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Journal of Nursing

Evidenced Based Guidelines: Ischemic Heart Disease

Madeleine Augier RN BSN [email protected]


Evidence-Based Guidelines: Ischemic Heart Disease

Madeleine Augier

The University of Tampa

NUR 680


Ischemic heart disease is the leading cause of death worldwide. In fact, this disease has remained the leading cause of death globally in the past fifteen years (World Health Organization, 2018). With this statistic, it is imperative to educate the public on how to reduce risk factors, but also necessary for nurse practitioners to provide primary prevention and improve correct diagnosis and treatment.

Definition

Ischemic heart disease (IHD), most commonly known as coronary artery disease, is defined as “the presence of atherosclerotic plaques in one or more of the major coronary arteries that supply blood to the heart or the muscle (Lewis & Davis, 2013).” Ischemia occurs when there is an imbalance between myocardial oxygen supply and a demand that is commonly caused by plaques that impede blood flow to tissue distal to the stenosis. There are two different types of IHD:

-Stable ischemic heart disease: Often manifests with having stable angina, or chest pain, that is usually retrosternal or substernal that is precipitated by physical or emotional stress. The chest pain has a predictable pattern and is relieved by rest or sublingual nitroglyercin (Lewis & Davis, 2013). Fihn et al. (2012), of American College of Cardiology Foundation (ACCF)/ American Heart Association (AHA) reports that stable ischemic heart disease includes known stable or suspected IHD, including those with new onset chest pain that are deemed to have low-risk unstable angina (UA). Low risk angina is classified as those under the age of 70 years with symptoms of chest pain during exertion lasting less than 20 minutes that does not accelerate, with a normal 12-lead EKG, and no elevation of cardiac enzymes.

-Unstable ischemic heart disease: Often referred to as acute coronary syndrome (ACS), with either unstable angina, acute non-ST elevation myocardial infarction, or acute ST elevation myocardial infarction. The patient will often present with angina at rest, new onset angina that markedly limits physical activity, or increasing angina that is more frequent and longer with less activity (Simons & Breall, 2019).

Incidence

As mentioned, heart disease is the leading cause of death worldwide. It is estimated that 6.7% of all American adults over the age of 20 years has IHD. The prevalence of IHD amongst males is 7.4% and 6.2% for females (Benjamin et al., 2019).

Pathogenesis

The most common cause of ischemic heart disease is from atherosclerosis, which can affect one or all three of the major epicardial coronary arteries. Atherosclerosis occurs when there is an accumulation of intracellular and extracellular lipids, proliferation of vascular smooth muscle cells, formation of scar tissue, and calcification (Porth, 2015). This forms a growing plaque inside the vessel which can eventually occlude the vessel or predispose to thrombus formation leading to a reduction in blood flow. The plaque buildup in the arteries leads to the inability of the coronary arteries to supply blood to meet the metabolic demands of the heart which can present as chest pain and lead to either ACS or IHD depending on the severity.

Predisposing Factors







  • Familial history

  • Cigarette smoking

  • Diabetes mellitus

  • Dyslipidemia

  • Hypertension


  • Physical inactivity

  • Obesity BMI>30

  • Low fruit and vegetable consumption

  • Alcohol overconsumption

  • Men older than 45 and women older than 55


(Lewis & Davis, 2013)







Common Complaints

  • chest pain/pressure

  • chest pain with exertion

  • palpitations

  • shortness of breath

  • heart burn

  • discomfort in neck, arms, jaw


Signs and Symptoms

  • angina

  • angina with exertion

  • nausea

  • dizziness/fatigue

  • diaphoresis

  • shortness of breath


Questions

When did your chest pain start?

What were you doing when the chest pain started?

What makes your symptoms better or worse?

Do you or anyone in your family have a history of heart disease?

Do you have a history of high cholesterol?

Do you smoke or drink alcohol?

Physical Examination

General/Constitutional: inspect for pallor, fever, dizziness, fatigue, diaphoresis, and signs of acute distress.


Cardiovascular: Auscultate rate and rhythm.  Assess for S1, S2 and any heart murmurs, rubs, or gallops.


Respiratory: Auscultate lungs and assess for any adventitious lung sounds. Assess for symmetric respirations, tachypnea, labored breathing, or use of accessory muscles. Palpate for any tenderness to chest.


Peripheral/Extremities: Assess peripheral pulses for bounding or absent pulses. Palpate extremities for edema. Assess for cyanosis or clubbing of the nails.

Diagnosis













Differential Diagnosis

Working Diagnosis


  • Pneumonia J18.9

  • GERD K21.0

  • Esophageal spasm K22.4

  • Pancreatitis K85.0

  • Pulmonary Embolism I26.0

  • Pericarditis I30.0

  • Myocardial Infarction I21.0


  • Ischemic heart disease I25.0


 


Goals

The goals of management of ischemic heart disease are to:



  • Promote a heart healthy lifestyle

  • Symptom relief (decreasing frequency and severity of angina)

  • Prevent secondary myocardial infarction

  • Increase in functional capacity and longevity


Non-Pharmaceutical Interventions

Dietary modifications: low fat diet, reduce sodium intake, increase fruits and vegetable intake.

