results in insufficient oxygen reaching cardiac muscle, causing
cardiac muscles to die (necrosis). Myocardial infarction is commonly known as a heart
attack.

The area of infarction is often caused by a buildup of plaque over time (atherosclerosis).
It may also be caused by a clot that develops in association with the atherosclerosis
within the vessel. Patients are typically (not always) symptomatic, but some patients will
not be aware of the event; they will have
what is called a silent MI.

Types of MI
● Transmural Myocardial Infarction: most dangerous type characterized by
occlusion of both right and left coronary artery
● Subendocardial myocardial Infarction: characterized by occlusion of either right
or left coronary artery
Predisposing/Precipitating Factors
● Sex: Male
● Race: Black
● Smoking
● Obesity
● CAD: Atherosclerotic
● Thrombus formation
● Genetic predisposition
● Hyperlipidemia
● Sedentary lifestyle
● Diabetes Mellitus
● Hypothyroidism
● Diet: increased saturated fats
● Type A personality

Signs & Symptoms

● Chest pain that is unrelieved by rest or nitroglycerin, unlike angina.
● Pain that radiates to arms, jaw, back, and/or neck.
● Shortness of breath, especially in the elderly or women.
● Nausea or vomiting possible.
● May be asymptomatic, known as a silent MI, which is more common in
● diabetic patients.
● Heart rate more than 100 beats per minute (tachycardia) because of
● sympathetic stimulation, pain, or low cardiac output.
● Variable blood pressure.
● Anxiety.
● Restlessness.
● Feeling of impending doom.
● Pale, cool, clammy skin; sweating (diaphoresis).
● Sudden death due to arrhythmia usually occurs within first hour.

Diagnostic Highlights
● ECG.
o T-wave inversion or hyperacute T-waves—sign of ischemia.
o ST-segment elevated or depressed—sign of injury.
o Significant Q-waves—sign of infarction.
● Decreased pulse pressure because of diminished cardiac output.
● Increased white blood count (WBC) due to inflammatory response to injury.
● Blood chemistry:
 o Cardiac Enzyme: Elevated CK-MB—usually done serially, the numbers will
rise along a predetermined curve to signify myocardial damage and
resolution.
o Elevated troponin I- and troponin T-proteins elevated within an hour of
myocardial damage.
● Less than 25 mL/h of urine output due to lack of renal blood flow.

Common Management
● Establish a patent IV line
● Administer narcotic analgesic as ordered: Morphine Sulfate IV; provide pain relief
(given IV because after an infarction, there is poor peripheral perfusion &
because serum enzyems would be affected by IM injection as ordered)
o Side effect: Respiratory Depression
o Antidote: Naloxone (Narcan)
o Naloxone Toxicity: tremors
● Administer oxygen low flow 2-3 L/min
● Enforce CBR in semi fowler’s position without bathroom privileges
● Instruct client to avoid forms of Valsalva maneuver
● Monitor VS strictly, I&O, ECG tracing and hemodynamic procedures
● Perform complete lung and cardiovascular assessment
● Monitor urinary output and record
● Maintain a quiet environment
● Administer stool softeners as ordered
● Relieve anxiety associated with coronary care unit environment
● Medications:
o Vasodilators: Nitroglycerin, Isosorbide dinitrate: sublingual
o Anti arrhythmic agents: Lidocaine, Brithylium
▪ Side effects: confusion and dizziness
o Beta Blockers: Propranolol (Inderal)
o Ace Inhibtors: Captopril
o Calcium channel blockers: Nefedipine
o Thrombolytics/Fibrinolytic Agents: Streptokinase, Urokinase
▪ Monitor for bleeding time
o Anticoagulants
▪ Heparin: Check for Partial Thrombin Time
▪ Warfarin: Check for Prothrombin time
o Anti Platelet: Aspirin
▪ Side effects: tinnitus, heartburn, dyspepsia, indigestion

RELIEVING PAIN AND OTHER SIGNS AND SYMPTOMS OF ISCHEMIA

Balancing myocardial oxygen supply with demand (e.g., as evidenced by the relief of
chest pain) is the top priority in the care of the patient with an ACS. Oxygen should be
given along with medication therapy to assist with relief of symptoms. Administration of
oxygen raises the circulating level of oxygen to reduce pain associated with low levels
of myocardial oxygen. The route of administration (usually by nasal cannula) and the
oxygen flow rate are documented. Vital signs are assessed frequently as long as the
patient is experiencing pain and other signs or symptoms of acute ischemia.

IMPROVING RESPIRATORY FUNCTION

Regular and careful assessment of respiratory function detects early signs of pulmonary
complications.

PROMOTING ADEQUATE TISSUE PERFUSION

Bed or chair rest during the initial phase of treatment helps reduce myocardial oxygen
consumption.

REDUCING ANXIETY
Alleviating anxiety and decreasing fear are important nursing functions that reduce the
sympathetic stress response.

Cardiogenic shock is a shock state which result from profound left ventricular failure
usually from massive MI leading to a low cardiac output with consequent hypoperfusion
and hypoxia
Typically characterized by persistent hypotension (<90mmHg systolic BP) unresponsive
to volume replacement and is accompanied by clinical features of peripheral
hypoperfusion, such as elevated arterial lactate (>2mmol/L)

Hallmark: Hypoperfusion of vital organs and extremities

Signs & Symptoms
● Decrease systolic Blood Pressure
● Oliguria
● Cold, clammy skin
● Weak pulse
● Cyanosis
● Mental lethargy
● Confusion
Common Management
● Counterpulsation (mechanical cardiac assistance/diastolic augmentation
 o Involves introduction of the intra aortic balloon catheter via the femoral
artery
o Intra Aortic Balloon Pump augments diastole, resulting in increased
perfusion of the coronary arteries and the myocardium and a decrease in
left ventricular workload
o The balloon is inflated during the diastole, it is deflated during systole.
o Indications: Cardiogenic shock, AMI, Unstable angina, Open heart surgery
● Medications:
o Vasodilators: Nitroglycerine
o Inotropic agents: Digitalis, Dopamine
o Diuretics: Furosemide
o Sodium bicarbonate: relieve lactic acidosis
o Morphine sulfate: reduces venous return
o Aminophylline, reduces bronchospasm caused by congestion
o Vasodilators, to reduce venous return

● Perform hemodynamic monitoring

● Administer oxygen therapy
● Correct hypovolemia, administer IV fluids as ordered
● Provide psychosocial support
● Decrease pulmonary edema
o Auscultate lung fields for crackles and wheezes
o Note for dyspnea, cough, hemoptysis and orthopnea
o Monitor ABG for hypoxia and metabolic acidosis
o Place in fowler’s position to reduce venous return

Direction: Create at least 5 Nursing Diagnosis for patients with coronary vascular
disorders. Rationalize why these are the priority nursing diagnosis.

References

Dillon, P. (2017). Nursing Health Assessment. New York: F.A. Davis Company.
Hinkle, J., & Cheever, K. (2018). Brunner & Suddarth's Textbook of Medical-Surgical
Nursing. Philadelphia: Lippincott Williams & Wilkins.
Keogh, J. (2019). Medical-Surgical Nursing Demystified. New York: McGraw Hill
Education.
Sommers, M. (2019). Diseases and Disorders: A Nursing Therapeutics Manual.
Philadelphia: F.A. Davis.