Cathe management of Acute Coronary Syndrome

Outline :-Objective - Statistics -Atherosclerosis -Pathophysiology-Risk factor -Acute coronary syndrome -Angina pectoris-Pathophysiology principle -Classification of angina -cardiac catheterization-Use of cardiac catheterization -Technique of cardiac catheterization - Type of cardiac catheterization-Nursing intervention of cardiac catheterization -Self management after cardiac catheterization

Objective :1-Describe the pathophysiology of atherosclerosis .

2- Describe the risk factors .

3- Determine the acute coronary syndrome

4- Determine the angina and the classification of angina

5- determine the cardiac catheterization

6- describe the technique and the type oa cardiac catheterization

Statistics

• Cardiovascular diseases: number one cause of death globally

• In 2005: an estimated 17.5 million people died from cardiovascular disease, 30 % of all global deaths.

• Of these deaths, 7.6 million were due to heart attacks and 5.7 million due to stroke.

• About 80% of these deaths occurred in low- and middle-income countries.

• By 2015 an estimated 20 million people will die from cardiovascular disease (mainly from heart attacks and strokes).

Atherosclerosis

• A major cause of cardiovascular disease.

• A complex, insidious process, beginning long before symptoms occur.

PathophysiologyPathophysiology• Injury to endothelium

– Increased levels of cholesterol/triglycerides– Hypertension – Cigarette smoking

• Deposits in the lining of the artery– Cholesterol, cellular waste, calcium, and fibrin

• Atheroma (lipid plaque with a fibrous covering)– Keeps building to partial or complete blockage

• Fibrous plaques are most often found in the coronary, popliteal, and internal carotid arteries and in the abdominal aorta.

• Because of the fibrous plaque, the amount of blood flow through the artery is reduced, resulting in decreased supply of oxygen to tissues.

• Symptoms often do not occur, however, until 75% or more of the blood supply to the area is occluded.

• The occurrence of symptoms may depend to an extent on the development of collateral circulation.

Risk Factors

• Non-modifiable – Age

– Heredity

• Combination of environmental and genetic influences

– Race

• Rates of hypertension, obesity, and diabetes

– Sex

• Modifiable– Cigarette smoking

even second hand – High cholesterol-LDL

vs. HDL– Hypertension – Physical inactivity – Obesity– Diabetes mellitus

The cause of atherosclerosis is not clearly knownMajor Risk Factors

• Stress – (smoking, overeating)

• Sex hormones – (Female hormones and HDL)

• Birth Control Pills (old vs new) – (smoking & hypertension)

Contributing Risk Factors

• Excessive Alcohol Intake – (hypertension, heart failure, stroke, high

triglycerides, and dysrhythmias)• Homocysteine Levels

– (increased platelet adhesiveness, enhances LDL deposition in the arterial wall, and activates the coagulation cascade)

Contributing Risk Factors

Acute coronary syndromeAcute coronary syndrome

• A relatively new term used to describe patients who have clinical symptoms compatible with acute myocardial ischemia.

• Acute coronary syndrome includes unstable angina and acute MI.

Angina Pectoris

Is the term used to describe chest pain or discomfort that results from coronary artery disease.

• The patient may describe the sensation as: pain, pressure, fullness, squeezing, or heaviness.

Pathophysiological Principles• Caused by transient, reversible myocardial

ischemia. • Myocardial oxygen demand ≠ myocardial oxygen

supply• Most commonly, decreased oxygen supply

– Atherosclerotic narrowing– Dynamic obstruction: intense focal spasm of a

coronary artery– Arterial inflammation (arterial narrowing,

plaque destabilization, rupture, and thrombogenesis)

– A marked increase in oxygen demand (fever, tachycardia, and thyrotoxicosis)

Classification of Angina

• Stable – chronic stable angina, classic angina– Paroxysmal, occurs with physical

exertion (predictable)– Relieved by rest or nitroglycerin

Classification of Angina• Unstable – preinfarction angina or crescendo angina

– Unexpected chest pain or discomfort that usually occurs while at rest.

– More prolonged and severe– Need to be treated immediately: risk for acute

MI, cardiac dysrhythmias, or cardiac sudden death

• Variant – Prinzmetal’s angina, vasospastic angina – Result of coronary artery spasm – Occurs at rest (a form of unstable angina)

– Severe coronary atherosclerosis!!

Cardiac catheterization

Introduction : is an invasive diagnostic procedure in which radiopaque arterial and venous catheter are introduced into selected blood vessels of the right and left sides of the heart .

-Catheter advancement is guided by fluoroscopy .

-Most commonly , the catheters are inserted percutaneously through the blood vessels ,or via cutdown procedure if the patient has poor vascular access

-pressure and oxygen saturation level in the four heart chambers are measured .

Use of cardiac catheterization :is most frequently used to diagnose CAD , assess coronary artery patency , and determine the extent of atherosclerosis and determine whether revascularization procedures , including PCI or coronary artery bypass surgery , may be of benefit to the patient . -Is also used to diagnose pulmonary arterial hypertension or to or to treat stenotic heart valves via percutaneous balloon valvuloplasty

The technique of cardiac catheterization :

-during cardiac catheterization , the patient has one or more IV lines in place for the administration of sedatives , fluid , heparin , and other medications .-The site of the catheter insertion in the femoral or radial artery , the patients anticoagulation status and other variable (eg, advanced age , obesity , bleeding disorder ) .

-The use of smaller (4 or 6 fr ) catheter is associated with shorter recovery times .

Several options to achieve arterial hemostasis after catheter removal , including manual pressure , mechanical compression devices such as the femostop (placed over puncture site for 30 minutes ) and percutaneously deployed devices , are used .

