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MS2 exam 2 > Angina & Myocardial Infarction > Flashcards

Angina & Myocardial Infarction Flashcards

1
Q

CAD

A
  • Accumulation of atherosclerotic plaque in the coronary arteries
  • could lead to development of collateral circulation, angina, acute coronary syndrome, myocardial infarction, dysrhythmias, heart failure, or death
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2
Q

Myocardial ischemia

A
  • caused by declining artery circumference or lack of blood supply
  • increased demand for oxygen or decreased supply of oxygen
  • usually occurs when a coronary artery is >75% occluded (or stenosed)
  • cardiac cells can sustain about 20 mins of no O2 before necrosis
  • most common cause is atherosclerosis
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3
Q

Collateral circulation

A
  • tiny vessels connecting the large coronary arteries
  • often develops in the presence of atherosclerosis to allow for continued blood flow
  • an alternative route blood to flow from the aorta to the cardiac muscle tissue
  • reroute blocked artery by minor vessels
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4
Q

Angina

A

-chest pain resulting from reduced coronary blood flow
-imbalance between myocardial blood (and O2) supply and demand
-3 types of angina
S/S: chest pain & tightness, indigestion

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5
Q

Precipitating factors of angina

A
  • physical exertion
  • temperature extremes
  • anxiety/anger
  • consumption of a heavy meal
  • smoking
  • sexual activity
  • drugs (stimulants)
  • dysrhythmias
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6
Q

Stable angina

A
  • predictable pattern of increased work of the heart resulting in chest pain and relieved by rest or nitrates
  • symptoms: pain, SOB, nausea and vomiting, palpitations and weakness
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7
Q

Prinzmental angina

A
  • coronary artery vasospasm
  • occurs unpredictably (not associated w/ physical activity)
  • most often occurs at night while at rest
  • unknown causes, though presumed to be caused by : -hyperactive sympathetic respsonse
  • Altered calcium flow
  • reduced prostaglandins that promote vasodilation
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8
Q

Unstable angina

A
  • unpredictable pain without contributing factors
  • at rest or during activity
  • departing from usual pattern
  • May last more than 20 minutes
  • marked by increasing frequency, severity, and duration of chest pain symptoms
  • patho: atherosclerosis
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9
Q

Patient history

A
  • PQRST
  • P:precipitating events
  • Q:quality of pain
  • R:radiation of pain
  • S:severity of pain
  • T:timing-when is began, with what activity?
  • do they take medications?
  • risk factors : family history, stressors
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10
Q

Acute coronary syndrome (ACS)

A

-when blood flow is significantly reduced but not fully occluded causing myocardial injury
-precipitating factors: -coronary artery vasospasm
-rupture of atherosclerotic plaque resulting in a thrombus formation
-increasingly occlusive atherosclerotic plaque
-inflammation of coronary artery
-diastolic and systolic dysfunction (HF)
Some symptoms: SOB, dizzy, light headed, sweating, nausea, not feeling right

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11
Q

Plaque rupture in ACS

A

1) hemodynamic changes cause plaque to rupture
2) platelet aggregation
3) clot formation
4) cell ischemia and injury
5) lactic acid production causes chest pain

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12
Q

Acute myocardial infarction

A
  • when blood flow to a portion of the cardiac muscle is completely blocked
  • complete occlusion results in prolonged ischemia which kills cardiac cells permanently
  • irreversible cell damage leads to poor cardiac functioning (ie: arrhythmias, HF, cardiogenic shock, death)
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13
Q

AMI: electrical changes

A

The T-wave will invert or the ST segment of ECG tracing will become elevated

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14
Q

AMI: ST segment elevation

A
  • > 0.04 secs after J point
  • > 1 mm (1 small box) in 2 or more contiguous chest leads
  • contiguous means limb leads that “look” at the same area of the heart or are numerically consecutive chest leads
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15
Q

Stages of myocardial insult

A

1) ischemia
2) injury
3) infarct

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16
Q

Ischemia stage of myocardial insult

A
  • lack of oxygenation
  • ST depression or T wave inversion
  • permanent damage avoidable
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17
Q

Injury stage of myocardial insult

A
  • prolonged ischemia
  • may have ST elevation
  • permanent damage avoidable
18
Q

Infarct stage of myocardial insult

A
  • permanent death of myocardial tissue

- may have ST elevation and/or Q wave

19
Q

STEMI vs. Non-STEMI

A

STEMI: ST segment elevation present

  • may or may not have elevation of cardiac enzymes initially
  • complete occlusion

Non-STEMI: no ST segment elevation(possible ST depression or T wave inversion)

  • diagnosed by elevated cardiac enzymes
  • partial occlusion
20
Q

Diagnostic tests for ACS

A
  • 12 lead EKG
  • cardiac enzymes
  • CXR (portable)
  • echocardiogram
  • trans-esophageal Echo (TEE)
  • exercise stress test
  • nuclear cardiology
  • cardiac cath
21
Q

Call for help!

A
  • CP unrelieved with rest
  • new onset CP
  • increasing SOB
  • prolonged period of pain
  • unable to identify the cause
  • do not drive
  • do not wait
22
Q

Caring for pts. With chest pain

A
  • EKG priority
  • quick history and descriptions of symptoms
  • vital signs
  • IV access with blood draw (cardiac enzymes)
  • medications
  • closely monitor pts. Vitals and reports of chest pain
23
Q

When a pt is having chest pain…

A

You go fast!

