Acute Coronary Syndromes Flashcards
Cardiovascular Disorders - PPT 1
1
Q
Signs & Symptoms of Acute Coronary Syndrome
KNOW THIS!!!
A
- ↑ BP
- EKG changes
- Shortness of breath
- Tachypnea
- Nausea / vomiting
- Cool, clammy, diaphoretic
- Light headedness
- Crackles (L ventricle is failing causing fluid to back up in the lungs)
- Anxiety
- Restlessness
- Fear / feeling of impending doom
2
Q
Signs & Symptoms of Acute Coronary Syndrome in patient populations
- Males
- Females
- Geriatric
- Diabetics
KNOW THIS!!!
A
Males:
* chest pain,
* ↑ BP
* EKG changes
* SOB
* tachypnea
* N/V
* diaphoresis
* lightheadedness
* crackles
Females:
* back pain / chest pain with radiation
* tired
* more likely to deny pain
Geriatrics:
* ONLY shortness of breath
* ↑ RR
* crackles
* confusion
* dyspnea
* weakness
Diabetics:
* No pain (unaware ACS is occuring)
3
Q
KEY signs & symptoms of Acute Coronary Syndrome (ACS) in males
KNOW THIS!!!
A
- Chest pain
- ↑ BP
- EKG changes
- SOB
- Tachypnea
- N/V
- Diaphoresis
- Light-headedness
- Crackles (L ventricular failure = fluid back up in the lungs)
4
Q
KEY signs & symptoms of Acute Coronary Syndrome (ACS) in females
KNOW THIS!!!
A
- Tired / lack of energy
- SOB
- Pain with radiation to the back or shoulder
- More likely to deny pain
5
Q
KEY signs & symptoms of Acute Coronary Syndrome (ACS) in diabetics
KNOW THIS!!!
A
Silent Ischemia
* no pain
* no s/s
Pt is unaware Acute Coronary Syndrome event / heart attack is occuring
6
Q
KEY signs & symptoms of Acute Coronary Syndrome (ACS) in the elderly
KNOW THIS!!!
A
- Weakness
- Dyspnea
- Confusion
- SOB (may be the only symptom they have)
7
Q
List 4 potential diagnoses of Acute Coronary Syndrome
A
- STEMI
- NSTEMI
- Unstable Angina
- Non-Cardiac
8
Q
Signs & Symptoms of Acute Coronary Syndrome in males
KNOW THIS
A
- Chest pain
- ↑ BP
- EKG changes
- SOB
- Tachypnea
- N/V
- Cool, clammy, & diaphoretic
- Light headed
- Crackles
9
Q
Signs & Symptoms of Acute Coronary Syndrome in Geriatric Population
KNOW THIS
A
- only SOB (no pain)
- Dyspnea
- Confusion
- Weakness
10
Q
Signs & Symptoms of Acute Coronary Syndrome in Females
KNOW THIS
A
- Chest pain with radiation to the back or shoulder
- Tired / lack of energy
- More likely to deny pain
11
Q
Signs & Symptoms of Acute Coronary Syndrome in Diabetics
KNOW THIS
A
No Pain (unaware pain is occuring due to nerve damage)
12
Q
Nursing Interventions for Acute Coronary Syndrome (ACS)
Know These
A
- Priority Concern = treat angina pain
- Have patient sit & rest (no activity)
- EGK assessed or obtained
- Administer O2
- Administer ordered meds
- Reperfusion (cardiac cath lab)
13
Q
EKG changes seen on a STEMI
KNOW THIS!!!
A
- T wave inversion = ischmeia
- ST elevation = injury has occured
- Q wave = tissue death / infarction
hyperacute / peaked T-waves (due to hyperkalemia)
Elevated Troponin, CK, & CK-MB (Cardiac Biomarkers) are also seen
14
Q
What does T-wave inversion on an EKG indicate?
KNOW THIS!!!
A
Ischemia
inadequate blood supply to the heart
15
Q
What does ST elevation on an EKG indicate?
KNOW THIS!!!
A
Injury has occured
16
Q
What does the presence of a Q-wave on an EKG indicate?
KNOW THIS!!!
A
Infarction
tissue death
17
Q
What do the following EKG changes identify?
- T wave inversion
- ST Elevation
- Q Wave
KNOW THIS!!!
A
- T wave inversion = ISCHEMIA (inadequate blood supply)
- ST Elevation = injury has occured
- Q wave = tissue death / infarction
18
Q
What labs are drawn on patients with suspected Acute Coronary Syndrome?
