SL.

N
O
TIME SPECIFIC
OBJECTIVE
CONTENT A.V
AIDS
TEACHERS
ACTIVITY
LEARNERS
ACTIVITY
EVALUAT
-ION
1





2















2 min





2min





















The students
will be able
to say the
meaning of
the important
terminologies










INTRODUCTION:
Cardiovascular disease is the major cause of death in the world
Coronary artery disease develops coronary arteries the major
blood vessels that supply heart with blood, oxygen and nutrients
become damaged or diseased
Terminologies
ATHEROSCLEROSIS:
It is an abnormal deposition of lipid or fatty substances
and fibrous tissue in vessel wall which creates blockage or
narrowing of vessel
ATHEROMA: fatty deposits
ISCHEMIA:
When blood flow through coronary artery is partially or
completely blocked ,results in insufficient oxygen is
supplied to meet the requirements of myocardium
INFARCTION:
It occurs when severe ischemia is prolonged and
irreversible damage to tissue results
ANGINA PECTORIS:
It is a pain in the chest in the heart , when a temporary
Introduces
the topic and
evaluates the
previous
knowledge
on the topic


Lists down
and explains
the
terminologies










Guesses the
topic






Listens and
takes notes




















What is the
meaning of
atherosclero
sis ?

















3























10min























The students
will be able
to recall the
anatomy and
physiology of
heart











imbalance between coronary arteries ability to supply
oxygen and cardiac muscle demand for oxygen occurs
ACUTE CORONARY SYNDROME:
It is a atherosclerotic plaque in coronary artery
ruptures , resulting in platelet aggregation ,thrombus
formation and vaso constriction .amount of disruption
determines the degree of obstruction of coronary artery
ANATOMY AND PHYSIOLOGY
CORONARY CIRCULATION
Heart is supplied by TWO CORONARY arteries:
1- Right coronary artery---(RCA)
2- Left coronary artery---(LCA)
These coronary arteries arise at the root of the aorta.
Coronary artery & their branches
LCA---- -Lt Anterior Descending (LAD)
-Marginal Artery
-Circumflex Artery
RCA ---- -Marginal Artery
-Posterior descending branch
Left coronary artery (LCA) Divides in
Anterior Descending (LAD)
Circumflex artery
LAD--- Supplies anterior and apical parts of heart ,and
Anterior 2/3
rd
of interventricular septum.







Explains the
coronary
circulation





















Listens
,discussion
and taking
note




















Explain the
coronary
circulation?






















4























2 min























The students
will be able
to justify the
significance
upon the 70%
coronary
blood flow









Circumflex branch-- supplies the lateral and posterior
surface of heart.
Right coronary artery(RCA) supplies:
Right ventricle
Part of interventricular septum (posterior 1/3
rd
)
Inferior part of left ventricle
AV Node
CORONARY BLOOD FLOW
Coronary blood flow in Humans at rest is about 225-250
ml/minute, about 5% of cardiac output.At rest, the heart extracts
60-70% of oxygen from each unit of blood delivered to heart
[other tissue extract only 25% of O
2
.
Why heart is extracting 60-70% of O
2
?
It is Because heart muscle has more mitochondria, up to 40% of
cell is occupied by mitochondria, which generate energy for
contraction by aerobic metabolism, therefore, heart needs O
2
.
When more oxygen is needed e.g. exercise, O
2
can be increased to
heart only by increasing blood flow.
B Bl lo oo od d f fl lo ow w t to o H He ea ar rt t d du ur ri in ng g S Sy ys st to ol le e & & D Di ia as st to ol le e
During systole when heart muscle contracts it compresses the
coronary arteries therefore blood flow is less to the left ventricle
during systole and more during diastole.
To the subendocardial portion of Left ventricle it occurs only
during diastole Phasic changes in coronary blood flow










Teaches the
coronary
blood flow





















Listens and
clarifies
doubts





















Why
coronary
blood flow
is more?




















































































