Test 2 CAD Flashcards
Insufficient oxygen supply to the myocardium….
Ischemia
Necrosis when ischemia is prolonged and decreased perfusion causes irreversible damage to tissue….
Infarction
Difference in Stable & Unstable angina in regards to what is clogging the artery…
Stable Angina: Fixed atherosclerotic plaque
Unstable Angina: Plaque & Platelets
Describe difference in the artery clog with:
Non ST elevation MI
ST elevation MI
Non ST elevation MI: Plaque, Platelets, Thrombus blocks vessel part way
ST elevation MI: Plaque, Platelets, Thrombus blocks vessel fully
Formation of Plaque within artery wall
Possibly due to injury
Causes;
Mechanical
Chemical
Physiological
Impaired Na-K pump
Diabetes
Inflammation
Atherosclerosis
Cholesterol is needed for body functioning
20 - 40% comes from food.
Where does the rest come from…
Produced by the liver
HDL
Optimal
Desirable
Undesirable
Optimal >60
Desirable >40
Undesirable <40
Triglycerides
Low
Borderline
High
Very high
Low: <150
Borderline 150 - 199
High 200 - 499
Very high >500
Total cholesterol
Desirable
Borderline
High
Desirable <200
Borderline 200 - 239
High >240
LDL
Optimal
Near Optimal
Borderline
High
Very high
Optimal <100
Near Optimal 100 - 129
Borderline 130 - 159
High 160 - 189
Very high >190
Define:
Moves cholesterol away from the arterial wall
Carries cholesterol to the arterial wall
Transfers triglycerides to cells
High density lipoprotein cholesterol
HDL
Moves cholesterol away from the arterial wall
Low Density lipoprotein cholesterol
LDL
Carries cholesterol to the arterial wall
Very low-density lipoprotein
VLDL
Transfers triglycerides to cells
______ is a chronic disease where plaque builds up inside arteries, leading to narrowing and reduced blood flow. It is a leading cause of cardiovascular diseases like coronary artery disease (CAD), stroke, and peripheral artery disease (PAD).
Atherosclerosis
Atherosclerosis is a chronic disease where plaque builds up inside arteries, leading to narrowing and reduced blood flow. It is a leading cause of cardiovascular diseases including (3)
Coronary artery disease (CAD)
Stroke,
Peripheral artery disease (PAD).
Fatty steak develops in between layers of the artery wall.
_____ engulf the deposited cholesterol & convert to Giant Foam Cells
Formation of Fibrous cap over lipid core
QUESTION….
- This plaque can rupture & a thrombus forms at the site causes blockage of oxygen & death to heart muscles THIS IS CALLED…
- The plaque stays stable and continues to thicken. This disease process…
Macrophages
- Acute coronary syndrome
- Stenosis
Causes of atherosclerosis (5)
Endothelial Damage: Injury to the artery lining due to factors like:
High blood pressure
High cholesterol
Smoking
Diabetes
Lipid Accumulation: LDL (low-density lipoprotein) cholesterol enters the damaged wall and oxidizes.
Inflammation: White blood cells (macrophages) engulf oxidized LDL, forming foam cells.
Plaque Formation: Foam cells accumulate, leading to fatty streaks and plaque formation.
Narrowing of Arteries: Plaques can calcify, harden, or rupture, causing blood clots.
DASH stands for
Dietary Approach to Stop Hypertension
____ juice can prevent & reverse atherosclerosis
Pomegranate
Teachings for: HMG coA Reductase Inhibitors (Statins)
Teachings (3)
Take in evening (When cholesterol synthesis occurs)
Avoid Grapefruit Juice (Increases SE)
Monitor CK levels (Statins can cause muscle damage)
How do statins work…
They inhibit the enzyme HMG in the liver which stops the production of cholesterol. They also remove LDL fron the blood
What does Pleiotropic effects of Statins mean….
Addition good effects the medication causes.
Anti-inflammatory and plaque-stabilizing properties, further contribute to cardiovascular protection.
Low cholesterol levels will have these problems…
Increased risk of viral infection & cancer
Hormonal
Neurological
Vitamin deficiency
Gemfibrozil
Fenofibrate
Examples of which type of medication…
With what effects…
Used alone?
Fibric Acid Derivatives
Reduces LDL, VLDL, & Triglycerides. INCREASE HDL levels
Appears beneficial on insulin resistance
Used alone or with Statins
Fibric Acid Derivatives
(Fenofibrate & gemfibrozil)
Lower all bad cholesterol & raise good
Benefical on insulin resistance
Used alone or in conjunction with Statins
Name
SE & TEACHINGS…
Muscle pain or weakness (myalgia)
Headache
Nausea or upset stomach
Diarrhea or constipation
Fatigue
Mild elevations in liver enzymes
Serious
Myopathy: Severe muscle pain with elevated creatine kinase (CK).
Rhabdomyolysis: Rare but life-threatening condition causing severe muscle breakdown, leading to kidney damage.
Liver toxicity: Significant liver enzyme elevation or hepatitis.
