Coronary Artery Disease

Overview

Coronary artery disease (CAD) causes impaired blood flow in the arteries that supply blood to the heart. Also called coronary heart disease (CHD), CAD is the most common form of heart disease and affects approximately 16.5 million Americans over the age of 20.

It’s also the leading cause of death for both men and women in the United States. It’s estimated that every 40 seconds, someone in the United States has a heart attack.

A heart attack can come from uncontrolled CAD.

Causes of coronary artery disease

The most common cause of CAD is a vascular injury with cholesterol plaque buildup in the arteries, known as atherosclerosis. Reduced blood flow occurs when one or more of these arteries become partially or completely blocked.

The four primary coronary arteries are located on the surface of the heart:

• right main coronary artery
• left main coronary artery
• left circumflex artery
• left anterior descending artery

These arteries bring oxygen and nutrient-rich blood to your heart. Your heart is a muscle that’s responsible for pumping blood throughout your body. According to the Cleveland Clinic, a healthy heart moves approximately 3,000 gallons of blood through your body every day.
Like any other organ or muscle, your heart must receive an adequate, dependable supply of blood in order to carry out its work. Reduced blood flow to your heart can cause symptoms of CAD.
Other rare causes of damage or blockage to a coronary artery also limit blood flow to the heart.

Symptoms of CAD
When your heart doesn’t get enough arterial blood, you may experience a variety of symptoms. Angina (chest discomfort) is the most common symptom of CAD. Some people describe this discomfort as:

• chest pain
• heaviness
• tightness
• burning
• squeezing

These symptoms can also be mistaken for heartburn or indigestion.

Other symptoms of CAD include:

• pain in the arms or shoulders
• shortness of breath
• sweating
• dizziness

You may experience more symptoms when your blood flow is more restricted. If a blockage cuts off blood flow completely or almost completely, your heart muscle will start to die if not restored. This is a heart attack.

Don’t ignore any of these symptoms, especially if they are excruciating or last longer than five minutes. Immediate medical treatment is necessary.
Symptoms of CAD for women

Women may also experience the above symptoms, but they’re also more likely to have:

• nausea
• vomiting
• back pain
• jaw pain
• shortness of breath without feeling chest pain

Men have a higher risk of developing heart disease than premenopausal women. Postmenopausal women by age 70 have the same risk as men.

Due to decreased blood flow, your heart may also:

• become weak
• develop abnormal heart rhythms (arrhythmia) or rates
• fail to pump as much blood as your body needs

Risk factors for CAD

Understanding the risk factors for CAD can help with your plan to prevent or decrease the likelihood of developing the disease.

Risk factors include:

• high blood pressure
• high blood cholesterol levels
• tobacco smoking
• insulin resistance/hyperglycemia/diabetes mellitus
• obesity
• inactivity
• unhealthy eating habits
• obstructive sleep apnea
• emotional stress
• excessive alcohol consumption
• history of preeclampsia during pregnancy

The risk for CAD also increases with age. Based on age alone as a risk factor, men have a greater risk for the disease beginning at age 45 and women have a greater risk beginning at age 55. The risk for coronary artery disease is also higher if you have a family history of the disease.

Pharmacology review: Drugs that alter blood coagulation

The vascular system delivers oxygen and nutrients to all body cells and removes waste products from tissues. This closed system functions as a pressure system, with blood flowing continuously from high-pressure to low-pressure areas. Injury of a blood vessel compromises the closed system, causing blood to flow out of the injured vessel (now a low-pressure area). With the severe injury to a vessel, the entire circulatory system may be compromised and the patient could die.
Blood vessel injuries are common, occurring, for instance, when someone hits the edge of a table, coughs too hard, or falls down. They initiate a series of normal reactions that stops blood flow and maintains balance within the system. The reactions include:

• reflex vasoconstriction
• platelet aggregation
• blood coagulation (clot formation), which causes blood to solidify
• clot resolution, which returns blood to the fluid state.

In many clinical situations, drugs are used to slow or stop this pro­cess, the with the goal of preventing tissue damage from the decreased blood flow that occurs when the clotting process cuts off blood supply to an area. This article reviews the processes the body uses to maintain the cardiovascular system and discusses the mechanisms of action, benefits, and risks of drugs used to alter coagulation.
Indications for drugs that alter coagulation

In certain clinical situations—for instance, coronary artery disease, immobility, atrial fibrillation, and joint replacement—interfering with coagulation helps prevent clots that could impede blood flow and cause tissue damage or death. Patients with coronary artery disease, for example, have narrowed vessels. An immobile patient loses the protective massaging of veins caused by muscle fiber contractions; also, blood pools and doesn’t return to the heart efficiently. With atrial fibrillation, blood pools in the heart’s auricles and may clot. The artificial parts of a hip or knee replacement initially may damage a blood vessel, leading to clotting.
All drugs that alter coagulation interfere with the normal protective reflexes. As a nurse, you need to be aware of the dangers of eliminating these reflexes, which could include serious or even fatal bleeding episodes. Drugs that alter coagulation include platelet inhibitors and anticoagulants. 

