Acute Coronary Syndrome Flashcards
Coronary artery disease
Accounts for most CV deaths in the US
Mostly caused by ______
_____ disease
Risk factors: nonmodifiable (genetics), modifiable (diet, smokin), contributing modifiable (_____)
atherosclerosis
Progressive
An example of contributing modifiable ~ Metabolic Syndrome criteria: large waist circumference (> 40” for men, >35” for women), triglyceride level (>150mg/dL), HDL (<40 for men, < 50 mg/dL for women), HTN, fasting blood sugar (>100 mg/dL)
In 90% of people, the ____ supplies the AV node and 55% the SA node.
What is the significance of this statement? What type of MI is this particularly concerning (causing blocks)?
RCA
STEMIs
Ischemia: increased myocardial oxygen demand (________) or decreased myocardial oxygen supply (_____) or both.
may cause ischemia->_____ (impaired perfusion) >_____ (no perfusion, tissue death). We must intervene to stop the progression.
How do we reduce ischemia?
myocardial oxygen demand - exercise, shoveling snow
myocardial oxygen supply - clot, anemia
injury
infarction
administer oxygen
_______: the culprit for most MIs
Blocked coronary artery
MI Classification
Affected area of the heart: anterior, lateral, inferior, or posterior
EKG changes produced: STEMI vs NSTEMI
Time-frame within progression of MI: acute, evolving, old
Ischemia, injury, and infarction: imbalance between myocardial blood supply and oxygen demand
Infarcted regions are _____ inactive
electrically
EKG evolution during acute STEMI
If successful _________ of the coronary occlusion is achieved, the elevated ST segments return to baseline without subsequent T wave inversion or Q wave development.”
Emphasizes the importance of early intervention, such as ________
early reperfusion
percutaneous coronary intervention.
A term used to refer to distinct conditions caused by a similar sequence of pathologic events that involve a temporary or permanent blockage of a coronary artery.
Patient presentation may be the same, but treatment varies on the diagnosis.
Acute Coronary Syndrome (ACS)
Acute Coronary Syndrome (ACS)
Unstable angina-
Partially occluded by a thrombus
Negative cardiac enzymes
NSTEMI-
Partially occluded by a thrombus
Positive cardiac enzymes
STEMI-
Totally occluded by a thrombus
Positive cardiac enzymes
Stable angina
What usually causes it? What usually relieves it?
Predictable. Can take nitro
Stable angina. Stable angina is the most common form of angina. It usually happens during activity (exertion) and goes away with rest or angina medication. For example, pain that comes on when you’re walking uphill or in the cold weather may be angina.
Stable angina pain is predictable and usually similar to previous episodes of chest pain. The chest pain typically lasts a short time, perhaps five minutes or less.
Unstable angina
New in onset, or chronic stable angina that increases in ________________
occurs at _________
pain refractory to ____
New in onset, or chronic stable angina that increases in frequency, duration, or severity
occurs at rest or minimal exertion
pain refractory to NTG
Know the difference between stable and unstable angina
Stable angina: predictable and consistent pain that occurs on exertion and is relieved by rest and/or nitroglycerin
•Unstable angina : symptoms increase in frequency and severity; may not be relieved with rest or nitroglycerin
Pain
PQRST
Precipitating events
Quality of pain
Radiation of pain
Severity of pain
Timing
Patient history of events particularly important with ACS. Why?
Time= determines treatment
Myocardial infarction (MI)
Irreversible myocardial cell death-_____ function of the heart stops in the necrotic area(s)
Cell death occurs after approximately ______ of ischemia
_______ causes 80-90% of all acute MIs (other causes?)
Role of collateral circulation
contractile
20 minutes
Thrombus formation
drugs, stress, allergic reactions, stress of surgery
Ischemic ST-segment depression of 0.5 mm (0.5 mV) or greater -OR- Dynamic T wave inversion with pain or discomfort / Transient ST elevation of 0.5 mm or greater for less than 20 minutes.”
NSTEMI
New ST segment elevation at the J point in at least two contiguous leads of ≥ 2 mm (0.2 mV) in men or ≥ 1.5 mm (0.15 mV) in women in leads V2-V3 and/or of ≥ 1 mm (0.1 mV) in other contiguous chest leads or the limb leads -OR- new or presumed new left bundle branch block.”
STEMI
Clinical manifestations of MI
Pain
severe immobilizing chest pain not relieved by rest, position change, or nitrate administration
“elephant on my chest”, “pressure”, “tightness”, “crushing”
Substernal, retrosternal, epigastric; may radiate to neck, jaw, arms or back
May occur at rest, with exertion, asleep, or awake
Clinical manifestations of MI
skin
ashen, clammy, & cool to touch, diaphoretic
Clinical manifestations of MI
cardiovascular
BP & HR increased at first.
