COMPREHENSIVE MANAGEMENT OF CHRONIC CAD

A patient who has chronic CAD should be enrolled in a long-term treatment plan. These patients include people with chronic stable angina and people with stable coronary artery disease after having been treated for acute coronary syndromes.

Outpatient Monitoring and Guidance

Each patient is an individual and will need an individualized treatment program. Such programs include education of the patient and family on medications, therapeutic lifestyle changes, possible revascularization (reperfusion) surgery, and treatment of associated disorders.

The primary goals of care for patients with CAD include strategies that focus on stabilizing any progression of disease and improving symptoms while improving physical function, quality of life, and psychosocial well-being.

Medications

Drug therapy is a key part of the treatment of coronary artery disease. To reduce the likelihood of developing obstructive clots, patients who have CAD or are at high risk of developing CAD should take antiplatelet drugs daily. To lessen the work of the heart, most patients with CAD also take beta blockers. For relief of angina, nitrates are prescribed.

The standard medication therapies for CAD include:

• Antiplatelet therapy
• Beta-adrenergic blocking agents (beta blockers)
• Angiotensin-converting enzyme (ACE) inhibitors/angiotensin II receptor blockers (ARBs)
• Calcium channel blocking agent
• LDL-lowering drug, when needed
• Nitrates (short- and long-acting)

Medications are essential to the care of heart patients. Elderly patients with CAD who do not take their prescribed medications regularly are twice as likely to develop acute coronary syndromes. By asking patients at each visit whether they are taking their medicines all the time and having them describe their dosing regime, it is possible to intervene and to lower the risk of serious complications.

ASPIRIN AND OTHER ANTIPLATELETS

Long-term antiplatelet therapy makes acute ischemic episodes less likely in all forms of coronary artery disease. Aspirin is the first-line antiplatelet drug, unless the patient has an aspirin allergy or a history of or risk for gastrointestinal bleeding. It inhibits cyclooxygenase, which produces thromboxane A2, a potent platelet activator.

The initial dose is typically between 65 mg and 325 mg, and then 81 mg to 325 mg per day. It should be continued indefinitely unless contraindicated. Clopidogrel (Plavix), plasugrel (Effient), or cangrelor (Kengreal) can be added for up to 12 months to increase the inhibition of clot formation, and these drugs can also be given to patients when aspirin is contraindicated. Any patient taking anticoagulants should avoid foods high in vitamin K, as these may interfere with the therapeutic effect of the medications (Lewis et al., 2020).

Newer research, however, supports that aspirin may be efficacious only in preventing secondary atherosclerotic cardiovascular disease (when there has already been an episode of a myocardial infarction or a stroke), in which case the benefits outweigh the risks. It is believed that aspirin is less likely to prevent primary atherosclerotic cardiovascular disease (ASCVD). Therefore, the use of aspirin prophylactically for primary ASCVD is becoming controversial because the benefits in preventing an MI or stroke may not outweigh the risks unless the patient’s risk score is very high (Albert et al., 2019).

Ticagelor (Brilinta) is a newer antiplatelet medication that has proved to be effective in preventing blood clots in patients with CAD and, therefore, the occurrence of first MIs and CVAs. Ticagelor has shown better efficacy than clopidogrel but less than plasugrel, which is almost as new. In some studies, clopidogrel has fewer side effects of bleeding and dyspnea (Turgeon et al., 2020).

Patients may need to discontinue antiplatelet or anticoagulant therapy for up to 10 days before undergoing elective surgery, as not doing so can lead to cancellation or postponement of the operation or, worse, cardiac events or other potentially catastrophic developments during or following surgery. Patients considering elective surgery should therefore coordinate their antiplatelet/anticoagulant regimens with their primary care provider, cardiologist, and surgeon (Lewis et al., 2020).

NITROGLYCERIN

Nitrates, such as nitroglycerin, dilate blood vessels throughout the body. By lowering the arterial resistance to blood flow, nitrates ease the work of the heart by lowering the blood pressure, and by dilating the coronary arteries, they increase the blood flow to the myocardium. Nitrates may also prevent or control vasospasm.

Nitroglycerin relieves the pain of angina, and if taken approximately five minutes before exercise or stress, it can prevent angina. The nitroglycerin in sublingual tablets is absorbed quickly and completely, and it generally works within two to three minutes and lasts for half an hour. All patients with angina should be given sublingual nitroglycerin with specific instructions about its use. Nitroglycerin is also available as an oral spray and as long-lasting tablets, ointment, and patches.

The long-lasting forms of the drug are used to prevent angina and will also help to control hypertension as a therapeutic side effect. The alternate forms of the drug and their dosages are as follows:

• Tablets: 0.3, 0.4, 0.6 mg
• Capsules: 2.5, 6.5, 9 mg
• Spray: 0.4 mg/spray
• Transdermal patch: 0.1, 0.2, 0.3, 0.4, 0.6, 0.8 mg/hour
• Ointment: 2%
• Infusion solution: 25, 50, 100 mg/250 ml
• Injectable solution: 5 mg/ml
  (Lewis et al., 2020)

USE OF SUBLINGUAL NITROGLYCERIN

(Adapted from MedicineNet, 2018)
Purpose	To relieve angina from CAD To prevent chest pain in stressful or active situations Intravenously to treat heart failure related to MI or hypertension during surgery
When to use	As soon as chest pain or tightness begins 5 to 10 minutes before an event expected to cause chest pain or tightness (e.g., climbing stairs, going outdoors in cold weather, having sex)
How to use	Sit down to prevent falling if feeling faint after taking nitroglycerin. Place one tablet under the tongue. Let the tablet dissolve naturally. Do not swallow it whole; if swallowed by mistake, put another tablet under the tongue. While the tablet is dissolving, do not eat, drink, smoke, or chew tobacco.
What to expect if it works	Chest discomfort should decrease in 1 to 5 minutes.
What to do if it does not work	If discomfort does not decrease after taking one tablet, call 911 immediately and report chest pain. Alternately, for those used to taking nitro, take up to three tablets before calling 911.
Typical side effects	Burning or tingling under the tongue Dizziness, lightheadedness, or fainting secondary to hypotension Flushing of the face or neck Headache Nausea/vomiting Blurred vision
Side effects to report immediately to primary care provider	Blurred vision Skin rash, itching, or swelling Sweating Feeling of extreme pressure in the head Unusual tiredness or weakness Pale skin Fast heartbeat Difficulty breathing
Drugs that can be taken before or after nitroglycerin (to prevent or treat headache)	Aspirin Other pain relievers approved by the primary care provider
Drugs not to be taken with nitroglycerin	Erectile dysfunction medicines (Viagra, Cialis, Levitra)
Storage	Keep tablets tightly sealed in their original container between 59 °F and 86 °F and away from heat, light, and moisture. Replace tablets every 6 months.

BETA BLOCKERS

Beta-adrenergic blocking agents (beta blockers) are antihypertensive drugs that also reduce heart rate contractility and reduce afterload. This takes effect by inhibiting sympathetic nervous stimulation of the heart. By this action, beta blockers reduce the heart’s demand for oxygen. Beta blockers lower the incidence of episodes of angina and also reduce the likelihood of myocardial infarctions and death in CAD patients.

Special care must be taken when prescribing beta blockers to patients with asthma, other obstructive airway conditions (e.g., COPD), intermittent claudication, insulin-requiring diabetes, certain heart conduction problems, and clinical depression. When the side effects of beta blockers become a problem, calcium channel blockers, such as diltiazem or verapamil, or Ranolazine can be substituted, with similar effects.

Until recently, beta blockers were not given to patients with reactive airway disease such as COPD. Since 10% of the beta cells in the body reside in the lungs, adrenergic beta blocking agents can cause difficulty breathing. Several beta blockers are referred to as cardioselective in that they only work to block the beta 1 cells in the heart and spare the lungs. These cardioselective beta blockers are:

• Atenolol
• Esmolol
• Metoprolol
• Bisoprolol

ACE INHIBITORS

Angiotensin-converting enzyme (ACE) inhibitors, such as ramipril (Altace), are antihypertensive drugs that can reduce the likelihood of acute ischemic episodes, strokes, and death in patients with CAD. These drugs prevent angiotensin II from converting to angiotensin I, a powerful vasoconstrictor. The resulting vasodilation causes lowering of the blood pressure. They also cause endothelial dysfunction, reducing atherosclerosis formation.

STATINS

Lipid-lowering drugs are frequently prescribed for people with CAD. Statins, such as atorvastatin (Lipitor) and simvastatin (Zocor), are the preferred lipid-lowering drugs for coronary artery disease, but some lipid abnormalities should be treated with nicotinic acid or fibric acid. Patients with liver disease should not take statins.

High levels of LDL cholesterol initiate and worsen atherosclerosis. In patients with high blood levels of cholesterol, the first medical intervention is lifestyle changes, especially a low-fat diet and increased exercise (see below). When this does not lower a patient’s cholesterol to safe levels, lipid-lowering drugs are prescribed. These drugs reduce morbidity and mortality from CAD. Two infrequently occurring (<1%) side effects of statins are liver failure and rhabdomyolysis.

OTHER MEDICATIONS

Patients who have moderate to severe depression may be prescribed antidepressant medications as part of their management program. Selective serotonin reuptake inhibitors (SSRIs), including sertraline and citalopram, are a form of antidepressant therapy safe to use with patients who have CAD (Lewis et al., 2020).

Cardiac Rehabilitation

Cardiac rehabilitation (CR) is a proven method of reducing morbidity and mortality in patients with CAD, particularly in those who have undergone cardiac surgery (see also “Postoperative Cardiac Rehabilitation Goals” earlier in this course).

A broad CR program may include exercise training, dietary counseling, medication management, tobacco cessation counseling, and psychosocial assessment interventions. CR has proved very effective in helping those with heart disease and recovering from heart surgery to increase physical strength, reduce their weight, reduce LDL cholesterol, manage stress, reduce blood pressure, resume activities of daily living (ADLs), and reduce cardiac symptoms and additional cardiac tissue damage (Choxi et al., 2021; Sears, 2019).

Hospitalization for a cardiac event or surgery is often the time when the phase I of cardiac rehabilitation begins. Once the patient is discharged, referral to an outpatient rehabilitation program is initiated. Patients can begin formal outpatient cardiac rehabilitation programs as early as 10 days postoperatively depending on their condition. Cardiac rehabilitation may last 3 to 6 months or longer.

Cardiac rehabilitation may begin in an acute care hospital. Rehabilitation hospitals or units may provide the most extensive and comprehensive care and should be a consideration for patients who have good potential for recovery and can participate in and tolerate aggressive therapy.

Rehabilitation can also be offered in nursing homes or in the home environment with a less intensive approach that lasts longer and is better suited to patients less able to tolerate therapy (e.g., frail or older adult patients). However, one of the disadvantages of home-based CR is the lack of access to exercise equipment such as weights, treadmills, balance balls, and resistance machines. One resolution that has proven very effective is to use the patient’s own body weight in the form of push-ups, squats, sit-to-stand, and balancing/stretching exercises, negating the need for exercise equipment (Choxi et al., 2021).

Ideally, the patient’s care is coordinated by a multidisciplinary team who sees the patient regularly. For patients recovering from myocardial infarctions or surgical cardiac procedures, the team should include cardiac rehabilitation specialists. Cardiac rehabilitation specialists may include a cardiologist, nurse educator, nurse practitioner, dietitian, exercise physiologist, occupational therapist, physical therapist, psychologist, and psychiatrist who are all trained in cardiac rehabilitation programs. Also, family members may need help learning how to adjust to the patient’s disability and how to help the patient (NHLBI, 2021a).

Cardiac rehabilitation models are continuing to evolve to meet a variety of age groups and needs. Advanced age is associated with a higher prevalence of CAD as well as increased morbidity and mortality. Cardiac rehabilitation programs designed to meet the needs of older patients (>65 years of age) should include strength, balance, coordination, and flexibility. Evidence-based programs show that older patients can realize positive benefits from an exercise-based cardiac rehabilitation program to increase functional capacity, glucose control, quality of life, enhanced ability to perform ADLs, and reduced incidence of hospitalization.

In recent studies, exercise-based CR was found to be very cost-effective, with physiology and symptomology results similar to traditional CR. The beneficial effects of exercise for cardiac patients are weight reduction, reduction of LDL cholesterol, stress management, and blood pressure reduction (Edwards et al., 2017). CR/PR has also been found to increase longevity by 26%, reduce hospital admissions by 18%, and improve the quality of life of CAD patients who participate (AHA, 2021f).

Tai chi was found to be an effective exercise in a CR program. Although not widely accepted by the medical community as a successful adjunct to the rest of CR therapy, tai chi has been found to out-perform other exercises for stress management (Liu et al., 2018).

The 2018 Bipartisan Budget Act provided for physician assistants, nurse practitioners, and clinical nurse specialists to supervise patients in CR/PR beginning in 2022. This will make cardiac rehabilitation more accessible and less expensive, and the increase in the numbers of practitioners are hoped to greatly decrease wait times (AHA, 2021f).

