Modifiable Risk Factors & Education
Modifiable risk factors include elevated serum lipids, elevated blood pressure, tobacco use, physical inactivity, obesity, diabetes, metabolic syndrome, psychological states, and elevated homocysteine level, substance abuse
Describe Chronic Stable Angina
Intermittent chest pain that occurs over a long period with the same pattern of onset, duration, and intensity of symptoms
5 to 15 minute duration
ST segment depression and/or T-wave inversion
Control with drugs
Describe Long-Acting & Short-Acting Nitrate Meds and Education for Them
Long-acting nitrates
To reduce angina incidence
Main side effects: headache, orthostatic hypotension
Methods of administration
Oral
Nitroglycerin (NTG) ointment
Transdermal controlled-release NTG
Short-acting nitrates
Dilate peripheral and coronary blood vessels
Give sublingually (tablet) or by spray
If no relief in 5 minutes, call EMS; if some relief ,repeat every 5 minutes for maximum 3 doses
Patient teaching
Can use prophylactically
Education
Be careful with admin, wear gloves, as it will lower BP
Teach about side effect of headache
If no relief in 5 minutes, call EMS; if some relief ,repeat every 5 minutes for maximum 3 doses
Get up slowly due to orthostatic hypotension
Describe Omega-3 Fatty Acid meds, their side effects, and nursing considerations for them
icosapent ethyl (Vascepa) (eicosapentaenoic acid [EPA])
SE:
Arthralgia
Considerations:
Used for patients with severe hypertriglyceridemia (levels ≥ 500 mg/dL).
Used with statin therapy for patients with CAD who have high triglyceride levels.
High incidence of bleeding when taken with drugs that increase the risk of bleeding, such as aspirin or warfarin
omega-3 acid ethyl esters (Lovaza) (eicosapentaenoic acid [EPA] and docosahexaenoic acid [DHA])
SE:
Anaphylaxis
Rash
Taste changes
GI problems (e.g., constipation, vomiting)
Considerations:
Used for patients with high triglycerides.
Give with meals and do not open or dissolve capsules.
What can't you delegate with CAD?
What is the education for the modifiable risk factors?
Hypertension
Monitor home-based BP and obtain regular checkups.
Take prescribed drugs for BP control.
Reduce salt intake.
Stop tobacco use. Avoid exposure to environmental tobacco (secondhand) smoke.
Control or reduce weight.
Perform physical activity daily.
High Serum Lipids
Reduce total fat intake.
Reduce saturated fat intake.
Take prescribed drugs for lipid reduction.
Adjust total caloric intake to achieve and maintain ideal body weight.
Engage in daily physical activity.
Increase amount of complex carbohydrates, fiber, and vegetable proteins in diet.
Follow-up with HCP for regular lipid panel assessments.
Tobacco Use
Begin a tobacco cessation program.
Change daily routines associated with tobacco use to reduce desire to smoke.
Substitute other activities for smoking.
Ask caregivers to support efforts to stop smoking.
Avoid exposure to environmental tobacco smoke.
Describe Prinzmetal's Angina
Occurs at rest usually in response to spasm of major coronary artery
Seen in patients with a history of migraine headaches and Raynaud’s phenomenon
Spasm may occur in the absence of CAD
Occurs at rest due to spasm of a major coronary artery
May occur with or without CAD
Not precipitated by increased demand
Chest pain with marked, transient ST-segment elevation
Describe ATP-Citrate Lyase Inhibitor meds, side effects, and nursing considerations for them
bempedoic acid (Nexletol)
SE:
Diarrhea
Fatigue
Muscle pain
Upper respiratory tract infection
Considerations:
Monitor uric acid levels due to increased risk of gout.
Use in caution with patients who have had a previous tendon rupture.
Describe Bile-Acid Sequestrants meds, their side effects, and nursing considerations for them
colesevelam (Welchol)
colestipol (Colestid)
cholestyramine (Prevalite)
SE:
Unpleasant quality to taste
GI problems (e.g., indigestion, constipation, bloating)
Considerations:
Effective and safe for long-term use.
Side effects lessen with time.
Interferes with absorption of many drugs (e.g., digoxin, thiazide diuretics, warfarin, some antibiotics [e.g., penicillin]).
Teach patient to take other drugs 1 hour before or 3–4 hr after bile-acid sequestrants.
