Coronary artery disease (CAD) or ischemic heart disease
Introduction
Coronary artery disease (CAD) or ischemic heart disease is one of the most common types of heart problems in America (Saman, 2017). After serving two presidential terms in 2001, Bill Clinton was diagnosed with CAD and underwent surgery in 2004 (Glass, 2017). The quadruple bypass operation revealed that he had extensive sighs of heart blockages and disease where the arteries were blocked by more than 90 percent. Days before the operation, the former president had complained of shortness of breath and chest pains that he had experienced for months. Despite the success of the first surgery, former President Bill Clinton was readmitted in February 2010 (Glass, 2017). The new procedure involved placing two stents into the coronary artery. The need for a new surgery could be as a result of problems with the initial graft, the development of a new blockage, or the presence of a problem that developed beyond the graft site.
CAD is caused by a buildup of plaques or cholesterol deposits on the artery lining. Also known as atheromatous or atheromas, the plaques cause the arterial wall to thicken and narrow the arterial space where blood flows to the heart. Therefore, CAD causes the amount of blood being supplied to the myocardium with nutrients and oxygen to reduce (Saman, 2017). Normally, an atheroma starts developing as a result of damage to the endothelium in the artery. After the damage is done to the endothelium, lipoproteins, fats, and cholesterol begins to accumulate in the artery intima (Ambrose & Singh, 2015). Over time, the low-density lipoprotein (LDL) start to occur in high concentrations and penetrate the damaged endothelium before undergoing oxidation. The altered composition of LDL starts to attract leukocytes to move towards the walls of the vessel.
Soon afterward, foam cells are formed when the macrophages engulf the lipoproteins. The foam cells developed the first form of the fatty streak, which attracts smooth muscles to the damaged endothelium, multiply, and begins to produce proteoglycan and collagen in an extracellular matrix (Saman, 2017). The matrix constitutes the largest part of the plaque and turns the atheromatous lesion into fibrous plaque. Thus, the lesion begins to bulge into the inner blood vessel wall that leads to the narrowing of the arterial space. Through the angiogenesis process, the fibrous plaque starts to develop small vessels to support itself through the blood supply. Calcium deposits at the site make the plaque to calcify. In the end, the plaque is made up of a fibrous tissue cap with necrotic cells and lipids (Ambrose & Singh, 2015). The region becomes prone to rupture and exposes the cap to thrombogenic factors that causes clot formation on the plaque, which narrows down the artery further (Saman, 2017). Such is the common case in acute coronary disease. Narrowing of the arteries and the presence of plaques in the arteries results in angina, shortness of breath, nausea, and light-headedness as the heart muscles are oxygen-deprived. Continued narrowing of the blood vessels can cause an obstruction that can lead to myocardial infarction.
History
The pathophysiology of CAD has evolved. In the past, it was assumed that CAD was a simple condition caused by the narrowing of the arteries, which results in complete artery blockage. However, recent studies have provided a different explanatory paradigm that has shifted towards the coronary plaques spectrum. Recent research shows that CAD is a result of stable plaques, including poor lipid and thick fibrous cap to a thin fibrous cap ad high amounts of lipids, which is unstable. Current studies show that unstable plaques are more likely to rupture, and when they do, vasoconstrictive factors and the release of prothrombotic factors increase the probability of artery occlusion. Therefore, the history of the pathophysiology of CAD has shifted from it being viewed as a narrowing of arteries to the body’s balance between the thrombolytic and prothrombotic pathways at the epithelial rupture that determines the clinical manifestation and outcome of CAD (Ambrose & Singh, 2015). This explains the differences in clinical manifestation where permanent occlusion results in transmural myocardial infarction, while transient occlusion results in pain and ischemia.
Several factors contribute to the development of CAD. One of the leading factors includes age, gender, and family history. One experiences an increased risk of being diagnosed with CAD as one gets older. Before the age of 60, studies show that men are at a greater risk of having CAD than women (Ambrose & Singh, 2015). An individual is also more likely to have CAD if he or she has a close blood relative who has suffered from heart disease. Several other risk factors can increase the risk of getting CAD, including increased blood cholesterol levels, increased triglycerides with low cholesterol, diabetes, smoking, excessive stress, high blood pressure, excessive alcohol, having an inactive lifestyle, and obesity (Ambrose & Singh, 2015).
Planning
The management and treatment of CAD take part in a combination of short term and long term goals. The first short term goal involves the provision of immediate action. Nurses should be well equipped with information and resources to respond to CAD symptoms among patients, such as reducing chest discomfort. The second short-term goal involves reducing risk factors associated with CAD. While some of the risk factors such as age, gender, and family history cannot be controlled, other risk factors such as high blood pressure and smoking can be controlled. At this point, nurses can work closely with patients and other medical practitioners to help patients stop smoking, lower their cholesterol levels, reduce weight in cases of obesity, and manage high blood pressure and diabetes. The long-term goals that the patients should adopt involve enhancing the mental wellbeing through the development of a better mindset and attending a cardiac rehabilitation program. Nurses can work with the patient to achieve their long-term goals. For instance, they can work with other health care professionals to develop a cardiac rehabilitation program that will cater to all the needs of CAD patients.