KNOW THIS!!!
A
- CBC
- BMP
- BNP
- Troponin
- CK
- CK-MB
- PT, PTT, & INR are helpful to know about clotting ability
bold = cardiac biomarkers
19
Q
EKG Changes seen in NSTEMIs (non-ST elevated MI)
KNOW THIS!!!
A
- ST segment depression
- T-wave inversion = ischemia
- Elevated cardiac biomarkers (Troponin, CK, CK-MB)
20
Q
Cardiac Biomarkers
A
Troponin = most sensitive cardiac markers
* levels rise 4-6 hours after onset of ischemic symptoms
* Peak at 18-24 hours after MI
* Most sensitive cardiac markers (Troponin I & Troponin T)
Creatinine Kinase (CK-MB)
* not as sensitive in early MI less than 6 hours after onset
* levels rise 4-8 hours after onset
* Peak 12-24 hours
* Returns to normal around 24-48 hours
Myoglobin = muscle damage
* very sensitive marker, but not cardiac specific
* can be increased due to intense exercise, crush injuries, car accident, etc.
21
Q
Primary Therapeutic Goals for MIs
A
- Optimize blood flow
- Reduce amount of myocardial necrosis
22
Q
Order of Medications that are given for Chest Pain suggestive of Ischemia
KNOW THIS!!!
A
Aspirin – 160 - 325 mg
Oxygen – 4 L/min (if O2 less than 94%)
Nitroglycerin (assess pain, HR, BP, & RR before & after admin)
Morphine
23
Q
Aspirin for Ischemic chest pain
* action
* normal dosage
* who should receive this medication?
* risks with this medication
KNOW THIS!!!
A
ACTION = Anti-Platelet
DOSE: 160 - 325 mg (taken ASAP)
RISKS: ↑ bleeding risk
- Administer as soon as possible for ALL patients w/ acute MI chest pain
24
Q
Oxygen - when is it given in patients with a potential acute MI?
KNOW THIS
A
4 L / min if O2 saturation is less than 94%
25
**SUBLINGUAL Nitroglycerin for patients with potential acute MI**
* **How does it work?**
* **Nursing Responsibilities**
| **KNOW THIS!!!**
**Sublingual = up to 3 doses every 5 minutes**
**How it works**
* **↑ venous dilation**
* ↓ venous blood return to heart (orthostatic hypotension)
* **↓ preload**
* ↓ cardiac oxygen consumption
**Nursing Responsibilities**
* pain rating
* vitals
26
**IV Nitroglycerin**
* Nursing responsibilities
* **Frequent BP monitoring**
* **Continuous EKG monitoring**
* **do not stop abruptly (titrate off)**
* Usually only used for 24 hours
* MUST be done in an ER or critical care setting
27
**Morphine**
* Dose
* Nursing Responsibilities
* When is it given?
| **KNOW THIS!!!**
**Dose: 1-5 mg every 5-30 minutes**
**Nursing Responsibilties (what to monitor)**
* BP
* RR
* HR
* Level of consciousness
* Respiratory depression
* Assess pain
28
**How does Nitroglycerin work in patients with acute MIs?**
| **Know This!!!**
**Venous Dilation:** heart doesn't have to pump as hard
* ↓ venous blood return to the heart **(orthostatic hypotension)**
* **↓ preload**
* **↓ O2 demand of the heart**
* dilation (↑) coronary artery
* venous pooling
29
**How does Morphine work for patients who might have an acute MI?**
| **KNOW THIS!!!**
**↓ O2 demand of the heart**
## Footnote
CONCERNS:
* ↓ RR
* ↓ BP
30
**How do ADP-Receptor Inhibitors work?**
**Examples & typical dosing**
**Risks associated with the medication**
| **KNOW THIS!!!**
**decrease platelet aggregation**
* *Clopidogrel (Plavix): 300-600 mg PO* (ASAP)
* *Prasugrel (Effient): 60 mg PO* (ASAP)
**Risks:** ↑ bleeding risks
## Footnote
**can be used WITH Aspirin**
31
**Glycoprotein IIb-IIIa Inhibitors**
* What is it / how does it work?
* When is it indicated?
