Chapter 37: Coronary Artery Disease and Acute Coronary Syndrome Flashcards by Jennifer Latimer

What increases C-reactive protein (CRP) levels?

systemic inflammation or coronary artery disease

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High ____________ and ____________ levels may contribute to atherosclerosis

homocysteine, lipoprotein(a)

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pathogenesis of atherosclerosis includes which four stages

chronic endothelial injury, fatty streak, fibrous plaque, complicated lesion

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lipid-filled smooth muscle cells; lipids accumulate and migrate into smooth muscle cells

fatty streak

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collagen covers fatty streak, vessel lumen is narrowed, blood flow is reduced, fissures can develop

fibrous plaque

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plaque rupture, thrombus formation, further narrowing or total occlusion of vessel

complicated lesion

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alternative arterial anastomoses or connections within the coronary circulation

collateral circulation

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nonmodifiable risk factors for coronary artery disease

age, gender, ethnicity, family history, genetics

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modifiable risk factors for coronary artery disease

high serum lipids, high blood pressure, tobacco use, physical inactivity, obesity, diabetes, metabolic syndrome

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Men or women are more likely to die after their first MI

women

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four major modifiable risk factors for coronary artery disease

elevated serum lipids, hypertension, tobacco use, physical inactivity

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types of substance use most likely to contribute to coronary artery disease

cocaine, methamphetamine

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normal total cholesterol levels

<200 mg/dL

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normal HDL levels

males: >45 mg/dL
females: >55 mg/dL

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normal LDL levels

<130 mg/dL

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normal triglyceride levels

males: 40-160 mg/dL
females 35-135 mg/dL

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statin therapy is recommended for these four patients

Patients with known CVD
LDL cholesterol >190 mg/dL
Age 40-75 with diabetes and LDL 70-189 mg/dL
Age 40-75 with LDL 70-189 mg/dL and 10-year risk for CVD at least 7.5%

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side effects of statins

rash, GI problems, increased liver enzymes, myopathy, rhabdomyolysis* (tea-colored urine, muscle pain)

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side effects of niacin

flushing, pruritis, GI problems, orthostatic hypotension

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gemfibrozil

fibric acid derivative

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fenofibrate

fibric acid derivative

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lipid-lowering drug class that interferes with GI and absorption of many different drugs (take _______ before eating or taking other drugs)

bile sequestrants, 2 hours

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drug that further reduces LDL when used with a statin

ezetimibe

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drug used with high-risk hyperlipidemia to decrease cholesterol and associated 10-year risk

ezetimibe

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give this drug ___________ prior to reduce flushing associated with niacin

NSAID, 30 minutes

this lipid-lowering drug class increases hyperglycemia and interacts with metformin and antihyperglycemics

fibric acid derivatives

drugs in this class have "chole" or "cole" in drug name

bile acid sequestrants

angina that occurs intermittently over a long period of time with a similar pattern

chronic stable angina

angina that involves chest pain that is new in onset that occurs at rest or with increasing frequency and duration

unstable angina

variant and rare form of angina that occurs at rest and not with increased physical demand

Prinzmetal's angina

factors contributing to Prinzmetal's angina

substance use (alcohol, cocaine), caffeine use, medications that cause vasoconstriction, cold weather exposure

angina in which chest pain is related to myocardial ischemia from atherosclerosis or spasm of small distal branch vessels in coronary circulation

microvascular angina

acute care for angina (7 steps)

1. position upright (Fowler's), apply oxygen 2. assess vital signs, heart/breath sounds 3. continuous ECG; 12-lead ECG 4. pain relief (nitroglycerin, IV opioid if needed) 5. cardiac biomarkers 6. chest X-ray 7. support, reduce anxiety

gold standard cardiac biomarker

troponin

purpose of chest X-ray in patient with angina

see if heart is enlarged

give this drug for headache caused by nitroglycerin

acetaminophen

drugs that dilate peripheral and coronary arteries and collateral vessels

short-acting nitrates

when does SL NTG relieve angina

5 minutes after administration

how long does SL NTG last

30-40 minutes

how often can a dose of SL NTG be repeated

3 doses every 5 minutes

side effects of SL NTG

headache, dizziness, flushing, orthostatic hypotension

store NTG tablets away from _______ and _______

light, heat

NTG tablets should be replaced every ________ after the bottle is opened

6 months

prophylactic use of NTG

take tablet/spray 5-10 minutes before activity known to cause angina

drug class used for LV dysfunction, elevated BP, or MI

beta blockers

drug class in which drugs end in "lol"

beta blockers

drug class that causes vasodilation and decreases contractility

calcium channel blockers (CCBs)

drug class in which many of its drugs end in "dipine"

calcium channel blockers

diltiazem

calcium channel blocker

verapamil

calcium channel blocker

last-chance drug for control of chronic stable angina

ranolazine

three drug classes used to treat chronic stable angina

beta blockers, calcium channel blockers, sodium current inhibitor

diagnostic studies for chronic stable angina (7)