Novel technological advances have been introduced in the treatment and improvement of CAD. 3-D printing of cardiac conditions has proved to be effective in treating and diagnosing myocardial damage. However, this approach is not sufficient in treating CAD since the images are viewed on 2-D screens that limit complete visualization, simulation, and surgical planning (Mojto, 2019). Stem cell therapy is another significant technological approach that has proved effective in reversing CAD effects by increasing blood supply and repairing myocardial damage. Technological approaches can be used, such as through percutaneous coronary revascularization. In this process, a catheter is placed in the narrowed section of the artery (Mojto, 2019). A deflated balloon is passed via the catheter and inflated once it reaches the narrowed area to compress the deposits on the arterial wall. A coronary artery stent is, thereby, left to ensure the artery remains open (Mojto, 2019). Coronary artery bypass surgery can also be conducted. In both cases, the procedures are short term since they do not guarantee that the artery will not narrow at another point.
Intervention
Several interventions are effective in promoting the health of patients with CAD. Surgical interventions include intracoronary atherectomy, transmyocardial revascularization, and coronary artery bypass grafting. During these procedures, nurses can help ensure a successful surgical procedure by preparing the patient before and after surgery, checking for their vital signs, and providing patients with emotional support. Furthermore, patients are required to commit to adopting healthier lifestyles that will reduce their risk of exacerbating CAD. For instance, nurses should encourage patients to reduce stress, exercise regularly, quit smoking, lose excess weight, and eat healthier foods. Nurses can aid in the actualization of such goals by conducting follow up care, developing focus groups such as those aimed at smoking patients, advising patients on a personal level, and encouraging them to participate in health promotion activities.
Secondly, patients can be introduced to medications that help treat CAD on a long-term basis. Cholesterol-modifying medications are essential in reducing cholesterol amounts in the blood. The medications can range from bile acid sequestrants to statins (Roffi et al., 2015). Blood thinners such as aspirin are also essential in reducing the tendency for blood clots, which increases the risk of CAD. Additionally, beta-blockers are essential in lowering the blood pressure, which is essential in reducing future risks of a heart attack. Calcium channel blockers can be used with beta-blockers if the latter is not effective in reducing chest pain symptoms. Patients can also take angiotensin-converting enzyme (ACE) inhibitors to reduce blood pressure (Roffi et al., 2015). Ranolazine and nitroglycerin are other medications that can be used to reduce angina. B complex vitamins and folic acid are important supplements for CAD patients since it helps reduce homocysteine levels.
Evaluation
An evaluation of the plan of care is essential in the realization of long-term and short-term goals. The evaluation plan involves an assessment of the incorporated measures in improving the clinical manifestation of CAD and treating the disease. The first process involves an evaluation of all the factors that are important in preventing the chronic development of CAD, which might result in a heart attack. In such a situation, it is essential to review lifestyle modifications and the associated risk factors that are necessary for preventing the disease from becoming worse. Within this context, a nurse is required to evaluate whether the underlined measures are applicable in managing and preventing CAD symptoms in the future. It also involves conducting a follow up by checking whether the patient is following through with the developed plan.
The second step involves the medication that the patient is given to managing CAD. The nurse’s role in this situation involves ascertaining that the patient and the immediate family are aware of the medications that the patient needs to use, including the adverse effects, the correct dosage, and the action of the medication. To evaluate if the patient is taking the medication that he or she was given, the nurse can monitor certain body functions and indicators. The nurse can commence by monitoring the blood pressure, respiration, and heart rate during the initial treatment date and every hospital visit. Nurses should also monitor the ECG reading for ST-elevation and arrhythmias to ensure the patient is following the provided medication and guidelines.
References
Ambrose, J. A., & Singh, M. (2015). Pathophysiology of coronary artery disease leading to acute coronary syndromes.F1000 Prime Reports. 7(8), 1.
Glass, A. (2017, June 6). Bill Clinton undergoes heart surgery. Politico. Retrieved from https://www.politico.com/story/2017/09/06/bill-clinton-undergoes-heart-surgery-sept-6-2004-242298
Mojto, V. (2019). New Technologies for Treatment of Coronary Artery Disease. Biomedical Journal of Scientific & Technical Research, 13(3), 10022-10028.
Roffi, M., Patrono, C., Collet, J., Valgimigli, M., Bax, J.J., Andreotti, F.,…Chew, P. (2015). 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). European Heart Journal, 37(3), 267-315.
Saman, S. J. (2017). Diagnosis, management, and nursing care in acute coronary syndrome. Nursing Times, 113(3), 31-35.