Coronary Artery Disease Flashcards
Pharmacotherapy for myocardial infarction
a) To restore circulation to the affected myocardium and prevent further blockage
i. antiplatelets
ii. anticoagulants
iii. fibrinolytic agents such as alteplase
iv. Revascularization procedures such as angioplasty and stent placements
b) To decrease myocardial oxygen demand and increase myocardial oxygen supply
i. nitrates
ii. Beta-blocker
iii. CCB
iv. Angiotensin-converting enzyme inhibitors
v. Analgesics such as morphines
c) Control risk factors to prevent future MI
i. Antilipidemics
ii. Antihypertensive drugs such as beta-blockers and ACE inhibitors
iii. Antidiabetic medications
Examples of antiplatelets
Non-steroidal anti-inflammatory drugs: Aspirin
Platelet aggregation inhibitor:
- Clopidogrel
- Prasugrel
- Tricagrelor
- Ticlopidine
pharmacologic class of aspirin
Non-steroidal anti-inflammatory drug
pharmacologic class of clopidogrel, pradugrel, trigacelor, ticlopidine
Platelet aggregation inhibitor
Pharmacologic goals of antiplatelets (Unstable Angina)
To restore circulation to the affected myocardium and prevent further blockage
Pharmacologic goals of carvedilol, nitroglycerin and morphine (Unstable Angina)
To decrease myocardial oxygen demand and increase oxygen supply
Pharmacologic goals of atorvastatin (unstable angina, 2x hyperlipidemia)
Control risk factors to prevent a further episode of ACS
Mechanism of Action of Aspirin
It inhibits the synthesis of prostacyclin and their derivatives, thromboxane A2. This prevents the aggregation of platelets
Mechanism of Action of Ticagrelor
It blocks the adenosine diphosphate receptors on the plasma membrane, causing the membrane to not be able to receive chemical signals for aggregation. This prevents aggregation of platelets.
The rationale of prescribing dual antiplatelet to Mr Lee
Administration of dual antiplatelet for a period of 6-12 months reduces atherothrombic complications and prevent stent thrombosis.
side effects of antiplatelets
Bleeding, thrombocytopenia
Reason for administering DAPT medications pre-PCI.
Aspirin and trigacelor is given pre-PCI to prevent in-sent thrombosis/ occlusion of the stent
Side effects of aspirin
Gastric bleeding, thrombocytopenia, ototoxicity
Side effects of platelet aggregation inhibitor medications
Haemorrhage thrombocytopenia anemia
Side effects of unfractioned heparin or Low molecular weight heparin
Haemorrnage,Hepatitis,Hyperkalemia
Important side effects of opiates
Opiates - morphine, pethidine
Respiratory depression hypotension drowsiness
Important side effects of beta blocker
Bradycardia bronchoconstriction , masks signs of hypoglycemia, non selective beta blocker has higher incidence of bronchoconstriction
Side effects on angiotensin-converting inhibitor and angiotensin receptor blocker
Angioedema, cough, hyperkalemia, renal dysfunction, ARB has less incidence of angioedema and cough
Nursing considerations to monitor and minimize the adverse effect of bleeding while on DAPT. Provide rationale
- Observe for and report any signs of abnormal bleeding such as
1) increased bruising
2) haematuria (presence of blood in urine)
d) intracranial bleeding
rationale: bleeding is an adverse effect of antiplatelet. Immediate medical attention is needed to stop bleeding to prevent further complications - Monitor full blood count regularly, This is to identify decreased red blood cells, haemoglobin and platelet count caused by the medication
- Clarify with doctor if there is a plan for the patient going for surgery or any other invasive procedures such as tooth extraction, scopes, etc.
- aspirin, ticlopidine and prasugrel should be discontinued at least 1 week before surgery
Rationale: antiplatelet needs to be discontinued prior to invasive surgery. This is to prevent complication such as excessive bleeding during and after surgery
Use the MOA to explain the difference in the analgesic action of nitroglycerin and morphine
Nitroglycerin: dilates the main coronary artery and increases the oxygen delivery to the heart. It also dilates the peripheral vein and arteries to reduce the preload and afterload, thus reducing oxygen demand.
Morphine: Opioid binds to the opioid receptors sites and alters the release of neurotransmitters. This alters the perception and tolerance of pain
Why is nitroglycerin preferred over morphine in the treatment of chest pain
Nitroglycerin is preferred over morphine as morphine depresses respiration, reduce myocardial contractility and is a potent venous vasodilator. Morphine delays the antiplatelet activity of Trigacelor leading to poorer outcomes and an increase in mortality.
