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1、Coronary Artery Disease,Atherosclerosis动脉粥样硬化is often referred to as “hardening of the arteries”. Although this condition can occur in any artery in the body, the atheromas血管硬化(fatty deposits) have a preference for the coronary arteries. Ateriosclerotic Heart Disease (ASHD)动脉粥样硬化性心脏病, Cardiovascular
2、 Heart Disease (CHD)心血管心脏病, and Coronary Artery Disease (CAD)冠状动脉疾病are synonymous terms used to describe this disease process.,Etiology and pathophysiology病因和病理生理,Atherosclerosis动脉粥样硬化is the major cause of CAD. It is characterized by a focal deposit of cholesterol胆固醇and lipids血脂, primarily within th
3、e intimal wall of the artery. The concept of endothelial injury内皮损伤is central to current theories of atherogensis. The genesis of plague斑块 formation is the result of complex interactions between the components of the blood and the elements forming the vascular wall.,Etiology and pathophysiology病因和病理
4、生理,Development stages 发展过程 CAD takes many years to develops. When it becomes symptomatic, the disease process is usually well advanced. The states of development in atherosclerosis are: Fatty streak脂肪条纹 Raised fibrous plaque resulting from smooth muscle cell proliferation纤维斑块增加 Complicated lesion复杂病
5、变,Risk factors风险因素,Three most significant risks are: elevated serum lipids血脂, hypertension and cigarette smoking. Risk factors can be categorized as unmodifiable and modifiable Unmodifiable factors: Age, gender and race Family history and heredity Modifiable major risk factors Elevated serum lipids血
6、脂 Hypertension Smoking Physical inactivity Modifiable minor risk factors Obesity Diabetes mellitus糖尿病 Stress and behavior patterns,Health promotion and maintenance健康促进和维护,Identification of high-risk Management of high-risk Physical fitness Health education Nutritional management Pharmacologic manage
7、ment Drugs that increase lipoprotein removal Drugs that restrict lipoprotein production,Clinical manifestation of CAD临床表现,There are three major clinical manifestation of CAD: angina心绞痛 acute MI心肌梗死 sudden cardiac death猝死,Angina pectoris心绞痛,Myocardial ischemia心肌缺血is expressed symptomatically as angin
8、a心绞痛. More specifically, angina pectoris is transient短暂的chest pain caused by myocardial ischemia心肌缺血. Angina usually lasts for only a few minutes (3 to 5 minutes) and commonly subsides解除when the precipitating factor (usually exertion) is relieved.,Pathophysiology of Angina pectoris病理生理,Myocardial is
9、chemia develops when the demand for myocardial oxygen exceeds the ability of the coronary arteries to supply it. The primary reason for insufficient flow is narrowing of coronary arteries by atherosclerosis. For ischemia as a result of atherosclerosis to occur, the artery is usually 75% or more sten
10、osed狭窄.,Pathophysiology of Angina pectoris病理生理,With the total occlusion of the coronary arteries, contractility ceases after several minutes, depriving the myocardial cells of glucose葡萄糖for aerobic metabolism有氧代谢. Anaerobic metabolism无氧代谢 begins and lactic acid乳酸accumulates. Myocardial nerves fibers
11、 are irritated by the increased lactic acid and transmit a pain message to the cardiac nerves and upper thoracic posterior roots上部胸椎神经后根(the reason for referred cardiac pain to the left shoulder and arm).,Precipitating factors激发因素,Extracardiac factors my precipitate myocardial ischemia and anginal p
12、ain including: Physical exertion Strong emotion Consumption of a heavy meal Temperature extremes Cigarette smoking Sexual activity Stimulants Circadian rhythm patterns 昼夜节律模式,Types of angina,Stable angina稳定型心绞痛 Stable angina (classic) refers to chest pain occurring intermittently间歇性over a long perio
13、d with the same pattern of onset, duration, and intensity of symptoms. Stable angina is usually exercise induced. Pain at rest is unusual. An ECG usually reveals ST segment depression ST段压低， indicating subendocardial ischemia. Stable angina can be controlled with medications on an outpatient basis.
