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Module 1 > Acute Coronary Syndrome > Flashcards

Acute Coronary Syndrome Flashcards

1
Q

Coronary artery disease

Accounts for most CV deaths in the US

Mostly caused by ______

_____ disease

Risk factors: nonmodifiable (genetics), modifiable (diet, smokin), contributing modifiable (_____)

A

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)

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2
Q

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)?

A

RCA

STEMIs

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3
Q

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?

A

myocardial oxygen demand - exercise, shoveling snow
myocardial oxygen supply - clot, anemia

injury
infarction

administer oxygen

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4
Q

_______: the culprit for most MIs

A

Blocked coronary artery

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5
Q

MI Classification

A

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

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6
Q

Ischemia, injury, and infarction: imbalance between myocardial blood supply and oxygen demand

Infarcted regions are _____ inactive

A

electrically

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7
Q

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 ________

A

early reperfusion

percutaneous coronary intervention.

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8
Q

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.

A

Acute Coronary Syndrome (ACS)

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9
Q

Acute Coronary Syndrome (ACS)

A

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

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10
Q

Stable angina

What usually causes it? What usually relieves it?

A

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.

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11
Q

Unstable angina

New in onset, or chronic stable angina that increases in ________________

occurs at _________

pain refractory to ____

A

New in onset, or chronic stable angina that increases in frequency, duration, or severity

occurs at rest or minimal exertion

pain refractory to NTG

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12
Q

Know the difference between stable and unstable angina

A

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

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13
Q

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

A
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14
Q

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

A

contractile

20 minutes

Thrombus formation
drugs, stress, allergic reactions, stress of surgery

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15
Q

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.”

A

NSTEMI

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16
Q

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.”

A

STEMI

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17
Q

Clinical manifestations of MI

Pain

A

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

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18
Q

Clinical manifestations of MI

skin

A

ashen, clammy, & cool to touch, diaphoretic

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19
Q

Clinical manifestations of MI

cardiovascular

A

BP & HR increased at first.

Later, decreased BP with decreased cardiac output.

May have distant heart sounds, S3, S4, or loud holosystolic murmur

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20
Q

Clinical manifestations of MI

GI

A

N &V

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21
Q

Clinical manifestations of MI

fever

A

low grade within first 24 hrs up to 1 week

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22
Q

Clinical manifestations of MI

A

Pain
Skin
GI
Fever

Sympathetic nervous system

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23
Q

Clinical manifestations - atypical

A

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

24
Q

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

A

Half

Ventricular fibrillation(VF) or pulseless ventricular tachycardia

4 hours

seek help early and don’t drive yourself, call 911

25
Q

ACS Diagnostic studies

A

12- lead ECG

Serum cardiac markers

Coronary Angiography (cardiac cath)

26
Q

ACS Diagnostic Studies 1

Distinguish between unstable angina (UA), non-ST segment elevation myocardial infarction (NSTEMI), ST elevation myocardial infarction (STEMI)

A

12-lead ECG (Obtain within 10 min on arrival to ED)

Serial

If available, will compare to old ECG

27
Q

Why compare to old EKG? What is a pathologic Q wave?

A

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

28
Q

ACS Diagnostic Studies 2

Serum Cardiac Markers

A

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

29
Q

ACS Diagnostic Studies 3

evaluate patency of coronary arteries and collateral circulation

A

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

30
Q

______ exists to assist providers with decision-making in ACS.

A

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

31
Q

Healing Process after MI

Inflammatory process:

________: changes in the infarcted myocardium causes changes in the unaffected myocardium

A

Leukocytes, cardiac enzymes released (within 24 hours)
Macrophages (by the fourth day)
Collagen matrix (10-14 days)
Scar tissue (by 6 weeks)

Ventricular remodeling

32
Q

I. Complications of MI – arrhythmias

A

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

33
Q

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

A

Ischemia, electrolyte imbalance, SNS stimulate

34
Q

II. MI Complications

~ Heart failure

Signs and symptoms of right heart failure?

Signs and symptoms of left heart failure?

A

HF-occurs subtly initially-mild dyspnea, restlessness, sl. tachy.

Right- Periperheal edema, engorged liver, JVD

Left- Pulmonary edea, crackles, wet cough, sputum

35
Q

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

A

anterior

intra-aortic balloon pump (IABP) counterpulsation

36
Q

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:

A

2-3

sharp, stabbing chest pain

sits up and leans forward
Lying down and deep breathing

NSAIDs, ASA, or corticosteroids

37
Q

IV. MI Complications

Dressler Syndrome “post myocardial infarction syndrome

develops _____. after MI

pericarditis with ___, ____, ____

elevated ___, ____

_____ throughout all 12 leads

Treatment: NSAIDS, corticosteroids

A

4-6 wks

fever, pleuritic pain, and effusion

WBC, ESR

elevated ST segments

38
Q

V. Rare MI Complications

A

~ Ventricular Aneurysm

~ Papillary muscle dysfunction

39
Q

MI complications

A

arrhythmias
heart failure
cardiogenic shock
acute pericarditis
Dressler Syndrome

40
Q

Collaborative Care ACS

Ambulance/ED

A
  • 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
41
Q

MONA; check vital signs before and after ___ and ____

MONA- morphine, oxygen, nitrogen, aspirin

A

NTG and Morphine

42
Q

Collaborative care for patient with unstable angina/NSTEMI

A

Admit to monitored bed or chest pain unit

Acute intensive drug therapy: nitroglycerin, antiplatelet & anticoagulation therapy

Possible PCI (depending on risk stratification)

43
Q

Collaborative care for patient with STEMI and positive cardiac markers

A

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)

44
Q

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.

A

90 minutes

confirmed STEMI

45
Q

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

A

30 minutes
6-12 hours

IV

46
Q

c.) Coronary Artery Bypass Graft (CABG)

Coronary Surgical Revascularization

Nursing care:

Complications ie. Most common arrhythmia after CABG?

A

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

47
Q

Collaborative Care: ACS: Pharmacology Therapy

A

dual antiplatelet therapy (aspirin and clopidogrel)
systemic anticoagulation
nitroglycerin IV
morphine sulfate
B-adrenergic blockers
ACE inhibitors
antidysrhythmic drugs
lipid-lowering drugs
stool softeners

48
Q

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)?

A

Drops BP too much

Affects preload and can bottom out the patient

49
Q

Ongoing Nursing Considerations

A

Concentrated repeated pain assessment
Physiological monitoring
Alleviation of stress & anxiety
Depression is common after having an MI and CABG
Gradually increase activity

50
Q

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

A

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)

51
Q

List what conditions fall under the term “ACS

A

Unstable angina, Nstemi, and Stemi

52
Q

What are the two main diagnostic tools to determine an MI?

A

12 lead, troponin

53
Q

What are 3 interventions for MI?

A

Reperfusion therapy
a.) mechanical reperfusion-PCI if available (cath lab)
b.) pharmacologic reperfusion-thrombolytic therapy (ED/ICU)
c.) surgical revascularization- CABG (OR)

54
Q

Most common cause of death in prehospital setting

A

arrthymias

55
Q

First line of treatment for confirmed STEMI

A

PCI

Module 1 (11 decks)

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