Coronary Artery Disease

Question 1

Pharmacotherapy for myocardial infarction

Answer 1

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

Question 2

Examples of antiplatelets

Answer 2

Non-steroidal anti-inflammatory drugs: Aspirin

Platelet aggregation inhibitor:

1. Clopidogrel
2. Prasugrel
3. Tricagrelor
4. Ticlopidine

Question 3

pharmacologic class of aspirin

Answer 3

Non-steroidal anti-inflammatory drug

Question 4

pharmacologic class of clopidogrel, pradugrel, trigacelor, ticlopidine

Answer 4

Platelet aggregation inhibitor

Question 5

Pharmacologic goals of antiplatelets (Unstable Angina)

Answer 5

To restore circulation to the affected myocardium and prevent further blockage

Question 6

Pharmacologic goals of carvedilol, nitroglycerin and morphine (Unstable Angina)

Answer 6

To decrease myocardial oxygen demand and increase oxygen supply

Question 7

Pharmacologic goals of atorvastatin (unstable angina, 2x hyperlipidemia)

Answer 7

Control risk factors to prevent a further episode of ACS

Question 8

Mechanism of Action of Aspirin

Answer 8

It inhibits the synthesis of prostacyclin and their derivatives, thromboxane A2. This prevents the aggregation of platelets

Question 9

Mechanism of Action of Ticagrelor

Answer 9

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.

Question 10

The rationale of prescribing dual antiplatelet to Mr Lee

Answer 10

Administration of dual antiplatelet for a period of 6-12 months reduces atherothrombic complications and prevent stent thrombosis.

Question 11

side effects of antiplatelets

Answer 11

Bleeding, thrombocytopenia

Question 12

Reason for administering DAPT medications pre-PCI.

Answer 12

Aspirin and trigacelor is given pre-PCI to prevent in-sent thrombosis/ occlusion of the stent

Question 13

Side effects of aspirin

Answer 13

Gastric bleeding, thrombocytopenia, ototoxicity

Question 14

Side effects of platelet aggregation inhibitor medications

Answer 14

Haemorrhage thrombocytopenia anemia

Question 15

Side effects of unfractioned heparin or Low molecular weight heparin

Answer 15

Haemorrnage,Hepatitis,Hyperkalemia

Question 16

Important side effects of opiates

Answer 16

Opiates - morphine, pethidine

Respiratory depression hypotension drowsiness

Question 17

Important side effects of beta blocker

Answer 17

Bradycardia bronchoconstriction , masks signs of hypoglycemia, non selective beta blocker has higher incidence of bronchoconstriction

Question 18

Side effects on angiotensin-converting inhibitor and angiotensin receptor blocker

Answer 18

Angioedema, cough, hyperkalemia, renal dysfunction, ARB has less incidence of angioedema and cough

Question 19

Nursing considerations to monitor and minimize the adverse effect of bleeding while on DAPT. Provide rationale

Answer 19

1. 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
2. Monitor full blood count regularly, This is to identify decreased red blood cells, haemoglobin and platelet count caused by the medication
3. 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

Question 20

Use the MOA to explain the difference in the analgesic action of nitroglycerin and morphine

Answer 20

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

Question 21

Why is nitroglycerin preferred over morphine in the treatment of chest pain

Answer 21

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.

Question 22

health education to monitor and minimize the adverse effect of bleeding while on DAPT

Answer 22

1. 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

Question 23

Adverse effects of nitroglycerin

Answer 23

Headache, hypotension, reflex tachycardia, dizziness, orthostatic hypotension

Question 24

Nursing considerations to monitor and minmize the adverse effect of nitroglycerin (Hypotension and reflex tachycardia)

Answer 24

1. Monitor blood pressure and heart rate

rationale: to detect hypotension and reflex tachycardia

Question 25

Nursing considerations to monitor and minimize the adverse effect of nitroglycerin (dizziness and orthostatic hypotension)

Answer 25

2. 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

Question 26

Nursing considerations to monitor and minimize the adverse effect of nitroglycerin (headache)

Answer 26

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

Question 27

Mode of action of enalapril

Answer 27

inhibits the conversion of angiotensin I to angiotensin II. This leads to vasodilation and reduces blood pressure

Question 28

Pharmacological class of enalapril

Answer 28

Angiotensin-converting enzyme inhibitors

Question 29

Patient education to minimize and monitor for the adverse effects of SL GTN

Answer 29

1. 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
2. Instruct patient to move slowly when rising

Rationale: to prevent the risk of fall due to dizziness and orthostatic hypotension caused by the medication

3. 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

Question 30

Patient education to minimise the adverse effect of metoprolol

Answer 30

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

Question 31

Definition of coronary artery disease

Answer 31

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.

Question 32

Nursing interventions to manage pt with unstable angina

Answer 32

1. 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

2. Administer oxygen at _______ as SpO2 is ____%.
   rationale: supplemental oxygen increases oxygen supply to myocardium, decrease ischemia and pain
3. Administer medications as ordered:
4. Prepare Mr Lee for percutaneous coronary intervention

Rationale: to open up the artery that is blocked and allow perfusion to the affected heart muscles

Question 33

Rationale for administering IV morphine 4mg stat, if pain unrelieved by IV NTG

Answer 33

to relieve demand on the myocardium by reducing the chest pain

Question 34

The rationale for administering IV nitroglycerin 10-40 mcg/min

Answer 34

to vasodilate, decreases pre-load of the heart and allows better perfusion to the heart muscle/ to reduce pain and improve ischemia

Question 35

The rationale for administering PO soluble Aspirin

Answer 35

to reduce platelet aggregation

Question 36

Rationale for administering Ticagrelor

Answer 36

to prevent in-stent thrombosis

Question 37

Nursing interventions taken to minimize adverse outcomes from PCI

Answer 37

1. 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
2. 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

3. To serve the loading dose of :
   PO Aspirin 325mg stat
   PO Ticagrelor 180 mg stat

Rationale: to prevent in-stent thrombosis and thromboembolic event

4. To check validity of consent for PCI

Rationale: To verify that Mr Lee is aggreable to the treatment

Question 38

discharge planning for patients with CAD

Answer 38

1. 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
2. refer to a smoking cessation programme (if pt smokes)
   rationale: nicotine causes vasoconstriction, increases heart rate, decrease myocardial perfusion and increase cardiac workload
3. 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

4. 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
5. To attend a supervised exercise programme
   rationale: exercise slows the atherosclerotic process and develop collateral circulation to the heart muscle

Question 39

pharmacologic goals of ACS

Answer 39

1. restore circulation to the affected myocardium and prevent further blockage
2. to decrease myocardial oxygen demand and increase oxygen supply
3. Control risk factors to prevent further episodes of ACS

Question 40

medications to achieve pharmacological goal - restore circulation to the affected myocardium and prevent further blockage

Answer 40

aspirin, ticagrelor (antiplatelets)`

Question 41

adverse effects of nitroglycerin (nitrates)

Answer 41

• hypotension
• reflex tachycardia
• headache

Question 42

pharmacological class and therapeutic class of glyceryl trinitrate (GTN) S/L, IV nitroglycerin

Answer 42

nitrates , antianginal

Question 43

pharm classand therapeutic class of aspirin

Answer 43

non-steroidal anti-inflammatory drug , antiplatelet

Question 44

pharm class and therapeutic class of clopidogrel ticagrelor, prasugrel

Answer 44

platelet aggregation inhibitor , antiplatelet

Question 45

pharm class , therapeutic class of warfarin

Answer 45

coumarin derivative