Effect of cardiac muscle contraction
Coronary blood flow to the right side is not much affected during
systole.
Reason---Pressure difference between aorta and right
ventricle is greater during systole than during diastole,
therefore more blood flow to right ventricle occurs during
systole.
Factors Affecting Blood Flow to CORONARY ARTERIES
-Pressure in aorta
-Chemical factors
-Neural factors
NOTECoronary blood flow shows considerable
Autoregulation.
Chemical factors affecting Coronary blood flow
Chemical factors causing Coronary vasodilatation (Increased
coronary blood flow)
NOTE Adenosine, which is formed from ATP during
cardiac metabolic activity, causes coronary vasodilatation.
Neural factors affecting Coronary Blood Flow
-Effect of Sympathetic stimulation
-Effect of Parasympathetic stimulation
Sympathetic stimulation
Coronary arteries have
Alpha Adrenergic receptors which mediate vasoconstriction
Beta Adrenergic receptors which mediate vasodilatation













































































5




6






7











1 min




1 min






5 min











The students
will be able
to define
CAD

The students
will be able
to enumerate
the incidence
rate of CAD


The students
will be able
to explain the
hypothesis
behind the
CAD



Effect of Parasympathetic stimulation
-Vagus nerve stimulation (Parasympathetic) causes
coronary vasodilatation
CORONARY ARTERY DISEASE
Definition
Coronary artery disease (CAD) is characterized by
atherosclerosis in the epicardial coronary arteries,progressively
narrow the coronary artery lumen and impair antegrade
myocardial blood flow.
Incidence
Declines over the past 10 yrs
75% men are affected when compared to women
1 in 25 sec get an attack in the world
App 70 lakh people get debilitated and 1 million are
affected every year in india
Higher in south india
India has the highest number of death in the world due to
CAD 1.5million- 2002

CAD-HYPOTHESIS
1)The lipid hypothesis
The elevation in lipid plasma levels promotes lipid penetration of
arterial walls
-Low-density lipoproteins (LDLs) are the primary atherogenic
lipid, whereas high-density lipoproteins (HDLs) have a protective
effect and probably help mobilize LDLs.
-When LDLs undergo oxidation in the body, they become harder
to mobilize and locally cytotoxic.
2) chronic endothelial injury hypothesis
-The initial step in the formation of atherosclerosis is a
weakening of the arterial glycosaminoglycans (GAGs) layer.



Defines the
CAD



Explains the
incidence






Lecture on
hypothesis









Listens




Listening







Listens and
discusses









Define
CAD?



Say the
incidence
rate of
CAD?




Explain the
CAD-
Hypothesis?









8























5 min























The students
will be able
to enlist and
explain the
causes of
CAD














-GAGs protect the internal lining of the artery (the endothelium)
and promote its repair.
-The exposed endothelial cells of the artery are subject to, free-
radical damage
CAUSES
The damage may be caused by various factors, including:
Smoking
High blood pressure
High cholesterol
Diabetes or insulin resistance
Radiation therapy to the chest, as used for certain types of
cancer
Sedentary lifestyle
Smoking
Cigs contain about 2000 compounds
Main harmful are tar, nicotine and CO
Tar contains hydrocarbons and other carcinogenic
substances
Nicotine causes release of epinephrine and nor epinephrine
resulting in increased HR, BP, cardiac output, stroke volume,
contractility, oxygen consumption, and coronary blood flow
CO reduces oxygen carrying capacity of the blood; can
precipitate angina
Contributes to development of atherosclerosis
Lowers levels of HDL
causes deterioration of elasticity of vessels
Responsible for 20% of all deaths from heart disease
Female smokers have a higher risk than male smokers





Explains the
causes
elaborately





















Takes notes
and clarifies
doubts





















List and
explain the
cause of
CAD?