14、Medication can be timed to provided peak effects during the time of day when angina is liking to occur.,Types of angina,2. Unstable angina不稳定型心绞痛 Unstable angina (progressive进展的, cresendo渐强的, or preinfarction angina心肌梗死前心绞痛) may be the first manifestation of CAD. The patient with previously diagnose
15、d stable angina will describe a significant change in the pattern of angina. It will be occurring with increasing frequency, easily provoked by minimal or no exercise, during sleep or even at total rest.,Types of angina,3. Prinzmetals angina 变异型的心绞痛 Prinzmetals angina (variant angina), is a rare for
16、m of angina, often occurs at rest, usually in response to spasm of a major coronary artery. Factors precipitate coronary spasm includes increased myocardial oxygen demand and increased levels of a variety of substances (e.g., histamine组胺, angiotensin血管紧张素, epinephrine肾上腺素, norepinephrine去甲肾上腺素, pros
17、taglandins前列腺素) When spasm occurs, the patient experience pain and marked, transient ST segment elevation. The pain may occur during rapid eye movement (REM) sleep快速眼动睡眠 when myocardial oxygen consumption increases. Cyclical周期性的, short bursts of pain at a usual time each day may also occur with this
18、 type of angina.,Clinical manifestation临床表现,The most common initial symptom is chest pain or discomfort. Patient may had a vague sensation, an unpleasant feeling, often described as a constrictive缩窄, squeezing压缩, heavy, choking, or suffocating sensation. Although most of the person with angina exper
19、ience discomfort substernally, the sensation may occur in the neck or radiate放射to various locations including jaw下巴, shoulders and down the arms. Often people will complaint of pain between the shoulder blades肩胛骨之间and dismiss it as not being heart pain. Associated symptoms may includes: shortness of
20、 breath, cool sweat, weakness, or paresthesia 感觉异常 of the arm(s). Relief of classic angina is usually obtained with rest or cessation of activity.,Diagnostic studies辅助检查,Chest X-ray Serum lipid Cardiac enzyme values ECG Nuclear imaging Angiography Echocardiography,Emergency management chest pain,Est
21、ablish and maintain airway Administer oxygen by nasal cannula if not in respiratory distress; otherwise use high flow (100%) by nonbreather mask. Anticipate need for intubation if respiratory distress evident Start 2 IV lines with large-gauge needles Remove clothing; comfort and reassure patient Mon
22、itor cardiac rate and rhythm; monitor vital signs including level of consciousness Be prepared to perform cardiopulmonary resuscitation心肺复苏, defirbillation电除颤, external pacing or cardioversion外部起搏或电复律 Assess severity and location of pain, medicate for pain as order Assess for indications and contrai
23、ndications for thrombolytic therapy Prepare to initiate thrombolytic therapy溶栓治疗if indicated,Therapeutic management,Pharmacologic management药理管理 Antiplatelet aggregation therapy抗血小板聚集治疗: is the first line of pharmacologic intervention in the treatment of angina. Aspirin阿司匹林is the drug of choice. Nit
24、rates硝酸盐: which are commonly classified as vasodilators, are the next step in the treatment of angina. Nitroglycerin硝酸甘油: it is given sublingually for acute angina attacks, usually relieve pain in approximately 3 minutes and has a duration of approximately 20 to 45 minutes. Nitrates produce their pr
25、inciple effects by the following: Dilating peripheral blood vessels Dilating coronary arteries and collateral侧支vessels,Pharmacologic management,Nitrates硝酸盐 The usual recommended dose is 1 tablet taken sublingually (SL)舌下, which can be followed at 5-minute intervals with two more doses. If relief fro
26、m anginal pain has not been obtained after 3 tables and 15 minutes, the patient should be instructed to seek medical attention. The predominant side effect of nitrate drugs is headache from the dilatation of cerebral blood vessels. Other complications of the vasodilator drugs are orthostatic hypoten
27、sion体位性低血压(nitrate syncope硝酸晕厥) and an aggravation of cerebral vascular insufficiency. Thus, monitor BP and pulse prior to long-acting nitrates administration (if BP is 30 mm Hg below baseline or 90 mm Hg, withhold medication and notify the doctors)。,Nitrates硝酸盐 The patient needs to be instructed in
