MS1 Chapter 24

• Cardiovascular Disease (CVD) is the leading cause of disability and death in the United States
• CVD affects the quality of life and activities of daily living (ADL’s)
• Modifiable factors can lead to CVD, and education is important for prevention and treatment
• Arteriosclerosis involves thickening, loss of elasticity, and calcification of artery/arteriole walls
• Atherosclerosis is a type of arteriosclerosis characterized by plaque formation in arteries
• Atherosclerosis can begin in childhood and progress to coronary artery disease (CAD)
• In atherosclerosis, injury and inflammation to the artery endothelial cell lining occur
• Smooth muscle cells grow despite damage, collagen and fibrous proteins are secreted, and lipids, platelets, and clotting factors accumulate
• Atherosclerosis can lead to reduced blood flow from narrowing arteries and the development of a plaque with a calcium fibrous cap
• Nonmodifiable risk factors for atherosclerosis and CVD include age, gender, ethnicity, and genetic predisposition
• Modifiable risk factors for atherosclerosis and CVD include blood glucose control, hypertension, hyperlipidemia, obesity, smoking, sedentary lifestyle, depression, infection, stress, and excessive alcohol intake
• Diagnostic tests for atherosclerosis and CVD include cholesterol levels, triglycerides, C-reactive protein, and imaging tests
• Therapeutic interventions for atherosclerosis include eating a heart-healthy diet, not smoking, exercising, and taking lipid-lowering agents
• Coronary Artery Disease (CAD) involves the obstruction of coronary artery blood flow, usually from atherosclerosis
• Angina Pectoris is chest pain due to ischemia, resulting from reduced coronary artery blood flow and oxygen delivery to the heart muscle
• Types of angina include stable angina, unstable angina, variant angina, and microvascular angina
• Angina diagnostic tests include electrocardiogram, stress tests, echocardiography, and coronary angiography
• Goals for angina management include identifying risk factors, relieving pain, weight reduction, heart-healthy diet, and stress reduction
• Medications for angina include vasodilators/nitrates, calcium channel blockers, beta blockers, angiotensin-converting enzyme (ACE) inhibitors, and statins
• ACE inhibitors block the production of angiotensin II, a potent vasoconstrictor. Examples include captopril, lisinopril, ramipril, enalapril
• Medications for Angina:

  • Statins lower cholesterol levels by reducing cholesterol production in the liver, preventing and treating atherosclerosis. Examples: atorvastatin, pravastatin, simvastatin
  • Antiplatelets help prevent cardiovascular events by inhibiting platelet activation, adhesion, or procoagulant activity. Examples: aspirin, clopidogrel (Plavix), ticagrelor (Brilinta)
• Acute Pain: Ensure IV access for drug administration, rate pain, administer oxygen, administer NTG as prescribed, report if unrelieved after three doses, administer aspirin and morphine as prescribed, remain with the patient, provide emotional support
• Acute Coronary Syndrome (ACS) is caused by a sequence of inflammatory processes and includes unstable angina and myocardial infarction
• Silent Ischemia:

  • Myocardial infarction without chest pain
  • Occurs in older patients, often seen with hypertension and diabetes
• Sudden Cardiac Death:

  • Cardiac arrest triggered by lethal ventricular arrhythmias or asystole from an abrupt occlusion of a coronary artery
  • Prompt treatment required to prevent death
• Myocardial Infarction (MI) Pathophysiology:

  • Coronary artery blockage reduces blood supply to heart muscle
  • Identified by changes seen on EKG
  • Non-STEMI: Caused by a partial coronary artery blockage
  • STEMI: Caused by a complete coronary artery blockage
• EKG Changes With STEMI:

  • Injury: ST-segment elevation
  • Ischemia: ST-segment inversion
  • Necrosis: large Q-wave and ST-segment elevation
• MI Signs and Symptoms:

  • Crushing, viselike chest pain
  • Radiates to arm/shoulder/neck/jaw
  • Not relieved by rest or NTG
  • Diaphoresis, dizziness, fainting, dyspnea, nausea, restlessness
• Timely Treatment of MI is Important:

  • Denial common, waiting leads to further myocardial damage
  • "Time is muscle": More muscle lost as time passes
  • Call 911, do not drive, reperfusion time critical
• Women and MI:

  • CAD/MI leading cause of death in women
  • African American women at higher risk
  • More complications than men
  • Prodromal symptoms may include unusual fatigue, sleep disturbances, dyspnea
• Older Adults and MI:

  • Atypical presentation of symptoms is normal
  • Report symptoms to healthcare provider
  • May have silent MI
  • Collateral circulation may offer protection
• MI Diagnosis:

  • Consider patient history
  • Diagnostic tests: EKG, serum cardiac troponin, myoglobin, CK-MB, CRP, electrolytes
• MI Pre-Hospital Care:

  • "Time is muscle": Chew one uncoated adult aspirin, call 911 after 5 minutes for unrelieved chest pain
• MI Therapeutic Interventions:

  • Morphine sulfate, oxygen, nitrates, aspirin, thrombolytics, vasodilators, beta blockers, antiarrhythmics
• MI Therapeutic Interventions (continued):

  • Invasive procedures: PCI, balloon angioplasty, coronary artery stents
• Coronary Artery Stent:

  • Insertion of a coronary artery stent involves advancing a balloon catheter with a collapsed stent to the location of a coronary artery lesion, inflating the balloon to expand the stent and compress the lesion, then deflating and removing the balloon, leaving the expanded stent in place
• Myocardial Revascularization:

  • Coronary artery bypass graft (CABG) bypasses coronary artery occlusions with vein/artery grafts
  • Types of bypass surgery: arrested heart surgery, beating heart surgery, minimally invasive surgery
• Peripheral Vascular Disease:

  • Common in older adults and diabetics
  • Types: Arterial, Venous
• Arterial Thrombosis/Embolism:

  • Arterial blood clot can become an embolus
  • Pathophysiology: Sudden and dramatic arterial occlusions, common in lower and upper extremities
• Arterial Thrombosis/Embolism Signs and Symptoms:

  • May have abrupt onset with acute arterial occlusion
  • Chronic arterial insufficiency symptoms may develop more slowly
  • Clinical signs: Six P's (Pain, Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia)