medical

1. INSTITUTE OF HEALTH SCIENCE
SHOOL OF NURSING AND MIDWIFERY
DEPARTMENT OF NURSING
SPECIALITY :ADULT HEALTH NURSING (PG)
ADULT HEALTH NURSING II SEMINAR PRESENTATION
TITLE: ISCHEMIC HEART DISEASE
BY: ZEWUDE MULATU
NOVEMBER 2022
NEKEMTE,ETHIOPIA
2/8/2023
by Zewude M 1

2. Ischemic heart disease
Epidemiology
Pathophsiology
Classificaton
Clinical manifestations
Compilications
Diagnosis
Management
2/8/2023
by Zewude M 2

3. Define IHD
Describe pathophysiology of IHD
List classification of IHD
Mention c/m
List diagnosis of IHD
Describe both medical and nursing management of
IHD
2/8/2023
by Zewude M 3
At the end of this session,the
students will be able to:

4. Coronary circulation: is the circulation of blood in the blood vessels of the
heart muscle (myocardium).
Cardiac arteries include
 Left coronary arteries
 Right coronary arteries
 They are the only source of blood supply to the myocardium
As they run on the surface of the heart, they can be called:
 Epicardial coronary arteries
The coronary arteries that run deep within the myocardium are referred to as :
 Subendocardial
2/8/2023
by Zewude M 4

5. 2/8/2023
by Zewude M 5

6. 2/8/2023
by Zewude M 6

7. Ischemia is defined as inadequate blood supply (circulation) to a
local area due to blockage of the blood vessels supplying the area.
Ischemic means that an organ (e.g.the heart) is not getting
enough blood and oxygen.
Principal component of cardiovascular diseases (CVD)
Ischemic heart disease (IHD) describes a group of clinical
syndromes characterized by myocardial ischemia, an imbalance
between myocardial blood supply and demand.
2/8/2023
by Zewude M 7

8. When the blood flow to the heart muscle is completely
blocked, the heart muscle cells die, which is termed a heart
attack or myocardial infarction (MI).
Caused mainly by Atherosclerosis of Coronary Artery
Can also caused by artherisclerosis, aortic valve stenosis,
mitral valve prolapse
IHD known as Coronary Artery Disease (CAD).
No alternative blood supply exists
2/8/2023
by Zewude M 8

9. 2/8/2023
by Zewude M 9

10. 2/8/2023
by Zewude M 10

11. Atheroma: is an accumulation of degenerative material in the tunica
intima (inner layer) of artery walls.
The material consists of :
 macrophage cells, or debris
containing lipids (cholesterol and fatty acids)
calcium and a variable amount of fibrous connective tissue
The accumulated material forms a swelling in the artery
wall, which may intrude into the channel of the artery,
narrowing it and restricting blood now.
2/8/2023
by Zewude M 11

12.  Progressive inflammatory disorder of the arterial wall
characterised by focal lipid rich deposits of atheroma
 Remain clinically asymptomatic
 Until large enough to impair tissue perfusion
 Ulceration and disruption of the lesion result in thrombotic
occlusion
2/8/2023
by Zewude M 12

13.  Atherosclerosis can
affect any artery in the
body, including arteries
in the
 heart
 brain
 arms
 legs
 pelvis and
 kidneys.
2/8/2023
by Zewude M 13

14. IHD is the most common, serious, chronic, life-
threatening disease all over the world.
2/8/2023
by Zewude M 14

15. 2/8/2023
by Zewude M 15

16. 2/8/2023
by Zewude M 16

17. 2/8/2023
by Zewude M 17

18.  According to study done on Global Epidemiology of
Ischemic Heart Disease: Results from the Global Burden
of Disease Study, 2020 by Moien AB Khan,et al.
◦ IHD affects around 126 million individuals (1,655 per 100,000),
which is approximately 1.72% of the world’s population.
◦ Nine million deaths were caused by IHD globally.
◦ Incidence typically started in the fourth decade and increased with
age.
◦ Men were more commonly affected than women
2/8/2023
by Zewude M 18

19.  Ischaemic heart disease (IHD), previously considered rare in sub-Saharan
Africa, now ranks 8th among the leading causes of death in men and
women in the region.
 According to study ,Dietary and Behavioral Risk Factors of Ischemic Heart
Disease Among Patients of Medical Outpatient Departments in Southern
Ethiopia: Unmatched Case-Control Study,2021 Meron Hadis
Gebremedhin,et al.
◦ In Ethiopia, ischaemic heart disease is one of the top three prevalent
CVDs.
◦ .
 2/8/2023
by Zewude M 19

20.  Another study in Addis Ababa, Ethiopia showed IHD occupied a 7.4% of
death.
◦ The reduction in the mortality rate due to CVDs is slower than for
communicable diseases and other causes of mortality
2/8/2023
by Zewude M 20

21. 2/8/2023
by Zewude M 21

22. Myocardial oxygen supply is decreased
 Narrowed coronary arteries
 ( thrombus, spasms, Coronary embolism, vasculitis)
 Hypotension
 Severe anemia
 increased carboxyhemoglobin
2/8/2023
by Zewude M 22

