Acute Coronary Syndrome

Question 1

Angina

Answer 1

Temporary chest pain of sensation of pressure when the heart muscle is not receiving enough oxygen causing ischemia (May lead to necrosis)

• Narrowed arteries
• Usually occurs first during physical exertion or stress
• Heart works harder and increases the need for O2 but can’t get it through the arteries
• If arteries narrowed 70% or more, may have angina even at rest
• Worse in the cold

Types
Silent, Nocturnal, Variant, Unstable

Symptoms
Pain (discomfort/heaviness) in either shoulder, inner arm, through to the back, in the throat , jaw or teeth

Unstable angina = worsening and more frequent attacks which can lead to MI

Question 2

Diagnostics for Angina

Answer 2

• Symptoms and presence of risk factors
• EKG – sometimes of no use
• Give Nitroglycerine - relief within 3 minutes
• Exercise/Drug Stress tests
• Echocardiogram
• Angiography
• Cardiac caths
• Holter monitor

Question 3

Treatment for Angina

Answer 3

Goal is to prevent or slow ischemia –by slowing the progression of CAD

• Treat HTN and cholesterol
• Lifestyle changes

Drugs:

• Beta blockers
• Nitrates
• Calcium channel blockers
• ACE inhibitors
• Antiplatelet
• Other – anticoags, thrombolytics, opioids
• ***Cannot give rectal suppositories

Question 4

Myocardial Infarction (MI)

Answer 4

Irreversible myocardial cell damage usually due to thrombus formation

MI takes time – unstable angina then MI

• Days to weeks ahead – fatigue, SOB intermittent chest pain
• These become more frequent even with less exertion
• Cardiac cells begin to die in 20 min of no O2: Starts on the inside of the muscle & progresses to the full thickness in 4-6 hours

Symptoms
Pain – heaviness, tightness, burning, constriction, crushing
- Location
- Substernal, retrosternal, epigastric areas
- Some have no pain
Nausea/Vomiting
Fever
CV - Abnormal heart sounds, elevated BP then a drop, decreased urine output, crackles, jugular distention, peripheral edema

Diagnostics
- Goal is to differentiate between unstable angina and MI
EKG
- To look at the ST segment and T wave – Elevate =extensive damage
- May look normal if just happening – repeat for changes

Serum Cardiac Markers

• Troponin - protein released from necrotic heart muscle- if they have this, they have an MI
• Isoenzymes – CK-MB
• Myoglobin protien – Injury
• C-Reactive protien
• Cardiac Natriuretic Peptide Markers (ANP, BNP, NT-Pro-BNP)
• Homocysteine
• Serum Lipids

Treatment

• Position upright
• Oxygen – keep sat at 93%
• Get VS and 12 Lead and continuous monitoring
• Start an IV
• Don’t give a suppository
• Sublingual Nitroglycerine and ***chewable ASA- needs to be chewed so that it disolves better and quickly to make the platelets more slippery, morphine, beta blockers- should happen right away, and ACE inhibitors- may not have to happen right away
• Obtain diagnostic Lab tests within 10 minutes of admission to the ED.
• Angina is telling you that the heart isn’t getting enough oxygen
• **Clot busters need to be given within the first 6 hours of pain starting. **Do not give clot busters to patients with GI bleeds, strokes, b/p problems, or fresh post op

The doctors may consider opening the vessel (PCI- cath) or even thrombolytic therapy. There are surgical interventions also

If pt. came in by ambulance, a lot of this would have already been done but you need to find out the time of treatments from EMT

Question 5

ACS Care

Answer 5

Nursing Diagnosis:
Ineffective cardiac tissue perfusion- can sit patient up and make sure they are getting a good amount of oxygen. 
Risk for fluid imbalance
Risk for ineffective peripheral tissue perfusion
Death anxiety
Deficient knowledge
Pain
Activity Intolerance

Rehab:

• Up in a chair
• Walk to Bathroom and non stressful activity– 2/3
• Lifestyle changes- diet and exercises, stop smoking
• Increase activity
• After discharge, amount and intensity of activity is increased slowly to full range
• Outpatient rehab is usually 12 weeks- Usually go the full 3 months for cardiac rehab, but usually after about 6 weeks they are in better shape

Collaborative Problems:
Acute pulmonary edema
Dysrhythmias and cardiac arrest
Scar tissue = weakened muscle action
Heart failure
Cardiogenic shock
Pericarditis and cardiac tamponade
Ventricular aneurysm
Clots

Patient Teaching:
Diet- DASH diet, low fat (chicken, fish, veggies, fruit, diabetic diet)

Physical activity (761)- increase physical activity

Lifestyle changes

Sexual activity (760)- encourage the patient and sexual partner to talk to the doctor about safe sexual activity