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Coronary Atherosclerosis- Diagnosis, prevention, management

DIAGNOSIS

  • Symptoms-e.g chest pain on exertion, shortness of breath
  • Blood tests
  • Electrocardiogram
  • Echocardiogram
  • Imaging studies (e.g thallium scans and angiograms)

PREVENTION

Four modifiable risk factors—cholesterol abnormalities, cigarette smoking (tobacco use), hypertension, and diabetes mellitus— have been cited as major risk factors for CAD and its consequent complications. As a result, they receive much attention in health promotion programs.

MANAGEMENT

CONTROLLING CHOLESTEROL ABNORMALITIES

  • The desired goal is to have low LDL values and high HDL values. The desired level of LDL depends on the patient:
    • Less than 160 mg/dL for patients with one or no risk factors
    • Less than 130 mg/dL for patients with two or more risk factors
    • Less than 100 mg/dL for patients with CAD or a CAD risk equivalent
  • Serum cholesterol and LDL levels can usually be controlled by diet and physical activity.
  • Depending on the patient’s LDL level and risk of coronary heart disease, medication therapy may also be prescribed.
  • The level of HDL should exceed 40 mg/dL and should ideally be more than 60 mg/dL. A high HDL level is a strong negative risk factor (is protective) for heart disease.

DIETARY MEASURES

  • Soluble dietary fibers help lower cholesterol levels.
  • Soluble fibers, which are found in fresh fruit, cereal grains, vegetables, and legumes, enhance the excretion of metabolized cholesterol.
  • Intake of at least 20 to 30 grams of fiber each day is recommended.

NUTRIENT RECOMMENDED INTAKE

Total calories             Balance intake and expenditure to maintain desirable weight

Total Fat                       25%–35% of total calories

Saturated fat               <7% of total calories

Polyunsaturated Fat   Up to 10% of total calories

Monounsaturated Fat  Up to 20% of total calories

Carbohydrate               50%–60% of total calories

Fiber                           20–30 g/day

Protein                         Approximately 15% of total calories

Cholesterol             <200 mg/day

PHYSICAL ACTIVITY

  • Regular, moderate physical activity increases HDL levels and reduces triglyceride levels.
  • The goal for the average person is a total of 30 minutes of exercise, three to four times per week.
  • An inactive patient should start with activity that lasts 3 minutes. For sustained activity, patients should begin with a 5-minute warm-up period to stretch and prepare the body for the exercise.
  • When the weather is hot and humid, the patient is advised to exercise during early morning or indoors and wear loose-fitting clothing.
  • When the weather is cold, the patient should be instructed to wear extra clothing. The patient has also to avoid adverse weather conditions.
  • The nurse should inform patients to stop any activity if they develop chest pain, unusual shortness of breath, dizziness, light headedness, or nausea.

MEDICATIONS

  • Medications are used to control cholesterol levels.
  • If diet alone cannot normalize serum cholesterol levels, several medications have a synergistic effect with the prescribed diet.
  • Lipid-lowering medications grouped into four types:

 

MEDICATION SIDE EFFECTS CONTRAINDICATIONS
HMG-CoAReductase

Inhibitors

Myopathy, increased liver enzyme levels Active or chronic liver disease, concomitant use of certain drugs
Nicotinic Acid Flushing, hyperglycemia, hyperuricemia, upper gastrointestinal distress,hepatotoxicity Chronic liver disease, severe gout, Diabetes, hyperuricemia, peptic ulcer disease 
Fibric Acids  Dyspepsia, gallstones, myopathy, unexplainednon-CHD deaths Severe renal disease, severehepatic disease
Bile AcidSequestrants Gastrointestinal distress, constipation,decreased absorption

of other drugs

Dysbetalipoproteinemia,TG >200 mg/dL

PROMOTING CESSATION OF TOBACCO USE

  • Encourage to stop tobacco use through any means possible:counseling, consistent motivation, reinforcement messages,support groups and medications.
  • Some people have found complementarytherapies (eg, acupuncture, guided imagery, hypnosis)to be helpful.
  • People who stop smoking reduce their risk of heartdisease by 30% to 50% within the first year and the risk continuesto decline as long as they refrain from smoking.

MANAGING HYPERTENSION

  • Hypertension is defined as blood pressure measurements that repeatedly exceed 140/90 mm Hg.
  • Hypertension increases the work of the leftventricle, which must pump harder to eject blood into the arteries.
  • Over time, the increased workload causes the heart to enlargeand thicken and eventuallylead to cardiac failure.
  • Early detection of high blood pressure and adherence to atherapeutic regimen can prevent the serious consequences associatedwith untreated elevated blood pressure.

GENDER AND ESTROGEN LEVEL

  • In women younger than age 55, the incidence of CAD is significantly lower than in men.
  • However, after age 55, the incidence in women is approximately equal to that in men.
  • The age difference of the incidence of CAD in women may be related to estrogen.
  • Hormone replacement therapy (HRT) for menopausal women has been promoted as prevention for CAD, research studies do not support HRT as an effective means of CAD prevention.

BEHAVIOUR  PATTERN

  • Stress and certain behaviors contribute to the pathogenesis of CAD even.
  • People who are prone to heart disease: excessive competitiveness, a sense of time urgency or impatience, aggressiveness, and hostility.
  • A person with these behaviors is classified as type A coronary-prone.
  • Nurses can assist these people by teaching them cognitive restructuring and relaxation techniques.

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