23. Myocardial oxygen demand is increased
• Left ventricle hypertrophy
• Fever
• Tachycardia
2/8/2023
by Zewude M 23

24. Uncontrollable(non- modifiable) Controllable (modifiable)
Sex :Males are more prone to
IHD.
However, in postmenopausal
women, the risk is almost
similar to that of men
Hereditary
Race
Age
HTN
DM
Smoking
Physical inactivity
Obesity(BMI>30)
Alcohol overconsumption
Stress and anger
Low daily fruit and vegetables
consumption
2/8/2023
by Zewude M 24

25. 2/8/2023
by Zewude M 25

26. 2/8/2023
by Zewude M 26

27. Stable angina pectoris refers to recurrent
characteristic/atypical chest pain induced by
 Physical activity or emotional stress and is relieved by rest .
 Is the most common kind of angina.
 The key cause is atherosclerosis, with narrowing of the
coronary blood vessels leading to reduction in blood supply to
the myocardium.
2/8/2023
by Zewude M 27

28. 2/8/2023
by Zewude M 28

29. Central/retrosternal or precordial squeezing chest pain or
heaviness on the chest which may radiate into the left
arm, neck or jaw, and is relieved by rest
The pain usually happens during physical activity. WHY?
No typical signs are found in patients with stable angina
Physical findings which indicate the presence of risk
factors may be observed: hypertension, obesity, etc)
2/8/2023
by Zewude M 29

30. Unstable angina-symptoms of myocardial ischemia (typical
or atypical) but no elevation in cardiac enzymes, with or
without ECG changes indicative of ischemia.
Unstable angina is considered to be present in the following
circumstances:
 Rest angina >20 minutes in duration
 Increasing angina- more frequent or longer in duration, or
occurs with less exertion than previous angina.
2/8/2023
by Zewude M 30

31. 2/8/2023
by Zewude M 31

32.  Clinical features
Chest pain of:Acute onset but not very sudden
Diffuse and usually difficult to localize.
Localization of the site with a single finger makes the ischemia to be less
likely.
Described as tightness, heaviness or constrictive in nature
Persisting for more than 20 minutes
Not relieved by rest or nitroglycerin
May radiate to the arm/s, the neck or jaw, the upper abdomen
(epigastrium), the back (inter scapular region)
2/8/2023
by Zewude M 32

33.  Other symptoms include sudden onset of the following:
Nausea
 Vomiting
 Sweating
Shortness of breath or fatigue
2/8/2023
by Zewude M 33

34.  Some patients with ACS present without chest pain.
These presentations include
Dyspnea
nausea and/or vomiting
palpitations
syncope and
cardiac arrest.
 Elderly,diabetic and female patients are more likely to
present with painless ACS.
2/8/2023
by Zewude M 34

35.  Physical findings may include:
Excessive sweating, respiratory distress
Pulse: Tachycardic or bradycardic or normal. It can be
irregular or regular, feeble or full
Blood pressure: low/unrecordable, high or normal
Bilateral crepitations in the chest when there is left
ventricular failure
Presence of a third or fourth heart sound
2/8/2023
by Zewude M 35

36.  N.B Patients should not be moved outside the critical
care unit for the sake of
investigations such as Chest X-ray and Echocardiography
2/8/2023
by Zewude M 36

37. 2/8/2023
by Zewude M 37

38. 2/8/2023
by Zewude M 38

39.  Myocardial infarction occur when cardiac myocytes
die due to prolonged myocardial ischemia.
 Sudden cardiac death
 Unexpected death from cardiac causes.
A complication and often the first clinical manifestation of
IHD.
2/8/2023
by Zewude M 39

40. Dizziness
Tachycardia or bradycardia
Heaviness in or across the
chest
Pain in the chest lasting
more than 20 minutes. The
pain may radiate to the
back, jaw, and other areas
of the upper body
Dyspnoea (shortness of
breath)
Fatigue
Syncope
Pale and sweating
Vomiting
2/8/2023
by Zewude M 40

41.  Contractile dysfunction
 Pericarditis
 Myocardial rupture
 Congestive heart failure
 Cardiogenic shock
 Arrhythmias
2/8/2023
by Zewude M 41

42.  Cardiac enzymes: CK-MB(CK-MB,
found in the heart),
 Troponins
 BUN and creatinine, electrolytes
 Random blood sugar
 Serum lipid profile
 CBC
 Chest X-ray
 Echocardiography
 Coronary arteriograph
 detailed anatomical information
about the extent and nature of
coronary artery disease
 indicated when non-invasive tests
have failed to establish the cause
of atypical chest pain
2/8/2023
by Zewude M 42

43.  Stable angina pectoris
 Objectives
 Decrease the severity and frequency of symptoms
 Improve quality of life/functional status
 Decrease present modifiable risk factors
2/8/2023
by Zewude M 43