* Examples
| **KNOW THIS!!!**
## Footnote
Adjunctive Treatment
**inhibit platelet aggregation**
**Indications:**
* ACS w/ NSTEMI
* Unstable Angina
* ACS undergoing PCI (cath lab)
**Examples:**
* eptifibatide (Integrilin)
* abciximab (Reopro)
32
**List the 3 Anti-Ischemic Adjuvent Therapies**
| **KNOW THIS!!!**
## Footnote
Adjuvant Therapies
* **Beta Blockers:**
* **ACE Inhibitors**
* **Caclium Channel Blockers**
33
**Beta Blockers**
* How do they work?
* Effects on the body
* Contraindications
* Examples
| **KNOW THIS!!!**
## Footnote
Adjunctive Therapies
**How do they work?**
* ↑ fill time
* ↓ Oxygen consumption of the heart
**Effects on the Body**
* ↓ HR
* ↓ BP
* ↓ myocardial O2 demand & workload
**Contraindications:**
* **Heart failure**
* Low cardiac output
* Increased risk of cardiogenic shock
**Examples**
* Metrop**olol**
* Propran**olol**
* Aten**olol**
34
**Calcium Channel Blockers**
* How do they work?
* Examples
| **KNOW THIS!!!!**
## Footnote
Adjunctive Therapies
**Action = VASODILATION**
* prevent ischemia
**Examples**
* Verapamil
* Diltiazem
35
**ACE Inhibitors**
* How do they work?
* Actions
* Nursing Considerations
* Examples
| **KNOW THIS!!!**
## Footnote
Adjunctive Therapies
**Convert angiotensin I to II**
ACTIONS
* **↓ BP**
* **↓ O2 demand**
* ↓ sudden death & recurrent MI
* lowers peripheral vascular resistance
**Nursing Considerations**
* Monitor for orthostatic hypotension
* Monitor potassium levels
* Monitor renal function
* Nagging cough = common side effect
**Examples:**
* Enala**pril**
* Capto**pril**
## Footnote
**"-pril"**
36
**What is the primary action of Beta Blockers (ACS)?**
* *What effects do beta blockers have on the body?*
* *Examples of Beta Blockers*
| **KNOW THIS!!!**
## Footnote
PER HAYLEY
**↑ ventricular filling time**
* **↓ oxygen demand of the heart**
**EFFECTS ON THE BODY:**
* **↓ HR & ↓ BP**
**EXAMPLES:**
* metrop**olol**
* propran**olol**
* aten**olol**
## Footnote
**"-olol"**
37
**What is the primary action of nitrates, diuretics, & morphine (ACS)?**
| **KNOW THIS!!!**
## Footnote
PER HAYLEY
**↓ Preload**
| **heart does *NOT* need to stretch/fill as much to reach maximum fill*
## Footnote
heart won't have to work as hard
38
**What is the primary action of ACE inhibitors on the heart (ACS)?**
| **KNOW THIS!!!**
## Footnote
PER HAYLEY
**↓ afterload**
## Footnote
Heart won't have to pump/push against as much of a force to get blood out to the rest of the body
39
**List the Anti-Coagulation Adjunctive Therapies**
| **KNOW THIS!!!**
* Heparin
* Low Molecular Weight Heparin (LMWH)
* Direct Thrombin Inhibitors
40
**What is the reversal agent for heparin?**
| **KNOW THIS!!!!!!!!!!!!**
**Protamine Sulfate**
41
**Heparin** (Adjunctive therapy)
* What does it do?
