Coronary Vascular Disorders — Master Notes

What is it?

Chronic, progressive accumulation of lipids and fibrous tissue within arterial walls leading to plaque formation, luminal narrowing, and reduced coronary blood flow — causing ischemia and potential infarction.

What does it look like?

• Often asymptomatic for years.
• Exertional chest discomfort (angina), dyspnea on exertion, fatigue.
• Atypical: back or epigastric pain, indigestion, jaw/arm pain, or “silent ischemia” (especially in women/older adults).

Diagnosis

• Risk: Framingham calculator (age, BP, lipids, smoking, DM, meds).
• Labs: fasting lipid panel, A1C, hs-CRP.
• 12-lead ECG (may be normal between episodes).
• Echocardiogram for structure and EF; stress testing if symptoms suggestive.

Treatment & Management

• Lifestyle: heart-healthy diet, exercise ≥150 min/wk, weight reduction, smoking cessation.
• Lipids: statins (cornerstone). Monitor LFTs; report myalgia. Other options: ezetimibe, PCSK9 inhibitors, fibrates, niacin, bile-acid resins, omega-3s.
• Risk control: manage HTN, DM, obesity; med adherence.
• Antiplatelet: aspirin per provider if appropriate.

Nursing Priorities

• Teach risk-factor modification, medication adherence, symptom recognition (especially atypical).
• Reinforce safe exercise targets and when to stop activity.

What is it?

Chest discomfort due to transient myocardial ischemia without necrosis.

• Stable: predictable with exertion/emotion; relieved by rest or nitroglycerin.
• Unstable (UA): new-onset, increasing, or at rest; not relieved by rest/nitro — medical emergency.

What does it look like?

• Pressure/heaviness/tightness; may radiate to left arm, jaw, or back; ± dyspnea, diaphoresis, nausea.
• Women/older adults: back or epigastric pain, fatigue.
• Use PQRST assessment; duration matters.

Diagnosis

• 12-lead ECG during pain: ST depression ± T-wave inversion; normalizes after relief.
• Cardiac biomarkers: normal (rules out MI).
• Stress testing (exercise/pharmacologic) or Holter monitor.
• Coronary angiography to define lesions if intervention considered.

Treatment & Management

• Chemical: SL nitroglycerin (1 tab q5 min × 3; check BP before each). Long-acting nitrates, β-blockers, or CCBs for chronic control. Aspirin ± clopidogrel. Lipid management per CAD.
• Electrical: Treat arrhythmias if present per ACLS.
• Procedural: PCI or CABG for refractory/high-risk disease.
• Nursing: Stop activity; semi-Fowler’s; vitals; ECG; oxygen if hypoxic; nitro after BP check; reassess pain; reduce anxiety; educate on when to seek care.

What is it?

Spectrum of acute ischemia: UA (no biomarkers), NSTEMI (↑ troponin, no ST elevation), STEMI (ST elevation + troponin ↑ → transmural infarction).

What does it look like?

• Persistent chest pain > 20 min, crushing/pressure, radiating to arm/jaw/back; dyspnea, diaphoresis, N/V, anxiety, sense of doom.
• Atypical presentations frequent in women/older adults.

Diagnosis

• Immediate 12-lead ECG (repeat serially).
• STEMI: ST elevation in contiguous leads. NSTEMI/UA: ST depression or T-wave inversion.
• Lead localization: II, III, aVF = inferior; V1–V2 = septal; V3–V4 = anterior; V5–V6, I, aVL = lateral.
• Biomarkers: troponin I/T ↑ (specific), ± CK-MB, myoglobin (early).
• Labs: CBC, electrolytes, renal, glucose, lipids, CRP.
• Echo: wall motion, EF; CXR to rule out other causes.

Treatment & Management

• Immediate:
  • Aspirin (chew immediately).
  • Nitroglycerin if BP adequate (avoid if hypotensive).
  • Morphine if pain persists after nitrates.
  • O₂ only if SpO₂ < 90% or distress.
  • Early β-blocker (if no contraindications).
  • Heparin/anticoagulation and P2Y12 inhibitor (if PCI planned).
  • High-intensity statin.
• Reperfusion: STEMI → PCI (door-to-balloon ≤ 90 min) or fibrinolytics if delay. NSTEMI/UA → antithrombotics + early invasive evaluation.
• Electrical: Defibrillate VF/pulseless VT; synchronized cardioversion for unstable tachy; temporary pacing for high-grade block.
• Procedural: PCI + stent (DAPT ≥ 6–12 mo); CABG for left-main/multivessel/failed PCI.
• Nursing: Rapid assessment, ECG, IVs, draw serial troponins, telemetry, prep for cath lab, verify BP before nitro, semi-Fowler’s, calm reassurance, patient education.