Platelet inhibitors
Platelet inhibitors are often the first line of defense in preventing vascular clots; they don’t affect clots that already have formed. These drugs block platelets’ ability to adhere and aggregate to form the platelet plug—the first step in sealing the vascular system and preventing blood loss into body tissues.
Current platelet inhibitors include abciximab (ReoPro), anagrelide (Agrylin), aspirin, cilostazol (Pletal), clopidogrel (Plavix), dipyridamole (Persantine), eptifibatide (Integrilin), ticlopidine (Ticlid), ticagrelor (Brilinta), and tirofiban (Aggrastat). These drugs are used to treat cardiovascular diseases in which vessels become occluded, as well as to maintain venous and arterial grafts and prevent cerebrovascular occlusion. They’re also given as adjuncts to thrombolytic therapy in treating myocardial infarction (MI) and preventing post-MI reinfarction. Ticagrelor, released in 2011, is indicated only to prevent thromboembolic events in acute coronary syndrome. Its black-box warning cites the risk of excessive bleeding and dangers of sudden withdrawal, which can trigger an acute cardiovascular event.
Most platelet inhibitors block receptors on platelets to prevent adhesion; anagrelide prevents platelet formation in the bone marrow. Bleeding (including bleeding caused by toothbrushing and excessive bleeding after injury) is the most common adverse effect. Easy bruising also may occur.

Nursing considerations
When caring for patients receiving platelet inhibitors, minimize invasive procedures and take other steps to guard against blood loss. Be sure to teach about self-care. Advise them to avoid injury, use a soft-bristled toothbrush, shave with an electric razor, and avoid contact sports. Encourage them to carry or wear Medic-Alert jewelry that alerts healthcare pro­viders to platelet inhibitor use. Stress the importance of telling all healthcare providers they’re taking a platelet inhibitor—especially dentists, surgeons, and others planning an invasive procedure. Caution patients to check with a physician before taking other agents that alter coagulation, including aspirin, nonsteroidal inflammatory drugs, and certain herbs. Emphasize the need to avoid excessive dosages, because no rapid antidote exists for excessive bleeding caused by drug overdose or overreaction. Teach patients about warning signs of excessive blood loss, and advise them to report these immediately.

Anticoagulants
Although commonly called blood thinners, anticoagulants don’t actually thin the blood. Like platelet inhibitors, they don’t dissolve clots that have already formed but they can prevent the formation of new clots. In patients with clots, deep vein thrombosis, or occluded vessels that have caused an MI or a stroke, clot prevention is crucial, because new clot formation may compound the patient’s problem. 

Anticoagulants fall into two categories—injectable and oral.
Injectable anticoagulants
These agents act rapidly to directly block the formation of thrombin from prothombin. Clotting changes occur rapidly after injection. Injectable anticoagulants in current use include antithrombin III (Thrombate III), argatroban (Acova), bivalirudin (Angiomax), desirudin (Iprivask), fondaparinux (Arixtra), heparin (generic), and the low-molecular-weight heparins dalteparin (Fragmin) and enoxaparin (Lovenox).
Indications for injectable anticoagulants include acute treatment and prevention of venous thrombosis and pulmonary embolism, treatment of atrial fibrillation with embolization, prevention of clotting in blood samples and in dialysis and venous tubing, and diagnosis and treatment of disseminated intravascular coagulation.

Nursing considerations 

Be aware that in patients with excessive bleeding caused by anticoagulants, protamine sulfate can be injected as a rapid antidote to restore clotting activity. This drug directly reacts with thrombin, freeing it up to allow clots to form.
Also, know that several serious to fatal medication errors have occurred when patients have inadvertently received two anticoagulants at the same time. Such errors are possible when, for instance, a hospital patient is put on a protocol that uses an anticoagulant and then is transferred to another unit, where she receives an anticoagulant from a different protocol. Warnings, labels, and effective communication among nurses at transfer points can help prevent this problem.
The major drawback of injectable anticoagulants is that they must be injected. Some patients may be discharged on low-molecular-weight heparin to inject themselves; be sure to teach them proper injection technique and proper disposal of needles and syringes. Advise patients that they must have their blood tested frequently to check crucial coagulation indices. Whole blood clotting time must be maintained at 2.5 to 3 times the control value, or activated partial thromboplastin time (APTT) must be maintained at 1.5 to 3 times the control value. Be sure to provide other protective measures and cover the same teaching topics as for patients receiving platelet inhibitors.

