Coronary artery disease (CAD) and angina pectoris: Nursing process (ADPIE)

Dwayne Harris is a 52 year old African American male client presenting to the cardiac catheterization lab to undergo a percutaneous coronary intervention, also known as PCI.

Mr. Harris has a diagnosis of coronary artery disease, chronic stable angina, hyperlipidemia, and is a current smoker with a 20 pack year history.

Because his angina is no longer responding to treatment, his cardiologist recommended PCI for Mr. Harris.

Coronary artery disease, or CAD, is the narrowing or obstruction of coronary arteries.

This narrowing is caused by atherosclerosis, a lipid containing plaque that accumulates on artery walls.

Over time, the plaque build up reduces myocardial perfusion and causes ischemia as the demand for oxygen exceeds the supply.

Myocardial ischemia leads to a type of chest pain called angina, which can be either stable or unstable.

Stable angina usually occurs when atherosclerotic plaque is fixed to the artery wall and occludes at least 75 percent of the coronary artery, whereas with unstable angina, the plaque ruptures and almost completely occludes the artery lumen.

The clinical presentation helps to differentiate stable and unstable angina using the acronym OPQRST.

O stands for onset, which for stable angina is during activity or emotional stress, due to increased oxygen demand, whereas for unstable angina, onset can be sudden or even at rest.

P is for palliation. Stable angina is relieved by re st or vasodilators like nitroglycerin, whereas unstable angina is not relieved.

Q stands for the quality of pain, which often involves pressure, crushing, squeezing, or tightness. Pain is more severe with unstable angina.

R stands for radiation of pain, because it often radiates to the shoulders, arms, jaw, neck, or back.

S is for site, which is deep, substernal, and sometimes hard to localize, meaning the client is unable to point to the site of pain with a single finger.

T stands for time. With stable angina, pain can last 15 seconds to 15 minutes, whereas in unstable angina, the pain will last longer than 20 minutes.

Besides causing angina, the myocardial oxygen supply and demand imbalance from CAD can also lead to dyspnea, diaphoresis, palpitations, dizziness, pallor, and digestive disturbances.

Now, there are several non-modifiable and modifiable risk factors contributing to CAD and its complications.

Advanced age is the greatest risk factor, with men over 45 and women over 55 years of age being at most risk.

Other non-modifiable risk factors include biological male sex, family history of hypercholesterolemia, and belonging to African American, Native American, Native Hawaiian, and South Asian demographic groups.

Modifiable risk factors include smoking tobacco, hypertension, dyslipidemia, diabetes mellitus, obesity, and physical inactivity.

Psychosocial factors, such as stress and depression can be risk factors for CAD too, due to their association with factors like smoking, physical inactivity, and obesity as well as their association with elevated systemic inflammation which contributes to atherosclerosis.

OK, treating CAD centers around lifestyle modifications, medication management and, if needed, coronary revascularization procedures.

Lifestyle modifications involve controlling modifiable risk factors.

Several medications are used to treat CAD as well.

Nitrates, like nitroglycerin, and calcium channel blockers, such as amlodipine, work by dilating coronary arteries.

Beta blockers like propranolol reduce myocardial oxygen demand by decreasing heart rate and contractility.

Antiplatelet medications, like aspirin, are used to reduce platelet aggregation in coronary arteries.

Cholesterol lowering medications are prescribed to reduce atheroscleoritc plaque formation, including statins like atorvastatin, fibric acid derivatives such as fenofibrate, omega 3 fatty acids, bile acid sequestrants like colestipol, cholesterol absorption inhibitors such as ezetimibe, and PCSK9 inhibitors like evolocumab.

If stable angina isn’t effectively treated by lifestyle modifications and medication therapy, coronary revascularization procedures may be necessary.

PCI is a minimally invasive procedure that involves inserting a catheter through the radial or femoral artery and injecting contrast dye to locate the blockage.

After the blockage is located, a tiny balloon is inserted in the obstructed coronary artery to compress plaque against the artery wall.

If needed, a stent can be placed during PCI to keep the artery patent.

Alternatively, atherectomy devices are used to remove the plaque.

Coronary bypass grafting, or CABG, can be done instead of PCI.

This is a major surgical procedure that involves using a vein or artery from elsewhere in the body to bypass the blockage and improve myocardial blood flow.

OK, let’s get back to Mr. Harris and begin his assessment.

You introduce yourself, perform hand hygiene, and confirm his identity.

After asking if he feels ready for his procedure, he says he is anxious but hopeful it will help him have less chest pain when taking his daily walks.

Your assessment reveals warm, dry, intact skin with good turgor.

His oral temperature is 97.8°F, or 36.6°C.

Lungs are clear with a respiratory rate of 18 breaths per minute and SpO2 is 98% on room air.

Heart sounds are normal, and he has a regular heart rate of 76 beats per minute and blood pressure of 128/76 mmHg.

Bowel sounds are active, and Mr. Harris confirms he hasn’t had anything to eat or drink since midnight.