Physical activity: 30-60 minutes of moderate aerobic activity 5-7 days per week supplemented by an increase of daily activities


Weight loss: goal of BMI between 18.5 and 24.9


Smoking cessation


Alcohol intake: no more than 1 serving/day. Serving= 4 oz. of wine, 12 oz, beer, 1 oz. spirits

Pharmaceutical Therapy for Stable IHD





























Drug

Role and Precautions

Beta Blockers:

Bisoprolol, carvedilol, metoprolol


  • Role: lowers heart rate, lengthens diastole, consequently increasing coronary blood flow and relieving angina symptoms in addition to lowering blood pressure.

  • Precautions: can cause hypotension, bradycardia, heart block, bronchospasm, and worsening heart failure

Calcium Channel Blockers:

Amlodipine, felodipine


  • Role: symptom relief of angina and a decrease in blood pressure if beta blockers are contraindicated. Reduce oxygen demand by causing systemic vasodilation and decreasing afterload.

  • Precautions: caution with severe heart failure second to negative inotropic effects

Nitrates:

Nitroglycerin, isosorbide mononitrate

Role: reduce angina by relaxing vascular smooth muscle, which decrease preload and afterload allowing a decrease in oxygen demand.

Precautions: use for acute episodes of angina. Tolerance can occur, must be nitrate free for 8-12 hrs to reduce tolerance, can cause hypotension. Watch for hypotension with older adults.

Aspirin:

75-162 mg daily

Role: anti-platelet therapy, reduction of clot formation

Precautions: if not tolerated, clopidrogel can be substituted.

Statins:

high dose therapy

atorvastatin 20-80 mg/day. Rosuvastatin 10-40 mg/day

Role: help decrease formation of coronary plaques

Precautions: for elderly, start at a lower dose and titrate to high dose as tolerated


(Lewis & Davis, 2013)

Education



  • Importance of non-pharmaceutical therapy: exercise, weight loss, and heart healthy diet

  • Self-monitoring skills: how to pace their activities and set goals based on stress, anxiety, or depression on symptoms.

  • Action plan: develop a plan for what to do if they experience recurrent angina. Advise to stop activity any time symptoms occur, take a sublingual nitroglycerin (unless contraindicated). If symptoms continue after a total of 3 doses, call EMS.

  • Adherence: importance of maintaining a healthy lifestyle and adhering to prescribed medications

  • Educating every visit on the importance of smoking cessation.


Follow Up/Referral

Patients with suspected coronary artery disease should be referred to a cardiologist for further diagnostic tests. Patients with chronic stable ischemic heart disease require follow-up on a regular basis, often every 6-12 months (Lewis & Davis, 2013). At each visit a detailed history and physical should be performed.


It is important to obtain:



  • A change in physical activity

  • Any change in frequency, severity, or pattern of angina

  • Tolerance of and compliance with medial program

  • Modification of risk factors

  • The development of new or worsened comorbid illnesses

  • Laboratory studies with blood glucose and lipid profile

  • EKG if change in history and physical


References

Benjamin, E. J., Muntner, P., Alonso, A., Bittencourt, M. S., Callaway, C. W., Carson, A. P.,...Virani, S. S. (2019). Heart disease and stroke statistics- 2019 update. Circulation, 139(10), e56-e528. doi:https://doi.org/10.1161/CIR.0000000000000659

Fihn, S. D., Blankenship, J. C., Alexander, K. P., Byrne, J. G., Fonarow, G. C., Levine, G. N.,...Smith, P. K. (2014). 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurse Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. The Journal of Thoracic and Cardiovascular Surgery, 149(3), e5-e23. doi:http://dx.doi.org/10.1016/j.jtcvs.2014.11.002

Fihn, S. D., Gardin, J. M., Abrams, J., Berra, K., Blankenship, J. C., Dallas, A. P.,...Williams, S. V. (2012). 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: Executive summary. Journal of the American College Cardiology, 60(24), 2564-2603. doi:http://dx.doi.org/10.1016/j.jacc.2012.07.012

Lewis, J. M., & Davis, L. L. (2013). Management of Stable Ischemic Heart Disease. The Journal for Nurse Practitioners, 9(10), 661-668. doi:http://dx.doi.org/10.1016/j.nurpra.2013.08.020

National Heart, Lung, And Blood Institute. (2017). Ischemic heart disease. Retrieved from http://www.nhlbi.nih.gov/health-topics/ischemic-heart-disease

Porth, C. M. (2015). Essentials of pathophysiology: Concepts of altered health states (4 ed.). Philadelphia: Lisa McAllister.

Simons, M., & Breall, J. A. (2019). Overview of the acute management of non-ST elevation acute coronary syndromes. Up to Date. Retrieved from https://www-uptodate-com.esearch.ut.edu/contents/overview-of-the-acute-management-of-non-st-elevation-acute-coronary- syndromes?search=acute%20coronary%20syndrome& source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

World Health Organization. (2018). The top 10 causes of death. Retrieved from http://www.who.int/news-room/fact-sheets/detail/the-top-10-causes-of-death


 

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