Later, decreased BP with decreased cardiac output.
May have distant heart sounds, S3, S4, or loud holosystolic murmur
Clinical manifestations of MI
GI
N &V
Clinical manifestations of MI
fever
low grade within first 24 hrs up to 1 week
Clinical manifestations of MI
Pain
Skin
GI
Fever
Sympathetic nervous system
Clinical manifestations - atypical
Women: dizziness, SOB, unusual tiredness
Patients with diabetes mellitus: asymptomatic or atypical (dyspnea), “silent MI”
Older patient: change in mental status, dizziness, SOB, or a arrhythmia
Ignoring signs and symptoms
____ of the patients who die of ACS do so before reaching the hospital.
_____ or _____ is precipitating rhythm
VF likely to develop in first ____ after onset of symptoms
Education:
BLS: recognizing symptoms, activate EMS, early CPR, early defib with AED
Half
Ventricular fibrillation(VF) or pulseless ventricular tachycardia
4 hours
seek help early and don’t drive yourself, call 911
ACS Diagnostic studies
12- lead ECG
Serum cardiac markers
Coronary Angiography (cardiac cath)
ACS Diagnostic Studies 1
Distinguish between unstable angina (UA), non-ST segment elevation myocardial infarction (NSTEMI), ST elevation myocardial infarction (STEMI)
12-lead ECG (Obtain within 10 min on arrival to ED)
Serial
If available, will compare to old ECG
Why compare to old EKG? What is a pathologic Q wave?
myocardial infarction causes deep Q waves as a result of absence of depolarization current from dead tissue and receding currents from opposite side of heart
ACS Diagnostic Studies 2
Serum Cardiac Markers
Cardiac-specific troponin: Troponin T and Troponin I: serial sampling q6-8 hr x 3 (watch trend)
CK-MB isoenzyme (if a troponin test is unavailable, considered an acceptable substitution)
Myoglobin: one of the first to appear, lacks cardiac specificity
ACS Diagnostic Studies 3
evaluate patency of coronary arteries and collateral circulation
Coronary Angiography (cardiac cath)–
- STEMI patients
- high-risk patients with UA or NSTEMI, depending on risk stratification
Other Measures
Exercise or pharmacologic stress testing (after 3 negative troponins)
echocardiogram
______ exists to assist providers with decision-making in ACS.
risk stratification
Do not need to memorize
TIMI Risk Score: estimates mortality with UA, NSTEMI, STEMI
UA/NSTEMI
STEMI
GRACE ACS estimates admission-6month mortality for patients with ACS
HEART: predicts 6 week risk of major adverse cardiac event
EBP: CRP level and coronary artery calcium scoring to improve risk classification
Healing Process after MI
Inflammatory process:
________: changes in the infarcted myocardium causes changes in the unaffected myocardium
Leukocytes, cardiac enzymes released (within 24 hours)
Macrophages (by the fourth day)
Collagen matrix (10-14 days)
Scar tissue (by 6 weeks)
Ventricular remodeling
I. Complications of MI – arrhythmias
PVC- irritable heart-may precede vtach, vfib. This premature beat occurs in 90% of pts with acute MI
V. FIB.- Life-threatening arrhythmias occur most often with anterior wall infarction
3RD DEGEE HEART BLOCK- This can develop when significant portion of conduction system destroyed; this arrhythymia occurs in 20% of patients with RV infarction
MI Complications - arrhythmias
Arrhythmias
Present in 80-90% 0f patients
Most common cause of death in prehospital setting (get AED!)
____, _____, ____ can affect the myocardial cell’s sensitivity to nerve impulses
Ischemia, electrolyte imbalance, SNS stimulate
II. MI Complications
~ Heart failure
Signs and symptoms of right heart failure?
Signs and symptoms of left heart failure?
HF-occurs subtly initially-mild dyspnea, restlessness, sl. tachy.
Right- Periperheal edema, engorged liver, JVD
Left- Pulmonary edea, crackles, wet cough, sputum
III. MI Complications
~ Cardiogenic shock:
shock state resulting from impairment or failure of the myocardium.
~ _____ MI at greatest risk
May require ______________
Cardiogenic shock-occurring less with early & rapid treatment
anterior
intra-aortic balloon pump (IABP) counterpulsation
IV. MI Complications
Acute Pericarditis
occurs ___ days after MI
__________, usually comes on quickly
The pain tends to ease when patient _________. ___________ worsens it.
