Coronary Vascular Disorders (Online Lecture)/Coronary Vascular Disorders Acute Coronary Syndrome Flashcards
acute ischemic heart disease
what is it
lack of adequate blood flow to the heart and results in inadequate oxygen supply to meet demands this results in supply-demand mismatch
diagnoses under acute coronary syndrome (5)
chronic (unstable) angina
unstable angina
Prinzmetals (Variant) angina
Non ST segment elevation MI (NSTEMI)
ST segment elevation MI (STEMI)
chronic stable angina
definition
angina that has not increased in frequency or severity over time
how is chronic stable angina relieved
with rest and sublingual nitroglycerine
what exacerbates chronic stable angina pain
exertion, cold, stress, emotion
people with chronic stable angina usually have a diagnosis of
hypetension
high cholesterol
CAD
atherosclerosis
is chronic stable angina predictable or not
yes it is predictable
unstable angina
definition
angina that is changed in frequency, severity, or duration or occurs with less exertion or rest
unstable angina
new or old onset
new onset
unstable angina
duration of pain
more than 20 minutes
unstable angina
how will this present in someone who has chronic stable angina
changed frequency
more severe
lasting longer
occurring with less exertion
could occur at rest
is unstable angina relieved with nitroglycerine or rest
no
is unstable angina something to go to the ER
yes, immediate medical attention
prinzemetal (variant) angina
definition
resting angina caused by coronary artery spasm
when does prinzemetal (variant) angina occur
always at rest
normally at night (12am-8am)
prinzmetal (variant) angina is associated with
acute MI
arrhythmias
sudden cardiac death
NSTEMI
defintion
intermittently occlusive thrombus that may cause myocardial necrosis of the inner most layer of the myocardium
NSTEMI and STEMI present the same as
unstable angina
how do we differentiate between NSTEMI AND STEMI
12 lead EKG
Cardiac biomarkers
if someone is diagnosed with a NSTEMI how long do we have to take them to cath
24 hours, longer than a STEMI
STEMI
definition
occlusive thrombus
thrombus occluding a coronary vessel for a prolonged period of time
reduced blood flow results in myocardial ischemia, injury, and necrosis with damage extending through all myocardial layers
if someone is diagnosed with a STEMI how long do we have to take them to cath
90 mins critical
clinical manifestations
males
shortness of breath
nasuea
anxiety
pressure
radiation of pain
prodromal symptoms (general malaise)
PQRST method
P
Provoke
- what provokes the pain or what precipitates the pain
PQRST method
Q
Quality
- what is the quality of the pain
PQRST method
R
Radiation
- does the pain radiate to locations other than the chest
PQRST method
S
Severity
- what is the severity of pain (scale 1-10)
PQRST method
T
Timing
- what is the time of onset of this episode of pain
why is timing of discomfit critial
chronic vs unstable angina
what else is important to ask
associated symptoms
effect of exertion and rest
effect of nitrates
who are 3 groups of people who present atypical
women
diabetics
elderly
women presents
tired
lack of energy
shortness of breath
more likely to deny pain
diabetic presents
silent ischemia (don’t experience pain in same regard)
elderly presents
weakness
dysnpnea
confusion
shortness of breath
areas where pain can radiate
back
area between shoulder blades
upper abdomen
elbows
ears
nursing diagnoses
risk for decreased cardiac perfusion
nursing interventions
priority nursing concern
treatment of angina pain
nursing interventions
stop all _________ and sit or rest in _____________
activity
bed
nursing interventions
assessment
VS
respiratory distress
