Chapter 33 Coronary Artery Disease and Acute Coronary Syndrome Flashcards

Question

Gender Men vs Women

Answer 1

- Men * 10-15 years earlier than women * MI vs Angina * Big ventricle * Classic symptoms * Acute MI- first evidence of CAD * Better collateral circulation - Women * More deaths * Fatigue * Menopause * Palpitations * Often not treated as quickly. * Symptoms not classic-Silent MI * Higher mortality with CABG

Answer 2

- serum cholesterol level greater than 200 mg/dL (5.2 mmol/L) - fasting triglyceride level greater than 150 mg/dL (3.7 mmol/L)

Answer 3

1) <100 Optimal or < 70 for very high risk 2) 100-129 Near optimal/above optimal 3) 130-159 Borderline high 4) 160-189 High 5) 190 Very high

Answer 4

1) <200 Desirable 2) 200-239 Borderline high 3) 240 High

Answer 5

1) <40 Low, Women should be > 50 | 2) 60 High

Answer 6

high-density lipoproteins (HDLs), LDLs, and very-low-density lipoproteins (VLDLs).

Answer 7

HDLs carry lipids away from arteries and to the liver for metabolism. This process of HDL transport prevents lipid accumulation within the arterial walls. Therefore high serum HDL levels are desirable and lower the risk of CAD.

Answer 8

higher in women, decrease with age, and are low in individuals with CAD. Physical activity and moderate alcohol intake increase HDL levels.

Answer 9

1) cholesterol than any of the lipoproteins and have an attraction for arterial walls. 2) cholesterol and triglycerides and may deposit cholesterol directly on the walls of arteries. 3) atherosclerosis and CAD. Therefore low serum LDL levels are desirable

Answer 10

1) high alcohol intake, high intake of refined carbohydrates and simple sugars, and physical inactivity. 2) a smaller, denser LDL particle is formed, which favors deposition on arterial walls. People with insulin resistance often have this pattern.

Answer 11

(1) age (2) gender (3) race (4) use of tobacco (5) diabetes (6) systolic BP (7) diastolic BP (8) use of BP drugs (9) total cholesterol level (10) HDL cholesterol level

Answer 12

- 160 mg/dL (4.14 mmol/L). | - less than 70 mg/dL (1.8 mmol/L)

Answer 13

- HDL Cholesterol- more protein * <40 Low, Women should be > 50 * 60 High - Triglycerides- * fasting > 150 mg/dl associated with coronary artery disease.

Answer 14

Low (lower than 100 mg/dL) or it will lower you to the ground

Answer 15

High (greater than 40 mg/dL) for patient to feel healthy and high on life

Answer 16

(1) patients with known CVD (2) patients with primary elevations of LDL cholesterol levels greater than or equal to 190 mg/dL (e.g., familial hypercholesterolemia) (3) patients between 40 and 75 years old with diabetes and LDL cholesterol levels between 70 and 189 mg/dL (4) patients between 40 and 75 years old with LDL cholesterol levels between 70 and 189 mg/dL and a 10-year risk for CVD of at least 7.5%

Answer 17

6 weeks of therapy. If they remain elevated, changes in drug therapy and additional dietary options should be considered.

Answer 18

1) Statins: Block synthesis of cholesterol, increase LDL receptors-hepatic * Monitor Liver, CK 2) Niacin: Inhibits VLDL, LDL-flushing * Take ASA or NSAID 3) Fibric Acid Derivatives- Lower triglycerides * Increase HDLs 4) Bile acid sequestrants: bind with bile salts * Interfere with medications

Answer 19

1) Mechanism of action: Block synthesis of cholesterol and increase LDL receptors in liver - ↓ LDL - ↓ Triglycerides - ↑ HDL 2) Side Effects: Rash, GI disturbances, elevated liver enzymes, myopathy, rhabdomyolysis 3) Nursing Considerations: Well tolerated with few side effects. Monitor liver enzymes and creatine kinase (if muscle weakness or pain occurs).

Answer 20

1) Mechanism of Action: Inhibits synthesis and secretion of VLDL and LDL - ↓ LDL - ↓ Triglycerides - ↑ HDL 2) Side Effects: Flushing and pruritus in upper torso and face, GI disturbances (e.g., nausea and vomiting, dyspepsia, diarrhea), orthostatic hypotension, elevated homocysteine levels 3) Nursing Considerations: Most side effects subside with time. Decreased liver function may occur with high doses. Taking aspirin or NSAID 30 min before drug may prevent flushing. Take drug with food. Treat elevated homocysteine levels with folic acid.

Answer 21

1) Mechanism of Action: Decrease hepatic synthesis and secretion of VLDL. Reduce triglycerides by ↓ VLDL - ↓ LDL - ↓ Triglycerides - ↑ HDL 2) Side Effects: Rashes, mild GI disturbances (e.g., nausea, diarrhea), elevated liver enzymes 3) Nursing Considerations: May ↑ effects of warfarin (Coumadin) and some antihyperglycemic drugs. When used in combination with statins, may increase adverse effects of statins, especially myopathy.

Answer 22

1) Mechanism of Action: Bind with bile acids in intestine, forming insoluble complex and excreted in feces Binding results in removal of LDL and cholesterol ↓ LDL 2) Side Effects: Unpleasant quality to taste, GI disturbances (e.g., indigestion, constipation, bloating) 3) Nursing Considerations: Effective and safe for long-term use. Side effects diminish with time. Interfere with absorption of many drugs (e.g., digoxin, thiazide diuretics, warfarin, some antibiotics [e.g., penicillins])

Answer 23

* Instruct patient that flushing (especially of face and neck) may occur within 20 minutes after taking drug and may last for 30 to 60 minutes. * Patient can premedicate with aspirin 30 minutes before taking to reduce flushing. * Use of extended-release niacin may decrease side effects.