Oral anticoagulantsPreviously, warfarin (Coumadin) was the only oral anticoagulant available. In recent years, two new oral anticoagulants have been approved by the Food and Drug Administration. Dabigatran (Pra­daxa) is a direct thrombin inhibitor; rivaroxaban (Xarelto) inhibits activated thrombin. Both stop the coagulation process.

Warfarin Warfarin blocks the liver’s use of vitamin K to produce clotting factors. It’s commonly prescribed for chronic conditions that might involve problems with clot formation, such as coronary artery disease, atrial fibrillation, knee or hip replacement, and immobility.

However, warfarin has several disadvantages. For one, it takes time to deplete already-formed clotting factors; clot formation may not decrease until 48 to 72 hours after warfarin therapy begins. Also, if the patient receives too much warfarin and is bleeding, no precise antidote exists. Although vitamin K can be injected to trigger the liver to resume making clotting factors, clotting activity may not return for 48 to 72 hours. In severe overdose and bleeding, blood products containing clotting factors may be given to stop the bleeding; however, the liver still needs time to restore a normal level of clotting factors.

Traditionally, warfarin was the only oral anticoagulant patients could take at home. In light of its slowness in halting clot formation, warfarin therapy usually is started while the patient is still receiving an injectable anticoagulant; the latter drug is withdrawn when warfarin kicks in. Also, warfarin may interact with many other drugs and certain herbal supplements. What’s more, its effects may be altered by changes in the liver or in vitamin K production by the normal intestinal flora. (See Herbs and other supplements that increase bleeding risk by clicking the PDF icon above.)

Patients on warfarin need to have frequent blood tests to evaluate its effectiveness and allow dosage adjustment if needed. The desired prothrombin time (PT) is 1.5 to 2.5 times the control value; the desired International Normalized Ratio (INR) is 2 to 3. If a drug is added to or removed from the patient’s regimen, warfarin dosage may need to be adjusted. As with any drug used to alter coagulation, be sure to provide education and support.

Dabigatran

This drug was approved in 2010 for the prevention of stroke and blood clots in patients with nonvalvular atrial fibrillation. Rather than affecting clotting-factor formation, it inhibits activation of a clotting factor, which stops the clotting cascade. Dabigatran has become the drug of choice for preventing clots in patients with chronic nonvalvular atrial fibrillation. It interacts with few drugs and its effects aren’t altered directly by liver function changes, so patients don’t need frequent blood testing to guide dosages. Because its half-life is 12 to 17 hours, the drug’s effects linger after the patient stops taking it.

Teach patients to use all tablets within 60 days of opening the bottle. Instruct them to swallow tablets whole without cutting, crushing, or chewing. Advise them to protect the drug from humidity and light exposure. Because no antidote exists, caution patients to stay alert for signs and symptoms of excessive bleeding, such as excessive bruising, easy bleeding from minor injuries, and bleeding from toothbrushing. Stress that they shouldn’t stop taking the drug suddenly because cardiovascular problems could result.

Rivaroxaban

This drug was approved in 2011 to prevent deep vein thrombosis after knee or hip replacement surgery and to reduce stroke risk in patients with nonvalvular atrial fibrillation. It affects clot formation by inhibiting activated clotting factor. It has a shorter half-life than dabigatran (5 to 9 hours), so it clears from the body faster and its effects don’t last as long. No specific antidote exists.

Caution patients not to stop taking rivaroxaban suddenly because this may cause a sudden reversal of effects, triggering a stroke. Inform them that combining rivaroxaban with other drugs or herbs that affect coagulation could lead to excessive bleeding.
Ensuring patient safety

Patient safety is a major concern for patients receiving drugs that affect coagulation because they’re at risk for excessive bleeding. Take the following measures to protect patients from injury and minimize invasive procedures:

• Help consolidate required blood withdrawals so the patient has fewer chances to bleed.
• Clearly document in the chart that the patient is on this drug, to alert other caregivers that invasive procedures could lead to blood loss.
• Use compression dressings over areas that could bleed.
• Check all drugs and supplements the patient is taking for their potential to alter coagulation, which could lead to more bleeding
• At least once during each shift, assess patients carefully for signs and symptoms of bleeding.
• Evaluate clotting-test results to help determine the drug’s therapeutic dosage, if appropriate.
• To help prevent or check for possible interactions, ask patients about all drugs, herbs, and other supplements they’re taking.

