Acute Coronary Syndrome (ACS)

Question 1

ACS continuum
1. unstable angina or 2. acute MI

ECG changes (ST elevation) present and elevated troponin = _________

ECG changes absent (no ST elevation) and elevated troponin = _______

ECG changes absent and normal troponin = ________

Answer 1

ECG changes (ST elevation) present -> elevated troponin = STEMI

ECG changes absent (no ST elevation) -> elevated troponin -> NSTEMI (heart damage present)

ECG changes absent -> normal troponin -> unstable angina (no heart damage)

Question 2

Unstable angina T/F
1. Often occurs at rest-usually more than 20 minutes duration
2. New-onset that markedly limits physical activity
3. Increasing angina more frequent, longer in duration, and occurs with less exertion than stable/previous angina
4. Relieved by rest or nitroglycerin
5. May have associated symptoms
6. Unpredictable and is an emergency
7. Elevations in serum troponin

Answer 2

1. Often occurs at rest-usually more than 20 minutes duration
2. New-onset that markedly limits physical activity
3. Increasing angina more frequent, longer in duration, and occurs with less exertion than stable/previous angina
   X 4. Poorly relieve by rest or nitroglycerin
4. May have associated symptoms
5. Unpredictable and is an emergency
   X 7. No elevations in serum troponin

Question 3

Women and atypical angina s/s (4)

Answer 3

Fatigue (most prominent)
SOA
Indigestion
Anxiety

Question 4

_________ pain

Precipitated by exertion/stress

Relieved by rest/nitroglycerin

Lasts < 15 minutes

Answer 4

stable angina

Question 5

_____ pain

Occurs without cause, often in early morning

Relieved only by opioids

Last 20 minutes or longer

Frequently presents with associated symptoms (n/v, diaphoresis, dyspnea, anxiety/fear, dysrhythmias)

Answer 5

MI

unstable angina
- often occurs at rest/without activity/exertion or with minimal activity (not morning)
- poorly relieved by rest or nitroglycerin
- lasts 20 mins or longer
- May have associated symptoms

Question 6

MI T/F
1. Process takes time (cells can stand ischemia x 20 minutes before cell death)

2. Subendocardium layer (inside layer) affected earliest (takes 4-6 hours for entire thickness of heart muscle to necrose)
3. The location correlates with the involved coronary circulation (i.e., blockage in the left anterior descending coronary artery causes damage to the left ventricle)
4. MIs are described based on severity of damage (anterior, inferior, lateral, septal or posterior)

Answer 6

Process takes time (cells can stand ischemia x 20 minutes before cell death)

Subendocardium layer affected earliest (takes 4-6 hours for entire thickness of heart muscle to necrose)

The location correlates with the involved coronary circulation (i.e., blockage in the left anterior descending coronary artery causes damage to the left ventricle)

X - MIs are described based on location of damage (anterior, inferior, lateral, septal or posterior)

Question 7

What does MI Pain feel like?

Severe, immobilizing chest pain not relieved by______, ________, or ________ (hallmark of MI)

Persistent or intermittent?
discomfort described as heaviness, pressure, tightness, burning, constriction, and crushing

________ and patients with ___________ may have different or no symptoms (silent MI)

Answer 7

Severe, immobilizing chest pain not relieved by rest, position changes, or nitrates (hallmark of MI)

Persistent & described as heaviness, pressure, tightness, burning, constriction, and crushing

Women/patients with diabetes mellitus may have different or no symptoms (silent MI)

Question 8

Complications of MI (5)

Answer 8

1. Dysrhythmias (most common complication; most common cause of pre-hospital death; reason patients must be on telemetry)
2. Heart failure (occurs from the reduced pumping action of heart; occurs esp. with damage to the left ventricle)
3. Cardiogenic shock (low BP/decreased perfusion due to severe left-ventricular failure; if occurs, high mortality rate)
4. Papillary muscle dysfunction (consequence: new murmur noted)
5. Pericarditis (occurs 2-3 days after acute MI; consequence: new pericardial friction rub)

Question 9

Complications of MI

1. ____________ (most common complication; most common cause of pre-hospital death; reason patients must be on telemetry)
2. Heart failure (occurs from the reduced pumping action of heart; occurs esp. with damage to the _________)
3. Cardiogenic shock (_______/________ due to severe left-ventricular failure; if occurs, high mortality rate)
4. Papillary muscle dysfunction (consequence: new _______ noted)
5. Pericarditis (occurs 2-3 days after acute MI; consequence: new ___________)

