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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 Heart
2、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 wa
3、ll 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
4、 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复杂病变,Risk factors风险因素,Th
5、ree most significant risks are:elevated serum lipids血脂,hypertension and cigarette smoking.Risk factors can be categorized as unmodifiable and modifiableUnmodifiable factors:Age,gender and raceFamily history and heredityModifiable major risk factorsElevated serum lipids血脂HypertensionSmokingPhysical i
6、nactivityModifiable minor risk factorsObesityDiabetes mellitus糖尿病Stress and behavior patterns,Health promotion and maintenance健康促进和维护,Identification of high-riskManagement of high-riskPhysical fitnessHealth educationNutritional management Pharmacologic managementDrugs that increase lipoprotein remov
7、alDrugs 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 tr
8、ansient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 oxyg
9、en 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
10、 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
11、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 exertionStrong emotionConsumption of
12、 a heavy mealTemperature extremesCigarette smokingSexual activityStimulantsCircadian 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.St
13、able 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 a
14、ngina 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 b
15、e 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.Fac
16、tors 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 elevatio
17、n.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.Patie
18、nt 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,sh
19、oulders 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 ce
20、ssation of activity.,Diagnostic studies辅助检查,Chest X-raySerum lipidCardiac enzyme valuesECGNuclear imagingAngiographyEchocardiography,Emergency management chest pain,Establish and maintain airwayAdminister oxygen by nasal cannula if not in respiratory distress;otherwise use high flow(100%)by nonbreat
21、her mask.Anticipate need for intubation if respiratory distress evidentStart 2 IV lines with large-gauge needlesRemove clothing;comfort and reassure patientMonitor cardiac rate and rhythm;monitor vital signs including level of consciousnessBe prepared to perform cardiopulmonary resuscitation心肺复苏,def
22、irbillation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 orderAssess for indications and contraindications for thrombolytic therapyPrepare to initiate thrombolytic therapy溶栓治疗if indicated,Therapeutic management,Pharmacologic management药理管理Antip
23、latelet 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
24、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 vesselsDilating coronary arteries and collateral侧支vessels,Pharmacologic management,Nitrates硝酸盐The us
25、ual 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
26、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
27、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 nitroglycerinIt should be easily accessible to the patient at all time.For protection from degradation退化,it should be kept in a tightly closed d
28、ark 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
29、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 repeat
30、ed 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
31、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 d
32、iscontinued 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 d
33、ecreased SVRDecreased 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 a
34、ction 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 r
35、elated to ischemia myocardiumAnxiety related to diagnosis and awareness of being a vitim of heart disease,pain and limited activity tolerance,uncertainties about the future,diagnostic tests,pending surgeryDecreased CO related to myocardial ischemia affecting contractilityActivity intolerance related
36、 to myocardial ischemia,Acute intervention,Establish and maintain airwayAdminister oxygen by nasal cannula if not in respiratory distress;otherwise use high flow(100%)by nonbreather mask.Anticipate need for intubation if respiratory distress evidentStart 2 IV lines with large-gauge needlesRemove clo
37、thing;comfort and reassure patientMonitor cardiac rate and rhythm;monitor vital signs including level of consciousnessBe 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 orderAsse
38、ss for indications and contraindications for thrombolytic therapyPrepare 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 fact
39、ors,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.,