Answer 24

1) 50 to 59 years old who have a calculated 10-year CVD risk of 10% or more, are not at increased risk for bleeding (e.g., history of GI bleeding), have a life expectancy of at least 10 years, and are willing to take low-dose aspirin for at least 10 years. 2) 10-year CVD risk of 10% or more, the decision to take low-dose aspirin is an individual one. 3) those younger than 50 or older than 70

Answer 25

- Low dose aspirin- - Plavix- prevent platelets in your blood from sticking together and forming a blood clot. Unwanted blood clots can occur with certain heart or blood vessel conditions. used to prevent blood clots after a recent heart attack or stroke, and in people with certain disorders of the heart or blood vessels.

Answer 26

1) either an increased demand for O2 or a decreased supply of O2. 2) narrowing of one or more coronary arteries by atherosclerosis. This leads to insufficient blood flow to the heart muscle. 3) usually blocked (stenosed) 70% or more (50% or more for the left main coronary artery)

Answer 27

1) physical exertion, stress, or emotional upset. 2) pressure, heaviness, or discomfort in the chest. This discomfort is often described as a squeezing, heavy, tight, or suffocating sensation. It may be associated with other symptoms such as dyspnea or fatigue. 3) position or breathing and is rarely described as sharp or stabbing.

Answer 28

atypical symptoms of angina including dyspnea, nausea, and/or fatigue.4 This is referred to as angina equivalent.

Answer 29

1) only a few minutes and commonly subsides when the precipitating factor is resolved (e.g., resting, calming down, using sublingual nitroglycerin (SL NTG) (Nitrostat). 2) UA. 3) ST segment depression and/or T wave inversion indicating ischemia. The ECG returns to baseline when the pain is relieved.

Answer 30

provide peak effects during the time of day when angina is likely to occur. For example, if angina occurs when rising, the patient can take medication as soon as awakening and wait 30 minutes to 1 hour before engaging in activity.

Answer 31

- P: What events or activities precipitated the pain or discomfort (e.g., argument, exercise, resting)? - Q: What does the pain or discomfort feel like (e.g., pressure, dull, aching, tight, squeezing, heaviness)? - R: Can you point to where the pain or discomfort is located? Does the pain or discomfort radiate to other areas (e.g., back, neck, arms, jaw, shoulder, elbow)? - S: On a scale of 0 to 10, with 0 indicating no pain and 10 being the most severe pain you could imagine, what number would you give the pain or discomfort? - T: When did the pain or discomfort begin? Has it changed since this time? Have you had pain/discomfort like this before?

Answer 32

- Etiology: Myocardial ischemia (usually secondary to CAD) caused by an O2 supply/demand mismatch -Charactertistics: • Episodic pain lasting a few minutes • Provoked by exertion or stress • Relieved by rest or nitroglycerin

Answer 33

- Etiology: Coronary vasospasm - Characteristics: • Occurs primarily at rest • Triggered by smoking and increased levels of some substances (e.g., histamine, epinephrine, cocaine) • May occur in presence or absence of CAD

Answer 34

- Coronary arteries can’t meet demands for oxygen - Reversible myocardial ischemia - Intermittent, same pattern - Constrictive, heavy - No change with position or breathing. - Pain subsides with rest

Answer 35

- Sensation of choking - Heaviness, weakness or numbness of upper extremities - Dizziness - Dyspnea - Indigestion or nausea

Answer 36

* Inhibits platelet aggregation * Alternative for patients who cannot take aspirin * Used to treat ACS with medical therapy alone or used in combination with aspirin after PCI for chronic stable angina or ACS

Answer 37

The treatment of chronic stable angina aims to decrease O2 demand and/or increase O2 supply. The reduction of risk factors is a priority and should include those strategies discussed for patients with CAD (see pp. 707-712). In addition to antiplatelet and lipid-lowering drug therapy, the most common therapeutic interventions for the management of chronic stable angina are the use of nitrates, angiotensin-converting enzyme (ACE) inhibitors, β-blockers, and calcium channel blockers to optimize myocardial perfusion

Answer 38

nitrates, angiotensin-converting enzyme (ACE) inhibitors, β-blockers, and calcium channel blockers to optimize myocardial perfusion

