1. CAD

2. Angina treatment
There are many options for angina treatment, including lifestyle changes, medications, angioplasty and stenting, or coronary bypass surgery. The goals of treatment are to reduce the frequency and severity of your symptoms and to lower your risk of heart attack and death.
However, if you have unstable angina or angina pain that's different from what you usually have, such as occurring when you're at rest, you need immediate treatment in a hospital.

3. Medications
If lifestyle changes alone don't help your angina, you may need to take medications. These may include:
Nitrates. 
Aspirin. 
Clot-preventing drugs. 
Beta blockers. 
Statins. 
Calcium channel blockers. 
Medical procedures and surgery
Angioplasty and stenting. 
Coronary artery bypass surgery. 

4. Myocardial infarction
Myocardial infarction or “heart attack” is an irreversible injury to and eventual death of myocardial tissue that results from ischemia and hypoxia.

5. Management
Prehospital care
For patients with chest pain, prehospital care includes the following:
Intravenous access, supplemental oxygen, pulse oximetry
Immediate administration of aspirin en route
Nitroglycerin for active chest pain, given sublingually or by spray
Telemetry and prehospital ECG, if available

7. Emergency department and inpatient care
Initial stabilization of patients with suspected myocardial infarction and ongoing acute chest pain should include administration of sublingual nitroglycerin if patients have no contraindications to it.
The American Heart Association (AHA) recommends the initiation of beta blockers to all patients with STEMI (unless beta blockers are contraindicated).
If STEMI is present, the decision must be made quickly as to whether the patient should be treated with thrombolysis or with primary percutaneous coronary intervention (PCI).

8. Rationale for therapy
A main goal of intervention for myocardial infarction is to limit the size of the infarcted area and thus preserve cardiac function.
Early recognition and intervention in a myocardial infarction have been shown to significantly improve the outcome and reduce mortality in afflicted patients.
If employed in the early stages of myocardial infarction, antiplatelet-aggregating drugs such as aspirin and clot-dissolving agents such as streptokinase and tissue plasminogen activator may be very effective at improving myocardial blood flow and limiting damage to the heart muscle.

9. Treatment for coronary artery disease usually involves lifestyle changes and, if necessary, drugs and certain medical procedures.
Lifestyle changes
Making a commitment to the following healthy lifestyle changes can go a long way toward promoting healthier arteries:
Quit smoking.
Eat healthy foods.
Exercise regularly.
Lose excess weight.
Reduce stress.

10. Medicines
You will probably have to take several medicines that lower your risk of a heart attack. These include:
Aspirin or other antiplatelets to help prevent blood clots.
An ACE inhibitor or a beta-blocker to help lower blood pressure and reduce the workload on your heart.
A statin to help lower cholesterol.
To manage symptoms, you might take an angina medicine, such asnitroglycerin.
If your angina symptoms get worse even though you are taking medicines, you may think about having a procedure to improve bloodflow to your heart. These include angioplasty  with or without stenting and bypass  surgery.

11. Other drugs such as vasodilators, β-adrenergic blockers and ACE inhibitors can also improve blood flow and reduce workload on the injured myocardium and thus reduce the extent of myocardial damage.
The development of potentially life-threatening arrhythmias is also common during myocardial infarction and must be treated with appropriate antiarrhythmia drugs.
Supportive therapies such as oxygen, sedatives and analgesics are also utilized.

12. Case 1
L.W. is a 64-year-old woman with a significant history of CAD, having had two MIs and three stent placements in the past 10 years. Her LVEF is more than 60%. She has developed shortness of breath and chest heaviness with activity during the past several months, despite being adherent to her medications.

13. She says she is requiring up to three doses of her sublingual nitroglycerin per day; however, she has severely curtailed her activity to avoid the discomfort.
She takes aspirin 325 mg/day, simvastatin 40 mg every night, enalapril 10 mg 2 times/day, and metoprolol tartrate 50 mg 2 times/day. Her vital signs include BP 132/80 mm Hg and HR 72 beats/minute.

14. A. Discontinue metoprolol tartrate, and begin diltiazem extended release 240 mg/day. B. Add ranolazine 500 mg two times/day. C. Add isosorbide mononitrate 30 mg every morning. D. Increase metoprolol tartrate to 100 mg two times/day, and add isosorbide mononitrate 30 mg every morning.

15. Both β-blockers and calcium antagonists can be used to achieve HR goals in patients with stable angina. However, this patient has a compelling indication for β-blockade over calcium antagonism (post-MI), and the dose can be increased.
Therefore, replacing the β-blocker with a nondihydropyridine calcium antagonist is not ideal.

16. adding a nitrate by itself is not advisable because of the potential for reflex tachycardia in an individual who already has a higher than desired HR. The addition of a nitrate (increased oxygen supply) and increased β-blockade (decreased oxygen demand) is the best option for this patient.