CARDIAC REHABILITATION PHASES

Cardiac rehabilitation may be divided into four phases:

Phase I: Inpatient

The first phase of cardiac rehab takes place before the patient is discharged from the hospital. This phase generally consists of evaluation and assessment of the patient’s condition, motivation, and risk factors, accompanied by education and discharge planning. Much of the evaluation is done by physical therapists and occupational therapists (discussed earlier in this course).

The patient is gradually introduced to exercise on day two of cardiac rehab, with an intensity of exercise up to four metabolic equivalents (METS) (i.e., four times the resting metabolic rate, or four times the amount of oxygen consumed at rest; 1 MET=3.5 liters of oxygen). Ideally, by day four, the patient will be walking in the corridor for 5 to 10 minutes, 3 to 4 times per day.

Phase II: After Discharge

Phase II is a supervised phase that occurs in an outpatient setting such as a physical therapy clinic or a physician’s office. The patient is given clear instructions on their individualized exercise plan. The rehabilitation team may include the following professionals who work closely with the patient: exercise physiologists, occupational therapists, and physical therapists.

If a patient is considered home bound, a home physical therapy evaluation is completed and a program of home exercises outlined for the patient. The initial mode of exercise is usually walking on level ground, with an intensity goal of 2–4 METS or a score of 11–12 on the Rating of Perceived Exertion Scale (i.e., moderate intensity). Patients are generally advised to stay indoors for the first day or two because they may expect to feel fatigued and/or anxious, though patients with uncomplicated coronary artery disease may be advised to increase their walking distance progressively to 3–5 kilometers per day after 4–6 weeks.

During phase II rehabilitation, exercises may include:

• Treadmill walking
• Stationary bike
• Using an upper body ergometer (UBE)
• Rowing
• Upper- and lower-body strengthening using free weights
• Stretching

As the patient gains strength, these same exercises may progress in intensity and duration as the patient transitions from phase II to phase III (Sears, 2019).

Phase III: Outpatient Exercise Program

The goal of this phase is to enable the patient to exercise safely in a structured environment and to understand the benefits of exercise. Before starting an exercise program, it is common for a patient to undergo an exercise stress test until symptoms become apparent. The exercise test can be used as either a diagnostic or prognostic tool or as a test of functional capacity.

Cardiac patients should exercise in the low to moderate range of exercise intensity, corresponding to 60%–75% of maximum heart rate or 60%–70% of maximum heart rate reserve, which is equivalent to a score of 12–14 on the Rating of Perceived Exertion Scale. (The maximum heart rate is usually calculated by subtracting the patient’s age from 220. The heart rate reserve is calculated by subtracting the resting heart rate from the maximum heart rate.) The outpatient exercise program may last from 8–12 weeks, and patients generally attend 2–3 times per week.

Exercises during this phase promote total physical conditioning and include:

• Treadmills
• Cycle and arm ergometers
• Stair climbers
• Rowing machines

The exercise session should be preceded by a warm-up period lasting approximately 15 minutes, and the session itself lasts for 30 to 35 minutes, followed by a 10-minute cool-down period.

While the above exercises are largely aerobic in nature, resistance training can also be used in patients at low to moderate risk. However, patients are advised to spend some time on aerobic-type exercises before they initiate resistance exercise.

Phase IV: Independent Ongoing Conditioning

In this phase, the patient exercises independently and maintains the recommended lifestyle modifications. Increased physical activity and enhanced physical fitness can promote cardiovascular health, provided the patient keeps up with the exercise program. Indeed, the change in exercise behavior that the patient achieves must be lifelong in order to have any lasting benefit.

The physical therapist’s evaluation of a patient undergoing cardiac rehabilitation may include:

• Sternal precautions and scar mobility
• Exercise endurance level
• Assessment of range of motion and strength
• Assessment of gait, balance, and mobility
• Functional mobility tests (6-Minute Walk Test, TUG Test)
  (Sears, 2019)

The occupational therapist’s role in evaluating and treating patients during cardiac rehabilitation may include:

• Evaluating self-care skills and other activities of daily living
• Home safety evaluation
• Self-care skills training
• Recommendations for home management tasks and instrumental activities of daily living
• Teaching, strategies, and tools for health management (e.g., medication reminders and appointment schedules)
  (AOTA, 2020)

EXERCISE PROGRAMS

Formal cardiac exercise programs are supervised and tailored to the abilities of the patient, and these programs increase exercise levels appropriately but gradually. Physical conditioning from a regular exercise program generally:

• Improves the body’s metabolism as well as conditioning the heart muscles
• Increases the amount of activity a patient can do before developing chest discomfort
• Helps with losing weight and in maintaining weight loss
• Makes smoking cessation easier
• Improves lipid levels
• Lowers blood pressure
• Increases the feeling of well-being
• Increases the chances of surviving a myocardial infarction

LIFESTYLE MODIFICATIONS

For patients with existing CAD, lifestyle changes will improve their quality of life and their sense of well-being as well as slow or even reverse their illness. Patients may have modifiable risk factors that will put them at increased risk for continued medical problems related to CAD (see also “Preventable Risk Factors” earlier in this course).

