Care of Patients with Acute Coronary Syndromes

Question 1

Single largest killer of American men and women in all ethnic groups
Broad term that includes chronic stable angina and acute coronary syndromes
Affects the arteries that provide blood, oxygen, and nutrients to the myocardium (heart muscle) - when diseased cannot provide O2 to tissue
partially/completely blocked
Ischemia occurs when insufficient oxygen is supplied to meet the requirements of myocardium: partially/completely blocked
Infarction (necrosis or cell death) occurs when severe ischemia is prolonged and decreased perfusion causes irreversible damage to tissue; scar tissue develops
Imp to have early intervention to reverse ischemia and get O2 to myocardium

Answer 1

Coronary artery disease (CAD)

Question 2

Chest pain caused by a temporary imbalance between the coronary arteries’ ability to supply oxygen and the cardiac muscle’s demand for oxygen - imbalance
Ischemia (lack of oxygen) that occurs is limited in duration and does not cause permanent damage - not long-term
Two types:

Answer 2

Angina pectoris

Question 3

Chronic stable angina
Unstable angina - acute coronary syndromes

Answer 3

Two types: - Angina pectoris

Question 4

Chest discomfort that occurs with moderate to prolonged exertion in a pattern that is familiar to the patient - know when going to happen
Frequency, duration, and intensity of symptoms remain the same over several months
Results in only slight limitation of activity and is usually associated with a fixed atherosclerotic plaque - not moving; same spot
Usually relieved by nitroglycerin or rest; managed with drug therapy

Answer 4

Chronic stable angina

Question 5

Term used to describe patients who have either unstable angina or acute myocardial infarction (MI)
Atherosclerotic plaque in the coronary artery ruptures (not fixed), resulting in platelet aggregation (clumping), thrombus (clot) formation, and vasoconstriction of arteries
40% of blood flow through arteries has to be blocked to impede blood flow
ACS classified into one of three categories according to the presence or absence of ST-segment elevation on the ECG and positive serum troponin markers:

Answer 5

Acute coronary syndromes

Question 6

ST-elevation MI (STEMI), traditional manifestation
Non-ST-elevation MI (NSTEMI), common in women
Unstable angina pectoris

Answer 6

ACS classified into one of three categories according to the presence or absence of ST-segment elevation on the ECG and positive serum troponin markers:

Question 7

Chest pain or discomfort that occurs at rest or with exertion and causes severe activity limitation
Increased pressure and intensity
Not predictable pattern
Pressure may last longer than 15 minutes
Poorly relieved by rest or nitroglycerin (PRN)
May present with ST changes (12-lead ECG) but do not have changes in troponin or creatine kinase (CK) levels
May include:

Answer 7

Unstable angina (pectoris)

Question 8

New-onset angina –
Variant (Prinzmetal’s) angina –
Pre-infarction angina –

Answer 8

May include: - Unstable angina (pectoris)

Question 9

describes the patient who has his or her first angina symptoms, usually after exertion or other things that increased demands on the heart

Answer 9

New-onset angina –

Question 10

chest pain or discomfort resulting from coronary artery spasm and typically occurs after rest

Answer 10

Variant (Prinzmetal’s) angina –

Question 11

refers to chest pain that occurs in the days or weeks before an MI

Answer 11

Pre-infarction angina –

Question 12

Most acute coronary syndrome
Occurs when myocardial tissue is abruptly and severely deprived of oxygen
When blood flow is quickly reduced by 80% to 90%, ischemia develops
Ischemia can lead to injury and necrosis/infarction of myocardial tissue if blood flow is not restored
Imp do intervention early on
Infarction Evolves over a period of several hours - imp do intervention early on
Extent of infarction depends on collateral circulation, anaerobic metabolism, and workload demands
Physical changes do not occur in the heart until 6 hours after the infarction
Once infarction occurs, scar tissue permanently changes the size and shape of the entire left ventricle (causes HF - causes morbidity and mortality - not contract - may have chronic ventricular dysrhythmias), called ventricular remodeling
Longer MI goes more necrotic and scar tissue forms

Answer 12

MI/Acute (AMI)

Question 13

First thing do if someone having MI is get an ECG to determine which intervention to be done
NSTEMI – non-ST-segment elevation myocardial infarction
ST and T-wave changes on an ECG
Indicates myocardial ischemia
Cardiac enzymes (troponin and CK) may be initially normal but elevate over the next 3 to 12 hours - multiple labs drawn
Causes: coronary vasospasm, spontaneous dissection, sluggish blood flow due to narrowing of the coronary artery

Answer 13

NSTEMI

Question 14

STEMI – ST-elevation myocardial infarction
ST elevation in two leads on a ECG
Indicates myocardial infarction and/or necrosis
Attributable to rupture of the fibrous atherosclerotic plaque leading to platelet aggregation and thrombus formation at the site of rupture
Emergency - imp to revascularize coronary arteries blocked to restore blood flow
Thrombus that got loose causes an abrupt 100% occlusion to the coronary artery - no blood flow cardiac tissue

