Courtesy to Yang Cortes and company

1. CORONARY ARTERY DISEASE

2. Coronary Artery Supply oxygen to the arterial wall

3. Coronary Artery Disease Result from development of Atherosclerosis Abnormal accumulation of lipid or fatty, substances and fibrous tissue in the lining of arterial blood vessel walls. hardening and narrowing of the coronary arteries

4. Atherosclerosis Creates blockage and narrow the coronary vessels that reduces the bloodflow to the myocardium Involves in repetitious inflammatory response to injury to the arterial wall

5. Atherosclerosis Genetics and environmental factors are involved in the progression of these lesions. The presence of inflammation has multiple effects on the arterial wall including the attraction of macrophages.

7. Intermediate lesion

8. Atheroma or plaque

11. Smoking

12. Hypertension

13. Diabetes mellitus

14. Obesity

15. Family History

17. Physical Activity

18. Medications

19. 3-Hydroxy-3-methyglutaryl coenzyme A (HMG-CoA) reductase inhibitors or statins – block cholesterol synthesis, lower LDL and triglyceride levels and increase HDL levels

20. Nicotinic Acids

21. Fibric Acid or fibrates

23. Prevention of Atherosclerosis Ceasation from Tobacco use Managing Hypertension The risk of cardiovascular disease increases as blood pressure increases. Controlling Diabetes Mellitus The relationship between diabetes mellitus and heart disease has been confirmed. Gender Behavior Pattern

24. Angina Pectoris Pain or pressure in the anterior chest or “Chest Pain” The cause is insufficient blood flow, resulting in a decreased oxygen supply

25. Myocardial Infarction An area of myocardium is permanently destroyed usually caused by reduced blood flow

26. Percutaneous Coronary Interventions (PCIs) Is an invasive procedure in which a catheter is placed in a coronary artery, and one of several methods is employed to remove a blockage with the artery or angioplasty

29. Percutaneous Coronary Interventions (PCIs) Coronary Artery Stent – is a metal mesh that provides support to a vessel at risk of closure. Position over angioplasty balloon Balloon is inflated, the mesh expands and presses against the vessel wall, holding the artery open The balloon is withdrawn but the stent is left permanently

30. Percutaneous Coronary Interventions (PCIs) Because of the risk of thrombus formation in the stent, the patient receives antiplatelet medication (clopidogrel and aspirin) for 3 to 6 months

31. Percutaneous Coronary Interventions (PCIs) Atherectomy – removal of the atheroma or plaque from a coronary artery by cutting , shaving or grinding. It may be used in conjunction with PTCA. A directional atherectomy device cuts away plaque, which is then collected in the tip of the device.

32. Percutaneous Coronary Interventions (PCIs) A rotational extraction device spins at a high speed and pulverizes plaque, which is then safely washed away in your bloodstream. Or, the device may filter or capture the particles of plaque to remove them from the blood.

33. Percutaneous Coronary Interventions (PCIs) A transluminal extraction device cuts away plaque using tiny rotating blades. The loose plaque is sucked into a tube through a vacuum.

34. Coronary Artery Revascularization

35. Atherectomy a form of coronary angioplasty, a procedure to remove plaque from an artery. Removing the plaque makes the artery wider so blood can flow more freely to the heart muscles. In an atherectomy, the plaque is shaved or vaporized away with tiny rotating blades or a laser on the end of a catheter.

36. What is a plaque? Plaque is the buildup in arteries of fat, cholesterol, calcium and other substances. When plaque builds it can block blood flow or it can rupture, causing blood clots. This build up of plaque is called atherosclerosis. An atherectomy is a treatment for atherosclerosis.

37. Procedure patient receives sedatives to help him or her relax. a catheter is gently inserted in an artery, usually in the groin or upper thigh area It's then guided through the blood vessel toward the heart When it's in place, dye is injected through the catheter and into the coronary arteries

38. The physician then uses tiny blades or a laser, attached to the end of the catheter, to cut away or vaporize plaque.

39. Coronary Artery Bypass Graft CABG

40. Coronary Artery BypassGraft is a surgical procedure in which one or more blocked coronary arteries are bypassed by a blood vessel graft to restore normal blood flow to the heart. These grafts usually come from the patient's own arteries and veins located in the leg, arm, or chest

41. Coronary Artery BypassGraft Coronary artery bypass graft surgery builds a detour around one or more blocked coronary arteries with a graft from a healthy vein or artery. The graft goes around the clogged artery (or arteries) to create new pathways for oxygen-rich blood to flow to the heart.