Answer 39

``` Element Treatment A Antiplatelet/anticoagulant therapy Antianginal therapy ACE inhibitor/angiotensin receptor blocker B β-blocker BP control C Cigarette smoking cessation Cholesterol (lipid) management Calcium channel blockers Cardiac rehabilitation D Diet (weight management) Diabetes management Depression screening E Education Exercise F Flu vaccination ```

Answer 40

* Promote peripheral vasodilation, decreasing preload and afterload * Promote coronary artery vasodilation * May prevent or control coronary vasospasm

Answer 41

* Inhibit sympathetic nervous stimulation of the heart * Reduce heart rate, contractility, and BP * Reduce ischemia * Decrease afterload

Answer 42

* Prevent calcium entry into vascular smooth muscle cells and myocytes (cardiac cells) * May prevent or control coronary vasospasm * Promote coronary and peripheral vasodilation * Reduce heart rate, contractility, and BP

Answer 43

1) Dilating peripheral blood vessels: This results in decreased SVR, venous pooling, and decreased venous blood return to the 716heart (preload). Therefore myocardial O2 demand is decreased because of the reduced cardiac workload. 2) Dilating coronary arteries and collateral vessels: This may increase blood flow to the ischemic areas of the heart. However, when the coronary arteries are severely atherosclerotic, coronary dilation is difficult to achieve.

Answer 44

1) 5 minutes and lasts approximately 30 to 40 minutes. 2) one tablet taken sublingually (SL) or one metered spray on the tongue for symptoms of angina. If symptoms are unchanged or worse after 5 minutes, tell the patient or caregiver to repeat NTG every 5 minutes for a maximum of three doses and contact emergency response system (ERS) if symptoms have not resolved completely.

Answer 45

1) away from light and heat sources, including body heat, to protect them from degradation. 2) light-resistant bottles with metal caps. Once opened, the tablets lose potency, and should be replaced every 6 months.

Answer 46

1) direct it on the tongue, not inhale it. 2) a headache, dizziness, or flushing may occur. 3) orthostatic hypotension may occur. 4) tablet or spray 5 to 10 minutes before beginning the activity. Tell the patient to report to the HCP any changes in the usual pattern of pain, especially increasing frequency, nighttime angina, or angina at rest.

Answer 47

1) Calcium Channel Blockers 2) Beta Blockers 3) Sublingual Nitroglycerin: short acting * Tablets * Spray 4) Nitroglycerin: long acting * Tablets or capsules * Paste * Transdermal- vacation at night.

Answer 48

- Sublinguinal: spray or tablet under tongue - Tingling sensation - Protect from light - Keep close by - Headache - Orthostatic hypotension- Rest with phone nearby - Prophylactic use before exercise or sex - Relieve pain in 3 min.

Answer 49

- One spray or one tablet sublingual * Unchanged or worse in 5 min., call EMS - One tablet or spray every 5 min. for three doses. * As long as pain is the same or lessening * Assessment ????? * Call EMS if symptoms not resolved in 15 min.

Answer 50

- One spray or one tablet sublingual * Unchanged or worse in 5 min., call EMS - One tablet or spray every 5 min. for three doses. * As long as pain is the same or lessening * Assessment: monitor BP after first dose * Call EMS if symptoms not resolved in 15 min.

Answer 51

1) headache from the dilation of cerebral blood vessels. Tell patients to take acetaminophen (Tylenol) to relieve the headache. Over time, the headaches may decrease, but the antianginal effects are still present. 2) BP after the first dose, since the venous dilation that occurs may cause a drop in BP, especially in volume-depleted patients. 3) 10- to 14-hour nitrate-free period every day. 4) translingual or SL NTG if angina develops.

Answer 52

1) upper body or arm, over a flat muscular area that is free of hair and scars. 2) anginal prophylaxis for 3 to 6 hours. It is especially useful for nighttime and UA. 3) 10- to 14-hour nitrate-free interval in order to prevent nitrate tolerance.

Answer 53

1) silicone gel and polymer matrix. 2) a 24-hour period. These preparations should also be removed in the evening to allow for a 10- to 14-hour nitrate-free interval.

Answer 54

* a dark, airtight container to maintain potency. * under the tongue. * on the tongue, not under the tongue. * erectile dysfunction (e.g., sildenafil [Viagra]) as severe hypotension can occur. * orthostatic hypotension because it may occur after administration. * Headaches are common * Use gloves * cardioverter-defibrillator over NTG ointment or transdermal patch. * 10- to 14-hour nitrate-free period.

Answer 55

- Decrease myocardial contractility - Decrease HR and SVR - Decrease oxygen demand of the heart - Sexual dysfunction - Respiratory problems - Depression - Mask signs of hypoglycemia

Answer 56

1) myocardial contractility, HR, SVR, and BP, all of which reduce the myocardial O2 demand. 2) LV dysfunction, heart failure (HF), or MI are carvedilol (Coreg), metoprolol (Lopressor, Toprol XL), and bisoprolol (Zebeta) 3) bradycardia, hypotension, wheezing from bronchospasm, and GI complaints. 4) weight gain, depression, fatigue, and sexual dysfunction. 5) bradycardia and acute HF. Patients with asthma should avoid β-blockers. 6) They mask signs of hypoglycemia. 7) increase in the number and intensity of angina attacks.

Answer 57

- Exercise Stress Testing- ST and T wave changes, cardiac dysrhythmias - Chest x-ray- heart enlargement - Pharmacologic Nuclear imaging - Calcium Scoring Screening heart scan - What about vital signs? - Cardiac Catheterization with angiography-PCI * Angioplasty- not as effective * Stent placement

Answer 58

1) chest x-ray looks for cardiac enlargement, aortic calcifications, and pulmonary congestion. 2) Any changes. 3) specific risk factors for CAD. 4) resting LV wall motion abnormalities, which may suggest evidence of CAD. 5) pharmacologic (adenosine [Adenocard] or dipyridamole [Persantine]) stress test with nuclear imaging, or a pharmacologic (dobutamine [Dobutrex]) stress echocardiogram may be ordered. 6) 70%

