Acute Coronary Syndrome (ACS) Flashcards
What is the most common reason for angina to develop ?
significant narrowing of 1 or more coronary arteries by atherosclerosis
What is myocardial ischemia ?
when demand for myocardial O2 exceeds the ability of the coronary arteries to supply the heart with O2
- increased demand for O2 or decreased supply of O2
- reversible
- non occlusive thrombus
- ST depression or T wave inversion (UA or NSTEMI)
What is the first sign of CAD progression usually ?
angina (Chest pain)
- manifestation of myocardial ischemia
What happens in the body when someone is having angina ?
- decreased O2 to myocardial cells (ischemia)
- causing contractility of heart muscle to decrease
- anaerobic metabolism begins and causes lactic acid build up
- lactic acid irritates myocardial nerve roots
- pain messages sent to cardiac nerves and upper thoracic posterior nerve roots
How do you assess angina ?
- onset of symptoms
- precipitating factors
- pain intensity (0-10): may describe as pressure, heaviness, tightness, squeezing or discomfort of chest
- location of pain: Most is substernal, may be epigastric or in middle of shoulder blades. Can radiate to jaw, neck, shoulders or arms
- other symptoms: SOB, diaphoresis, nausea, fatigue, may even report indigestion
What is chronic stable angina ?
pain that happens intermittently over a long period of time with similar pattern of onset, duration, and intensity of symptoms
- usually only few mins
- provoked by exertion, stress, emotions and resolves when activity stopped
- no pain at rest
- does not change with positioning or breathing
What is the tx for chronic stable angina ?
NITROGLYCERIN
- stop doing the activity
- take 1 sublingual pill or spray
- if pain unrelieved in 5 mins, call EMS or go to hospital (don’t drive youself)
- up to 2 more doses (3 in total) may be taken 5 mins apart
How does nitroglycerin work ?
dilate veins, arteries, and coronary arteries by relaxing the vascular smooth muscle
- perfuses the coronary arteries
What are some considerations for Nitroglycerin ?
- Can cause HA
- can cause orthostatic hypotension so monitor BP (move slowly)
- report use of Sildenafil (Viagra) because can’t use both at same time (causes vasodilation)
- stored away from light and heat sources (like body heat)
- can take 5-10 mins before doing activity that causes angina
What is acute coronary syndrome ?
when chest pain from ischemia is prolonged and not immediately reversible
- happens when a previously stable atherosclerotic plaque ruptures causing platelet aggregation and thrombus formation
- can cause STEMI or NSTEMI
What is unstable angina ?
partial occlusion of coronary artery
- begins at rest
- lasts for prolonged length of time (>10 mins)
- rest or meds don’t relieve pain
- EMERGENCY
What is a myocardial infarction ?
an abrupt stoppage of blood flow through a coronary artery because of a thrombus (tissue death/necrosis)
- irreversible myocardial cell death in heart muscle beyond blockage
- ST segment elevation, deep Q-waves, T-wave inversion (MI)
What are some S&S of a MI ?
- Angina: worse than any previous episodes lasting 20 mins or more
- heavy, pressure, tight, burning, constricted, or crushing pain
- Skin: ashen, clammy, cool to touch, and diaphoretic
- initially increased HR and BP due to vasoconstriction of peripheral vessels
- later BP will drop because of decreased CO
- blood not getting to renal system so decreased UO
What are some interventions for ACS ?
- 1st is give O2 (2L NC)
- VS and place on monitor
- 12 lead EKG
- auscultate heart and lungs (distant, or S3 and S4)
- admin aspirin (AASA 325 mg)
- assess and treat pain (1st nitrates and then morphine if unrelieved)
- admin high dose statin (atorvastatin 80mg)
- admin antiplatelet (clopidogrel or heparin)
- blood work (cardiac biomarkers)
Why is a EKG important for ACS ?
to determine the extent and area of myocardial injury
- looking for ST changes in EKG
What is the lead placement for a EKG ?