Cont:the product are placed over the puncture site as the catheter is removed and manual pressure is applied for 4 to 10 minutes .

- patient hospitalized for angina or acute MI who require cardiac catheterization usually return to their hospital rooms recovery .

Type of cardiac catheterization :1-Angiography

2-Aortography

3- Coronary arteriography

4- Right heart catheterization

5- left heart catheterization

AngiographyCardiac catheterization is usually performed with

angiography, technique in which a contrast agent is injected into the vascular system to outline the heart and blood vessel .when a specific heart chamber or blood vessel is singled out for study , the procedure is know as selective angiography .

Angiography makes use of cineangiograms , a series of rapidly changing films on an intensified fluoroscopic screen that record the passage of the contrast agent through the vascular site or sites . Recording allows for comparison of data over time . Common site for selective angiography are the aorta , the coronary arteries , and the right and left sides of the heart .

Are used to evaluate the degree of atherosclerosis and to determine treatment . They are also used to study suspected congenital anomalies of coronary arteries .

Aortography Is a form of angiography that outlines the lumen of

the aorta and the major arteries arising from it . In thoracic aortography , a contrast agent is used to study the aortic arch and its major branches . The catheter may be introduced into the aorta using the translumbar or retrograde brachial or femoral artery approach .

Coronary arteriography :coronary arteriography involves the introduction of a catheter into the right or left brachial or femoral artery , which is then passed into ascending aorta and manipulated into the right and left coronary arteries .

Right heart catheterization :

right heart catheterization usually precedes left heart catheterization . It involves passage of a catheter from an antecubital or femoral vein into the right atrium ,right ventricle , pulmonary artery , and pulmonary arterioles . Pressures and oxugen saturation levels from each of these areas are obtained and recorded . Although right heart catheterization is considered relatively safe , potential complication include cardiac dysrhythmias , venous spasm , infection of the insertion site , cardiac perforation , and rarely cardiac arrest .

Left heart catheterization :is performed to evaluate the patency of the coronary arteries and the function of the left ventricle and the mitral and aortic valves . Potential complication include dysrhythmias , MI , perforation of the heart or great vessels , and systemic embolization . In this approach , the physician insert the catheter into the right brachial artery or a femoral artery and advances it into the aorta and left ventricle .After the procedure , the catheter is carefully withdrawn and hemostasis is achieved using manual pressure or other techniques previously described . If the physician performed an arterial or venous cutdown , the sutured and a sterile dressing is applied .

Nursing intervention :nursing responsibilities before cardiac catheterization include the following :1- the patient is instructed to fast , usually for 8 to 12 hours ,before the procedure . If catheterization is to be performed as an outpatient procedure ,a friend , family member , or other responsible person must transport the patient home .2- the patient is informed of the expected duration of the procedure and advised that it will involve lying on a hard table for less than 2 hours .3- the patient is reassured that IV medication are given to maintain comfort .4- the patient is informed about sensation that will be experienced during the catheterization .5- the patient is encouraged to express fears and anxieties . The nurse provides teaching and reassurance to reduce apprehension .

Nursing intervention (cont ) :nursing responsibilities after cardiac catheterization may include the following :1- the catheter access site is observed for bleeding or hematoma formation .peripheral pulses are assessed in the affected extremity (dorsalis pedis and posterior tibial pulses in the lower extremity , radial pulse in the upper extremity ) every 15 minutes for 1 hour , and then every 1 to 2 hours until the pulses are stable .2- temperature , color ,and capillary refill of the effective extremity are frequently evaluated , per local nursing standards .the patient is assessed for effected extremity pain , numbness , or tingling sensation that may indicate arterial insufficiency .3- dysrhythmias are carefully screened by observing the cardiac monitor or by assessing the apical and peripheral pulses for change in rate and rhythm .4- bed rest is maintained for 2 to 6 hours after the procedure . If manual or mechanical pressure is used the patient must remain on bed rest for up to 6 hours with the affective leg straight and the head of the bed elevated no grater than 30 degrees .

Cont :5- the patient is instructed to report chest pain and bleeding or sudden discomfort from the catheter insertion sites promptly .

6- the patient is monitored for contrast agent induced nephropathy by observing for elevations in serum creatinine levels .

7- patient safety is ensured by instructing the patient to ask for help when getting out of bed the first time after the procedure . the patient is monitored for bleeding from the catheter access site and for orthostatic hypotension , indicated by complaints of dizziness or lightheadedness .

Self management after cardiac catheterization :after discharge from the hospital for cardiac catheterization , guidelines for self-care include the following :1- for the next 24 hours , do not bend at the waist (to lift any thing )strain , or lift heavy objects .2- avoid tub baths , but shower as desired .3- talk with your physician about when you may return to work , drive , or resume strenuous activities .4- call your physician if any of the following occur : bleeding , swelling , new bruising or pain from your procedure puncture site ,temperature of 38.6 or more .5- if test result show that you have coronary artery disease , talk with your physician about options for treatment , including cardiac rehabilitation programs in your community .6- talk with your physician and nurse about lifestyle changes to reduce your risk for further or future heart problem , such as quitting smoking , lowering your cholesterol level , initiating dietary changes , beginning an exercise program , or losing weight .

Cont :7- your physician may prescribe one or more new medication depending on your risk factors ( medications to lower your blood pressure or cholesterol ; aspirin or clopidogrel to prevent blood clots ) , take all of your medications as instructed , if you feel that any of them are causing side effects , call your physician immediately ,do not stop taking any medications before talking to your doctor .