1. 12-lead ECG 2. Lab studies: cardiac biomarkers, lipid profile, CRP 3. chest x-ray 4. echocardiogram 5. exercise stress test 6. electron beam computed tomography 7. coronary computed tomography angiography

gold standard test for patients with increasing angina symptoms that can identify and localize CAD

cardiac catheterization

cardiac catheterization and PCI preprocedure nursing management (5)

1. allergies (contrast dye) 2. baseline assessment: vital signs, pulse ox, heart/breath sounds, neurovascular 3. baseline laboratory studies 4. administer ordered drugs 5. patient education for preprocedure and postprocedure care

cardiac catheterization and PCI postprocedure nursing management

1. compare assessments to preprocedure 2. assess catheter insertion site for hematoma, bleeding, bruit every 15 minutes for first hour, then agency policy 3. ECG for dysrhythmia; chest pain or other pain 4. IV infusion of antianginals 5. monitor for complications 6. educate: discharge care and drugs; signs and symptoms to report to HCP

three drugs used during PCI

unfractionated heparin or low-molecular weight heparin direct thrombin inhibitor glycoprotein IIb/IIIa inhibitor

drugs used after PCI

dual antiplatelet therapy (DAPT): aspirin and ticagrelor or clopidogrel

coronary artery bypass graft (CABG) surgery recommended in these four situations

1. medical treatment failed 2. disease involves left main coronary artery or three vessels 3. PCI cannot be done 4. failed PCI or chest pain continues

coronary artery bypass graft (CABG) is an option in those who have any of these three conditions

diabetes, left ventricular dysfunction (LVD), chronic kidney disease (CKD)

two treatment options for STEMI

cardiac catheterization (if available at hospital): 90 minutes door to balloon if cardiac catheterization not available, start thrombolytic therapy

treatment for NSTEMI

cardiac catheterization within 12-72 hours

chest pain from ischemia is prolonged and not immediately reversible

acute coronary syndrome (ACS)

acute coronary syndrome (ACS) occurs on a spectrum from _____________ to ______________

non-ST elevation ACS (UA and NSTEMI) STEMI

diagnostic studies for acute coronary syndrome (ACS)

12-lead ECG, serum cardiac biomarkers

serum cardiac biomarkers for ACS

proteins released after MI cardiac-specific troponin T (cTNT) cardiac-specific troponin I (cTNI)

serum cardiac biomarkers are _________ for UA and ___________ for NSTEMI

negative, positive

________________ are better indicators of MI than _________ or ____________ (serum cardiac biomarkers)

cardiac-specific troponins, CK-MB, myoglobin

partial occlusion of coronary artery indicates _____ or ______

UA, NSTEMI

total occlusion of coronary artery indicates ________

STEMI

first treatment with confirmed STEMI

emergent PCI

two types of stents that may be used in emergent PCI

bare-metal stent (BMS), drug-eluting stent (DES)

with emergent PCI, patients with severe LV dysfunction may require ____________ and/or __________

VAD therapy, inotropes

five advantages of PCI (vs. CABG)

1. faster reperfusion to limit infarction size 2. performed with IV sedation and local anesthesia 3. ambulatory shortly after procedure 4. shorter length of stay 5. faster return to work

complications of PCI (6)

1. dissection or rupture of coronary artery 2. abrupt artery closure 3. acute stent thrombosis 4. failure to cross blockage with balloon or stent 5. extended infarction 6. in-stent restenosis

acute care for ACS after admitted to ICU/telemetry unit

1. monitor VS and pulse oximetry 2. continuous ECG 3. serial 12-lead ECGs 4. serial cardiac biomarkers 5. bed rest/limit activity

how long should an ACS patient be on bed rest and limit activity for when admitted to ICU/telemetry unit

12-24 hours (then increase gradually)