  • all chest pain is MI until proven otherwise
  • work with your team, don’t try to tackle all the tasks alone.. Your pt will suffer
24
Q

Rule out MI

A
  • MONA= every pt with chest pain
  • M- morphine
  • O - oxygen
  • N- nitroglycerin
  • A- aspirin
25
Q

Morphine

A
  • relieves pain-> reduces metabolic demand -> allows for more oxygen to be available to cardiac cells
  • vasodilates (increases coronary perfusion and decreases after load)
  • closely monitor pts BP (too much =drop in BP)
26
Q

Oxygen

A
  • increases amount of oxygen available to pts cardiac muscle
  • starts with 2L /min and increases as necessary
  • no need for O2 if SPO2 is 94% or greater
27
Q

Nitroglycerin

A

-short acting nitrates: first line therapy
- dilates peripheral blood vessels, coronary arteries/ collateral vessels
- SL nitroglycerin (pill or spray) 1 every 5mins
X 3

  • Long acting nitrates: nitroglycerin ointment
  • Isordil (isosorbide dinitrate) or Imdur (isosorbide mononitrate)
28
Q

Aspirin

A
  • must be administered before or upon arrival
  • OK if given and documented by EMS before arrival, or if pt says they took it at home and you document “pt tookprior to arrival”
  • either dose is acceptable: 162mg or 325mg
  • if pt cannot take it by mouth, must get order to take rectally
  • contraindications must be documented by the MD, ARNP, PA (ie: allergy or active bleeding present)
  • decreases platelet aggregation
29
Q

What may be seen in acute phase

A
  • chest pain
  • dyspnea, SOB
  • diaphoresis, pale, cool skin
  • N&V
  • reports of weakness
  • JVD
  • murmurs, abnormal heart sounds
  • crackles in lung bases
  • sense of impending doom
30
Q

Incidence of CAD

A
  • American heart association estimates that 1.2 million people will have a heart attack each year
  • 1/4 will die prior to getting to the ER
  • leading cause of death
31
Q

inferior wall

A
  • use caution when giving nitroglycerin to pts with inferior wall MI
  • inferior infarcts are usually from RCA occlusion resulting in right ventricular failure
  • typically will see hypotension and bradycardia with inferior wall MI
32
Q

joint commission core measures for AMI

A
  • aspirin on arrival and prescribed at discharge
  • ACEI or ARB for LVSD
  • smoking cessation advice/counseling
  • beta-blocker prescribed at discharge
  • fibrinolytic therapy within 30 mins of arrival or
  • PCI (“door-to-balloon”) within 90 mins
  • statin prescribed at discharge
33
Q

fibrinolytics

A
  • used when interventional procedures are not available
  • need to know when the chest pain began within a 12 hr window
  • ideal delivery within 30mins of arrival
  • monitor S/S of bleeding
  • be prepared for reperfusion dysrhythmias
34
Q

fibrinolytic therapy

A
  • most common: reteplase (recombinant plasminogen activator)
  • method of action: works by accelerating the formatin of plasmin from plasminogen, allowing rapid lysis of clots
35
Q

fibrinolytic contraindications: ABSOLUTE

A
  • any prior intra-cranial hemorrhage
  • cerebral vascular lesions
  • intra cranial neoplasms
  • ischemic stroke within 3 months
  • suspected aortic dissection
  • active bleeding (excluding menses)
  • head or facial trauma within 3 months
  • intracranial surgery within 2 months
  • uncontrolled hypertension
36
Q

fibrinolytic contraindications: RELATIVE

A
  • history of chronic/severe poorly controlled hypertension
  • HTN on presentation (SBP>180 or DBP >110)
  • history of prior ischemic stroke
  • dementia
  • traumatic or prolonged CPR
  • major surgery within 3 weeks
  • recent internal bleeding (2-4 wks)
  • non-compressable vascular punctures
  • pregnancy-active peptic ulcer
  • currently taking oral anticoagulant therapy
37
Q

PCI- percutaneous coronary intervention

A
  • catheter is fed through groin
  • dye is shot through the catheter to locate occlusion
  • occlusion is repaired via catheter.. no scalpel needed
  • pt is recovered in the ICU and closely monitored for at least 24 hrs
  • pt is on blood thinners for at least 1 yr post PCI
38
Q

complications that may develop post MI

A
  • dysrhythmias
  • heart failure
  • cardiogenic shock
  • structural defects
  • pericarditis
39
Q

healing

A
  • within 24 hrs tissues are being removed by macrophages
  • 10 days to 3 weeks scar tissue is being laid down
  • 6 weeks stability
40
Q

angina and ACS summary

A
  • pts can have intermittent ischemia from atherosclerosis called angina
  • when the diseased vessel becomes totally occluded it results in a myocardial infarction (cell death)
  • pts with chest pain should be treated rapidly
  • treatment options are determined based on the type of MI, pts vitals during event, & resources available at facility
  • pts who have experienced an MI should receive thorough education about managing their diagnoses as well as frequent follow up post- discharge

MS2 exam 2 (9 decks)

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