42. How is coronary bypass done? The chest is opened via a median sternotomy and the heart is examined by the surgeon The bypass grafts are harvested - frequent conduits are the internal thoracic arteries, radial arteries and saphenous veins. When harvesting is done, the patient is given heparin to prevent the blood from clotting.

43. How is coronary bypass done? In the case of "off-pump" surgery, the surgeon places devices to stabilize the heart. If the case is "on-pump", the surgeon sutures cannulae into the heart and instructs the perfusionist to start cardiopulmonary bypass (CPB). Once CPB is established, the surgeon places the aortic cross-clamp across the aorta and instructs the perfusionist to deliver cardioplegia to stop the heart.

44. How is coronary bypass done? One end of each graft is sewn on to the coronary arteries beyond the blockages and the other end is attached to the aorta. The heart is restarted; or in "off-pump" surgery, the stabilizing devices are removed. In some cases, the aorta is partially occluded by a C-shaped clamp, the heart is restarted and suturing of the grafts to the aorta is done in this partially occluded section of the aorta while the heart is beating.

45. How is coronary bypass done? Protamine is given to reverse the effects of heparin . The sternum is wired together and the incisions are sutured closed.

46. Cardiopulmonary Bypass

47. Cardiopulmonary Bypass is a technique that temporarily takes over the function of the heart and lungs during surgery, maintaining the circulation of blood and the oxygen content of the body. Cardiopulmonary bypass is commonly used in heart surgery because of the difficulty of operating on the beating heart. Operations requiring the opening of the chambers of the heart require the use of CPB to support the circulation during that period.

48. Operation A CPB circuit must be primed with fluid and all air expunged before connection to the patient. The circuit is primed with a crystalloid solution and sometimes blood products are also added. The patient must be fully anticoagulated with an anticoagulant such as heparin to prevent massive clotting of blood in the circuit.

50. Nursing Diagnoses Ineffective tissue perfusion related to reduce coronary blood flow Risk for imbalanced fluid volume Risk for ineffective peripheral tissue perfusion related to decrease cardiac output from left ventricular dysfunction Death anxiety related to cardiac event Deficient knowledge about post-ACS self-care

51. Nursing intervention 1. Monitor blood pressure, apical heart rate, and respirations every 5 minutes during an anginalattack. 2. Maintain continuous ECG monitoring 3. Place patient in comfortable position and administer oxygen, if prescribed, to enhance myocardial oxygen supply that are below the level at which anginal pain occurs. 4. Identify specific activities patient may engage in that are below the level at which anginal pain

52. Nursing intervention 4. Identify specific activities patient may engage in that are below the level at which anginalpain 5. Reinforce the importance of notifying nursing staff whenever angina pain is experienced. 6. Encourage supine position for dizziness caused by antianginals. 7. 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.

53. Nursing intervention 8. Explain to the patient the importance of anxiety reduction to assist to control angina. 9. Teach the patient relaxation techniques. 10. Review specific factors that affect CAD development and progression; highlight those risk

54. ASESSMENT Shortness of breath on exertion Chest pain Jaw pain, back pain, or arm pain, Palpitations (a sensation of rapid or very strong heart beats in your chest) Dizziness, light-headedness, or fainting Weakness on exertion or at rest Irregular heartbeat

55. Pre-operative Pre-operative IRREGULAR HEART BEAT -drug -Mild electric shock RISk of heart surgery -Abnormal heart rhythm -excessive bleeding -infection and kidney failure -damage to the heart muscle -stroke

56. Modifable risk factors cigarette smoking obesity high triglycerides high total cholesterol Diabetes Hypertension Hyperlipidemia Physical inactivity

57. Non-modifable risk factors Family history of CAD Increasing age (more than 45years for men: more than 55years for women Gender (men develop CAD at an earlier age than women)

58. Lifestyle Change -quit smoking -dietary and exercise recommendation -rehabilitation program

59. Tips for your continued successful recovery: Encourage each other to express and discuss your feelings. Open communication can minimize misunderstandings. Seek support by talking with others who have experienced similar circumstances. Sharing common concern can be reassuring. Reach out for help. Having to focus on changing several habits can be overwhelming. Behavior modification groups (i.e. Smoke Enders) provide structure as well as the mutual support helpful for success.

60. Tips for your continued successful recovery: Begin and maintain an exercise program for your physical and mental well being. Exercising with others can create added motivation. If you are feeling emotionally overwhelmed, seek professional advise. A trained counselor can help you to cope more adequately with your concerns. Consult your hospital social worker or physician for this service.