Answer 14

STEMI

Question 15

atherosclerosis is the primary factor in the development of CAD; nonmodifiable and modifiable risk factors contribute to atherosclerosis (causes CAD)
Nonmodifiable: age, gender, family history, ethnic background
Modifiable (focus on these): elevated serum lipid levels, smoking, limited physical activity, HTN, DM, obesity, excessive alcohol, excessive stress/decreased coping skills

Answer 15

Etiology: - CAD/Acute coronary syndromes

Question 16

average age for first MI, 65.1 years for men, 72 years for women, premenopausal women have a lower incidence than men, postmenopausal women in their 70’s or older have an equal chance for MI; screen women; women present diff via s/s

Answer 16

Incidence: - CAD/Acute coronary syndromes

Question 17

control or alter modifiable risk factors for CAD

Answer 17

Health promotion: - CAD/Acute coronary syndromes

Question 18

Eliminate smoking/tobacco use - quit
Diet – manage weight - low Na and fat
Have cholesterol and lipid levels checked regularly - if elevated, change with nutrition therapy and if not helpful then use statins
Increase physical activity
Manage diabetes
Manage hypertension
Manage weight
Limit alcohol use
Manage stress - big factor in heart disease

Answer 18

CAD prevention

Question 19

Subj and obj data; good assessment is imp
May complain of pain (know how describe) or pressure, assess according to onset, location, radiation, intensity, duration (when started), precipitating factors, relieving factors
Assess for associated symptoms such as N/V, diaphoresis, dizziness, weakness, palpitations, shortness of breath
Female not have classic s/s - have associated symp
Assess VS: BP, heart rate, cardiac rhythm, dysrhythmias common (afib); sinus tachycardia with PVCs frequently occur in the first few hours after an MI as heart tries to compensate
Assess distal peripheral pulses and skin temperature; poor cardiac output can be manifested by cool, diaphoretic skin and diminished or absent pulses; feel distal pulses and if there is any change
Auscultate for S3 gallop which often indicates heart failure – a serious and common complication of MI; assess for s/s of HF
Assess the respiratory rate and breath sounds, crackles or wheezes may indicate left-sided HF; increased RR because of anxiety
Assess for presence of jugular venous distention and peripheral edema
Assess for fever, patient with MI may experience temperature elevation for several days after infarction, in response to myocardial necrosis as high as 102, indicating the inflammatory response

Answer 19

Acute coronary syndromes - phys assessment

Question 20

Substernal chest discomfort
Radiating to the left arm - classic
Precipitated by exertion or stress (or after rest in variant angina)
Relieved by nitroglycerin or rest
Lasting less than 15 minutes
Few, if any, associated symptoms

Answer 20

Key features of angina

Question 21

Pain or discomfort
Substernal chest pain/pressure radiating to the left arm - key feature of angina; look at associated sym because not associated symp with MI so look at differences
Pain or discomfort in jaw, back, shoulder, or abdomen
Usually Occurring without cause, usually in the morning
Relieved only by opioids
Lasting 30 minutes or more
Frequent associated symptoms:

Answer 21

Key features of MI

Question 22

N/V; epigastric distress/GERD
Diaphoresis
Dyspnea
Feelings of fear or anxiety - really anxious; feeling impending doom
Dysrhythmias
Fatigue
Palpitations
Epigastric distress
Anxiety
Dizziness
Disorientation/acute confusion - not perfusing blood and O2
Feeling “short of breath” - pain and in gen

Answer 22

Frequent associated symptoms: - MI

Question 23

Psychosocial
Laboratory assessment - most common used
Imaging assessment –
Other – twelve-lead ECG, stress test, cardiac catheterization

Answer 23

assessment/acute coronary syndromes

Question 24

denial is common when first have chest pain that associated with angina/MI; waits more than 2 hrs before looks for treatment; edu on s/s of MI because want revascular ASAP because not want infarction/damage to tissue

Answer 24

Psychosocial –

Question 25

Cardiac markers
Troponins (T & I) – criterion standard used today; can be elevated within 3-4 hours and may remain elevated for 10-14 days; rise quickly; serial troponins
CK-MB – creatine kinase MB; after 24 hours after pain; specific to MI

Answer 25

Laboratory assessment - most common used

Question 26

thallium scans, contrast-enhanced cardiovascular magnetic resonance (CMR), echocardiogram, computed tomography coronary angiography (CTCA), CXR rules out aortic dissection but not used for MI; first thing do 12-lead ECG - having heart attack and location ischemia/infarction - depending on what shows determines if go to cath lab/stress test

Answer 26

Imaging assessment –

Question 27

Imp to assess, analyze ECG, analyze coronary markers to ensure pat care management
PCI - best 4-6 hrs after showing signs of MI
With new-onset atrial fibrillation, a cardiac workup should be done to rule out ACS - DM/CAD: neuropathy
First goal: Manage acute pain
Improve cardiopulmonary tissue perfusion - another goal
Thrombolytic therapy -
Percutaneous coronary intervention (PCI)
Increasing activity intolerance
Promoting effective coping
Identify and manage dysrhythmias - free of dysrhythmias but if present want manage them early; depending on heart affected determines what heart rhythm affected and higher risk for
Monitor for and manage heart failure - not develop but if do treat early to manage comps
Monitor for and manage recurrent symptoms and look at extension of injury