- V1: 4th intercostal space (ICS), Rt margin of sternum
- V2: 4th ICS along the Lt margin of sternum
- V4: 5th ICS, mid-clavicular line
- V3: midway between V2 and V4
- V5: 5th ICS, anterior axillary line (same level as V4)
- V6: 5th ICS, mid-axillary line (same level as V4)
- RA, RL: Rt arm, Rt leg
- LA, LL: Lt arm, Lt leg
How does the ST segment look like in unstable angina ?
ST segment is depressed or T-Wave inverted
How does the ST segment look like in a Non-ST elevated myocardial infarction (NSTEMI) ?
ST segment is depressed or T-wave inverted
How does the ST segment look like in a STEMI ?
ST segment is elevated above the isoelectric line
What is a myocardial injury ?
obstruction of blood flow/O2 by an occlusive thrombus
- can be reversible, may evolve to MI
- ST segment elevation (STEMI)
Which cardiac biomarker is most indicative for MI’s ?
troponin I
What does the presence of biomarkers help distinguish between ?
- UA: (-) biomarkers
- NSTEMI: (+) biomarkers
What meds does someone with a stent take ?
- dual antiplatelet (DAPT) for at least 1 yr (ASA and plavix) to prevent clots from attaching to stents
What are some pre-op consideration for a PCI (w stent)
- assess for allergies (check for contrast dye, iodine, and shellfish)
- NPO for procedure (at least 4-8hrs)
- get labs (creatinine because of contrast due so if elevated you can’t do procedure)
- neurovascular assessment
- MD/anesthesia gets consent
What are some post-op considerations for PCI (w stent) ?
- immediately post-op: apply pressure to site
- radial: deflate band
- femoral: pressure dressing
- assess VS/site/pulse q 15 mins for 1 hr and then q30 mins for 1 hr and then q1 hr for 4 hours, then normal standard
- entry site should be squishy and no bleeding
- should have same neurovascular assessment on limb as before
- Femoral access: strict FLAT bedrest for 4-6 hrs pos-op
- if having chest pain/angina then re-occlusion has occurred or a dissection (tear) EMERGENCY
What is the Tx for a STEMI ?
- undergo cardiac catheterization within 90 mins of presentation of ED
- or get thrombolytic therapy within 30 mins in agency without PCI capability
- goal is to open totally occluded artery and limit the infarction size
What is the benefit of thrombolytic therapy over PCI ?
advantage of availability and rapid intervention when no PCI available
- cost effective and easily administered
What are some disadvantages of thrombolytic therapy over PCI ?
- non specific
- can lead to brain hemorrhage: important to watch for changes in LOC and mental status and if changed then need to immediately stop infusion
- pt can have re-perfusion dysrhythmias
- pt selection important
What is the criteria to getting a Coronary artery bypass graft (CABG) ?
- too large of a blockage or all 3 vessels blocked
- too many blockages
- too complex of blockage (long or branched)
- continue having pain after PCI
- failed med management
- DM
- kidney damage
- allergy to contrast dye/iodine/shellfish
Where are the entry sites for a PCI ?
femoral or radial artery
What is some RN care for post-CABG ?
- pain assessment: should have no more angina after reperfusion
- physiologic monitoring: RR, VS, I/Os
- pain management
- early ambulation and prevention of DVT
- midline chest dressing for 24 hrs then open to air
- assess for arrythmias (very common for pt’s to go into afib after surgery)
- promote rest, comfort, alleviate stress and anxiety
- understand pt’s emotional and behavior reaction
What is some pt education for post MI or CABG ?
- reduce risks: stop smoking, improve diet, exercise
- diet: low fat and sodium
- physical activity: cardiac rehab, 30 mins 5x a week
- work: off 6-8 wks of work for CABG, less for PCI
- sex: when you can walk up 2 flights of steps without extreme SOB, may take nitro before sex as long as not taking sildenafil
- S&S education: chest pain, nitro sequence is when you go to hospital
How does morphine help with ACS ?
works as a vasodilator
- also pain and anxiety
- good for pre and afterload
What are the goals of tx ?
- preservation of myocardium
- relief of pain
- effective coping with illness and associated anxiety
- reduction of risk factors
- participation in rehab plan