Answer 59

1) radiation and IV contrast dye to provide images of the coronary circulation and identify the location and severity of any blockage. 2) corticosteroids. 3) hydration pre- and postprocedure. 4) renal dysfunction. Monitor renal function closely after the procedure. 5) percutaneous or surgical coronary revascularization.

Answer 60

positioned in the blockage and inflated. This compresses the plaque against the artery wall, resulting in vessel dilation and a larger vessel diameter. This procedure is called balloon angioplasty.

Answer 61

1) UA, non–ST-segment-elevation myocardial infarction (NSTEMI), and ST-segment-elevation myocardial infarction (STEMI). 2) STEMI. 3) UA and NSTEMI until serum cardiac biomarkers are measured

Answer 62

1) 20 minutes. 2) 20 minutes if there is no collateral circulation. With restoration of blood flow (reperfusion), aerobic metabolism resumes, contractility is restored, and cellular repair begins.

Answer 63

1) ruptures, releasing substances into the vessel. This causes platelet aggregation and thrombus formation. 2) partially blocked by a thrombus (manifesting as UA or NSTEMI) or totally blocked by a thrombus (manifesting as STEMI). 3) What causes the plaque to suddenly become unstable is not well understood, but systemic inflammation (described earlier) is thought to play a role. Patients with suspected ACS need immediate hospitalization.

Answer 64

- New onset or different chest pain - Occurs at rest - Change in pattern - Women: fatigue, shortness of breath - Coronary artery not completely occluded.

Answer 65

chest pain that is new in onset, occurs at rest, or occurs with increasing frequency, duration, or with less effort than the patient's chronic stable angina pattern. The pain usually lasts 10 minutes or more. Prompt treatment is needed for patients with suspected UA.

Answer 66

minimal or no exertion, during sleep, or even at rest. The patient without previously diagnosed angina describes anginal pain that has progressed rapidly in the past few hours, days, or weeks, often ending in pain at rest.

Answer 67

fatigue, shortness of breath, indigestion, and anxiety. Fatigue is the most prominent symptom.4 However, all these symptoms can relate to many different diseases and syndromes. Thus women often present with UA before CAD is diagnosed.

Answer 68

- Irreversible ischemia- death of cells - Thrombus formation - No contraction of necrotic tissue - Subendocardium- first to feel effects - Anterior, lateral, inferior or posterior

Answer 69

irreversible myocardial cell death (necrosis) in the heart muscle beyond the blockage. Most MIs occur in the setting of preexisting CAD

Answer 70

- caused by an occlusive thrombus - creates ST-elevation in the ECG leads facing the area of infarction - an emergency situation - to limit infarct size, artery must be opened within 90 minutes of presentation. This can be done either by PCI or thrombolytic (fibrinolytic) therapy. - PCI is the first-line treatment if a hospital is capable of performing PCI.

Answer 71

- caused by a nonocclusive thrombus - does not cause ST segment elevation on the 12-lead ECG. - Patients may or may not develop ST-T wave changes in the leads affected by infarction - patients do not go to catheterization laboratory emergently but usually undergo procedure within 12 to 72 hours if there are no contraindications. - Thrombolytic therapy is not indicated for NSTEMI patients

Answer 72

- hypokinesis (worsening myocardial contractility) or akinesis (absent myocardial contractility) in the necrotic area(s). - The degree of LV dysfunction depends on the area of the heart involved and size of the infarction.

Answer 73

1) subendocardium (the innermost layer of tissue in the heart muscle). 2) 4 to 6 hours for the entire thickness of the heart muscle to become necrosed. If the thrombus is not completely blocking the artery, the time to complete necrosis may be as long as 12 hours.

Answer 74

The majority of MIs affect the LV and are usually described based on the location of damage (e.g., anterior, inferior, lateral, septal, or posterior wall infarction). The location of the MI and ECG changes correlate with the involved coronary artery (see Table 35-14). For example, in most people, the right coronary artery provides blood to the inferior and posterior LV walls. Blockage of the right coronary artery results in an inferior wall and/or posterior wall MI. Anterior wall infarctions result from blockages in the left anterior descending artery. Blockages in the left circumflex artery usually cause lateral LV wall MIs. Damage can occur in more than one location, especially if more than one coronary artery is involved (e.g., anterolateral MI). Right ventricular MIs are much less common and treated differently than LV MIs.

Answer 75

- New onset or different chest pain - Occurs at rest - Change in pattern - Women: fatigue, shortness of breath - Coronary artery not completely occluded.

Answer 76

chest pain that is new in onset, occurs at rest, or occurs with increasing frequency, duration, or with less effort than the patient's chronic stable angina pattern. The pain usually lasts 10 minutes or more. Prompt treatment is needed for patients with suspected UA.

Answer 77

minimal or no exertion, during sleep, or even at rest. The patient without previously diagnosed angina describes anginal pain that has progressed rapidly in the past few hours, days, or weeks, often ending in pain at rest.

Answer 78

fatigue, shortness of breath, indigestion, and anxiety. Fatigue is the most prominent symptom.4 However, all these symptoms can relate to many different diseases and syndromes. Thus women often present with UA before CAD is diagnosed.

Answer 79