Answer 9

1. Dysrhythmias (most common complication; most common cause of pre-hospital death; reason patients must be on telemetry)
2. Heart failure (occurs from the reduced pumping action of heart; occurs esp. with damage to the left ventricle)
3. Cardiogenic shock (low BP/decreased perfusion due to severe left-ventricular failure; if occurs, high mortality rate)
4. Papillary muscle dysfunction (consequence: new murmur noted)
5. Pericarditis (occurs 2-3 days after acute MI; consequence: new pericardial friction rub)

Question 10

Pericardial friction rub

High-pitched, scratchy grating sound heard best with the patient sitting and leaning _______ and while holding their breath at end of ________

indicative of _________

caused by friction between the inflamed pericardial surfaces

Answer 10

High-pitched, scratchy grating sound heard best with the patient sitting and leaning forward and while holding their breath at end of expiration; indicative of pericarditis; caused by friction between the inflamed pericardial surfaces

Question 11

High-pitched, scratchy grating sound heard best with the patient sitting and leaning forward and while holding their breath at end of expiration; indicative of pericarditis; caused by friction between the inflamed pericardial surfaces

Answer 11

Pericardial friction rub

Question 12

How can you differentiate between pericardial friction rub (heart) and a pleural friction rub (lungs)?

Answer 12

Have patient hold their breath. If you still hear the rub, it is cardiac.

Question 13

Diagnostic testing for ACS: EKG

Used to _____ or _____ unstable angina/MI

Look for changes in the _____, _____, and ______

_______ = more extensive infarct

__________ and _______ = transient thrombosis/incomplete
occlusion

Serial EKGs may be ordered, as ______ and _______ can change over a matter of a few hours

Answer 13

Used to r/o or confirm unstable angina/MI

Look for changes in the QRS complex, ST segment & T wave

STEMI = “ST Elevated Myocardial Infarction” 
NSTEMI = “Non-ST Elevated Myocardial Infarction” 

STEMI – more extensive infarct
NSTEMI or UA = transient thrombosis/incomplete
occlusion

Serial EKGs may be ordered, as ischemia & infarction can change over a matter of a few hours

Question 14

ST elevation vs. depression in relation to the isoelectric line on an EKG

Normal: ST segment ______ the isoelectric line
ST elevation: ST segment _____ the isoelectric line
ST depression: ST segment ______ the isoelectric line

Answer 14

Normal: ST segment along the isoelectric line
ST elevation: ST segment above the isoelectric line
ST depression: ST segment below the isoelectric line

Question 15

Ischemia vs infarction

___________: reduced (but not obstructed) blood flow

__________: obstructed blood supply causing local tissue death

Answer 15

Ischemia: reduced (but not obstructed) blood flow

Infarction: obstructed blood supply causing local tissue death

Question 16

ST elevation vs depression
T/F

1. ST elevation occurs with infarction
2. this is reversible
3. ST depression occurs with ischemia

Answer 16

T - ST elevation occurs with infarction

F - (this is permanent)

T - ST depression occurs with ischemia

Question 17

Diagnostic testing for ACS: serum cardiac markers (Serum troponin, CK-MB & myoglobin.)

1. which has greater sensitivity & specificity ?
2. Troponin increases in __-__ hrs, returns to baseline in ___-___ days.

Answer 17

Serum troponin has greater sensitivity & specificity than CK-MB & myoglobin.

Troponin increases in 2-3 hrs, returns to baseline in 10-14 days.

Question 18

STEMI vs NSTEMI

1. ST segment elevation
2. ST segment depressed or normal
3. QRS usually pathologic (wide)/develops over hours
4. QRS normal
5. T wave inverted
6. T wave peaked, then inverted
7. Troponin elevated
8. Troponin elevated
9. Size of infarct larger
10. Size of infarct smaller
11. Better outcomes
12. Poor outcomes

Answer 18

S 1. ST segment elevation
N 1. ST segment depressed or normal

S 2. QRS usually pathologic (wide)/develops over hours
N 2. QRS normal

N 3. T wave inverted
S 3. T wave peaked, then inverted

N 4. Troponin elevated
S 4. Troponin elevated

S 5. Size of infarct larger
N 5. Size of infarct smaller

N 6. Better outcomes
S 6. Poor outcomes

Question 19

Progression of an acute MI

1. Ischemia (lack of ____ to ______)
   - ischemia is represented by what 2 EKG changes or both
2. injury
3. infarction (death of ______)
   - infarction is represented by what EKG change?