9























2 min























The students
will be able
to Recognise
the risk
factors of
CAD



POSSIBLE FACTORS
Sleep apnea.. Sudden drops in blood oxygen levels that
occur during sleep apnea increase blood pressure and strain the
cardiovascular system, possibly leading to coronary artery
disease.
C-reactive protein. C-reactive protein (CRP) is a normal
protein that appears in higher amounts when there's swelling
somewhere in your body
High triglycerides. This is a type of fat (lipid) in our blood.
High levels may raise the risk of coronary artery disease,
especially for women.
Homocysteine. Homocysteine is an amino acid our body
uses to make protein and to build and maintain tissue.
Lipoprotein (a). This substance forms when a low-density
lipoprotein (LDL) particle attaches to a specific protein.
Lipoprotein (a) may disrupt your body's ability to dissolve
blood clots.
RISK FACTORS
Controllable:
Smoking- increases risk 2-4x
High blood pressure
Diabetes
Lack of exercise
Stress
Obesity
Elevated Cholesterol
Uncontrollable:
Age- 83% are >65yo
Family history















Lists down
the possible
risk factors





















Lists down
the risk
factors based
on previous
knowledge



















List the risk
factors of
CAD









10























10 min























The students
will be able
to elaborate
the
pathophysiol
ogy of CAD















Gender- males are higher risk than females, and have
earlier onset of disease
Race- African Americans have a greater risk
PATHOPHYSIOLOGY
Atherosclerosis deposit in intima layer

Inflammatory response begins to injure vascular endothelium

Monocyte ingest lipids

Release biochemical substances

Further damage endothelium, attract platelet- intiate clotting

ATHEROMA formation

Protrude lumen

Collagen and elastic fibers form

Rupture Necrotic hemorrhagic calcified




Picturises the
pathophysiol
ogy





















Listens and
taking notes






















Explain the
pathophysio
logy of
CAD in
detail
























































































Thrombus formation

Infarction

Necrosis

MI/Angina
PROGRESSION OF ATHEROSCLEROSIS/
DEVELOPMENTAL STAGE
FATTY STREAK:
Injury of endothelial lining
Lipid filled smooth muscle cells
Yellow tinge appears
FIBROUS PLAGUE
Progressive changes in the endothelium of the arterial wall
Muscle proliferation and thickening of the arterial wall
Appears grayish or whitish
Circular fashion involve entire lumen
Narrowing of vessel lumen

COLLATERAL CIRCULATION











































































11











12











5 min











7 min











The students
will be able
to list the
types of CAD








The students
will be able
to recognise
the clinical
manifestation
of CAD




TYPES OF CAD
Acute Coronary Syndromes
Advanced Ischemic Heart Disease
Bifurcation Blockage
Fatty build-up is more likely to occur in the Y-
junction where vessels branch off from the main coronary artery
because of changes in blood flow. Narrowing in this region is
called bifurcation blockage, and it is treated using special
techniques to prop up the vessel.
Heart Attack (Myocardial Infarction)
Myo means muscle and cardial refers to the heart.
Infarction means death of tissue due to lack of blood supply. Heart
attack is myocardial infarction, and it causes permanent damage to
the heart muscle
CLINICAL MANIFESTATION
Pain severe ,immobilizing chest pain not relieved by rest
, position change,Heaviness, pressure ,tightness,
burning,constriction or crushing.
Locations substernal, retrosternal, or epigastric areas
Radiate neck ,jaw and arms or to the back is active at rest
,sleep or awake.
P-Q-R-S-T-A-A-A
P precipitating factor
Quality - dull/squeezing/ tightening/strangling
/constricting
Region radiation
changing
right arm/left arm


Lists down
the types of
CAD








Explains the
clinical
manifestation










Listening










Listens and
discuss











List the
types of
CAD








What the
clinical
manifestatio
ns of
patients
with CAD























13























10 min























The students
will be able
to expand the
diagnostic
study

Severity/Setting
rest vs exertion
after meals
scale of pain
Time (frequency and duration)
sudden/gradual onset
Alleviators
Position
Aggravators
food/position/exertion/people
constant/episodic
Associated Symptoms
SOB, cough, temp, nausea, diarrhea
Dyspnea
Confusion
Shortness of breath
Pulmonary edema
Dizziness
Dysrhyhthmia
DIAGNOSTIC STUDY
History
comorbid conditions.
cardiac risk factors, and a complete family history are
essential components.
The history should also include information about the
character and location of discomfort, radiation of discomfort,
associated symptoms
precipitating, exacerbating, or alleviating factors. The
importance of the family history should not be underestimated.


