Smoking cessation, reducing dietary calories and fats (especially saturated fats), and increasing exercise can significantly reduce a patient’s risk of further developing atherosclerotic cardiovascular disease. Therapeutic lifestyle changes are also the cornerstones of the treatment of diabetes, obesity, hypertension, insulin resistance, and most dyslipidemias (Lewis et al., 2020).

Smoking Cessation

Smoking injures cells throughout the body. Smoking contributes to the development of atherosclerotic cardiovascular disease, insulin resistance, type 2 diabetes, dyslipidemia, a variety of cancers, many lung diseases, gastrointestinal diseases, reproductive problems, osteoporosis, cataracts, age-related macular degeneration, hypertension, dental plaque formation, and hypothyroidism.

Patients should be educated on the medical consequences of smoking and strongly advised to stop smoking. It may be difficult for smokers to quit on their own. Counselors working with patients should encourage them to set a goal for a specific date they will begin to wean themselves from cigarettes. Patients may be referred to programs that include support, counseling, and the availability of antismoking medications.

Part of patient education about smoking is the information that nicotine is a very addictive drug. E-cigarettes, vaping, low-tar and nicotine cigarettes, and cigars all contain addicting dosages of nicotine.

Second-hand smoke is the name for the effects on nonsmokers who are exposed regularly to exhaled smoke. Inhaling smoke in this form is known to cause many of the same health problems that smokers incur. Recent studies show that e-cigarettes and vaping cause the same problems as second-hand smoke.

Weight Management

The ideal goal for a patient’s body mass index (BMI) should be between 18.5 and 24.9 kg/m², and the waist circumference should be <40 inches for men and <35 inches for women. Excess weight strains the heart, and excess fat leads to continuous high levels of blood lipids. Weight loss improves blood lipid profiles and helps lower blood pressure in overweight and obese people. For coronary artery disease patients who are overweight, weight loss can reduce the severity of their angina (CDC, 2020b; CDC, 2021e; Mayo Clinic, 2021c).

Exercise alone rarely leads to significant weight loss; a reduced-calorie diet is necessary. Reducing patients’ overall calorie intake will also improve their lipid profile. Besides eating fewer calories, scheduled meals and preplanned menus make weight loss easier. Weight loss programs include these and other techniques, and formal programs with regular advice, counseling, and supervision usually have the most success. From any starting weight, a loss of 10% should be considered a success if the patient manages to maintain the lower weight (WHO, 2021).

Nutrition

Eating nutritiously will slow the development of atherosclerosis. Simply reducing the calories in a patient’s diet will improve the lipid profile, and reducing the amount of fat will improve lipid levels even further.

For a heart-healthy diet, it is especially important to remove or limit foods that are high in saturated fats and trans fats. Instead, diets should focus on fresh fruits, vegetables, and whole grains. In addition, daily plant sterols and 10–25 g/day of soluble fiber (oat bran, beans, soy products, psyllium) are recommended. Moderate alcohol intake (≤20 g/day in men or ≤10 g/day in women) is associated with a reduced incidence of coronary artery disease events, although the mechanism behind this benefit is not well understood.

NUTRIENT COMPOSITION OF A HEART-HEALTHY DIET

Nutrient	Recommended Intake
(Cleveland Clinic, 2021b)
Saturated fat	5%–6% of total calories
Polyunsaturated fat	≤10% of total calories
Monounsaturated fat	≤20% of total calories
Total fat	26%–27% of total calories
Carbohydrates	50%–60% of total calories
Fiber	20–30 grams/day
Protein	Approximately 15% of total calories
Cholesterol	<200 mg/day
Total calories (energy)	Balance energy intake and expenditure to maintain desirable body weight and prevent weight gain

When choosing foods, it is important to read the nutrition label. Following are practical suggestions and information about managing the fats in one’s diet and maintaining a healthy diet:

• Monounsaturated and polyunsaturated fats are safe in moderate amounts (examples of monounsaturated fats are olive oil and canola oil; examples of polyunsaturated fats are soybean oil, corn oil, sunflower oil, and the oils in nuts).
• Fish usually have healthy oils, particularly omega-3, which is found in cold-water fish such as tuna, salmon, trout, sardines, and herring.
• Poultry without the skin has less fat than most cuts of beef.
• Beef, pork, chicken with skin, whole milk cheeses, and dairy products contain high amounts of cholesterol and saturated fat.
• Whole-grain foods, fruits, beans, and vegetables are healthy foods and high in fiber.
• Select 7–9 fruits and vegetables per day in various colors.
• Limit sweets, desserts, and sugary soda to a few times a month.
• Drink alcohol in moderation.
• Practice portion control.
  (Cleveland Clinic, 2021b)

Dental care and tooth replacement are an often-forgotten part of improving a patient’s diet, and oral health problems can indirectly increase the risk of developing cardiovascular disease. For instance, the bacteria from periodontal disease can cause an increase in C-reactive protein and inflammation. Inflammation from gum disease may then contribute to atherosclerotic plaque formation (Sanz et al., 2020).

Nutritional evaluation, counseling, and monitoring are essential to helping patients improve their diet. However, it is unrealistic to expect that a single nutritional educational session or program will result in long-term adherence to a sensible diet. Moreover, patients may find it difficult to absorb a large amount of information in a short period of time. Some patients, particularly those with comorbidities such as diabetes, obesity, or heart failure, as well as those from culturally and linguistically diverse backgrounds, may require more nutritional information and counseling than they can obtain in the context of a group program.

These factors make it especially important for patients and their family members to consult with a dietitian on a regular basis. Many hospitals offer preventive and therapeutic nutrition classes with an emphasis on cardiovascular health.

Emotional Support

For many patients, adjusting to the lifestyle changes needed to manage CAD can take time. Some patients may feel anxious or depressed and lose touch with their support system. Patients may also need to be away from their work for several weeks or months during treatment and recovery.

Counseling may be helpful for patients with depressive symptoms. Antidepressants may also be helpful for patients who have more severe or chronic symptoms. Occupational therapists can help in teaching new skills if a patient needs to modify activity levels because of their work or vocation.

Patients should be encouraged to learn stress reduction strategies that work for them. These may include mind-body techniques such as tai chi, yoga, journaling, guided imagery, or other creative outlets.

PATIENT EDUCATION GOALS

Patients should be taught the basics of the disease. They should learn that their sensitivity to ischemia will vary during the day. Angina is more likely in the early morning, with activities, just after meals, and according to the weather (cold weather is more stressful).

Patients can control their angina by the way they live their daily lives. Heart ischemia is brought on when the heart muscle is asked to work hard. Many tasks that cause chest pain can be done without discomfort simply by doing them more slowly or in smaller chunks.

Instruction and education from both physical and occupational therapists can assist patients if modifications are needed in activities of daily living in order to prevent ischemic symptoms. Walking, climbing stairs, vacuuming, raking, and lifting can all be done in a more leisurely way. Washing, carrying, and lifting should be done with fewer items. In their jobs, cardiac patients may have to learn to allot more time to each task.

For some people, anger, frustration, and other strong emotions can cause ischemic episodes. These patients need help in calming their emotions, and they should be referred to therapy programs that emphasize behavioral modification and that provide practical coping techniques for stressful situations. In addition, relaxation techniques, mental focusing strategies, guided imagery, and yoga have all proven useful in reducing stress for patients with coronary artery disease.

Patient and family education regarding the management of CAD may include the following:

• Understanding the warning signs of angina:
• Chest pain (may be described as heaviness, tightness, pressure, aching, burning, numbness, fullness, or squeezing)
• Pain or discomfort in other areas of the upper body, including the arms, left shoulder, back, neck, jaw, or stomach
• Difficulty breathing or shortness of breath
• Sweating or “cold sweat”
• Fullness, indigestion, or a choking feeling (may feel like heartburn)
• Nausea or vomiting
• Lightheadedness, dizziness, extreme weakness, or anxiety
• Rapid or irregular heart beats
• Calling 911 for severe chest pain that does not go away after five minutes
• Decreasing risk factors, including:
• Smoking or the use of tobacco products
• High blood cholesterol
• High blood pressure
• Uncontrolled diabetes
• Sedentary lifestyle
• Being obese or overweight
• Stress
• High-fat diet
• Taking medications as directed
• Understanding that cardiac procedures may be needed (now or in the future) to treat unstable disease
• The importance of regular visits to the cardiologist
  (Cleveland Clinic, 2021a)