* **What is the reversal agent?**
* Administration
* Considerations
| **Know This!**
**Anti-Thrombin** (prevents formation of thrombi)
**Reversal = Protamine Sulfate**
**Administration**
* 60 units/kg IV bolus (maximum 4,000 units initial dose)
* 12/units/kg/hr continuous IV infusion
**Considerations**
* contraindicated in active bleeding
* caution after recent surgery, bleeding, or severe HTN
## Footnote
**1.)** IV Bolus
**2.)** Continuous IV Infusion
Goal aPTT = 2.5 - 5.0
42
**Which medications for treatment of Acute Coronary Syndromes (including acute MIs) are types of anti-platelet therapy?**
* Aspirin
* Clopidogrel
43
**Early Invasive Strategies for the treatment of Acute Coronary Syndrome**
* **Percutaneous Coronary Intervention (PCI)** = cath lab
* **Fibrinolytic therapy (dissolves clots)**
* Combination of PCI with fibrinolytic therapy
44
**How fast does coronary stent placement have to occur?**
| **KNOW THIS!!!**
**within 90 minutes**
* from door to cath lab
45
**How fast does Fibrinolytic Therapy need to occur?**
| **KNOW THIS!!!**
**less than 30 minutes**
* from door to drug time
46
**How fast should the initial EKG be obtained in patients with a potential MI?**
| **KNOW THIS!!!**
**within 10 minutes of arrival**
47
**Patients with what type of MI should NOT receive fibrinolytic therapy?**
**NSTEMI**
| PCI within 24 hours
48
**Patient Teachings for MIs**
| **Know what is in bold**
**Recognize & take action for recurrent symptoms**
* call 911 if chest pressure or pain is not relieved in 15 minutes by taking 3 nitroglycerin
* healing is not complete post MI for 6-8 weeks
**Lifestyle Modifications**
* stop smoking
* reduce stress
* decrease caffeine
* modify intake of calories, sodium, & fat
**maintain regular physical activity**
49
**What is happening to the heart during a STEMI?**
Acute injury is occurring
* Cath lab ASAP
50
**If you see a "fire helmet" on an EKG, what should you do?**
Get the patient to the cath lab within 3 hours
51
**What is ischemia?**
Inadequate blood supply to the heart
52
**Describe what is seen in an NSTEMI**
| **KNOW THIS!!!**
* ST segment depression
* T-wave inversion
* Elevated biomarkers
53
**Describe the difference in what is seen during a STEMI vs. an NSTEMI**
**STEMI: ST elevation, hyperacute / peaked T-waves, Q-wave formation**
*NSTEMI:*
* ST depression
* T-wave inversion
54
**Describe unstable angina**
| **KNOW THIS!!!**
**Unexpected, occurs at rest, usually lasts more than 20 minutes**
* angina that has *changed in frequency, severity, or duration*
55
**What are the most sensitive cardiac biomarkers?**
**Troponin I & Troponin T**
56
**True or False:**
The biomarker myogloboin is very sensitive, but it is not cardiac specific
**True:** myoglobin is elevated with **all** tissue damage, not just cardiac tissue damage
57
**What is the treatment protocol for any patient who presents with chest pain?**
| **KNOW THIS!!!!!!**
**Aspirin**
**Oxygen** (if less than 94%)
**Nitroglycerin** (SL - up to 3 times 5 minutes apart)
* assess pain, HR, BP, RR (before & after nitro)
**Morphine** (IV)
* control pain
* reduce myocardial oxygen demands
58
**What is the action of Aspirin?**
| **KNOW THIS!!!**
**Anti-Platelet**
* inhibits platelet aggregation
59
**What is the action of nitroglycerin?**
| **KNOW THIS!!!**
**Venous Dilation** - so heart doesn't have to work as hard
* ↓ venous blood return to heart
* ↓ preload
* ↓ cardiac O2 consumption
60
**Side effect of nitroglycerin**
| **KNOW THIS!!!**
Orthostatic hypotension
61
**Action, Side Effects, & Nursing Responsibilities of Nitroglycerin**
| **KNOW THIS!!!**
*ACTION:* **Venous Dilation - heart doesn't have to pump as hard**
* ↓ venous blood return to heart
* ↓ preload
* ↓ cardiac oxygen consumption
**SE: orthostatic hypotension**
**Nursing Responsibilities**
* Initial pain assessment (and regular rechecks)
* Vitals (and rechecks)
62
**True or False:**
You should stop IV nitroglycerin abruptly
**FLASE**
63
**Nursing responsibilities associated with nitroglycerin**
* Initial pain assessment
* Vitals
## Footnote
Continuous EKG monitoring for IV nitro**;** done in critical care setting or ER**;** usually only used for 24 hours**; don't stop suddenly**
64