28、 the proper use of sublingual nitroglycerin It should be easily accessible to the patient at all time. For protection from degradation退化, it should be kept in a tightly closed dark glass bottle with metal caps. The patient should be instructed to place a nitroglycerin table beneath the tongue and al
29、low it to dissolve. This should cause a fizzing or slightly warm feeling locally. The patient should be warned that HR may increase and a pounding headache, dizziness头晕, or flushing脸红may occur. The patient should be cautioned against quickly rising to a standing position because postural hypotension
30、 may occur after nitroglycerin ingestion. if the pain has not been relieved after 5 minutes, the patient should be told to take another nitroglycerin tablet. This procedure may be repeated for pain relief every 5 minutes, not to exceed the ingestion of 3 tablets. If pain persist after three doses, t
31、he patient should seek immediate medical treatment.,Therapeutic management,Pharmacologic management -adrenergic blocking agents: propranolol普奈洛尔, metoprolol美托洛尔, nadolol钠多洛而, atenolol阿替洛尔. These drugs produce a direct decrease in myocardial contractility, HR, SVR and BP, all of which reduce the myoc
32、ardial oxygen demand. Side effect of these drugs includes brachycardia心动过缓, hypotension, wheezing and GI complaints, weight gain, depression and sexual dysfunction. The -adrenergic blockers should not be discontinued abruptly without medical supervision .,Pharmacologic management,Calcium-channel blo
33、cking agents: nifedipine硝本地平, verapimil维拉帕米, diltiazem地尔硫卓 and nicardipine 尼卡地平are the next step in the management of angina. The three primary effects of these drugs are: Systemic vascular vasodilatation with decreased SVR Decreased myocardial contractility,Calcium-channel blockers,Calcium-channel
34、blockers have a depressant effect on the sinoatrial (SA) node窦房结rate of discharge and the conduction velocity传导速度through AV node房室结is decreased, thus slowing the HR. Calcium-channel blocking agents地高辛potentiate the action of digoxin地高辛by increasing serum digoxin levels during the early part (first w
35、eek) of therapy. Therefore serum digoxin levels should be closely monitored upon institution of this therapy, and the patient should be taught the signs and symptoms of digoxin toxicity洋地黄中毒.,Nursing diagnosis护理诊断,Pain related to ischemia myocardium Anxiety related to diagnosis and awareness of bein
36、g a vitim of heart disease, pain and limited activity tolerance, uncertainties about the future, diagnostic tests, pending surgery Decreased CO related to myocardial ischemia affecting contractility Activity intolerance related to myocardial ischemia,Acute intervention,Establish and maintain airway
37、Administer oxygen by nasal cannula if not in respiratory distress; otherwise use high flow (100%) by nonbreather mask. Anticipate need for intubation if respiratory distress evident Start 2 IV lines with large-gauge needles Remove clothing; comfort and reassure patient Monitor cardiac rate and rhyth
38、m; monitor vital signs including level of consciousness Be prepared to perform cardiopulmonary resuscitation心肺复苏, defirbillation电除颤, external pacing or cardioversion外部起搏或电复律 Assess severity and location of pain, medicate for pain as order Assess for indications and contraindications for thrombolytic
39、 therapy Prepare to initiate thrombolytic therapy溶栓治疗if indicated,Chronic and home management,The patient needs to be reassured that a long, productive life is possible. The patient needs to be educated regarding CAD and angina, precipitating factors, risk factors, and medication. Educating the pati
40、ent and the family about diets that are low in sodium and reduced in saturated fat may be appropriated. Its important to educate the patient and their family in the use of nitroglycerin. Nitroglycerin硝酸甘油片tablets or ointments may be used prophylactically预防before an emotionally stressful situation, sexual intercourse or physical exertion.,