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*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Coronary Artery Disease,冠状动脉疾病,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 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 the 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,病因和病理生理,Development stages 开展过程,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 management,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 angina,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 ischemia 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 stenosed,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 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 pain 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 period 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. 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 diagnosed 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 form 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, prostaglandins,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 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 experience,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 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,Establish 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,Monitor 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 contraindications 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.,Nitrates,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 principle 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 from 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 hypotension,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 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 allow 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 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, the 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 myocardial 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 blocking 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 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 week) 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 being 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,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 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 contraindications for thrombolytic 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 patient 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.,
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