Saturday, March 14, 2009



Cardiovascular disease is the leading cause of death in the US

Occlusive disorders of the coronary arteries and resulting
complications are largely responsible

The most common causes of occlusive vascular diseases are
atherosclerosis, arteriosclerosis, clot formation and vascular spasm


Arteriosclerosis – during the natural aging process loss of
elasticity or hardening of the arteries

Atherosclerosis – the lumen of the artery fills with fatty
deposits or plaque – fig 31-1

Hyperlipidemia triggers atherosclerotic changes:

Factors contributing to hyperlipidemia:




diseases such as metabolic syndrome



Current research now shows that development of atherosclerosis
may be linked to prior infection with Chlamydia pneumoniae a
respiratory infection

A relationship between body fat & production of inflammatory &
thrombotic or clot forming proteins

Presence of multiple risk factors contribute to development of
arteriovascular disease


Arteriosclerotic & atherosclerotic changes in the coronary
arteries that supply the heart

Causes: multiple factors Box 31-1

S/S –depend on severity; range from mild fatigue to severe
chest pain or angina see table 31-1

DX: Lipid panels, exercise stress testing, EKG changes


Treatment-lifestyle changes, meds: NTG, beta blockers, calcium
channel blockers, ace inhibitors, antilipimic agents

Noninvasive: Enhanced External Counterpulsation or EECP; fig

Invasive: PTCA, stents, CABG, TMR

Nursing: client education, med administration & assessments

Percutaneous Transluminal Coronary
Angioplasty (PTCA)

Also known as balloon angioplasty

Fig 31-6

Complications may include arterial rupture, MI & abrupt

See discharge instructions

Coronary Stent

During PTCA a small metal coil with meshlike openings is placed
in the coronary artery

See fig 31-7

The stent stays in place. Restenosis usually does occur

New stents coated with an antiinflammatory/antibiotic substance
are available


Removal of the fatty plaque from the artery wall

Done by:

inserting a cardiac catheter with a cutting tool at the tip,
see fig 31-8

performing laser angioplasty

Coronary Artery Bypass Graft CABG

Used to revascularize the myocardium

A 10 – 12 inch midsternal incision is made

Heart is stopped during the procedure & blood routed through a
heart-lung machine

Use either a healthy leg vein or chest artery to reroute the
oxygenated blood to an area below the obstruction in the diseased coronary

Recovery time is several weeks, but results last longer than
the PCTA or stents

Transmyocardial Revascularization


A laser procedure used for those who do not respond to meds &
are not candidates for CABG

Performed through an incision in the chest wall. A laser is
aimed at the beating heart & it creates channels in the heart tissues which
seep blood. The heart muscle absorbs the oxygenated blood from them instead
of the coronary arteries

Myocardial Infarction (MI)

Infarct – an area of tissue that dies from inadequate

This occurs in the heart when there is a prolonged total
occlusion of coronary arterial blood flow

The location of the infarct depends on the area where the blood
supply to the myocardium is interrupted by the respective occluded coronary
artery - fig 31-9

Transmural or Qwave MI – extends through the full thickness of
the myocardium

NON Q wave MI – or subendocardial infarction only goes thru
partial thickness of the wall of the myocardium

Myocardial Infarction (MI)

Cause – most common is coronary thrombosis



cardiogenic shock

ventricular rupture

ventricular aneurysm

arterial embolism

venous thrombosis

pulmonary embolism


mitral insufficiency


S/S – vary but typically include sudden, severe cxp, may
radiate to jaw, left arm, shoulder, teeth, or throat. Rest or use of NTG
does not help

If dx within 6 hours of onset of symptoms may give thrombolytic
drugs to stop the process

Dx – series of serum enzymes that are elevated – table 31-3,
EKG changes usually within 2-12 hrs

Myocardial Infarction

Treatment –

thrombolytics or clot busters used unless contraindicated

symptomatic treatment

Drug Table 31-1

Nursing Care Plan 31-1


Raynaud’s Disease

periodic constriction of the arteries that supply the

Cause unknown

Brief spasm of arteries in fingers, toes, nose, ears or chin
causing ischemia, pain & paresthesia, coldness.

Place affected area in warm water, avoid smoking, use of
peripheral vasodilators

Thrombosis-a clot in a blood vessel

Phlebothrombosis-a clot in a vein without inflammation

Embolism-moving, mass/clot , solid or gas within the

Usually found in lower extremities due to venous stasis caused
by inactivity, immobility or trauma to the vein



Arterial clot – white, cold, & extremely painful

Venous clot - phlebothrombosis – may be asymptomatic

DVT- mild fever, pain, swelling & tenderness to affected
extremity; + Homan’s sign

DX: arteriography or venography with contrast dye


Arterial clot - IV heparin, narcotics for pain, thrombolitic
agents, surgery

Venous thrombosis: bed rest, elevate extremity, local heat,
analgesics, IV heparin, oral anticoagulants

Nursing care: monitor heparin therapy & labs, s/s of bleeding,
have antidote available:

for heparin – protamine sulfate

for oral anticoagulants – vit K



Valves become incompetent

saphenous veins in the legs are usually affected

Familial tendency, prolonged standing, obesity, pregnancy

S/S – tiredness, heaviness in legs esp after excessive
standing, dark discolored veins

Treatment: exercise, wt loss, TED hose, avoid prolonged sitting
or standing

Surgical: vein ligation or stripping, see fig 31-14

Nursing: assessment, teaching regarding risk factors


A stretching or bulging of an arterial wall

Most common site is the aorta

Causes: arteriosclerosis, HTN, trauma or congenital weakness
that affects elasticity of arterial wall

S/S: usually asymptomatic; may be diagnosed during xrays;
during physical or when the client has a massive hemorrhage

Treatment: control HTN; surgical intervention

Nursing: control HTN, avoid straining, monitor v/s, uop,
prepare for surgery

General Nutritional Considerations

High levels of LDL increases the risk of CAD

Persons 2 years of age & older are urged to follow the Step-One
diet to reduce their risk of heart disease

Omega-3 fatty acids, abundant in fish oils, lowers serum
triglyceride levels & platelet aggregation

ETOH intake should remain moderate in order to increase HDL
cholesterol & not have the adverse side effects of excessive intake: for men
-1- 2 drinks per day & for women < 1 drink per day

General Pharmacologic Considerations

MDs may prescribe aspirin, 325mg or 81mg per day for clients
with CAD to prevent MI

All NTG preparations are stored in their original container &
not mixed with other medications. Make sure the cap is tightly closed after
each use

NTG can cause a throbbing headache, flushing & nausea; these
effects can usually be relieved by decreasing the dose

Antidote for overdosage of thrombolytic therapy is Amicar

General Gerontologic Considerations

General physiological changes in the older adult predispose
them to vascular occlusive disorders

CAD is the most common cause of death in older adults

Older adults are more sensitive to the hypotensive effects of

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