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Sav NUR 405 exam 1 content > Acute Coronary Syndrome (ACS) > Flashcards

Acute Coronary Syndrome (ACS) Flashcards

1
Q

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 = ________

A

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)

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2
Q

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

A
  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
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3
Q

Women and atypical angina s/s (4)

A

Fatigue (most prominent)
SOA
Indigestion
Anxiety

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4
Q

_________ pain

Precipitated by exertion/stress

Relieved by rest/nitroglycerin

Lasts < 15 minutes

A

stable angina

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5
Q

_____ 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)

A

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

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6
Q

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

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

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)

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7
Q

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)

A

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)

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8
Q

Complications of MI (5)

A
  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)
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9
Q

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 ___________)
A
  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)
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10
Q

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

A

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

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11
Q

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

A

Pericardial friction rub

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12
Q

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

A

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

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13
Q

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

A

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

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14
Q

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

A

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

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15
Q

Ischemia vs infarction

___________: reduced (but not obstructed) blood flow

__________: obstructed blood supply causing local tissue death

A

Ischemia: reduced (but not obstructed) blood flow

Infarction: obstructed blood supply causing local tissue death

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16
Q

ST elevation vs depression
T/F

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

T - ST elevation occurs with infarction

F - (this is permanent)

T - ST depression occurs with ischemia

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17
Q

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.
A

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

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

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18
Q

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
A

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

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19
Q

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?
A
  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

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20
Q

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

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

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)

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21
Q

________ EKG = ST segment elevation in two anatomically contiguous leads

A

STEMI = ST segment elevation in two anatomically contiguous leads

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22
Q

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

A

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

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23
Q

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

A

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

24
Q

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)
A

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)

25
Q

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

A

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

26
Q

What is nitroglycerin - vasodilator or constrictor?

A

A potent coronary vasodilator

27
Q

PQRST assessment of angina

A

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?)

28
Q

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
A
  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
29
Q

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

A

Percutaneous Coronary Intervention (PCI)

30
Q

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

left or right?

A

LEFT heart cath

31
Q

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
A

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

32
Q

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.

A

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.

33
Q

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 ________

A

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.

34
Q

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

A

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

35
Q

Examples of fibrinolytics/clot busters

A

Tissue Plasminogen Activator
alteplase
(t-PA)

Reteplase (Retavase)

36
Q

Thrombolytic therapy contraindications

History of intracranial _______

Recent _______ surgery or stroke

Any active ________ (excluding menses)

A

History of intracranial hemorrhage

Recent abdominal surgery or stroke

Any active bleeding (excluding menses)

37
Q

Reasons for coronary artery bypass graft (CABG)

A

Elective vs emergency

38
Q

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

A

CABG procedure
coronary artery bypass graft

39
Q

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)

A

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

40
Q

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

A

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

41
Q

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

A

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

42
Q

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

A

unstable angina

43
Q
  • 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)
A

Unstable angina pain

44
Q

-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
A

MI pain

45
Q

complications of MI

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

dysrhythmias

46
Q

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

A

HF

47
Q

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

A

cardiogenic shock

48
Q

complications of MI
- Will cause a new murmur

A

papillary muscle dysfunction

49
Q

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

A

pericarditis

50
Q

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

A

NSTEMI and UA

51
Q

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

A

EKG/ECG

triponin
CKMB
myoglobin

coronary angiography/heart cath/cardiac cath

52
Q

which ACS labs/diagnostic tests

-dye in cardiac arteries
- blockages will show up

A

coronary angiography/heart cath/cardiac cath

53
Q

1st line treatment for patients with confirmed MI

A

emergent percutaneous coronary intervention (PCI)

54
Q

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

A

emergent percutaneous coronary intervention (PCI)

55
Q

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

A

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

Sav NUR 405 exam 1 content (7 decks)

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