assessment of pain
*ECG
nursing interventions
administer
oxygen
- maintain over 90%
nursing interventions
administer __________ as ordered
medications
nursing interventions
ultimate goal
reperfusion (cath lab)
nursing interventions
postion for
comfort
nursing interventions
administer nitroglycerine
- what does it do
vasodilator
- reduces blood flow and reduces myocardial oxygen consumption
- reduces preload
- causes venous pooling in LE
nursing interventions
administer morphine
- why
pain
nursing interventions
administer heparin
prevent new clot
nursing interventions
- quite and calm environment
decrease stress and anxiety
nursing interventions
administer aspirin
- what is it and what does it do
antiplatlet
- decrease platelet aggregation
when there is an occlusion an inflammatory response is to increase platelet migration
nursing interventions
administer beta blockers
- why
reduce myocardial oxygen consumption/demand by reducing heart rate and contractility
nursing interventions
administer calcium channel blockers
- why
reduce myocardial oxygen consumption/demand through decrease heart rate and strength of contraction
health teaching
- smoking
smoke cessation
health teaching
- diet
low fat/sodium
health teaching
- activity
physical and sexual
health teaching
- blood pressure and glucose
make sure it is under control
health teaching
- self monitoring
educate on the sign and symptoms and when seeking medical assistance is needed
why might these patients have crackles
left ventricle is failing
- unable to push blood out
if someone has fear of impending doom, what do you do
believe them
what is the priority from urgent to least urgent
STEMI
NSTEMI
unstable angina
noncardiac
acute coronary syndrome encompasses what 3 issues
STEMI
NSTEMI
unstable angina
why do we always rule out possible cardio before anything else
this will kill you the quickest
12 lead EKG how fast
10 mins upon admission
what are the 3 cardiac biomarkers
troponin
CK
CK-MB
what are some other labs we might want
BMP
CBC
PTT/INR (clotting and if they have to go to cath lab)
ST elevation must be seen in how many leads
2 or more leads
STEMI
- classification
ST changes
elevated cardiac biomarkers
STEMI needs to go to the cath lab in what time
90 mins
T wave inversion means
Ischemia
do we normally ever see T wave inversion presentation
no
this is an early sign and patient is normally not presenting to the ER at this point
ST elevation means
injury
- acute injury is happening
Q wave formation means
Infarct
persistent Q wave means
they had an MI before
NSTEMI
- classificiation
no ST elevation
elevated cardiac biomarkers
NSTEMI time to cath lab
24 hours
unstable angina
- classification
No ST elevation
no elevated cardiac biomarkers
instead of ST elevation in NSTEMI, what might you see
ST segment depression
inversion of what wave might also indicate a NSTEMI
T wave inversion
what is the most sensitive cardiac marker
troponin
troponin tells you
injury to myocytes, not just death
troponin levels rise
4-6 hours after onset of ischemic symptoms
troponin levels peak at
18-24 hours after an MI
troponin levels will return to normal
in 2 weeks
CK MB (creatine kinase)
sensitive for what
cardiac tissue but not as sensitive in early MI
CK MB (creatine kinase)
levels rise
4-8
CK MB (creatine kinase)
peaks
12-24
CK MB (creatine kinase)
returns to normal
24-48
myoglobin
sensitive to what
muscle damage, not cardiac specific though
myoglobin
elevates
1-3 hours
(very quick)
myoglobin
peaks
12 hours after infarct
myoglobin
returns
18-24 hours
additional diagnosis
chest X ray
- rule out others
echocardiography
- view ventricles
stress test
- out patient
primary therapeutic goals
optimize….