health education to monitor and minimize the adverse effect of bleeding while on DAPT
- Advice patient to observe and report any signs of abnormal bleeding such as
a) increased bruising, haematoma, petechia
b) harmaturia
c) intracranial bleeding
rationale: bleeding is an adverse effect of antiplatelet. Immediate medical attention is needed to stop bleeding to prevent further complications
2. Inform patient to go for regiular blood test as ordered by the doctor especially full blood count
3. Instruct patient to inform all health-care providers of use of antiplatelet therapy before any invasive procedures
Rationale: antiplatelet needs to be discontinued prior to invasive surgery. This is to prevent complication such as excessive bleeding during and after surgery
Adverse effects of nitroglycerin
Headache, hypotension, reflex tachycardia, dizziness, orthostatic hypotension
Nursing considerations to monitor and minmize the adverse effect of nitroglycerin (Hypotension and reflex tachycardia)
- Monitor blood pressure and heart rate
rationale: to detect hypotension and reflex tachycardia
Nursing considerations to monitor and minimize the adverse effect of nitroglycerin (dizziness and orthostatic hypotension)
- Supervise patient in ambulation or help patient to change position slowly when rising
rationale: to prevent the risk of fall due to dizziness and orthostatic hypotension caused by the medication
Nursing considerations to monitor and minimize the adverse effect of nitroglycerin (headache)
Inform patient that he/she may experience a burning or tingling sensation under the tongue (sublingual route) and develop a transient headache when he or she takes the drug
rationale: these are expected the headache will diminish over time
Mode of action of enalapril
inhibits the conversion of angiotensin I to angiotensin II. This leads to vasodilation and reduces blood pressure
Pharmacological class of enalapril
Angiotensin-converting enzyme inhibitors
Patient education to minimize and monitor for the adverse effects of SL GTN
- Teach patient how to monitor his/her blood pressure and heart rate and keep a record for doctor’s review during the next follow-up visit
rationale: to detect hypotension and reflex tachycardia as these are the adverse effects of the medication - Instruct patient to move slowly when rising
Rationale: to prevent the risk of fall due to dizziness and orthostatic hypotension caused by the medication
- Inform patient that he/she may experience a burning or tingling sensation under the tongue (sublingual route) and develop a transient headache when he/she takes the drug
rationale: these are expected. the headache will diminish over time
Patient education to minimise the adverse effect of metoprolol
Teach the patient to report any symptoms of wheezing and dyspnoea
rationale: drug may cause bronchoconstriction and worsen the symptoms of asthma and chronic obstructive pulmonary disease especially if non-selective BBs are used
Advise the patient to come back for regular ECG monitoring as instructed by the doctor
rationale: the drugs may cause bradycardia and ECG changes which can be life-threatening
Definition of coronary artery disease
Caused by impaired blood
flow to the myocardium
Accumulation of
atherosclerotic plaque in
the coronary arteries are the
usual cause.
May be asymptomatic or lead to angina, myocardial infarction, dysrhythmias, heart failure or sudden death.
Nursing interventions to manage pt with unstable angina
- Monitor vital signs incl heart rate, respiratory rate, blood pressure, temperature and SPO2
rationale: to establish baseline data and monitor for disease progress
Tachycardia and hypotension may indicate the development of cardiogenic shock
- Administer oxygen at _______ as SpO2 is ____%.
rationale: supplemental oxygen increases oxygen supply to myocardium, decrease ischemia and pain - Administer medications as ordered:
- Prepare Mr Lee for percutaneous coronary intervention
Rationale: to open up the artery that is blocked and allow perfusion to the affected heart muscles
Rationale for administering IV morphine 4mg stat, if pain unrelieved by IV NTG
to relieve demand on the myocardium by reducing the chest pain
The rationale for administering IV nitroglycerin 10-40 mcg/min
to vasodilate, decreases pre-load of the heart and allows better perfusion to the heart muscle/ to reduce pain and improve ischemia
The rationale for administering PO soluble Aspirin
to reduce platelet aggregation
Rationale for administering Ticagrelor
to prevent in-stent thrombosis
Nursing interventions taken to minimize adverse outcomes from PCI
- Instruct patient to keep nil by mouth for 6 hours prior to PCI
rationale: this is to prevent aspiration as sedation is given during the procedure - To check blood investigation results:
- PT/PTT
Rationale: As PCI is an invasive procedure, precautions are needed to prevent excessive bleeding if PT/PTT is prolong
-Renal Panel #1
Rationale: A contrast agent is injected through the catheter thus the kidneys will need to be prepared for the procedure if they’re signs of kidney impairment/ an increase in the urea and creatinine levels
- To serve the loading dose of :
PO Aspirin 325mg stat
PO Ticagrelor 180 mg stat
Rationale: to prevent in-stent thrombosis and thromboembolic event
- To check validity of consent for PCI
Rationale: To verify that Mr Lee is aggreable to the treatment
discharge planning for patients with CAD
- teach Mr lee to identify signs and symptoms of severe chest pain, unrelieved by rest and sublingual GTN
rationale: these are signs of ischemic changes that require early treatment - refer to a smoking cessation programme (if pt smokes)
rationale: nicotine causes vasoconstriction, increases heart rate, decrease myocardial perfusion and increase cardiac workload - refer pt to a dietician and advise him to adhere to a diet:
low in fat and cholesterol diet
low in salt and high in calcium
- Recommend participating in an approved weight loss program
rationale: organized weight lost programs provide structure for a balanced weight-reduction program decreasing the risk for CAD - To attend a supervised exercise programme
rationale: exercise slows the atherosclerotic process and develop collateral circulation to the heart muscle
pharmacologic goals of ACS
- restore circulation to the affected myocardium and prevent further blockage
- to decrease myocardial oxygen demand and increase oxygen supply
- Control risk factors to prevent further episodes of ACS
medications to achieve pharmacological goal - restore circulation to the affected myocardium and prevent further blockage
aspirin, ticagrelor (antiplatelets)`
adverse effects of nitroglycerin (nitrates)
- hypotension
- reflex tachycardia
- headache
pharmacological class and therapeutic class of glyceryl trinitrate (GTN) S/L, IV nitroglycerin
nitrates , antianginal
pharm classand therapeutic class of aspirin
non-steroidal anti-inflammatory drug , antiplatelet
pharm class and therapeutic class of clopidogrel ticagrelor, prasugrel
platelet aggregation inhibitor , antiplatelet
pharm class , therapeutic class of warfarin
coumarin derivative