- Irreversible ischemia- death of cells - Thrombus formation - No contraction of necrotic tissue - Subendocardium- first to feel effects - Anterior, lateral, inferior or posterior

Answer 80

irreversible myocardial cell death (necrosis) in the heart muscle beyond the blockage. Most MIs occur in the setting of preexisting CAD

Answer 81

- caused by an occlusive thrombus - creates ST-elevation in the ECG leads facing the area of infarction - an emergency situation - to limit infarct size, artery must be opened within 90 minutes of presentation. This can be done either by PCI or thrombolytic (fibrinolytic) therapy. - PCI is the first-line treatment if a hospital is capable of performing PCI.

Answer 82

- caused by a nonocclusive thrombus - does not cause ST segment elevation on the 12-lead ECG. - Patients may or may not develop ST-T wave changes in the leads affected by infarction - patients do not go to catheterization laboratory emergently but usually undergo procedure within 12 to 72 hours if there are no contraindications. - Thrombolytic therapy is not indicated for NSTEMI patients

Answer 83

- hypokinesis (worsening myocardial contractility) or akinesis (absent myocardial contractility) in the necrotic area(s). - The degree of LV dysfunction depends on the area of the heart involved and size of the infarction.

Answer 84

1) subendocardium (the innermost layer of tissue in the heart muscle). 2) 4 to 6 hours for the entire thickness of the heart muscle to become necrosed. If the thrombus is not completely blocking the artery, the time to complete necrosis may be as long as 12 hours.

Answer 85

1) inferior wall and/or posterior wall MI. 2) Anterior wall infarctions 3) lateral LV wall MIs. 4) much less common and treated differently than LV MIs.

Answer 86

more serious first MI than an older person with the same degree of blockage.

Answer 87

1) Zone of infarction and necrosis: O2 deprived, damage irreversible, causes "Q" wave on ECG 2) Zone of injury: Next to infarct. Tissue is viable as long as circulatin remains adequate. Increasing O2 may save this area from necrosis. Causes ST segment elevation on ECG 3) Zone of ischemia: Viability may not be damaged as long as MI doesn't extend and collateral circulation is able to compensate. Causes T wave inversion

Answer 88

- Pain- no relief from rest or nitrates - More common in early morning hours - Location of pain - May be weak or short of breath - May have no pain at all- diabetics

Answer 89

1) rest, position change, or nitrate administration is the hallmark of an MI. 2) heavy, pressure, tight, burning, constricted, or crushing feeling. 3) substernal or epigastric areas. 4) neck, lower jaw, and arms or to the back. 5) indigestion and take antacids without relief. 6) active or at rest, asleep, or awake. However, it often occurs in the early morning hours. 7) 20 minutes or longer and is more severe than usual anginal pain. 8) “discomfort,” weakness, nausea, indigestion, or shortness of breath. 9) discomfort, shortness of breath, or fatigue. 10) silent (asymptomatic) MIs because of cardiac neuropathy or may manifest atypical symptoms (e.g., dyspnea). 11) mental status (e.g., confusion), shortness of breath, pulmonary edema, dizziness, or a dysrhythmia.

Answer 90

1) catecholamines (norepinephrine and epinephrine) that are normally found in these cells. 2) release of glycogen, diaphoresis, increased HR and BP, and vasoconstriction of peripheral blood vessels. 3) ashen, clammy, and cool to touch.

Answer 91

1) decreased renal perfusion and urine output. 2) persist for several hours to several days, suggesting LV dysfunction. 3) right ventricular dysfunction. 4) S3 and S4. 5) ventricular septal defect, papillary muscle rupture, or valve dysfunction.

Answer 92

reflex stimulation of the vomiting center by the severe pain. They can also result from vasovagal reflexes initiated from the area of the infarcted heart muscle.

Answer 93

1) 100.4° F (38° C) within 24 to 48 hours. 2) 4 to 5 days. This increase in temperature is due to a systemic inflammatory process caused by the death of heart cells.

Answer 94

1) CK- MB - Rise 4-6 hours - Peak 18 hours - Elevated 2-3 days 2) Troponin - Rise 4-6 hours - Peak 10-24 hours - Elevated 10-14 days

Answer 95

1) complete coronary occlusion. ST elevation is first seen on the 12-lead ECG. Within a few hours to days, T wave inversion and pathologic Q waves develop. 2) transient thrombosis or incomplete coronary occlusion. These patients often develop ST depression or T wave inversion on the initial ECG. They usually do not develop pathologic Q waves. 3) `ischemia, injury, infarction, and resolution of the infarction

Answer 96

1) 4 to 6 hours after the onset of MI, peak at 10 to 24 hours, and return to baseline over 10 to 14 days. Serial cardiac biomarkers are drawn over 24 hours (e.g., every 6 hours × 3). 2) UA (negative biomarkers) and NSTEMI (positive biomarkers). 3) 6 hours after an MI, peak at about 18 hours, and return to normal within 24 to 36 hours. The CK enzymes are fractionated into bands. The CK-MB band is specific to heart muscle cells and helps to quantify myocardial damage. 4) 2 hours after an MI and peaks in 3 to 15 hours. Although it is one of the first serum cardiac biomarkers to appear after an MI, it lacks cardiac specificity. Its role in diagnosing MI is limited.

Answer 97

- Continuous EKG monitoring - 12 lead EKG- followed by serial EKGs - Bedrest, limit activity, semi fowlers - Start two IVs - Draw blood - Reduce environmental stress.

Answer 98

1) continuous ECG monitoring. 2) upright position unless contraindicated, and start O2 by nasal cannula to keep O2 saturation above 93%. 3) Obtain IV access for drug administration. 4) Give SL NTG and 162 to 325 mg of aspirin (chewable) if not given before arrival at the ED. 5) A high-dose statin (atorvastatin [Lipitor]) is started if not already taking prior to the hospitalization. 6) Morphine sulfate is given for pain unrelieved by NTG.