**Actions of ADP-Receptor Inhibitors**
**Side Effects of ADP-Receptor Inhibitors**
**Examples of ADP-Receptor Inhibitors**
| **KNOW THIS!!!**
**Anti-Platelet**
* inhibits platelet aggregation
**Side Effects:**
* severe bleeding risk
**EXAMPLES:**
* clopidogrel (Plavix)
* prasugrel (Effient)
65
**Examples of ADP-Receptor Inhibitors**
* clopidogrel (Plavix)
* prasugrel (Effient)
66
**Actions of ADP-Receptor Inhibitors & Glycoprotein IIb-IIIa Inhibitors**
| **KNOW THIS!!!**
**Anti-Platelet**
* inhibit platelet aggregation
67
**Examples of Glycoprotein IIb-IIIa Inhibitors**
| **KNOW THIS!!!**
* eptifibatide (Integrilin)
* abciximab (Reopro)
68
**Action of Glycoprotein IIb-IIIa Inhibitors**
**Indications for Glycoprotein IIb-IIIa Inhibitors**
**Examples of Glycoprotein IIb-IIIa Inhibitors**
| **KNOW THIS!!!!!**
**Anti-Platelet**
* inhibits platelet aggregation
**INDICATIONS:**
* ACS with NSTEMI
* Unstable angina
* ACS undergoing percutaneous cardiac intervention (PCI / cath lab)
**EXAMPLES:**
* eptifibatide (Integrilin)
* abciximab (Reopro)
69
**What are indications for eptifibatide (Integrilin) or abciximab (Reopro) (Glycoprotein IIb-IIIa Inhibitors)?**
* **ACS** with **NSTEMI** (non-Q-wave MI)
* **Unstable angina** medically managed
* **ACS** undergoing PCI (cath lab)
70
**List 3 types of anti-ischemia therapies for ACS**
* Beta-blockers
* ACE Inhibitors
* Calcium Channel Blockers
71
**Action of Beta Blockers**
**Contraindications for Beta Blockers**
**Examples of Beta Blockers**
| **KNOW THIS!!!**
**block sympathetic nervous system**
* **↓ HR**
* **↓ BP**
**CONTRAINDICATIONS:**
* Heart failure
* Low cardiac output
* Increased risk of cardiogenic shock
**EXAMPLES:**
* Metrop**olol**
* Propran**olol**
* Aten**olol**
72
**What drug class ends in -olol?**
Beta Blockers
73
**List examples of beta-blockers**
* Metropolol
* Propranolol
* Atenalol
74
**How do beta blockers work?**
**↓ activity of the heart (↓ cardiac work load & ↓O2 demand)**
* ↓ BP
* ↓ HR
75
**What do beta-blockers reduce?**
Workload of the heart & oxygen demand
76
* **Action of Calcium Channel Blockers**
* **Examples of Calcium Channel Blockers**
| **KNOW THIS!!!**
**Vasodilation**
* prevents ischemia
**EXAMPLES:**
* verapamil
* diltiazem (Cardizem)
77
**What drug class ends in -pril?**
**ACE Inhibitors**
78
**Action of ACE Inhibitors**
**Examples of ACE Inhibitors**
| **KNOW THIS!!!**
**↓ BP**
**↓ O2 demand**
**EXAMPLES:**
* linino**pril**
* enala**pril**
* capto**pril**
79
**What should nurses monitor for / what are common side effects in patients who are on ACE Inhibitors for the treatment of ACS?**
**SE = Nagging Cough**
**Monitor for:**
* orthostatic hypotension
* potassium levels & renal function
80
**What is the main anticoagulant used for acute coronary syndrome (ACS)?**
## Footnote
Heparin
Heparin
81
**What is the antedote for a Heparin overdose?**
| **KNOW THIS!!!!!!**
**Protamine sulfate**
82
**A patient with a STEMI should receive PCI (catheter) within how many minutes of arrival to the hospital / ER?**
| **KNOW THIS!!!**
90 minutes
83
**A patient with a STEMI should receive a fibrinolytic agent within how many minutes of arrival to the hospital / ER?**
| **KNOW THIS!!!**
30 minutes
84
**A patient with an NSTEMI should have PCI (cath) can be done within how many hours of arrival to the hospital / ER?**
| **KNOW THIS!!!**
24 hours
85
**For a patient wiht a poptential MI (STEMI or NSTEMI), an initial EKG should be obtained within how many minutes of arrival to the hospital / ER? **
| **KNOW THIS!!!!**
10 minutes
86
**For patients with an NSTEMI, they should receive fibrinolytic therapy within how many minutes of arriving to the hospital / ER?**
| **KNOW THIS!!!**
**NOT RECOMMENDED**
## Footnote
No fibrinolytic therapy
87
**Patients with a STEMI should receive PCI and fibrinolytic therapy within how many minutes of arriving to the hospital / ER?**
| **KNOW THIS!!!**
* **PCI =** within **90 minutes** of arrival
* **Fibrinolytics =** within **30 minutes** of arrival
88
**Patients with an NSTEMI should receive PCI and Fibrinolytic therapy therapy within how many minutes of arriving to the hospital / ER?**
| **KNOW THIS!!!**
**PCI =** within **24 hours** of arrival
**Fibrinolytics =**
**NEVER (contraindicated)**