Friction rub, fever
Treatment:
2-3
sharp, stabbing chest pain
sits up and leans forward
Lying down and deep breathing
NSAIDs, ASA, or corticosteroids
IV. MI Complications
Dressler Syndrome “post myocardial infarction syndrome
develops _____. after MI
pericarditis with ___, ____, ____
elevated ___, ____
_____ throughout all 12 leads
Treatment: NSAIDS, corticosteroids
4-6 wks
fever, pleuritic pain, and effusion
WBC, ESR
elevated ST segments
V. Rare MI Complications
~ Ventricular Aneurysm
~ Papillary muscle dysfunction
MI complications
arrhythmias
heart failure
cardiogenic shock
acute pericarditis
Dressler Syndrome
Collaborative Care ACS
Ambulance/ED
- 12 lead ECG and start continuous ECG monitoring
- O2 by NC to keep oxygen sat>94%
- monitor vital signs, pulse oximetry
- IV access
- chewable aspirin, SL NTG, morphine sulfate for pain unrelieved by NTG
- bedrest and limit activity for 12-24 hrs
MONA; check vital signs before and after ___ and ____
MONA- morphine, oxygen, nitrogen, aspirin
NTG and Morphine
Collaborative care for patient with unstable angina/NSTEMI
Admit to monitored bed or chest pain unit
Acute intensive drug therapy: nitroglycerin, antiplatelet & anticoagulation therapy
Possible PCI (depending on risk stratification)
Collaborative care for patient with STEMI and positive cardiac markers
Reperfusion therapy
a.) mechanical reperfusion-PCI if available (cath lab)
b.) pharmacologic reperfusion-thrombolytic therapy (ED/ICU)
c.) surgical revascularization- CABG (OR)
Concurrent drug therapy (antiplatelet & anticoagulant therapy)
a.) Percutaneous Coronary Intervention (PCI)
Emergent PCI
“Time is muscle” door-to-balloon inflation (PCI) goal = ____
First line of treatment for ______
Advantages- less invasive, less risk of strokes, quicker recovery
Nursing care
Complications
PCIs with stents best vs PTCA only
Putting a balloon or stent in.
90 minutes
confirmed STEMI
b.) Thrombolytic therapy
Thrombolytic therapy (also called fibrinolytic therapy)
“Time is muscle” door-to-needle goal (fibrinolysis) = ___ (no later than _____ after onset of symptoms)
Used in facilities that do not have interventional cardiac catheterization lab or too far away to transfer
Given)__– lysis of thrombus
-Inclusion criteria
-Absolute/relative contraindications
-Nursing care
-Complications
30 minutes
6-12 hours
IV
c.) Coronary Artery Bypass Graft (CABG)
Coronary Surgical Revascularization
Nursing care:
Complications ie. Most common arrhythmia after CABG?
Nursing care – Early ambulation (prevents pneumonia) , I&O, incision site infection risk, coughing and deep breathing, Incentive Spirometer (prevents pneumonia ), assessing pedal pulses, bowel function
Complications ie. Most common arrhythmia after CABG? A. Fib
Collaborative Care: ACS: Pharmacology Therapy
dual antiplatelet therapy (aspirin and clopidogrel)
systemic anticoagulation
nitroglycerin IV
morphine sulfate
B-adrenergic blockers
ACE inhibitors
antidysrhythmic drugs
lipid-lowering drugs
stool softeners
Precautions with nitroglycerin
Cannot give IV NTG to someone who has taken sildenafil within 24 hrs or tadalafil within 48 hrs-why?
Why is NTG given cautiously to patients with a right ventricular infarct (inferior MI)?
Drops BP too much
Affects preload and can bottom out the patient
Ongoing Nursing Considerations
Concentrated repeated pain assessment
Physiological monitoring
Alleviation of stress & anxiety
Depression is common after having an MI and CABG
Gradually increase activity
Discharge Educational Needs
Patient & Family teaching
Preventative: what to do if they have chest pain
Medication (what they are, schedule, why they help); ie.NTG SL
Diet/Nutrition:
C & DB (IS, splinting with pillow)
Incisional care
Exercise/Cardiac rehab
Smoking Cessation
Follow up w/ PCP
Low sat fat, low sodium, fruits and veggies: foods rich in folic acid such as green leafy vegetables, fruits; vitamins w/ folic acid, B complex vitamins (lowers blood homocysteine levels)
List what conditions fall under the term “ACS
Unstable angina, Nstemi, and Stemi
What are the two main diagnostic tools to determine an MI?
12 lead, troponin
What are 3 interventions for MI?
Reperfusion therapy
a.) mechanical reperfusion-PCI if available (cath lab)
b.) pharmacologic reperfusion-thrombolytic therapy (ED/ICU)
c.) surgical revascularization- CABG (OR)
Most common cause of death in prehospital setting
arrthymias
First line of treatment for confirmed STEMI
PCI