Answer 99

Initial • If unresponsive, assess circulation, airway, and breathing. • If responsive, monitor airway, breathing, and circulation. • Position patient upright unless contraindicated and give O2 by nasal cannula or non-rebreather mask. • Obtain baseline vital signs, including O2 saturation. • Auscultate heart and breath sounds. • Obtain 12-lead ECG. • Insert two IV catheters. • Assess pain using PQRST mnemonic (Table 33-7). • Medicate for pain as ordered (e.g., nitroglycerin, morphine). • Start continuous ECG monitoring and identify underlying rhythm. • Obtain baseline blood work (e.g., cardiac biomarkers, CBC, basic metabolic panel, coagulation studies). • Obtain portable chest x-ray. • Assess for contraindications for antiplatelet, anticoagulant, or thrombolytic therapy, or PCI as appropriate. • Give aspirin for heart-related chest pain unless contraindicated. • Give a high-dose statin. • Give antidysrhythmic drugs for life-threatening dysrhythmias. Ongoing Monitoring • Monitor ABCs, vital signs, level of consciousness, heart and breath sounds, heart rhythm, and O2 saturation. • Assess and record response to drugs (e.g., decrease in chest pain) and remedicate or titrate drugs (e.g., nitroglycerin) as needed. • Provide reassurance and emotional support to patient and caregiver. • Explain all interventions and procedures to patient and caregiver in simple terms. • Anticipate need for intubation if respiratory distress is evident. • Prepare for CPR and defibrillation if cardiac arrest is evident. • Anticipate need for transcutaneous pacing for symptomatic bradycardia or heart block.

Answer 100

1) the first few hours after admission and closely thereafter, according to agency protocol. 2) 12 to 24 hours, with a gradual increase in activity unless contraindicated.

Answer 101

1) - aspirin and heparin (UH or LMWH) recommended. - Dual antiplatelet therapy (e.g., aspirin and clopidogrel) and heparin recommended for NSTEMI patients. - Cardiac catheterization with possible PCI is considered for both UA and NSTEMI patients once patient is stabilized and angina controlled or if angina returns or increases in severity. 2) - reperfusion therapy started: includes emergent PCI (preferred) or thrombolytic therapy for STEMI - goal in treatment of STEMI is to save as much heart muscle as possible. - Dual antiplatelet therapy and heparin also used.

Answer 102

- IV Beta Blockers - Monitor for dysrhythmias - MONA

Answer 103

M: Morphine O: Oxygen N: Nitroglycerin A: ASA or Plavix

Answer 104

1) 90 minutes of arrival to a facility that has an interventional cardiac catheterization laboratory. 2) bare metal stent (BMS) or drug-eluting stent (DES) is inserted into the blocked coronary artery. 3) the addition of IABP therapy and/or inotropes (e.g., dobutamine). 4) CABG surgery.

Answer 105

- Get them to cath lab- door to balloon 60 min - Fibrinolytics: within 30 mins of arrival if no cath lab * Chest pain for < than 6 hours * 12 lead EKG changes * No history of other bleeding

Answer 106

(1) it provides an alternative to surgical intervention (2) it is performed with local anesthesia (3) the patient is ambulatory shortly after the procedure (4) the length of hospital stay is approximately 3 to 4 days after MI compared with the 4 to 6 days with CABG surgery, thus reducing hospital costs (5) the patient can return to work several weeks sooner after PCI, compared with a 6- to 8-week convalescence after CABG

Answer 107

1) availability and rapid administration in agencies that do not have an interventional cardiac catheterization laboratory or when one is too far away to transfer the patient safely. 2) dissolving the thrombus in the coronary artery and reperfusing the heart muscle. 3) 30 minutes of the patient's arrival to the ED. 4) the first medical contact to balloon inflation (PCI) time can be done within 120 minutes

Answer 108

* Minor or major bleeding can occur with thrombolytic drugs. * Place two or three IV lines before thrombolytic therapy is started. * If signs and symptoms of major bleeding occur (e.g., drop in BP, increase in HR, sudden change in the patient's mental status, blood in the urine or stool), stop the drug and notify the HCP.

Answer 109

- Reduce pain and increase coronary artery blood flow - Easily titrated - Rapid effect - Decrease preload and afterload - Hypotension- fluid bolus

Answer 110

1) preload and afterload while increasing the myocardial O2 supply. 3) control and stop chest pain. 4) BP during this time. Patients who do become hypotensive are often volume depleted and can benefit from an IV fluid bolus.

Answer 111

1) Preload: Pressure from volume of blood in ventricles at end of diastole (end diastolic pressure) - Increased in: Hypervolemia, Regurgitation of cardiac valves, HF 2) Afterload: Resistance left ventricle must overcome to circulate blood - Increased in: HTN, Vasoconstriction - Increased afterload= Increased cardiac workload

Answer 112

- Vasodilator - Pain relief - Reduce anxiety and fear

Answer 113

1) NTG. 2) cardiac workload by lowering myocardial O2 consumption, reducing contractility, and decreasing BP and HR. 3) anxiety and fear. 4) respirations. 5) bradypnea or hypotension, which are conditions to avoid in myocardial ischemia and infarction.

Answer 114

- Put all the tubes you need in before giving fibrinolytics - Preferably given within first hour but at least in 6hr - Within 30 min of arrival - Reperfusion: * Early and rapid rise of CK-MB * Pain is relieved * ST returns to baseline

Answer 115