Lecture cum
discussion






















Discussion























What are
the
diagnostic
studies for
CAD









































































Physical Examination

Dyspnoea
Palpitation
Fat globules presence in body
xanthalasma
Assessment of the abdominal aorta for an aneurysm or
bruits and palpation of lower extremity pulses is necessary to
evaluate for peripheral vascular disease.
Careful palpation of all peripheral pulses and assessment
of symmetry versus diminution are also valuable noninvasive
approaches for assessing the integrity of the arterial
circulation.
Finally, examination for xanthelasmas, tendon xanthomas,
retinal arterial abnormalities, and peripheral neuropathy can be
helpful.
Electrocardiography
When abnormal, especially when Q waves are present in a
regional myocardial territory of diagnostic duration can
signify the presence of a past MI with high accuracy.
Chest Radiography
Cardiac Computed Tomography Angiography
Echocardiography
Laboratory Studies

Fasting glucose and fasting lipid levels (total cholesterol,
high-density lipoprotein [HDL] cholesterol,
triglycerides, and
calculated low-density lipoprotein [LDL] levels).
















































































































































Other markers such as lipoprotein(a) (Lp[a]) and
high-sensitivity C-reactive protein, may be useful in
assessing cardiac risk in assessing the inflammatory level of
vascular disease and predicting future risk of vascular events,
such as MIs and cerebrovascular accidents.
Treadmill Scoring System*
Risk Group Annual Mortality Rate
Low (>4) 0.25%
Intermediate (-10-4) 1.25%
High (>-10) 5.0%
Coronary Arteriography
Cardiac catheterization remains the gold standard for determining
the presence of obstructive CAD. A cardiac catheterization yields
a 2-dimensional rendering of the coronary artery circulation.
Emergent PCI :
It is recommended as the first line of treatment for patients with
confirmed MI
Patient will have a cardiac catheterisation to locate the
blockage ,determine the presence of collateral circulation
and evaluate left ventricular function
Usually PCI with the placement of drug eluting stent will be
performed
Advantages
It provides an alternative to surgical intervention
It is performed with local anesthesia
The patient is ambulatory after 24 hrs after the procedure.
Complication of PCI:
Coronary artery could rupture
Cardiac tamponade












































































14







15 min























The students
will be able
to explain the
management
of CAD















Ischaemia and infarction
Decreased CO
Death
General Therapy
MONA
Morphine (q 5-15 min CLASS I)
Oxygen (pulse ox>90% CLASS I)
Nitroglycerin (0.4 mg SL NTG x 3 for ischemic
pain CLASS I)
Aspirin
Drug Therapy
Nitroglycerin
Aspirin
-Blocker
Anticoagulants
IV antiplatelet agent (glycoprotein IIb /IIIa inhibitor)
Calcium channel blockers
Cholesterol lowering drugs
Early Hospital Care
Anti-Ischemic Therapy
Class I
Bed/Chair rest and Telemetry
Oxygen (maintain saturation >90%)
Nitrates (SLx3 Oral/topical. IV for ongoing iscemia, heart
failure, hypertension)
Oral B-blockers in First 24-hours if no contraindications.
(IV B-blockers class IIa indication)
Non-dihydropyridine Ca-channel blockers for those with
contraindication fo B-blockers




Explains the
care of
clients with
CAD
ellaborately



















Listens,discu
sses,takes
notes and
clarifies
doubts



















Explain the
managemen
t of clients
with CAD










































ACE inhibitors in first 24-hours for heart failure or
EF<40% (Class IIa for all other pts) (ARBs for those
intolerant)
Statins
Early Hospital Care
Anti-Platelet Therapy
Class I
Aspirin (162-325 mg), non enteric coated
Clopidogrel for those with Aspirin allergy/intolerance
(300-600 mg load and 75 mg/d)
GI prophylaxis if a Hx of GI bleed
GP IIb/IIIa inhibitors should be evaluated based on
whether an invasive or conservative strategy is used
GP IIb/IIIa inhibitors recommended for all diabetics and
all patient in early invasive arm
Early Hospital Care
Statin Therapy

3086 patients with Non ST ACS
Total cholesterol <270 mg/dl
No planned PCI
Randomized to Atorvastatin vs Placebo
Drug started at 24-96 hours
Surgery and other procedures
Angioplasty and stenting.
A wire with a deflated balloon is passed through the
catheter to the narrowed area. The balloon is then inflated,
compressing the deposits against your artery walls. A mesh



















































































tube (stent) is usually left in the artery to help keep the artery
open.