More education for the risk factors?
Physical Inactivity
Develop and maintain at least 30 min of moderate physical activity daily (minimum 5 days a week).
Increase activities to a fitness level.
Psychological State
Increase awareness of behaviors that are harmful to health.
Change patterns that add to stress (e.g., get up 30 min earlier so that breakfast is not eaten on way to work).
Set realistic goals for self.
Reassess priorities considering identified risk factors.
Learn effective stress management strategies
Seek professional help if feeling depressed, angry, or anxious.
Plan time for adequate rest and sleep
Obesity
Change eating patterns and habits.
Reduce caloric intake to achieve body mass index of 18.5–24.9 kg/m2.
Increase physical activity to increase caloric expenditure.
Avoid fad and crash diets, which are not effective over time.
Avoid large, heavy meals. Consider smaller, more frequent meals.
Diabetes
Follow the recommended diet.
Control or reduce weight.
Take prescribed drugs for diabetes.
Monitor glucose levels regularly and follow up with HCP regularly.
Describe Fibric Acid Derivatives meds, side effects, and nursing considerations for them
fenofibrate (Tricor)
gemfibrozil (Lopid)
SE:
Rashes
GI problems (e.g., nausea, diarrhea)
↑ Liver enzymes
Considerations:
May ↑ effects of warfarin (Coumadin) and some antihyperglycemic drugs. When used in combination with statins, may increase adverse effects of statins, especially myopathy.
Describe Proprotein Convertase Subtilisin/Kexin 9 (PCSK9) Inhibitor meds, their side effects, and nursing considerations for them
alirocumab (Praluent)
evolocumab (Repatha)
SE:
Injection-site reactions
Muscle pain, limb pain, and fatigue
Consideration:
Used with diet and maximum statin therapy to treat familial hypercholesterolemia, those who need further LDL lowering, or are statin intolerant.
Given by injection every 2 wk or every 4 wk at a higher dose.
What dietary modifications can be made to help with CAD?
Saturated fats: Limit fats that are usually solid at room and refrigerator temperature (e.g., lard, butter, whole-milk products, fatty cuts of meat, bacon)
Trans fats: Mainly in foods made with hydrogenated vegetable oils, such as many hard margarines and shortenings
Unsaturated fats: In oils that are usually liquid at room and refrigerator temperature (e.g., olive, corn, sunflower, soybean). There are 2 types of unsaturated fats:
Monounsaturated fats: In greatest amounts in foods from plants, including olives, avocadoes, and canola, sunflower, and peanut oils.
Polyunsaturated fats: Found mostly in nuts, seeds, fish, seed oils, and oysters. Omega-3 fatty acid is a type of polyunsaturated fat that may help reduce the risk of CAD
Nutritional therapy
↓ Saturated fats and cholesterol
↑ Complex carbohydrates and fiber
↓ Red meat, egg yolks, whole milk
↑Omega-3 fatty acids
Low sodium diet
Describe HMG-CoA Reductase Inhibitors (Statins) meds, side effects, and nursing considerations for them
atorvastatin (Lipitor)
fluvastatin (Lescol XL)
lovastatin
pitavastatin (Livalo)
pravastatin (Pravachol)
rosuvastatin (Crestor)
simvastatin (Zocor)
SE:
Rash
GI problems
↑ Liver enzymes
Myopathy, rhabdomyolysis
Considerations:
Well tolerated with few side effects.
Monitor liver enzymes and recheck them after any increase in dosage.
Assess CK-MM if symptoms of myopathy (e.g., muscle aches, weakness) occur.
Describe Cholesterol Absorption Inhibitor meds, their side effects, and nursing considerations for them
ezetimibe (Zetia)
SE:
Infrequent, but may include headache and mild GI distress
Nursing Considerations:
When used with a statin, further reduces LDL.
Avoid use by patients with liver problems.
Describe niacin, its side effects, and nursing considerations for it
niacin (Niaspan)
SE:
Flushing and itching in upper torso and face
GI problems (e.g., nausea, vomiting, dyspepsia, diarrhea)
Orthostatic hypotension
Considerations:
Most side effects subside with time.
Taking aspirin or ibuprofen 30 min before drug may reduce flushing.
Take drug with food.
Decreased liver function may occur with high doses.