1) two or three lines for IV therapy. 2) bleeding. 3) time (30 to 90 minutes). Note the time at which therapy begins, and monitor the patient during and after giving the thrombolytic. 4) esponse to therapy. 5) this may indicate cerebral bleeding. 6) the return of the ST segment to baseline on the ECG. 7) a resolution of chest pain and an early, rapid rise of the serum cardiac biomarkers within 3 hours of therapy, peaking within 12 hours. These levels increase as the necrotic heart cells release proteins into the circulation after perfusion is restored to the area. 8) less reliable sign of reperfusion. These dysrhythmias are generally self-limiting and do not require aggressive treatment 9) The site of the thrombus is unstable, and formation of another clot or spasm of the artery may occur. Therefore IV heparin therapy is started. If another clot develops, the patient will have similar complaints of chest pain and ECG changes will return. 10) PCI capabilities as soon as possible so PCI can be performed if thrombolytic therapy fails. 11) bleeding. Ongoing nursing assessment is essential. Minor bleeding (e.g., surface bleeding from IV sites or gingival bleeding) is expected and controlled by applying a pressure dressing or ice packs.

Answer 116

- Three vessel disease | - Internal mammary vs saphenous vein grafts vs radial artery graft

Answer 117

- internal mammary (thoracic) artery (IMA or ITA) - saphenous vein - radial artery - gastroepiploic artery - inferior epigastric artery

Answer 118

attached to its origin (the subclavian artery) but then dissected from the chest wall. Next, it is anastomosed (connected with sutures) to the coronary artery distal to the blockage.

Answer 119

diffuse intimal hyperplasia. This contributes to future stenosis and graft occlusion. The use of antiplatelet and statin therapy after surgery improves vein graft patency.

Answer 120

(e.g., hand ischemia, wound infection) are rare after removal of the radial artery. Paresthesia and impaired sensation are common side effects after radial artery harvest

Answer 121

- Assess and relieve pain- O2, Nitro, MS - Monitoring- EKG, vital signs, I&O - Rest- decrease stress in environment * Bed or Chair rest * 12-24 hours - Relieve anxiety - Emotional/behavioral care: cardiac cripple

Answer 122

(1) position patient upright unless contraindicated and apply supplemental O2 (2) assess vital signs (3) obtain a 12-lead ECG (4) provide prompt pain relief first with NTG followed by an opioid analgesic if needed (5) assess heart and breath sounds. - The patient will most likely be anxious and may have pale, cool, clammy skin - BP and HR may be elevated - Auscultation of the heart may reveal an atrial (S4) or a ventricular (S3) gallop. - A new murmur heard during an anginal attack may indicate ischemia of a papillary muscle of the mitral valve. The murmur is likely to be transient and disappear when symptoms stop.

Answer 123

1) reducing HR, BP, and contractility. 2) reinfarction and the development of HF. 3) continued indefinitely.

Answer 124

1) 24 hours if the BP is stable and there are no contraindications. 2) STEMI or NSTEMI, with heart failure, or an EF of 40% or less. 3) ventricular remodeling and prevent or slow the progression of HF. 4) (e.g., angioedema, cough), ARBs should be considered.

Answer 125

Dysrhythmias are the most common complications after an MI. In general, they are self-limiting and not treated aggressively unless they are life threatening (e.g., sustained ventricular tachycardia).

Answer 126

lipid-lowering drugs indefinitely, unless contraindicated

Answer 127

aid bowel movements. This prevents straining and the resultant vagal stimulation from the Valsalva maneuver. Vagal stimulation produces bradycardia and can provoke dysrhythmias.

Answer 128

- Energy Expenditure- Cardiac Rehab - Driving all the way to shoveling snow - 5 or more times a week - Warm up and cool down

Answer 129

High-Energy Activities (6-8 METs or 6-8 cal/min) • Walking 5 mph • Performing carpentry • Mowing lawn using walking mower ``` Very-High-Energy Activities (>9 METs or >9 cal/min) • Cross-country skiing • Running at >6 mph • Cycling at >13 mph • Shoveling heavy snow ```

Answer 130

- NPO initially - Low salt, Low saturated fat, Low cholesterol - No heavy meals- rest 1-2 hours after if needed.

Answer 131

1) NPO (nothing by mouth) except for water until stable (e.g., pain free, nausea resolved). 2) low-salt, low-saturated-fat, and low-cholesterol diet

Answer 132

- Dysrhythmias- PVC, V-Tach, V-fib - Pericarditis- pain relief by leaning forward - Heart Failure - Mitral Valve Regurgitation - Ventricular Aneurysm

Answer 133

1) physiologic, psychologic, mental, spiritual, economic, and vocational. 2) cardiac rehabilitation program. 3) recovery and future health. These changes often are needed when a person is middle aged or older. 4) slow and gradual. However, with appropriate and adequate supportive care, recovery is more likely to occur.

Answer 134

1) Warm-Up/Cool-Down Perform mild stretching for 3-5 min before the physical activity and 5 min after the activity. Activity should not be started or stopped abruptly. 2) Frequency Perform physical activity on most days of the week. 3) Intensity Activity intensity is determined by the patient's HR. If an exercise stress test has not been performed, the HR of the patient recovering from an MI should not exceed 20 beats/min over the resting HR. 4) Type of Physical Activity Select physical activity that is regular, rhythmic, and repetitive, using large muscles to build up endurance (e.g., walking, cycling, swimming, rowing). 5) Time Physical activity sessions should be at least 30 min long. Begin slowly at personal tolerance (perhaps only 5-10 min) and build up to 30 min.

Answer 135

1) Cardioversion: Often is an Elective procedure, Client awake, but sedated, synchronized on the "R" wave, 50-100 Joules, ECG monitor 2) Defibrillation: Emergency, V-Fib/V-tach, CPR in progress, No cardiac output, begin with 120-200 Joules, Client unconscious, ECG monitor - safety alert: Be certain that all personnel are "clear" before the device is discharged

Answer 136