17. Case 2
L.J., a 58-year-old white man, is discharged from the hospital after a non-ST-segment elevation MI. His medical history is significant for hypertension. He was taking hydrochlorothiazide 12.5 mg/ day before hospitalization. An echocardiogram shows an LVEF of more than 60%.
His vital signs include BP 130/65 mm Hg and HR 64 beats/minute, and he states that he feels great. His drug regimen consists of aspirin 81 mg/day, atenolol 50 mg/day, hydrochlorothiazide 25 mg/day, atorvastatin 80 mg/day, and sublingual nitroglycerin 0.4 mg as needed for chest pain.

18. A. Discontinue hydrochlorothiazide; add diltiazem extended release 240 mg/day. B. Continue hydrochlorothiazide; add amlodipine 5 mg/day. C. Discontinue hydrochlorothiazide; add ramipril 5 mg/day. D. Continue hydrochlorothiazide; add vitamin E 400 IU/day

19. Because the patient is post-MI, his BP goal is less than 130/80 mm Hg, which he has achieved. Therefore, no decision must be made on the basis of improved BP control. Because he is post-MI, he has a compelling indication for β-blocker therapy, which he is already receiving.
He has not provided any information to indicate the need for additional antianginal therapies, so the addition of a calcium channel blocker is not necessary

20. He is taking appropriate antiplatelet and cholesterol-lowering drugs according to the requirements for individuals with CAD. An ACE inhibitor is indicated in all patients with CAD unless a contraindication exists.
Ramipril is reasonable to add to this patient's regimen, and discontinuing hydrochlorothiazide may be desirable to minimize the occurrence of hypotension.

21. Case 3
A 55-year old man present to his primary care doctor complaining of tightness in his chest when he digs the garden. it eases when he has a rest. On investigation he has a raised serum glucose concentration and is considered to be a newly diagnosed non-insulin –dependent type 2 diabetes.
The patient’s blood pressure and ECG should be checked and he should be examined for signs of hypertensive or diabetic target organ damage. his serum lipid profile should be measured

22. He should receive GTN spray or sublingual tablets for the chest symptoms that are almost certainly angina. He should take aspirin daily and a statin if his lipid profile is abnormal
Some prescribers would give a statin in almost all diabetic, CHD patients and likewise an ACEI.
Lifestyle modification is very important

23. The following patients are admitted for treatment of myocardial infarction:
An asthmatic
A man previously treated for infarction
A patient with rheumatoid arthritis
What contraindications or possible contraindications are there to standard treatments in the above patients?

24. An asthmatic should not receive a beta blocker without careful consideration and supervision because of the risk of bronchoconstriction, there is also a small risk of bronchoconstriction with aspirin
A previous infarct may have been treated with streptokinase and a repeat dose should be avoided. tissue plasminogen activator should be used instead

25. Fibrinolytics are contraindicated if there is a serious risk of bleeding . a patient with rheumatoid arthritis may be receiving NSAIDs or steroids and enquiries must be made into any history of gastrointestinal bleeding.
NSAIDs would also not be prescribed with ACE inhibitors because of the risk of impaired renal function. Aspirin is not contraindicated with NSAIDs, and may be useful but will increase the risk of gastrointestinal bleeding

26. When planning emergent care for a patient with a suspected MI, the nurse will anticipate administration of A. Oxygen, nitroglycerin, aspirin, and morphine. B. Oxygen, furosemide (Lasix), nitroglycerin, and meperidine. C. Aspirin, nitroprusside (Nipride), dopamine (Intropin), and oxygen. D. Nitroglycerin, lorazepam (Ativan), oxygen, and warfarin (Coumadin).

27. The American Heart Association's guidelines for emergency care of the patient with chest pain include the administration of oxygen, nitroglycerin, aspirin, and morphine.
These interventions serve to relieve chest pain, improve oxygenation, decrease myocardial workload, and prevent further platelet aggregation.

28. A hospitalized patient with a history of chronic stable angina tells the nurse that she is having chest pain. The nurse bases his actions on the knowledge that ischemia: A. Will always progress to MI B. Will be relieved by rest, nitroglycerin, or both C. Indicates that irreversible myocardial damage is occuring D. Is frequently associated with vomiting and extreme fatigue
Will be relieved by rest, nitroglycerin, or both

29. A nurse is admitting a client who has a suspected myocardial infarction (MI) and a history of angina. Which of the following findings will help the nurse distinguish angina from an MI? A. Angina can be relieved with rest and nitroglycerin. B. The pain of an MI resolves in less than 15 min. C. The type of activity that causes an MI can be identified. D. Angina can occur for longer than 30 min.
Angina can be relieved by rest and nitroglycerin.