Answer 19

1. Ischemia (lack of O2 to cardiac tissue
   represented by ST depression, T wave inversion)
2. injury
3. infarction (death of tissue
   represented by a pathological Q wave)

remember its a pendulum A –> UA –> NSTEMO –> STEMI

Question 20

ACS initial assessment
1. Consider ACS diagnosis w/ ________, ______ or other suggestive symptoms;
(______, _______& patients with _______ may have atypical presentations.)

2. _________ within 10 minutes of arrival
   (repeat every 10-15 mins if non-diagnostic, but suspicion remains)

Answer 20

Consider diagnosis w/ chest discomfort, SOA or other suggestive symptoms; women, older patients & patients with DM may have atypical presentations.

12-lead EKG within 10 minutes of arrival (repeat every 10-15 mins if non-diagnostic, but suspicion remains)

Question 21

________ EKG = ST segment elevation in two anatomically contiguous leads

Answer 21

STEMI = ST segment elevation in two anatomically contiguous leads

Question 22

________ or ________ EKG = ST depressions or deep T wave inversions without Q waves or possibly no EKG changes

Answer 22

NSTEMI or UA = ST depressions or deep T wave inversions without Q waves or possibly no EKG changes

Question 23

ACS initial interventions

-Assess/stabilize _____
-Position patient ________ to support oxygenation
-Administer ______ (NC initially)
-Obtain V.S., including O² sat
-Attach cardiac monitor (________ telemetry)
-Monitoring for _________ and _____ on tele
- Establish ____ access

Answer 23

Assess/stabilize ABCs
Position patient upright to support oxygenation
Administer oxygen (NC initially)
Obtain V.S., including O² sat
Attach cardiac monitor (continuous telemetry)
Monitoring for dysrhythmias & ST changes
Establish IV access

Question 24

More ACS initial interventions

• Give _____
• Assess ____using PQRST
• For pain:
  1. Give 3 _______ (0.4 mg) one at a time, spaced 5 minutes apart for persistent chest pain (monitor ____)
  2. Give _________ (2-4 mg IVP q 5-15 mins) for unacceptable, persistent discomfort
• Obtain baseline lab work (cardiac markers, electrolytes esp. K, Ca, and Mg, H&H; possibly coags)
• Monitor _____ sounds (murmur, gallop or rubs?) & _____ sounds (crackles may be heard with left HF from left ventricle infarction)

Answer 24

Give ASA 325 (chew/swallow)

Assess pain using PQRST

For pain:

1. Give 3 SL NTG (0.4 mg) one at a time, spaced 5 minutes apart for persistent chest pain (monitor BP)
2. Give morphine sulfate (2-4 mg IVP q 5-15 mins) for unacceptable, persistent discomfort

Obtain baseline lab work (cardiac markers, electrolytes esp. K, Ca, and Mg, H&H; possibly coags)

Monitor heart (murmur, gallop or rubs?) & lung sounds (crackles may be heard with left HF from left ventricle infarction)

Question 25

What may patients need instead of nitroglycerin if their BP is too low?

Answer 25

Morphine; morphine eases the workload on the heart (decreases preload and afterload) and also decreases anxiety

Question 26

What is nitroglycerin - vasodilator or constrictor?

Answer 26

A potent coronary vasodilator

Question 27

PQRST assessment of angina

Answer 27

Precipitating events (What precipitated?) Quality of pain (Feel like? Ache? Squeeze? etc) Radiation of pain (Where is the pain?) Severity of pain (1-10 scale) Timing (When did it begin?)

