acute coronary syndromes Flashcards
when do coronary arteries fill?
diastole
what is angina pectoris?
“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
which types of patients have atypical angina?
women
pts over 65
diabetic
troponin
hearts cry for help
draw until peak and trend
AMI treatment goals
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
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)
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.
initial interventions for AMI
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
immediate treatment for AMI
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
oxygen therapy is indicated if patient is…
Hypoxemic (SpO2 less than 90%)
Respiratory distress/dyspnea/cyanosis
Heart failure
subjective pain assessment
normal
onset
precipitating/aggravating/relieving factors
quality
region
severity/other symptoms
timing
understanding/perception
what patient position for AMI
semi-high fowlers
what are some nursing responsibilities for nitroglycerin
hold for sbp <90
no sildenafil within 24-48hrs
net effect of nitroglycerin
decreases preload and afterload
enhances coronary perfusion
decreases myocardial oxygen demand
whats morphine used for
- pain relief
- preload reduction
- afterload reduction
- decreased myocardial oxygen demand
what are ACE-Is used for
Vasodilation effect with afterload reduction
Inhibits secretion of renin
Inhibits secretion of aldosterone
Limits sodium and water reabsorption
Reduction of myocardial oxygen demand
what are selective beta-blockers used for
Decreases dromotropic, chronotropic, and inotropic action of the heart
Reduces incident of sudden cardiac death post AMI
Reduction of myocardial oxygen demand
what are calcium channel blockers used for
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
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
A. 0.4 mg sublingual nitroglycerin
Rational: Nitroglycerin in combination with sildenafil can cause irreversible hypotension.
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
B. Reduces myocardial workload
Rational: Metoprolol, a selective beta blocker, reduces myocardial workload by decreasing the dromotropic, chronotropic, and inotropic actions of the heart.
describe anti-thrombotic therapy
Function: To prevent further thrombus/clot formation
Anti-platelet agents Anticoagulant agents
describe fibrinolytic therapy
Function: Lyse/destroy clots
Fibrinolytic agents (clot busters)
describe heparin sodium
Alters clotting cascade
Potentiates the action of antithrombin III which inactivates thrombin and other factors
Prevents the conversion of fibrinogen to fibrin
describe low-molecular weight heparin (LMWH)
Acts similar to heparin, but also strongly inhibit Factor Xa
Ex: Enoxaparin (Lovenox)
what are you monitoring with heparin
PTT and APTT
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
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.
How does heparin affect PTT when it is therapeutic?
Increases PTT. Desired therapeutic effect is 1-2X normal. Ex: 50-70 seconds
What drug is used to antagonize the effects of heparin?
Protamine Sulfate
Other than bleeding what is another complication associated with heparin therapy? What drugs are used for this complication?
Heparin induced thrombocytopenia-HIT
Bivalrudin (Angiomax) or Argatroban (Acova)
whats the medical reperfusion therapy for STEMI
finbrinolytic therapy
what are the interventional reperfusion therapies for all ACS
PCI
CABG
evidence of reperfusion
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
whats the goal of fibrinolytic therapy
- limit size of MI
- eliminate clot
- timely reperfusion of tissue
whats the criteria for eligibility for fibrinolytic therapy
STEMI
Will only use if percutaneous coronary intervention (PCI) cannot be performed within 90 minutes
Several absolute and relative contraindications
examples of fibrinolytic therapy
Alteplase (t-PA)
Tenecteplase (TNK)
Reteplase (r-PA)
Streptokinase (SK
describe nursing management with fibrinolytic therapy
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
complications post PCI
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
describe nursing management post PCI
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
patient teaching post PCI
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
complications associated with AMI
- life threatening ventricular dysrhythmias (#1)
- heart failure
- pulmonary edema
- cardiogenic shock
discharge meds for AMI
Beta-blocker
Statin
Aspirin
Additional anti-platelets
- Clopidogrel (Plavix)
- Ticagrelor (Brilinta)
ACE-I (if indicated)
Nitroglycerin SL (if indicated)