Answer 27

Interventions

Question 28

Prompt intervention - restore blood flow does this - increase O2 supply and decrease O2 demand
Supplemental oxygen
Drug therapy: Nitroglycerin (reduces peripheral vasoconstriction and oxygen demand; relieves episodic anginal pain; tablet or spray can be administered every 5 minutes for a total of 3 doses; can be given IV – patient may experience a headache; angina resolves); IV Morphine Sulfate (decreases myocardial oxygen demand, relaxes smooth muscle, relieves pain)
Semi-Fowler’s position - enhances comfort and tissue oxygenation as long as not contraindicated
Quiet, calm environment - decreases anxiety

Answer 28

First goal: Manage acute pain

Question 29

Restoration of perfusion to injured area limits amount of extension of injury - want do quickly, improves left ventricular function - know done wants NSR, VS norm limits
4-6 hrs restored in NSTEMI and 90min for STEMI (total occlusion)
Complete, sustained reperfusion of coronary arteries after an ACS has decreased mortality rates - completely getting reperfusion
Aspirin 325 mg(antiplatelet) –
P2Y12 Platelet inhibitors-
Glycoprotein (GP) IIB/IIIa inhibitors –
Beta blockers –
ACE inhibitors or ARB’s –
Calcium channel blockers -
Statin therapy-

Answer 29

Improve cardiopulmonary tissue perfusion - another goal

Question 30

inhibits both platelet aggregation and vasoconstriction, decreases likelihood of thrombosis

Answer 30

Aspirin 325 mg(antiplatelet) –

Question 31

Clopidogrel (Plavix) or ticagrelor (brilinta). Work to prevent platelets from aggregating together to form clots.

Answer 31

P2Y12 Platelet inhibitors-

Question 32

administered IV to prevent fibrinogen from attaching to activated platelets at the site of a thrombus; observe for any bleeding; Abciximab (ReoPro); eptifibbatide (Integrilin); tirofiban (Aggrastat)

Answer 32

Glycoprotein (GP) IIB/IIIa inhibitors –

Question 33

decreases the size of the infarct, the occurrence of ventricular dysrhythmias, and mortality rates in patients with MI; slows the heart rate and decreases the force of cardiac contraction; if pulse less than 55 or systolic BP less than 100 check with provider before administering; monitor for bradycardia, hypotension, decreased LOC, chest discomfort, crackles (indicative of heart failure), wheezing (indicative of bronchospasm); carvedilol CR(Coreg CR); metoprolol XL (Toprol XL); reduces contraction of heart; NSTEMI/STEMI discharged on this

Answer 33

Beta blockers –

Question 34

usually prescribed within 48 hours of ACS if ejection fraction is equal to or less than 40% to prevent ventricular remodeling and the development of heart failure in HTN, DM, stable CKD; not short-term use

Answer 34

ACE inhibitors or ARB’s –

Question 35

used for angina (not indicated after a MI); vasodilation/perfusion; used if beta blockers not work

Answer 35

Calcium channel blockers -

Question 36

Reduces the risk of developing recurrent MI, mortality and stroke; d/c ACS on this

Answer 36

Statin therapy-

Question 37

fibrinolytics dissolves thrombi in the coronary arteries and restores myocardial blood flow (goals); observe for any bleeding; tissue plasminogen activator (t-PA) given IV or intracoronary; Reteplase (Retavase) given IV or intracoronary (cardiac cath); Tenecteplase (TNK) given IVP; contraindications exist; given in patients with indications of STEMI by ECG; not indicated for the NSTEMI patient population; best 6 hrs after coronary event; PCI required to determine if requirements met and if are more adv to go to cath lab and use PCI to reopen closed artery and open perfusion than if on thrombolytics

Answer 37

Thrombolytic therapy -

Question 38

Phase I – patients progress at their own rate to increase levels of activity
Phase II - cardiac rehabilitation (all patients with MI should be referred; can get back to baseline)

Answer 38

Increasing activity intolerance

Question 39

Denial, anger, depression - screen for depression and help with coping - grief response from loss of func

Answer 39

Promoting effective coping

Question 40

Patients who have recurrent discomfort despite medical therapy or who have ischemia during a stress test may require invasive correction to resolve angina or prevent MI

Answer 40

Monitor for and manage recurrent symptoms and look at extension of injury

Question 41

Percutaneous Coronary Intervention (PCI): not surgical; acute MI needs be done within 90 min of arriving; reduce frequency/severity of discomfort of pats with angina and prevent CABG
Coronary Artery Bypass Graft (CABG) - more invasive; open-heart; most common for older adults (65+); bypass venous/arteries; indicated: not respond to med management CAD/disease progression imminent

Answer 41

Patients who have recurrent discomfort despite medical therapy or who have ischemia during a stress test may require invasive correction to resolve angina or prevent MI