Question 28

Three reperfusion strategies for a blockage 1. ________ -for STEMI or NSTEMI 2. __________-for STEMI 3. __________- for patients with DM, 3 or more-vessel disease, or when blockage unreachable by catheter

Answer 28

1. Emergent percutaneous coronary intervention (PCI)-for STEMI or NSTEMI 2. Thrombolytic (fibrinolytic) therapy-for STEMI 3. Coronary artery bypass graft (CABG)-for patients with DM, 3 or more-vessel disease, or when blockage unreachable by catheter

Question 29

First-line of treatment for patients with confirmed MI Goal: perform within 90 minutes of ED arrival First must perform a cardiac cath to locate blockage(s), assess the severity of blockage(s), determine the presence of collateral circulation (compensatory/alternate circulation around a blockage), and evaluate left ventricular function

Answer 29

Percutaneous Coronary Intervention (PCI)

Question 30

Which location for heart cath is required to assess the coronary arteries? left or right?

Answer 30

LEFT heart cath

Question 31

Percutaneous coronary intervention (aka angioplasty or balloon procedure) steps 1. right or left cardiac cath? 2. ________ located 3. deflated balloon catheter placed at the ________ site in the coronary artery 4. _________ inflated 5. _________ flattened 6. _________ of coronary artery reestablished

Answer 31

1.right, left, or both cardiac cath --\> 2.blockage located --\> 3.deflated balloon catheter placed at the occlusion site in the coronary artery --\> 4.balloon inflated --\> 5.plaque flattened --\> 6.patency of coronary artery reestablished

Question 32

PCI: advantages Alternative to________intervention Performed with _____ anesthesia rather than general anesthesia Patient is ambulatory shortly after procedure Length of hospital stay = 1-3 days (4-6 days with CABG) Can return to work sooner Currently, more PCIs are performed than CABGs.

Answer 32

Alternative to surgical intervention Performed with local anesthesia rather than general anesthesia Patient is ambulatory shortly after procedure Length of hospital stay = 1-3 days (4-6 days with CABG) Can return to work sooner Currently, more PCIs are performed than CABGs.

Question 33

PCI: Nursing Care Similar to cardiac cath; monitor closely for manifestations of myocardial ischemia, such as: ______ ______ ______ ________ Patient typically on dual __________ therapy (ASA & heparin, for instance) Vascular ________ removal usually 4-6 hours after procedure (manual pressure x _____ minutes esp. if arterial puncture); check ____ & distal ________

Answer 33

Similar to cardiac cath; monitor closely for manifestations of myocardial ischemia, such as: chest pain EKG changes, dysrhythmias hemodynamic instability Patient typically on dual antiplatelet therapy (ASA & heparin, for instance) Vascular sheath removal usually 4-6 hours after procedure (manual pressure x 20 minutes esp. if arterial puncture); check site & distal circulation.

Question 34

clot blusters used to dissolve thrombi in coronary arteries- restores myocardial blood flow May be administered during cardiac catheterization Most effective when administered within ___ hours of coronary event Goal: start within ___ minutes of ED admission Important: Monitor for ________ post-administration

Answer 34

Thrombolytic therapy = Fibrinolytics (alteplase tPa) AKA clot blusters Fibrinolytics used to dissolve thrombi in coronary arteries- restores myocardial blood flow May be administered during cardiac catheterization Most effective when administered within 6 hours of coronary event Goal: start within 30 minutes of ED admission Important: Monitor for BLEEDING post-administration

Question 35

Examples of fibrinolytics/clot busters

Answer 35

Tissue Plasminogen Activator alteplase (t-PA) Reteplase (Retavase)

Question 36

Thrombolytic therapy contraindications History of intracranial _______ Recent _______ surgery or stroke Any active ________ (excluding menses)

Answer 36

History of intracranial hemorrhage Recent abdominal surgery or stroke Any active bleeding (excluding menses)

Question 37

Reasons for coronary artery bypass graft (CABG)

Answer 37

Elective vs emergency

Question 38

Graft (These pathways are typically created using blood vessels taken from the chest, leg, or arm) anastomosed distal and proximal to the blockage to flow around it

Answer 38

CABG procedure coronary artery bypass graft

Question 39

CABG grafts options May involve grafts using the _________ artery (runs parallel to the sternum) or a harvested _________ vein (starts at the foot and ends at the groin)

Answer 39

May involve grafts using the internal mammary artery or a harvested saphenous vein

Question 40

CABG complications: Stroke Myocardial infarction _________ (sternal wound, vein harvest sites) Dysrhythmias _______ effusion ________ effusion which can lead to ___________ ______ failure