44.  Initiate and/or maintain lifestyle modifications-
 weight control
increased physical activity
moderation of alcohol consumption
diet high in fresh fruits, vegetables, and
low-fat dairy products
 Smoking cessation and avoidance of exposure to environmental
tobacco smoke at work and home
 Taking rest during symptoms
2/8/2023
by Zewude M 44

45. During episodes of chest pain
 Sublingual Nitroglycerin (glyceryl trinitrate)
, 0.3mg to 0.5mg or 0.4mg sublingual spray (repeat every 5 min
as needed) for maximum of 3 doses
2/8/2023
by Zewude M 45

46.  Long-term Treatment
 Anti angina therapy
 beta blocker
 calcium channel blocker or long acting nitrate OR combinationof two or more of
these agents
1. Beta blockers
 Metoprolol
 Initial: 25mg P.O., BID; usual dosage: 50-200mg BID; maximum: 400mg/day
 Atenolol, 50-100mg, P.O., daily.
 Propranolol, 80-320mg/day P.O., in doses divided 2-4 times/day.
2/8/2023
by Zewude M 46

47.  Verapamil Initial: 180mg – 480mg/day; Immediate realse
Initial: 80-160 mg, P.O., TID
 Amlodipine, 5-10mg/day P.O.,daily
 Felodipine, 2.5-10mg/day P.O.
 Nifedipine slow release, 20-180mg/day P.O.
 Do not combine verapamil or diltiazem with beta blockers
because of potentially profound adverse effects on AV
(atrioventricular) nodal conduction, heart rate, or cardiac
contractility.
2/8/2023
by Zewude M 47

48.  3.Long acting Nitrate Isosorbide Dinitrate
, 10mg, 8-12 hourly P.O
2/8/2023
by Zewude M 48

49.  Acute myocardial infarction
 unstable angina, and
 sudden cardiac death
 ACS describes a group of clinical entities that are characterised
by severe, acute Myocardial ischemia or infarction resulting from
thrombotic occlusion of coronary artery/ies as a result of
atherosclerotic plaque erosion/rupture.
 Should be managed in the intensive care unit.
2/8/2023
by Zewude M 49
are referred to acute
coronary syndrome.

50. Reassure patient and encourage strict bed rest for at least 12 hrs.
Patients can be seated after 24hrs, walk in the room after 48-72
hrs if there are no complications or ongoing pain
Encourage cessation of smoking
Ensure weight reduction (in overweight and obese individuals)
2/8/2023
by Zewude M 50

51.  Immediate treatment –
1.Oxygen via nasal cannula or face mask if the patient SPO
is < 90% or in respiratory distress
2.Nitroglycerin, sublingual, 0.4 to 0.5mg every 05 minutes for a maximum of
three doses
3. Morphine, IV, 2 to 4mg, with increments of 2 to 8mg repeated at 5 to 15
minute intervals, should be given for the relief of chest pain or anxiety
4.Aspirin, (chew or disperse if dispersible), 300mg stat P.O. then 75-162mg,
oral, daily
5.Clopidogrel, Loading dose of 300-600mg followed by 75mg/d P.O
6.Anticoagulation – unfractionated heparin or low molecular weight heparin
2/8/2023
by Zewude M 51

52.  Unfractionated Heparin (UFH) , Bolus 60 U/kg (maximum
5,000 U) IV, followed by infusion of 12 U/kg per/h (maximum
1,000 U/h)
 Statins-Give high dose statin to all patients irrespective of
lipid levels
 First line statin: Atorvastatin, 80mg P.O.,. daily
 Alterantive statins: Rosuvastatin 20mg/day, Simvastatin
40mg/day
2/8/2023
by Zewude M 52

53. Invasive procedures used to open clogged coronary arteries
Passing a fine guide-wire across a coronary stenosis under
radiographic control
Balloon is placed and then inflated to dilate the stenosis
Then a coronary stent is deployed on a balloon
Mainly used in single or two-vessel disease
2/8/2023
by Zewude M 53

54. 2/8/2023
by Zewude M 54

55.  A coronary artery bypass graft involves taking a blood
vessel from another part of the body (usually the chest,
leg or arm) and attaching it to the coronary artery above
and below the narrowed area or blockage.
 This new blood vessel is known as a graft.
2/8/2023
by Zewude M 55

56. 2/8/2023
by Zewude M 56

57. Instruct patient to notify nurse immediately when chest pain
occurs.
Assess and document patient response to medication
Place patient at complete rest during anginal episodes.
Elevate head of bed if patient has shortness of breath.
Monitor heart rate and rhythm.
Administer antianginal medication(s) promptly as indicated:
2/8/2023
by Zewude M 57

58. Brunner and Suddarth’s text book of Medical –Surgical
nursing 14th edition ,2018
Global Epidemiology of Ischemic Heart Disease: Results from
the Global Burden of Disease Study Moien AB Khan, et al.
2020
Standard treatment guideline for general hospitals in Ethiopia
4th edition,2021
www.google.com
2/8/2023
by Zewude M 58

59. 2/8/2023
by Zewude M 59