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CCRN - cardiac > 3. Acute Coronary Syndrome (ACS) > Flashcards

3. Acute Coronary Syndrome (ACS) Flashcards

1
Q

Several Q about ACS on exam. May describe ECG findings and a clinical picture, then ask about what type of ACS the pt has. Or the question may tell you the type of aCS the pt has (e.g anterior MI) and expect you to know what the typical clinical picture would be for this type of MI. What do you need to understand?

A

Which leads are associated with which wall of the heart.

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2
Q

Risk factors for CAD: Non-modifiable include

A

Age, sex, family hx, genetics

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3
Q

Risk factors for CAD: Modifiable

A

Smoking, atherogenic diet, alcohol intake, physical activity, dyslipidemias, hypertension, obesity, diabetes, metabolic syndrome

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4
Q

Spectrum of Ischemic Heart Disease:

A
  1. Asymptomatic coronary artery disease (CAD)
  2. Stable angina, chest pain with activity, predictable, lesions are usually fixed and calcified.
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5
Q

Acute Coronary Syndrome

A
  1. Due to platelet-mediated thrombosis
  2. May result in sudden cardiac death
  3. three different types
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6
Q

What are the 3 diff types of ACS

A
  1. Unstable Angina
  2. Non-ST elevation Myocardial Infarction (NSTEMI)
  3. ST Elevation Myocardial Infarction (STEMI)
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7
Q

Unstable Angina:

A

Chest pain at rest, unpredictable, may be relieved with nitroglycerin, troponin negative, ST depression, or T-wave inversion on the ECG.

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8
Q

Non-ST Elevation Myocardial Infarction (NSTEMI)

A

Troponin positive, ST depression, T-wave inversion on the ECG, unrelenting chest pain

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9
Q

ST Elevation Myocardial Infarction (STEMI)

A

Troponin positive, ST elevation in 2 or more contiguous leads, unrelenting chest pain

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10
Q

**Variant or Prinzmetal’s angina

A

-A type of unstable angina associated with transient ST segment elevation.
-Due to coronary artery spasm with or w/out atherosclerotic lesions.
-Occurs at rest, may be cyclic (same time each da)
-May be precipitated by nicotine, ETOH, cocaine ingestion
-Troponin negative
-Nitroglycerin (NTG) administration results in relief of chest pain, STs return to normal.

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11
Q

Note: Pts may not have chest pain with an MI, especially

A

especially women, those with diabetes, and those older than 75. Nausea, SOB, extreme fatigue, syncope, acute delirium, or falling may be signs of ACS in these populations.

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12
Q

Management of Acute Chest Pain

A
  1. stat ECG
  2. Aspirin
  3. Anticoagulant
  4. Antiplatelet agents
  5. Beta blocker
    6 Treat pain
  6. Hx, Risk Factor asset
  7. ECG lead changes and location of CAD
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13
Q

Mgmt of Acute Chest Pain: Stat ECG

A

Stat ECGs, done and read within 10 minutes.
1. Allows categorization to STEMI or NSTEMI/unstable angina
2. Allows risk stratification to high, medium or low.

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14
Q

Mgmt of Acute Chest Pain: ECG results (3 possibilities)

A
  1. ST elevation…STEMI
  2. ST depression, T wave inversions… NSTEMI/UA
  3. No acute change
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15
Q

Mgmt of Acute Chest Pain: Aspirin:

A

Give ASAP!!! Aspirin is chewed; improves morbidity/mortality

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16
Q

Mgmt of Acute Chest Pain: Anticoagulant

A

Heparin or Enoxaparin

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17
Q

Mgmt of Acute Chest Pain: Antiplatelet agents

A

Clopidogrel (Plavix)
Abciximab (Reopro)
Eptifibatide (Integrillin)
Tirofiban (Aggrastat)

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18
Q

Mgmt of Acute Chest Pain: Beta Blocker

A

-unless ACS is due to COCAINE.
-Use cardioselective such as metoprolol (Lopressor)
-do NOT use non-cardioselective such as propranolol (infernal)
-Contraindications include hypotension, bradycardia, use of phosphodiesterase-inhibitor drugs such as sildenafil (Viagra)

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19
Q

Mgmt of Acute Chest Pain: Treat Pain

A

-Nitroglycerin
-Morphine

20
Q

Mgmt of Acute Chest Pain: History/Risk Factor Assessment

A

-Lab Assessment
-Cardiac biomarkers, lipid profile, CBC, electrolytes, BUN, creatinine, Magnesium, PT, PTT

21
Q

ECG lead changes and location of coronary artery disease

A

-Changes in II, III, aVF —> right coronary artery (RCA), inferior LV
-Changes in V1, V2, V3, V4 –> left anterior descending (LAD), anterior LV
-Changes in V5, V6, I, aVL–>circumflex, lateral LV
-Changes in V5, V6 —> low lateral LV
-Changes in I, aVL –> high lateral LV
-Changes in V1, V2 –>RCA, posterior LV
-Changes in V3R, V4R –> RCA, right ventricular (RV) infarct.

22
Q

Changes in II, III, aVF indicate

A

Right coronary artery (RCA), inferior LV

23
Q

Changes in V1, V2, V3, V4 indicate

A

left anterior descending (LAD), anterior LV

24
Q

Changes in V5, V6, I, aVL indicate

A

circumflex, lateral LV

25
Q

Changes in V5, V6

A

low lateral LV

26
Q

Changes in I, aVL indicate

A

high lateral LV

27
Q

Changes in V1, V2 indicate

A

RCA, posterior LV

28
Q

Changes in V3R, V4R indicate

A

RCA, right ventricular (RV) infarct

29
Q

Differentiation of the Types of Acute MI

A
  1. Inferior MI
  2. Right Ventricular (RV) infarct
  3. Anterior MI
  4. Lateral MI
30
Q

**Inferior MI is associated with

A

-Right Coronary Artery (RCA) Occlusion.
-ST elevation in II, III, and aVF
-Reciprocal changes in lateral wall (I, aVL)
-Associated with AV conduction disturbances: 2nd degree Type I AV block, 3rd degree AV block, sick sinus syndrome (SSS), and sinus bradycardia.
-Development of systolic murmur: mitral valve regurgitation (MVR) secondary to papillary muscle rupture (posterior papillary muscle has only one source of blood supply, the RCA).
-tachycardia is associated with inferior MI –> higher mortality
-Use beta blockers and NTG with CAUTION

31
Q

**Right Ventricular (RV) infarct:

A

-The RCA, which supplies the inferior wall of the LV, also supplies the RV; therefore about 30% of inferior wall MI pts also have a RV infarct.
-Size of the infarct will determine symptoms.
-A right-sided ECG may demonstrate the ST changes.
-Signs/symptoms:
-JVD at 45 degrees, high CVP, hypotension, usually clear lungs, bradyarrhythmias
-ECG with ST elevation in V3R, V4R
-Trmt: Fluids & positive inotropes
-Avoid:
-Preload reducers –>nitrates, diuretics
-Caution with beta blockers, often cannot give initially due to hypotension

32
Q

**Anterior MI is associated with

A

-Associated with Left Anterior Descending (LAD) occlusion
-ST elevation in V1 - V4: precordial leads, V leads
-Reciprocal changes (ST depression) in inferior wall (II, III, aVF)
-May develop 2nd-degree Type II AV block or RBBB (the LAD supplies the common bundle of His) —>OMINOUS sign
-Devpmt of systolic murmur: possible ventricular septal defect
-Higher mortality than inferior MI: HEART FAILURE

33
Q

Lateral MI associated with

A

-ST elevation in V5, V6 (low lateral)
-ST elevation in I, aVL (high lateral)
-Generally involves left circumflex artery

34
Q

Treatment for STEMI

A

-Determine onset of infarct, if symptoms < 12 hours–> REPERFUSION
-Percutaneous coronary intervention (PCI) – standard is door-to-balloon within 90 min.
-Fibrinolytic drug therapy – standard is door-to-drug within 30 min

35
Q

Eligibility criteria for STEMI trmt

A

-ST elevation in 2 or more contiguous leads OR new onset LEFT bundle branch block (LBBB).
-Onset of chest pain < 12 hours
-Chest pain of 30 min in duration
-Chest pain unresponsive to sublingual (SL) nitroglycerin (NTG)

36
Q

Patient care following reperfusion for STEMI (PCI pathway)

A

PCI (90 min, door-to-balloon inflation in coronary artery at point of lesion):
-monitor for signs of reocclusion: chest pain, ST elevation –>contact MD
-Monitor for vasovagal reaction during sheath removal –> give fluids, atropine
-Monitor for bleeding: sheath site
-Monitor for bleeding: retroperitoneal
-Monitor for vascular complications

37
Q

Patient care following reperfusion for STEMI (PCI pathway): Monitor for signs of reocclusion

A

chest pain, ST elevation –>contact MD

38
Q

Patient care following reperfusion for STEMI (PCI pathway): Monitor for vasovagal reaction during sheath removal

A

Give fluids, atropine
- Hypotension < 90 systolic with or without bradycardia, absence of compensatory tachycardia
- Associated symptoms of pallor, nausea, yawning, diaphoresis

39
Q

Patient care following reperfusion for STEMI (PCI pathway): Monitor for bleeding: sheath site

A

-Immediately apply manual pressure 2 finger breadths above the puncture site.
-Continue manual pressure for a minimum of 20 min (30 min if still on GP IIb/IIIa inhibitors) to achieve hemostasis.

40
Q

Patient care following reperfusion for STEMI (PCI pathway): Monitor for bleeding: retroperitoneal

A

Give fluids, blood products
Look for:
-sudden hypotension
-severe low back pain

41
Q

Patient care following reperfusion for STEMI (PCI pathway): Monitor for vascular complications

A

Do pulse assessments

42
Q

Patient care following reperfusion for STEMI (Fibrinolytic pathway)

A

30 minutes door-to-drug administration

43
Q

Absolute contraindications for Fibrinolytic Therapy

A

-Any prior intracranial hemorrhage
-Known structural cerebral vascular lesion (e.g., arteriovenous malformations)
-Known malignant intracranial neoplasm (primary or metastatic)
-Ischemic stroke within 3 months EXCEPT acute ischemic stroke within 3 hrs
-Suspected aortic dissection
-Active bleeding or bleeding diathesis (excluding menses)
-Significant closed-head or facial trauma within 3 months

44
Q

Patient care following reperfusion for STEMI (Fibrinolytic pathway): Evidence of Reperfusion**

A

Evidence of Reperfusion
-Chest pain relief: due to fibrinolysis of clot
-Resolution of ST segment deviations: due to return of blood flow
-Marked elevation of troponin/CK-MB: due to myocardial “stunning” when vessel opens
-Reperfusion arrhythmias (VT, VF, accelerated idioventricular rhythm [AIVR]): due to myocardial “stunning” when vessel opens

45
Q

Patient care following reperfusion for STEMI (Fibrinolytic pathway): Nursing Management

A

-Assess for major and minor bleeding
-Major bleed, change in LOC, brain bleed
-Institute bleeding precautions
-Assess for reperfusion (see above)
-Assess for reocclusion as evidenced by recurring chest pain, ST deviation

46
Q

Treatment of NSTEMI

A

-NO emergent reperfusion
-Same meds as STEMI
-If high risk score or continued chest pain, signs of instability, start GP IIb/IIIa inhibitors (Integrillin, Reopro) and prepare for diagnostic cardiac Cath within 24 hrs.

47
Q

Complications of Acute MI

A

ARRHYTHMIAS – MOST COMMON
-VT or VF
-Defib VF
-Drug therapy for stable, sustained VT and to prevent recurrent VF.
-Synchronized cardioversion for unstable, sustained VT

-Bradycardia, heart blocks, SSS (sick sinus syndrome)
-Afib
-increases risk of mortality 10 - 15%, even when returned to NSR

-HF
-Cardiogenic shock
-Reinfarction
-Thromboembolic events
-Pericarditis
-Ventricular aneurysm
-Ventricular septal defect
-Papillary muscle rupture
-Cardiac wall rupture

CCRN - cardiac (15 decks)

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