- Usually ventricular fibrillation - May have chest pain, palpitations - Dyspnea - Some have warning and some do not. - Left venticular dysfunction predictor

Answer 137

unexpected death resulting from a variety of cardiac causes. Almost 400,000 people experience SCD yearly

Answer 138

1) abrupt loss of CO and cerebral blood flow. The affected person may or may not have a known history of heart disease. SCD is often the first sign of illness for 25% of those who die of heart disease 2) Acute ventricular dysrhythmias (e.g., ventricular tachycardia, ventricular fibrillation) 3) LV hypertrophy, myocarditis, and hypertrophic cardiomyopathy. Hypertrophic cardiomyopathy is a risk factor for SCD, especially in young, athletic people. 4) conduction system (e.g., prolonged QT syndrome, Wolff-Parkinson-White syndrome). 5) LV dysfunction (EF less than 30%) and ventricular dysrhythmias following MI have been found to be the strongest predictors 6) syncope, LV outflow tract obstruction (e.g., aortic stenosis), male gender (especially African American men), and family history of ventricular dysrhythmias.

Answer 139

(1) those who did not have an acute MI (2) those who did have an acute MI - The first group accounts for the majority of cases of SCD. These people usually have no warning signs or symptoms. - Patients who survive SCD are at risk for another SCD event because of the continued electrical instability of the heart that caused the first event to occur. - prodromal symptoms, such as chest pain, palpitations, and dyspnea. Death often occurs within 1 hour of the onset of acute symptoms.

Answer 140

- Activity- Rehab and sexual activity - Diet - Drugs - Goal: Return to a vital and productive life - Phase One- Begins in the hospital - Phase Two- After discharge, 3 times per week - Phase Three- Long term

Answer 141

1) Phase I: Hospital • Occurs while the patient is still hospitalized • Activity level depends on severity of angina or MI. • Patient may first sit up in bed or chair, perform range-of-motion exercises and self-care (e.g., washing, shaving), and progress to walking in hallway and limited stair climbing. • Attention focuses on management of chest pain, anxiety, dysrhythmias, and complications. 2) Phase II: Early Recovery • Begins after the patient is discharged • Usually lasts from 2-12 wk and is held in an outpatient facility • Activity level is gradually increased under the supervision of the cardiac rehabilitation team and with ECG monitoring. • Team may suggest that physical activity (e.g., walking) be started at home. • Information regarding risk factor reduction is provided at this time. 3) Phase III: Late Recovery • Long-term maintenance program • Individual physical activity programs are designed and implemented at home, a local gym, or the rehabilitation center. • Patient and caregiver possibly restructure lifestyles and roles. • Therapeutic lifestyle changes should become lifelong habits. • Medical supervision is still recommended.

Answer 142

b. abnormal levels of cholesterol, especially low-density lipoproteins. c. accumulation of lipid and fibrous tissue within the coronary arteries. d. development of angina due to a decreased blood supply to the heart muscle.

Answer 143

a. I would like to add weight lifting to my exercise program. Rationale: Risk factors for coronary artery disease include elevated serum levels of lipids, elevated blood pressure, tobacco use, physical inactivity, obesity, diabetes, metabolic syndrome, certain psychologic states, and elevated homocysteine levels. Weight lifting is not a cardioprotective exercise. An example of health-promoting regular physical activity is brisk walking (3 to 4 miles/hr) for at least 30 minutes five or more times each week.

Answer 144

b. will be relieved by rest, nitroglycerin, or both Rationale: Chronic stable angina is chest pain that occurs intermittently over a long period with the same pattern of onset, duration, and intensity of symptoms. The chest pain is relieved by rest or by rest and medication (e.g., nitroglycerin). The ischemia is transient and does not cause myocardial damage.

Answer 145

b. Obtain vital signs and auscultate for a pericardial friction rub. Rationale: Acute pericarditis is inflammation of the visceral and/or parietal pericardium; it often occurs 2 to 3 days after an acute myocardial infarction. Chest pain may vary from mild to severe and is aggravated by inspiration, coughing, and movement of the upper body. Sitting in a forward position often relieves the pain. The pain is usually different from pain associated with a myocardial infarction. Assessment of the patient with pericarditis may reveal a friction rub over the pericardium.

Answer 146

a. ACE inhibitor b. Antiplatelet therapy e. intravenous nitroglycerin Rationale: In addition to oxygen, several medications may be used to treat unstable angina (UA): nitroglycerin, aspirin (chewable), and morphine. For patients with UA with negative cardiac markers and ongoing angina, a combination of aspirin, heparin, and a glycoprotein IIb/IIIa inhibitor (e.g., eptifibatide [Integrilin]) is recommended. Angiotensin-converting enzyme (ACE) inhibitors decrease myocardial oxygen demand by producing vasodilation, reducing blood volume, and slowing or reversing cardiac remodeling.

Answer 147

c. Begin an exercise program that aims for at least five 30-minute sessions per week. Rationale: Physical activity should be regular, rhythmic, and repetitive, with the use of large muscles to build up endurance (e.g., walking, cycling, swimming, rowing). Physical activity sessions should be at least 30 minutes long. Instruct the patient to begin slowly at personal tolerance (perhaps only 5 to 10 minutes) and build up to 30 minutes.

Answer 148

c. Left ventricular dysfunction Rationale: Left ventricular dysfunction (ejection fraction less than 30%) and ventricular dysrhythmias after myocardial infarction are the strongest predictors of sudden cardiac death (SCD).