Aspirin. Aspirin decreases blood clotting, helping to keep
blood flowing through narrowed heart arteries.
Thrombolytics. These drugs, also called clotbusters, help
dissolve a blood clot that's blocking blood flow to your heart.
Nitroglycerin. coronary and peripheral
vasodilatorvasodilator
Beta blockers. relax your heart muscle, slow your heart
rate and decrease your blood pressure, which decreases the
demand on your heart.
Angiotensin-converting enzyme (ACE) inhibitors and
angiotensin receptor blockers (ARBs). lower blood pressure
Calcium channel blockers. relax the heart and allow
more blood to flow to and from the heart.
Cholesterol-lowering drugs. Commonly used drugs
known as statins can lower your cholesterol levels, making
plaque deposits less likely, and they can stabilize plaque,
making it less likely to rupture.
Clot-preventing drugs. Medications such as clopidogrel
(Plavix) and prasugrel (Effient) can help prevent blood clots
from forming by making your blood platelets less likely to
stick together.
SURGERY
i)Coronary bypass surgery
This procedure creates an alternative route for blood to go around
a blocked coronary artery.
ii)Minimally invasive Direct coronary artery Bypass
iii)off pump coronary artery Bypass
vi)Transmyocardial LASER revascularisation



























JOURNAL REFERENCE
Plasma Homocysteine Levels and Mortality in Patients
with Coronary Artery Disease
Elevated plasma homocysteine levels are a risk factor for
coronary heart disease, but the prognostic value of
homocysteine levels in patients with established coronary
artery disease has not been defined.
CONCLUSIONS
Plasma total homocysteine levels are a strong predictor of
mortality in patients with angiographically confirmed coronary
artery disease
REFERENCE

www.nlm.nih.gov/medlineplus/coronaryarterydisease.htm
https://www.nhlbi.nih.gov/health/health-topics/topics/cad/
www.mayoclinic.org/diseases.../coronary-artery-disease/..
my.clevelandclinic.org/heart/disorders/cad/understanding
cad.aspx
www.heartandstroke.com Heart Disease Heart Disease
Conditions
en.wikipedia.org/wiki/Coronary_artery_disease

APOLLO COLLEGE OF NURSING
TEACHING PRACTISE
ON
CORONARY ARTERY DISEASE

SUBMITTED TO: Prof.Lizy Sonia
Vice principal
Submitted by: ms.anusarannya
m.sc(n)ii year
submitted on:
20.09.2014
GENERAL OBJECTIVES:
At the end of the session the students will be able to get adequate knowledge on the disease condition coronary artery disease
and will be prepared to diagnose and care the coronary artery disease clients accordingly
SPECIFIC OBJECTIVES:
The students will be able to
say the meaning of the important terminologies
recall the anatomy and physiology of heart
justify the significance upon the 70% coronary blood flow
define CAD
enumerate the incidence rate of CAD
explain the hypothesis behind the CAD
enlist and explain the causes of CAD
Recognise the risk factors of CAD
elaborate the pathophysiology of CAD
list the types of CAD
recognise the clinical manifestation of CAD
expand the diagnostic study

explain the management of CAD


NAME OF THE STUDENT: MS.ANU SARANNYA
NAME OF THE SUBJECT: MEDICAL SURGICAL NURSING
TOPIC: CORONARY ARTERY DISEASE
CLASS GROUP: B.SC(N) II YEAR
PREVIOUS KNOWLEDGE OF STUDENT: B.SC(N) I YEAR ANATOMY AND PHYSIOLOGY
DATE/TIME: 20.09.2014
VENUE: APOLLO COLLEGE OF NURSING, SEMINAR HALL