Management of ST-Elevation Myocardial Infarction (STEMI) Flashcards
A patient arrives in the emergency department complaining of chest pain that has lasted longer than 1 hour and is unrelieved by nitroglycerin. The patient’s electrocardiogram reveals elevation of the ST segment. Initial cardiac troponin levels are negative. The patient is receiving oxygen via nasal cannula. Which drug should be given immediately?
a. Aspirin 325 mg chewable
b. Beta blocker given IV
c. Ibuprofen 400 mg orally
d. Morphine intravenously
A
This patient shows signs of acute ST-elevation myocardial infarction (STEMI). Because cardiac troponin levels usually are not detectable until 2 to 4 hours after the onset of symptoms, treatment should begin as symptoms evolve. Chewable aspirin (ASA) should be given immediately to suppress platelet aggregation and produce an antithrombotic effect. Beta blockers are indicated but do not have to be given immediately. Ibuprofen is contraindicated. Morphine is indicated for pain management and should be administered after aspirin has been given.
A nurse is discussing fibrinolytic therapy for the acute phase of STEMI management with a group of nursing students. Which statement by a student indicates understanding of this therapy?
a. “Fibrinolytics are effective when the first dose is given up to 24 hours after symptom onset.”
b. “Fibrinolytics should be given once cardiac troponins reveal the presence of STEMI.”
c. “Fibrinolytics should be used with caution in patients with a history of cerebrovascular accident.”
d. “Patients should receive either an anticoagulant or an antiplatelet agent with a fibrinolytic drug.”
C
Patients with a history of cerebrovascular accident (CVA) should not receive fibrinolytic agents because of the increased risk of intracranial hemorrhage. Fibrinolytics are most effective when given within 30 minutes of arrival in the emergency department. Because cardiac troponins are not detectable until 2 to 4 hours after the onset of symptoms, fibrinolytics should be administered before these laboratory values are available. Patients receiving fibrinolytics should receive both an anticoagulant and an antiplatelet drug.
A nurse is evaluating a patient admitted to the emergency department with an evolving STEMI for possible administration of thrombolytic therapy. Which information, identified during history taking, would contraindicate this type of therapy?
a. The patient just completed her last menstrual cycle.
b. The patient states that the chest pain started 1 hour ago.
c. The patient has a history of a small cerebral aneurysm.
d. The patient has hypertension that is well controlled by diuretic therapy.
C
Patients with a history of CVA should not receive fibrinolytic therapy. This patient has had a known cerebral aneurysm. Active internal bleeding is a contraindication for thrombolysis except for menses, but the patient has indicated she has completed her last cycle. Fibrinolytic therapy should be administered for chest pain that has been present for no longer than 12 hours. Poorly controlled or severe hypertension is a relative contraindication. Thrombolytics can be administered with caution.
A patient diagnosed with STEMI is about to undergo a primary percutaneous coronary intervention (PCI). Which combination of pharmacotherapeutic agents will be given to augment this procedure?
a. Beta blocker and nitroglycerin
b. Abciximab and a fibrinolytic drug
c. Angiotensin-converting enzyme (ACE) inhibitor and aspirin
d. Heparin, aspirin, and clopidogrel
D
Patients undergoing a primary PCI should receive heparin intravenously combined with aspirin and either clopidogrel or prasugrel. Abciximab and fibrinolytic drugs are not indicated. Beta blockers and nitroglycerin do not prevent thromboses. ACE inhibitors do not prevent thromboses.
A patient in the emergency department has severe chest pain. The nurse administers morphine intravenously. The patient asks the nurse why morphine is given. Which response by the nurse is correct?
a. “Morphine helps by reducing anxiety and relieving pain.”
b. “Morphine helps by reducing pain and dissolving clots.”
c. “Morphine helps by relieving pain and lowering blood pressure.”
d. “Morphine helps by relieving pain and reducing the cardiac oxygen demand.”
D
IV morphine is the treatment of choice for STEMI-associated pain. Besides relieving pain, it promotes vasodilation and reduces cardiac preload, which lowers the cardiac oxygen demand. It does not reduce anxiety, dissolve clots, or lower blood pressure.
A patient is admitted to the coronary care unit from the emergency department after initial management of STEMI. A primary percutaneous coronary intervention has been performed. The nurse notes an initial heart rate of 56 beats per minute and a blood pressure of 120/80 mm/Hg. The patient has a history of stroke and a previous myocardial infarction. Which order will the nurse question?
a. Aspirin
b. Beta blocker
c. Clopidogrel
d. Heparin
B
A beta blocker would be contraindicated in this patient, because it slows the heart, and this patient is already bradycardic. Aspirin, clopidogrel, and heparin are recommended in patients who have had a primary PCI.
A nurse is giving aspirin to a patient during acute management of STEMI. The patient asks why a chewable tablet is given. Which response by the nurse is correct?
a. “Aspirin is absorbed more quickly when it is chewed.”
b. “Chewing aspirin prevents it from being metabolized by the liver.”
c. “Chewing aspirin prevents stomach irritation.”
d. “More of the drug is absorbed when aspirin is chewed.”
A
Aspirin should be chewed to allow rapid absorption across the buccal mucosa. Chewing aspirin does not affect hepatic metabolism, stomach irritation, or the amount absorbed.
A patient has undergone a primary percutaneous coronary intervention with a sirolimus-eluting stent. The provider has ordered a daily dose of 243 mg of aspirin. What will the nurse tell this patient about the dose of aspirin?
a. It will be necessary indefinitely.
b. It will decrease to 81 mg per day in 6 months.
c. It will decrease to 162 mg per day in 3 months.
d. It will increase to 325 mg per day in 1 month.
C
Patients who have undergone PCI with a sirolimus-eluting stent take a higher dose of ASA for 3 months and then a low dose indefinitely. The high dose is not taken indefinitely with this type of stent. The dose will be reduced in 3 months, not 6 months. The dose will not increase.
A patient has undergone a PCI, and the provider orders clopidogrel to be given for 12 months, along with an ACE inhibitor and heparin. What will the nurse do?
a. Question the need for heparin.
b. Request an order for a beta blocker.
c. Request an order for aspirin.
d. Suggest ordering clopidogrel for 14 days.
C
Patients who have undergone a PCI should receive heparin, ASA, and a fibrinolytic; therefore, this patient needs ASA added to the drug regimen. Heparin should be given before, during, and for at least 48 to 72 hours after the procedure. Beta blockers are not necessarily indicated. Clopidogrel should be given at least 12 months after the procedure.
Patients with a history of myocardial infarction should take which medications indefinitely? (Select all that apply.)
a. ACE inhibitors
b. Alteplase
c. Aspirin
d. Beta blockers
e. Clopidogrel
A, C, D
Patients who have had an MI should take ACE inhibitors, ASA, and beta blockers indefinitely to prevent recurrence and to minimize continuing cardiac remodeling. Alteplase is given during acute management, and clopidogrel is used during acute management and as an adjunct to reperfusion therapy.