blood flow to the myocardium to reduce the amount of myocardial necrosis
restoration and maintence of blood flow to myocardium is important to improve
patient outcomes
2 interventions we can do to optimize blood flow
pharm
mechanical
since MONA is not in the correct order, what is the correct order
AONM
AONM
- A stands for
aspirin
AONM
- O stands for
oxygen
AONM
- N stands for
nitroglycerine
AONM
- M stands for
morphine
aspirin
- action
antiplatelet
aspirin
- dose
160-325mg
when do we want to administer aspirin
as soon as possible
aspirin is standard therapy for
all patients with new pain suggestive of AMI
oxygen is given if saturation is less than
94%
if saturation is less than 94% what L do we start at
4L/min
what is nitroglycerins action
venodilator
what does a venodilator do
cause venous pooling
which leads to
less blood returning to heart
which leads to
reducing myocardial oxygen consumption and demand
which leads to
reduction in preload
dilates coronary artery
which leads to
collateral flow (all other arteries are open)
oral nitroglycerine side effects
orthostatic hypotension
hypotension
right sided MI = extreme hypotension
what do we assess before and after giving nitroglycerine
BP & HR
VS
pain
what is the maximum nitroglycerin does
3 mins
what is the time frame in between doses
5 mins
what other forms can nitroglcycerine be given
IV
IV nitro side effects
severe headache
dizziness
light headedness
orthostatic hypotension
if the patient is on nitro IV what is going to be on continuous
ECG
what is the key point with IV nitro
do not stop abruptly
we must taper
what to assess before and after giving morphine
respirations
BP
sedation/LOC
pain
morphine does
1-5mg every 5-30 mins
antiplatelet therapies (3)
aspirin
ADP-receptor inhibitors
glycoprotein IIb/IIIa inhibitors
patients who are on anti platelet are at risk for
bleeding and fall
ADP-receptor inhibitors
action
decrease platelet aggregation
ADP-receptor inhibitors
can it be used with aspirin
yes
ADP-receptor inhibitors
- drugs (2)
Plavix (clopidogrel)
Effient (Prasugrel)
ADP-receptor inhibitors
risk
bleeding
glycoprotein IIb/IIIa inhibitors
- drugs (2)
eptitibatide (intergrilin)
abciximab (repro)
glycoprotein IIb/IIIa inhibitors
- action
potent inhibitors of platelet aggregation
glycoprotein IIb/IIIa inhibitors
- indications
NSTEMI
unstable angina
ACS undergoing cath lab procedure
anti ischemia therapies
4 classes
beta blocekrs
ACEI
ARBS
calcium channel blockers
beta blockers
- ending
olol
beta blockers
- reduce (4)
HR
BP
myocardial oxygen demand
myocardial work load
beta blockers
- contraindications
heart failure
low CO
increased risk of cariogenic shock
beta blockers
- drug examples (3)
metropolol
propranolol
atenolol
calcium channel blockers
- action
vasodialtion
prevent ischemia
calcium channel blocekers
- drugs (2)
verapamil
diltiazem
ACEI
- action (3)
decrease BP
lower peripheral vascular resistance
decrease O2 demand
ACEI drugs
enalapril
captopril
ACEI
- what should we monitor for
orthostatic hypotension
syncope
serum potassium levels
renal function studies
ACEI
- side effects (2)
dry nagging cough
angioedema
what is the major anticoagulation drug that you will encounter in the hospital
heparin
heparin
- class
antithrombin
- prevents formation of thrombi
reversal for heparin
protamine sulfate
heparin
- contraindications/cautions
active bleeding
following recent surgery
recent bleed
severe hypertension
drugs that decrease the activity of coagulation systems with anti platelet therapy
aspirin
clopidogrel
drugs increase ventricular filling time and decrease heart rate
beta blockers
drugs that decrease preload
nitrates
diuretics
morphine
drugs that decrease afterload
ACEI
hydralazine (?)
drugs that decrease myocardial oxygen consumption
beta blockers
2 ways we can destroy the clot
cath lab
fibrinolytic therapy
what is the gold standard
-cath lab or fibrinolytic therapy
cath lab
cath lab/PCI uses dye, what do we assess for
allergies
kidney function (BUN, CR before and after)
STEMI door to balloon
90 mins
fibrinolytic therapy door to drug
30 mins
why might fibrinolytic therapy be used over PCI
rural setting that has no cath lab
major risks of fibrinolytic therapy
hemorrhage
stroke
allergy
what can be done on a STEMI
- PCI
- fibrinolytic
both
what can be done on a NSTEMI
- PCI
- fibrinolytic
fibrinolytic is not recomended
NSTEMI PCI time frame
24 hours
MI teaching
recognize and take action for recurrent symptoms
lifestyle changes
- stop smoking
- reduce stress
- decrease caffeine
- modify intake of calories, sodium, fat
ischemia is what wave
inverted T wave
injury is what wave
elevated ST wave
infarction is what wave
Q wave
