CAD Flashcards
What is CAD?
gradual buildup of plaques in arteries, as plaques grow they can rupture or disrupt blood flow. If plaques form in vessels that feed into heart muscle, rupture or disruption of flow can cause MI. MI = lack of O2 to tissue of heart muscle.
Platelets will try to repair artery where plaque has ruptured, but that clotting can also block blood flow and cause MI.
CAD: RFs
Nonmodifiable:
- age
- gender (high in males initially although equalizes after age 75)
- ethnicity (more common in Caucasian background)
- family history
- genetics
Modifiable:
- elevated serum lipids
- elevated BP
- tobacco use
- physical inactivity
- obesity
- diabetes
- metabolic syndrome
Nursing Care of Pt with CAD
Decrease modifiable risk factors. Educate on diet, exercise, quitting smoking, blood sugar control.
Meds:
- statins: lower cholesterol
- fibric acid derivatives (gemfibrozil): give if statins cannot be tolerated b/c statins can cause rhabdomyolysis and liver injuries in which case you need to take them off statins and give gemfibrozil
- antiplatelet (baby aspirin, Plavix, Xeralto): to prevent clot from forming (move away from warfarin b/c you need to have regular labs done w/ it)
Angina: Types
- chronic stable angina
- silent ischemia
- unstable angina
- microvascular angina
- prinzmetal’s angina
*Can have chronic stable and develop unstable
Chronic Stable Angina
Intermittent
Predictable
Discerned pattern
Managed w/ rest and meds
Silent Ischemia
- No subjective symptoms
- Area of heart is not getting O2, but person doesn’t’ know d/t no symptoms
- often seen in pt w/ DM b/c ability to feel s/sx of chest pain are decreased
Unstable Angina
new occurs at rest increasing frequency and duration need prompt care may present differently in men than women
dangerous b/c women can have vague symptoms like fatigue, indigestion, SOB, and anxiety
ACS
Acute Coronary Syndrome
sudden onset of chest pressure/pain and sometimes include sudden stop of the heart.
symptoms likely with angina (mostly unstable)
caused by plaque blockage or rupture in heart
doesn’t always indicate MI happening, person can have ACS, need to do all testing and find out if they have MI or not (troponins)
Tx: thrombolytics (stop clotting from happening), beta blockers
Microvascular Angina
- spasm of the small distal vessels of coronary circulation
- prolonged, brought on by exertion
- inconsistent response to nitrates (d/t how distal and far away from main vessels that feed the heart)
Sx = chest pain brought on by exertion, not very responsive to nitrates so they get angioplasty to increase blood flow
Prinzmetal’s Angina
- Rare
- coronary artery spasm
- transient ST elevation seen
- result of increased O2 demand
Tx:
- determine that it’s Prinzmetal’s b/c it presents as MI
- meds: vasodilator usually but depends on what is causing and how severe it is for the pt
What happens during an MI?
Most commonly as a result of CAD, a fatty plaque causes a blockage in the heart vasculature that feeds the heart muscle.
Can present as ACS (crushing chest pain, not feeling well, unstable)
Ischemia = lack of O2 to heart tissue > tissue damage which can be permanent
In MI there is SNS stimulation – adrenal response (sweating, anxious, they don’t feel right, irritable, know something is wrong but may not be able to pinpoint it)
Other sx: Nausea/Vomiting/low grade fever
What distinguishes MI from Angina?
Need cardiac biomarkers (troponins)
Need EKG that shows ST elevation or depression (indicating vessel in heart is not getting enough blood flow)
MI: Pain
NOT consistent between male and female:
- Females may have jaw pain, indigestion, heart burn, GI upset
- Men tend to present w/ more predictable symptoms (chest pain, left arm pain, neck pain)
What diagnostic tests are run when MI is suspected?
cardiac biomarker (Troponin)
- cardiac specific enzyme released during cardiac muscle injury (normal = 0.0-0.04 ng/mL)
- Hospitals now look at higher sensitivity troponin (even more cardiac specific, can pick up lower levels earlier on). Normal = less than or equal to 14.
EKG
Coronary Angiography: looking at heart vessels and possibly performing some sort of intervention to open up those vessels if they aren’t intact or open enough. Gold standard for MI to get them from door entering ED into cath lab to do angiography is less than 90min. Over 90min will lead to tissue damage.
What medications would anticipate giving in MI?
MONA:
- morphine: vasodilation effects and reduces chest pain
- O2: help bring O2 to areas not getting any
- nitro: vasodilator (SE = hypotension)
- aspirin: decrease platelets and hopefully prevent clot
Beta blockers and ACE-I
-long term meds to prevent remodeling of heart and help increase cardiac function
Anticoagulation and thrombolytics (agrostat for stent then switched to long term med like aspirin, eloquist, xerolto, Plavix)
PCI
Percutaneous Coronary Intervention
catheter is inserted and you treat vessel that is blocked or narrowed (opening it back up w/ balloon or stent)
in cath lab
want this done w/in 90 min of their arrival to ED
MI: Tx
depends on what happened during MI
- CABG (in severe cases)
- Rehab. (aerobic programs to slowly increase activity for heart muscle)
- Manage risk factors.(educating about modifiable RF and eliminate them if possible)
- Lifestyle education.
- Gradual return to physical activity.
- Resuming sexual activity. (decision is left up to doctor if there is concern about this and doc will speak to pt , nurse needs to be prepared to talk about this though and answer questions)
MI: What meds is pt on at discharge?
Beta blockers
ACE-I
Anti-Platelet
Post-MI Nursing Considerations
- Anxiety. (normal for a pt who went through this)
- Rest.
- Continuous monitoring. (in hospital and at home)
- Pain. (not uncommon, but should improve slowly)
- Psychological response. (may have PTSD situation, anxiety/fear)
- Still an MI risk – short term and long term.
Cardiac Cath
- Usually done via radial artery or femoral artery.
- Outpatient procedure in most cases.
- Diagnostic tool in non-emergency (in emergency it’s PCI)
- Differences between right heart and left heart cath has to do with what they are doing:
- Left heart cath: looking at vessels feeding heart
- Right heart cath: looking at hemodynamic numbers for someone who doesn’t have Swan-Ganz catheter
Cardiac Cath: Nursing Care
- Manage anxiety (normal)
- Check renal status (dye used during cardiac cath can be nephrotoxic, check UO, bolus w/ fluids after if needed)
- Monitor puncture site. (accessing major arteries directly, monitor by checking site, make sure it’s not actively bleeding or has hemotoma)
- Retroperitoneal bleed risk (if procedure is done femorally, pressure and bleeding can surround kidney area which is very dangerous)
- If femoral, pt remains on bedrest and flat for 2-6 hrs post procedure (not discharged right away)
- Monitor UO (need 0.5ml/kg/hr)
- Pulse checks in affected limb
Targeted Temperature Management
If patient has cardiac arrest as a result of MI, then ROSC, but does not wake up.
Cooled (to 33 degrees C) for 24 hours.
Allows for decreased O2 demand and rest for heart and organs (since they depend on heart)
After cooling, rewarming process takes about 8 hours and then we wait and see if they wake up.
