acute coronary syndromes

Question 1

when do coronary arteries fill?

Answer 1

diastole

Question 2

what is angina pectoris?

Answer 2

“chest pain” or discomfort caused by decreased blood flow to the heart

a symptom of CAD

occurs as a result of an oxygen supply-demand imbalance to the heart as a result of CAD

stable vs unstable

Question 3

which types of patients have atypical angina?

Answer 3

women
pts over 65
diabetic

Question 4

troponin

Answer 4

hearts cry for help

draw until peak and trend

Question 5

AMI treatment goals

Answer 5

maintain cardiac output

minimize cardiac workload
- Restore myocardial oxygen supply-demand imbalance
- Decrease myocardial oxygen demand
- Limit zone of myocardial injury

prevent complications associated with AMI

patient and fam education

Question 6

The nurse knows which of the following is the most serious acute coronary syndrome and requires immediate intervention?

A. Stable angina
B. Unstable angina
C. ST-elevation myocardial infarction (STEMI)
D. Non-ST elevation myocardial infarction (NSTEMI)

Answer 6

C. ST-elevation myocardial infarction (STEMI)

Rational: STEMI requires immediate intervention because there is a zone of injury, and the myocardium is at risk of becoming infarcted.

Question 7

initial interventions for AMI

Answer 7

Pain assessment
Check vital signs and O2 sats
Obtain/review 12 lead ECG
Establish IV access
Brief /targeted history and physical
Review/complete fibrinolytic checklist
Obtain initial cardiac biomarkers, electrolytes, and coagulation studies
Obtain a portable chest x-ray

Question 8

immediate treatment for AMI

Answer 8

Oxygen therapy-if patient is hypoxemic (O2 sat <90% or respiratory distress)
Administer Aspirin 160-325 mg (if not given by EMS)
Dual anti-platelet therapy (DAPT)
Administer Nitroglycerin sublingual, spray or IV
Administer Morphine IV if pain NOT relieved by Nitroglycerin
Monitor/support ABCs
Be prepared to provide CPR and defibrillation

Question 9

oxygen therapy is indicated if patient is…

Answer 9

Hypoxemic (SpO2 less than 90%)
Respiratory distress/dyspnea/cyanosis
Heart failure

Question 10

subjective pain assessment

Answer 10

normal
onset
precipitating/aggravating/relieving factors
quality
region
severity/other symptoms
timing
understanding/perception

Question 11

what patient position for AMI

Answer 11

semi-high fowlers

Question 12

what are some nursing responsibilities for nitroglycerin

Answer 12

hold for sbp <90

no sildenafil within 24-48hrs

Question 13

net effect of nitroglycerin

Answer 13

decreases preload and afterload
enhances coronary perfusion
decreases myocardial oxygen demand

Question 14

whats morphine used for

Answer 14

• pain relief
• preload reduction
• afterload reduction
• decreased myocardial oxygen demand

Question 15

what are ACE-Is used for

Answer 15

Vasodilation effect with afterload reduction
Inhibits secretion of renin
Inhibits secretion of aldosterone
Limits sodium and water reabsorption
Reduction of myocardial oxygen demand

Question 16

what are selective beta-blockers used for

Answer 16

Decreases dromotropic, chronotropic, and inotropic action of the heart
Reduces incident of sudden cardiac death post AMI
Reduction of myocardial oxygen demand

Question 17

what are calcium channel blockers used for

Answer 17

Examples: diltiazem and verapamil
Not 1st line treatment for ACS
Only use if patient cannot tolerate nitrates or beta blockers
Decrease afterload
Decreases dromotropic, chronotropic, and inotropic action of the heart

Question 18

The nurse is caring for a patient with 10/10 chest pain with the following vital signs: BP 168/98; P: 108; R 16; T 97° F, SpO2 98% on room air. The patient states he took his sildenafil yesterday. Which of the following orders would the nurse question?

A. 0.4 mg sublingual nitroglycerin
B. 1 mg IV push morphine
C. 25 mg PO metoprolol
D. 10 mg PO lisinopril

Answer 18

A. 0.4 mg sublingual nitroglycerin

Rational: Nitroglycerin in combination with sildenafil can cause irreversible hypotension.

Question 19

Which of the following is the primary benefit of administering metoprolol to a patient after a non-ST elevation MI?

A. Enhances coronary artery perfusion
B. Reduces myocardial workload
C. Increases preload
D. Increases secretion of renin

Answer 19

B. Reduces myocardial workload

Rational: Metoprolol, a selective beta blocker, reduces myocardial workload by decreasing the dromotropic, chronotropic, and inotropic actions of the heart.