Cardiac Catheterization

Cardiac catheterization is a medical procedure that cardiologists, or heart specialists, use to evaluate heart function and diagnose cardiovascular conditions.

During cardiac catheterization, a long narrow tube called a catheter is inserted into an artery or vein in your groin, neck, or arm. This catheter is threaded through your blood vessel until it reaches your heart. Once the catheter is in place, your doctor can use it to run diagnostic tests. For example, a dye can be injected through the catheter that allows your doctor to look at the vessels and chambers of the heart with the use of a special X-ray machine.

Cardiac catheterization is performed in a hospital by a cardiologist and a team of doctors, nurses, technicians, and other medical professionals.

Why is cardiac catheterization needed?

Your doctor may ask you to undergo cardiac catheterization to diagnose a heart problem or to determine a potential cause of chest pain.

During the procedure, your doctor can:

• confirm the presence of a congenital heart defect (a defect present at birth)
• check for narrow or blocked blood vessels that could cause chest pain
• look for problems with your heart’s valves
• measure the amount of oxygen in your heart (hemodynamic assessment)
• measure the pressure inside your heart
• perform a tissue biopsy from your heart
• evaluate and determine the need for further treatment

How to prepare for cardiac catheterization

Your doctor will let you know if you can eat or drink before the procedure. In most cases, you won’t be able to have any food or drink starting at midnight the day of your procedure. Having food and liquid in your stomach during the procedure can increase your risk of complications. You might need to reschedule if you weren’t able to fast. Also, ask your doctor before taking any medications before the procedure.

Before the catheterization begins, you’ll be asked to undress and put on a hospital gown. You’ll then lie down and a nurse will begin an intravenous (IV) line. The IV, which is usually placed in your arm or hand, will deliver medication and fluids to you before, during, and after the procedure.

A nurse may need to shave the hair from around the catheter insertion site. You may also receive an injection of an anesthetic to help numb the area before the catheter is inserted.

What are the stages of the procedure?

The catheter is guided by a short, hollow, plastic cover called a sheath. Once a catheter is in place, your doctor will proceed with the tests needed to diagnose your condition.

Depending on what they’re looking for, your doctor may perform one of the following procedures:

Coronary Angiogram. In this procedure, contrast material or dye is injected through the catheter. Your doctor will use an X-ray machine to watch the dye as it travels through your arteries, heart’s chambers, valves, and vessels to check for blockages or narrowing in your arteries.

Heart biopsy. In this procedure, your doctor will take a sample of heart tissue (biopsy) for further testing.

Your doctor may perform an additional procedure if they discover a potentially life-threatening problem during the catheterization. These procedures include:

Ablation. This procedure corrects heart arrhythmia (irregular heartbeat). Doctors use energy in the form of heat (radio-frequency energy) or cold (nitrous oxide or laser) to destroy heart tissue and stop the irregular heart rhythm.

Angioplasty. During this procedure, doctors insert a tiny inflatable balloon into the artery. The balloon is then expanded to help widen a narrowed or blocked artery. Angioplasty may be combined with a stent placement — a small metal coil that is placed in the blocked or clogged artery to help prevent any future narrowing problems.

Balloon valvuloplasty. In this procedure, doctors inflate a balloon-tipped catheter into narrowed heart valves to help open the restricted space.

Thrombectomy (blood clot treatment). Doctors use a catheter in this procedure to remove blood clots that could potentially dislodge and travel to organs or tissue.

You’ll be sedated during a catheterization, but you’ll remain alert enough to respond to instructions from doctors and nurses.

During the catheterization, you may be asked to:

• hold your breath
• take deep breaths
• cough
• place your arms at various positions

This will help your healthcare team get a better image of your heart and arteries.

What are the benefits of the procedure?

Cardiac catheterization can help your doctor diagnose and treat problems that might otherwise cause larger issues, such as a heart attack or stroke. You may be able to prevent a heart attack or stop a future stroke if your doctor is able to correct any problems discovered during the procedure.

What are the risks of the treatment?

Any procedure that involves your heart comes with a particular set of risks. Cardiac catheterization is considered relatively low risk, and very few people have any problems. The risks of complications, though rare, are higher if you have diabetes or kidney disease, or if you’re 75 years or older.