Answer 40

Stroke Myocardial infarction Infection (sternal wound, vein harvest sites) Dysrhythmias Pleural effusion Pericardial effusion Cardiac tamponade (fluid accumulation in the pericardium) Renal failure

Question 41

ACS ongoing care: Continuous monitoring with _______ Rest & comfort-activity restrictions Help examine source of anxiety & address For anxiety teach at patient’s level-not from pre-packaged program Help deal with emotional and behavioral reactions Patient teaching – timing is important; start where the patient “is” Teaching regarding resumption of sexual activity

Answer 41

Continuous monitoring with telemetry Rest & comfort-activity restrictions Help examine source of anxiety & address For anxiety teach at patient’s level-not from pre-packaged program Help deal with emotional and behavioral reactions Patient teaching – timing is important; start where the patient “is” Teaching regarding resumption of sexual activity

Question 42

ECG/EKG changes – no Elevated troponin – no (this means no Heart damage)

Answer 42

unstable angina

Question 43

- often occurs at rest/without activity/exertion or with minimal activity - lasts longer than 20 mins - angina is increasing, is more frequent, longer duration, and occurs with less exertion than previous angina - poorly relieved by rest or nitroglycerin - May have associated symptoms - unpredictable - emergency (precedes MI)

Answer 43

Unstable angina pain

Question 44

-occurs w/out cause (often early morning) - relieved only with opioids (not by rest, position changes, or nitrates) -lasting >20 mins -severe, persistent, immobilizing chest pain -other pain descriptions: - heaviness – something sitting on chest -pressure -tightness -burning -constriction -crushing - frequent associated symptoms: -n/v -diaphoresis -dyspnea -feelings of anxiety/fear -dysrhythmias

Answer 44

MI pain

Question 45

complications of MI - We put patients on telemetry to monitor for this - Most common complications - Most common cause of pre-hopsital death

Answer 45

dysrhythmias

Question 46

complications of MI - happens b/c reduced pumping action of heart from Necrosis and muscle death

Answer 46

HF

Question 47

complications of MI - happens b/c of Severe left ventricle failure - High mortality rate (without LV, can’t sustain cardiac output)

Answer 47

cardiogenic shock

Question 48

complications of MI - Will cause a new murmur

Answer 48

papillary muscle dysfunction

Question 49

complications of MI - Inflammatory response occurs 2-3 days after acute MI - Will cause a new pericardial friction rub – sounds like sandpaper rubbing

Answer 49

pericarditis

Question 50

characterized by transient (temporary) thrombosis or incomplete occlusion of a coronary artery. This means that the blood clot blocking the artery is not completely blocking the flow of blood, leading to less severe heart muscle damage compared to a STEMI

Answer 50

NSTEMI and UA

Question 51

3 ACS labs/diagnostic tests 1. 2. labs = (3) 3.

Answer 51

EKG/ECG triponin CKMB myoglobin coronary angiography/heart cath/cardiac cath

Question 52

which ACS labs/diagnostic tests -dye in cardiac arteries - blockages will show up

Answer 52

coronary angiography/heart cath/cardiac cath

Question 53

1st line treatment for patients with confirmed MI

Answer 53

emergent percutaneous coronary intervention (PCI)

Question 54

Procedure within 90 mins of arrival with confirmed MI: 1st – perform cardiac cath (left, right, or both) to: -Locate blockages -Assess severity of blockages -Determine presence of collateral circulation (compensatory vessel connections body naturally. Makes) -Evaluate LV function – vital for CO 2nd – perform with angioplasty/balloon procedure -pull out cath and balloon once it inflates and smashes plaque against the vessel wall and patency is reestablished -can put a stent in there to keep vessel patent

Answer 54

emergent percutaneous coronary intervention (PCI)

Question 55

purpose of cardiac cath (left, right, or both) : -Locate ________ -Assess _______ of blockages -Determine presence of __________ (compensatory vessel connections body naturally. Makes) -Evaluate ____ function – vital for CO

Answer 55

purpose of cardiac cath (left, right, or both) to: -Locate blockages -Assess severity of blockages -Determine presence of collateral circulation (compensatory vessel connections body naturally. Makes) -Evaluate LV function – vital for CO