Question 20

describe anti-thrombotic therapy

Answer 20

Function: To prevent further thrombus/clot formation

Anti-platelet agents
Anticoagulant agents

Question 21

describe fibrinolytic therapy

Answer 21

Function: Lyse/destroy clots

Fibrinolytic agents (clot busters)

Question 22

describe heparin sodium

Answer 22

Alters clotting cascade
Potentiates the action of antithrombin III which inactivates thrombin and other factors
Prevents the conversion of fibrinogen to fibrin

Question 23

describe low-molecular weight heparin (LMWH)

Answer 23

Acts similar to heparin, but also strongly inhibit Factor Xa
Ex: Enoxaparin (Lovenox)

Question 24

what are you monitoring with heparin

Answer 24

PTT and APTT

Question 25

For which of the following is it necessary to monitor the APTT every 6 hours?

A. Heparin sodium 1,000 units/hr IV infusion
B. Heparin sodium 5,000 units SQ q8hr
C. Lovenox (enoxaparin sodium) 40mg SQ q 12 hr
D. All of the above

Answer 25

A. Heparin sodium 1,000 units/hr IV infusion

Rational: Only continuous infusion of heparin should have continuous APTT or PTT monitoring due to the half life.

Question 26

How does heparin affect PTT when it is therapeutic?

Answer 26

Increases PTT. Desired therapeutic effect is 1-2X normal. Ex: 50-70 seconds

Question 27

What drug is used to antagonize the effects of heparin?

Answer 27

Protamine Sulfate

Question 28

Other than bleeding what is another complication associated with heparin therapy? What drugs are used for this complication?

Answer 28

Heparin induced thrombocytopenia-HIT
Bivalrudin (Angiomax) or Argatroban (Acova)

Question 29

whats the medical reperfusion therapy for STEMI

Answer 29

finbrinolytic therapy

Question 30

what are the interventional reperfusion therapies for all ACS

Answer 30

PCI
CABG

Question 31

evidence of reperfusion

Answer 31

Cessation of chest pain

Elevated ST segments return to baseline

Reperfusion dysrhythmias, e.g. bradycardia, AIVR (accelerated idioventricular rhythm), PVCs, ventricular tachycardia

Early and marked peaking of troponin

Question 32

whats the goal of fibrinolytic therapy

Answer 32

• limit size of MI
• eliminate clot
• timely reperfusion of tissue

Question 33

whats the criteria for eligibility for fibrinolytic therapy

Answer 33

STEMI

Will only use if percutaneous coronary intervention (PCI) cannot be performed within 90 minutes

Several absolute and relative contraindications

Question 34

examples of fibrinolytic therapy

Answer 34

Alteplase (t-PA)
Tenecteplase (TNK)
Reteplase (r-PA)
Streptokinase (SK

Question 35

describe nursing management with fibrinolytic therapy

Answer 35

Assessment and identification of candidates for thrombolytic therapy
Initiate IV access prior to administration

Assessment for clinical signs of reperfusion

Prevent and monitor for complications such as bleeding

Patient and family education

Question 36

complications post PCI

Answer 36

Coronary spasm
Coronary artery dissection
Coronary thrombosis
Bleeding and hematoma formation
Compromised blood flow to extremity
Retroperitoneal bleeding-abdominal/back pain
Contrast-induced renal failure
Ventricular Dysrhythmias
Vasovagal response

Question 37

describe nursing management post PCI

Answer 37

head to toe

prevent/minimize complications of catheter procedures
- Chest pain/Angina
- Site assessment/peripheral vascular - checks
- Vascular closure devices
- Renal protection

monitor for reperfusion dysrhythmias

patient and family education

Question 38

patient teaching post PCI

Answer 38

Bedrest for 4-6 hours following sheath removal (femoral only)
HOB no higher than 30 degrees (femoral only)
Keep extremity straight
Report any pain
Report numbness in extremity
Report chest pain/associated symptoms
Begin home-going teaching

Question 39

complications associated with AMI

Answer 39

• life threatening ventricular dysrhythmias (#1)
• heart failure
• pulmonary edema
• cardiogenic shock

Question 40

discharge meds for AMI

Answer 40

Beta-blocker
Statin
Aspirin
Additional anti-platelets
- Clopidogrel (Plavix)
- Ticagrelor (Brilinta)
ACE-I (if indicated)
Nitroglycerin SL (if indicated)