The risks associated with catheterization include:

• an allergic reaction to the contrast material or medications used during the procedure
• bleeding, infection, and bruising at the catheter insertion site
• blood clots, which may trigger a heart attack, stroke, or another serious problem
• damage to the artery where the catheter was inserted or damage to the arteries as the catheter travels through your body
• irregular heart rhythm (arrhythmias)
• kidney damage caused by the contrast material
• low blood pressure
• torn heart tissue

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Cardiology — The Importance of Heart Diagnostic

Cardiovascular disease is among the principal causes of death in many countries. Besides the general practitioner, the cardiologist follows certain patients called at risk. Based on increasingly precise examinations and an increasingly effective therapeutic arsenal, this specialist takes your health very seriously. Cardiology involves the study of the functioning of the cardiovascular system (heart and vessels) and the diseases that affect it.

There are many cardiovascular diseases. Without claiming to be exhaustive, the following may be mentioned — hypercholesterolemia, heart failure, arterial hypertension, myocardial infarction, pericarditis, endocarditis, pulmonary embolism, rhythm disorders. After consulting your general practitioner, the latter may be able to refer you to a heart specialist Boynton Beach.

Elderly people, smokers or people with hypertension, hypercholesterolemia and diabetes are more likely than others to have heart disease. Sedentariness and overweight are also on the list of risk factors, as well as a family history of cholesterol or myocardial infarction. It is important to identify who in your family was affected by a cardiovascular event, be it cardiac or cerebral (stroke) and at what age.

Through electrocardiogram, the heart specialist Boynton Beach has an electrical image of the heart and possibly detects troubles of his rhythm (arrhythmia) or the trace of an old infarction. It can also test the patient’s health through physical.

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Simple Exercise to Avoid Heart Attack

Maintaining ideal body weight and managing cholesterol levels is crucial to avoid the heart attack. Research suggests that 30 minutes of routine exercise regime can help in avoiding a heart attack. Exercise also reduces stress levels and thus makes your heart healthier and happier. Here we provide you with an easy exercise routine to avoid a heart attack.

Aerobic exercise:

A combined research by Harvard and Stanford University suggest that aerobic exercises are equally effective in preventing heart attacks as expensive medications like statins, beta-blockers, diuretics, and anti-platelet drugs. 30 minutes of aerobic exercise like jogging, walking, swimming, and cardio-workouts helps to burn 300, 180, 360, and 370 kcal respectively. One’s goal must be to burn at least 500-600 calories using different forms of exercises. Exercise not only helps to maintain proper body weight but also reduces the risk of heart attack by controlling blood pressure, diabetes, and stress.

Yoga:

Yoga exercise is often ignored, but they are indeed a real need for today’s world. It is suggested that 15-20 minutes of yoga and pranayama following the aerobic exercise increases the effectiveness of the workout and also relaxes the body. 5 minutes of pranayama and the 5 minutes of Anulom-Vilom breathing exercise are greatly helpful in reducing the blockage in the blood vessels of the heart and improves oxygen supply to it. However, the patient with serious heart ailments and history of heart surgery must perform the exercise slowly and must avoid overdoing it. 10 Surya-Namaskar a day is also recommended for those having high cholesterol levels and obesity.

Link: https://heartcongress.pulsusconference.com/

5 Foods That Will Help Prevent Heart Diseases

1. Green vegetables: 

Vegetables have low fat and calories but are rich in fiber, vitamins and minerals. Your diet should include dark, green, fresh and leafy vegetables to control your weight and blood pressure. Asparagus, Swiss chard, kale, spinach and kale, have vitamins A, C, E and K in abundance and contain certain antioxidants that help you get of rid toxins from the body. Additionally, calcium, magnesium and potassium in the greens put them on the top of the list for heart health.

2. Potatoes: 

There is no reason as to why potatoes are slammed, ridiculed and criticized. As long as they are not deep fried, potatoes can be good for maintaining a healthy heart. They are rich in calcium, carbohydrates, starch and potassium, which can help lower blood pressure. They are also fiber-rich, which again is associated with reduced risk for heart disease.

3. Citrus fruits: 

Citrus fruits like oranges are high in vitamin C and flavonoids. Therefore, they have been linked to reducing the risk of heart disease. But you should not include citrus fruit juices in your diet as they contain added sugar which may lead to weight gain and an unhealthy heart.

4. Nuts: 

Almonds, walnuts, cashews and pistachios are all good for a healthy heart. They have proteins, healthy fats and fiber. You can snack on some unsalted raw nuts, add them into your smoothies or nut butter. Simply having a few nuts in the morning breakfast can also do wonders for your heart health.

5. Dark chocolate:

 Not all chocolates but only dark chocolate can be beneficial for a healthy heart. Dark chocolate contains flavonoids called polyphenols, which may help in controlling the blood pressure, inflammation and clotting. Milk chocolates and many candy bars are not a great option to protect your heart.