What is it?

Coronary angiography using contrast via radial or femoral access for diagnosis or PCI intervention.

Pre-Procedure

• Consent; check allergy to contrast.
• Assess renal function; hold metformin per policy (typically 48 h).
• Ensure NPO status, stable vitals, rhythm control.

Post-Procedure

• Hemostasis (TR band/radial or femoral manual compression).
• Monitor bleeding, hematoma, distal pulses, color/temp.
• Hydrate; monitor urine output.
• Telemetry for arrhythmias.
• Educate on DAPT adherence after stent (stent thrombosis prevention).

What is it?

Surgical revascularization using vein or arterial grafts to bypass obstructed coronaries; may use cardiopulmonary bypass.

Post-Op Course

• Midline sternotomy ± leg/arm harvest site; chest tubes; intubated initially; possible inotropes (dopamine/dobutamine).

Complication Monitoring

• Continuous ECG for arrhythmias (VT/VF risk).
• Assess chest tube output and for tamponade (hypotension, JVD, muffled sounds).
• Monitor renal function and wound integrity.

Treatment/Nursing Care

• Pain control, pulmonary hygiene (IS, ambulation), fluid/electrolyte optimization.
• Watch for pericardial effusion/tamponade → prepare for pericardiocentesis.
• Wound care, DVT prophylaxis, patient/family teaching on medication adherence and recovery.

• Arrhythmias: VT/VF → defibrillate; brady/AV block → atropine/pacing.
• Heart Failure/Cardiogenic Shock: hypotension, oliguria, cool skin, pulmonary congestion; treat with O₂/ventilation, inotropes, vasopressors, revascularization.
• Pericardial Syndromes: effusion/tamponade (Beck triad → urgent pericardiocentesis); Dressler = post-MI pericarditis → anti-inflammatories.
• Thromboembolism/DVT: prevent with SCDs, early ambulation, avoid leg crossing, ROM exercises.

• ST elevation = STEMI → urgent reperfusion.
• ST depression/T inversion = ischemia (UA/NSTEMI).

• Nitroglycerin SL: under tongue; don’t swallow; expect tingling. Check BP > 90 mmHg; avoid with PDE-5 inhibitors < 24–48 h.
• Statins: monitor LFTs; report muscle pain/weakness.
• Aspirin/Clopidogrel (DAPT): never stop post-stent without cardiology approval.
• Heparin: monitor for bleeding; assess platelets.
• β-blockers/CCBs: reduce O₂ demand; monitor HR/BP.
• Oxygen: only if hypoxic/distressed.

Acute Chest Pain (Suspected ACS)

• Stop activity; semi-Fowler’s.
• Vitals + SpO₂; 12-lead ECG ASAP.
• IV access; draw biomarkers.
• Aspirin (chew) → nitro if BP OK → morphine if persistent.
• O₂ if SpO₂ < 90% or distress.
• Notify provider/cath lab; telemetry; frequent reassessment.

Post-Cath (Radial/Femoral)

• Site checks q15–30 min; distal pulses, color, temp.
• Monitor for hematoma/bleeding; manage TR band per protocol.
• Hydration, urine output, creatinine review.
• Educate: no heavy lifting; adhere to DAPT and meds.

CABG Post-Op

• Monitor rhythm, hemodynamics, chest tube output.
• Pain control, pulmonary hygiene (IS), early mobility.
• Watch for tamponade; maintain DVT prophylaxis & incision care.

Patient Education

• Recognize atypical symptoms (women/older adults).
• Carry SL nitro and know usage steps.
• Avoid OTC decongestants that raise BP/...BP/HR without provider approval.
• Exercise regularly but avoid extremes of temperature.
• Report increased chest pain, BP out of goal, or medication side effects promptly.
• For diabetes: maintain strict glucose control and monitor BP at home if directed.