Teaching:
Avoid ETOH can cause elevated liver enzymes
Nicotinic Acid (Niacin)
Action….
SE….
High doses will lower VLDL & Raise HDL
SE:
FLUSHING & Itching
Increased Uric Acid
Increased BS
Ezetimide (Zetia)
Cholesterol Absorption Inhibitors
Prevents Absorption in…..
Small intestines
Cholestyramine
Colestipol
Colesevelam
Examples of which type of medication…
SE…
Bile Acid Resins
SE
Constipation
Reduced ability to absorb other meds
Cholestyramine
Colestipol
Colesevelam
(Bile Acid Resins)
Action…
Use….
SE….
Action:
Decreases reabsorption of bile acid in small intestine
To create more Bile Acid, Liver must pull LDL from plasma
Use (Off Lable)
Diarrhea
SE:
Constipation
Flatulence
Decreases absorption of other meds
Omega-3 Acid inhibitor
Omega 3 Acid Ethyl Esters (Lovaza)
Action…
SE….
Action: Reduces hepatic formation of triglycerides / May increase HDL
SE: Altered taste, belching, dyspepsia (Pain in upper stomach associated with eating), FLU LIKE SYMPTOMS
Problem:
Occurs when the heart’s oxygen demand exceeds supply during physical or emotional stress due to narrowed coronary arteries. It is predictable and relieved by rest or nitroglycerin.
Problem….
Stable angina
Monitor: Assess pain (location, intensity, duration, triggers), ECG for ischemic changes.
Interventions:
Administer nitroglycerin for pain relief.
Encourage lifestyle modifications
(healthy diet, regular exercise, smoking cessation).
Educate on recognizing triggers (e.g., exertion, heavy meals, stress).
Stable Angina
List meds for stable Angina (5)
Medications:
aspirin
Beta-blockers
calcium channel blockers
nitrates
statins.
Problem:
Unpredictable and occurs at rest or with minimal exertion. It is caused by plaque rupture, leading to reduced coronary blood flow and risk of heart attack.
Problem…
Unstable Angina
Monitor: Continuous ECG to identify ischemia or arrhythmias; assess cardiac enzymes.
Interventions:
Provide oxygen if SpO₂ <90%.
Administer nitroglycerin for pain and morphine if pain persists.
Prepare for potential coronary angiography or PCI (percutaneous coronary intervention).
Troponin levels not elevated
Problem…
Unstable Angina
Medications for Unstable Angina
Medications:
Dual antiplatelet therapy (aspirin and clopidogrel),
anticoagulants (e.g., heparin), beta-blockers,
ACE inhibitors / ARB
Morphine
Nitroglycerin
Statins
Problem: Caused by coronary artery spasms, occurs at rest and is often associated with transient ST-segment elevation. It is unrelated to physical exertion or stress.
Variant (Prinzmetal) Angina
Monitor: ECG during episodes to confirm ST-segment elevation that resolves with treatment.
Interventions:
Administer calcium channel blockers (e.g., diltiazem) or nitrates to relieve and prevent spasms.
Avoid beta-blockers, as they can worsen vasospasms.
Problem…
Variant (Prinzmetal) Angina
Educate: Avoid triggers such as smoking, cold exposure, and stimulant use (e.g., cocaine).
This problem….
Variant (Prinzmetal) Angina
Medications for Prinzmetal Angina
Medications:
Calcium channel blockers
nitrates for long-term management.
Problem: Occurs due to partial coronary artery occlusion, leading to myocardial injury without complete necrosis…..
Non-ST Elevation Myocardial Infarction (NSTEMI)
It is less severe than STEMI but still requires urgent care.
Monitor: Continuous ECG, cardiac enzymes (troponin, CK-MB), and hemodynamic status.
Interventions:
Administer MONA (Morphine, Oxygen, Nitroglycerin, Aspirin).
Facilitate coronary angiography if needed.
Problem…
Non-ST Elevation Myocardial Infarction (NSTEMI)
Medications: For NSTEMI
Medications:
Dual antiplatelet therapy, anticoagulants
beta-blockers
ACE inhibitors
statins.
Problem: Complete coronary artery occlusion, leading to significant myocardial damage if not treated promptly. It is a medical emergency
ST Elevation Myocardial Infarction (STEMI)
Monitor: Continuous ECG, monitor for arrhythmias or signs of heart failure.
Interventions:
Administer MONA immediately.(Morphine, Oxygen, Nitroglycerin, Aspirin)
Facilitate reperfusion therapy: PCI within 90 minutes or fibrinolytics if PCI is unavailable.
Provide hemodynamic support as needed.
This problem…
STEMI
ST Elevation Myocardial Infarction
ST Elevation Myocardial Infarction
Meds (5)
Medications:
Dual antiplatelet therapy, anticoagulants
beta-blockers
ACE inhibitors
statins.
Is an IV of NTG nitroglycerin ever appropriate…
Yes
Ongoing chest discomfort
HTN
Pulmonary congestion
Describe action of nitroglycerin…
Dilates Coronary Arteries
Peripheral arteries & veins
Describe Dosing of nitroglycerin
1 tab / spray Sublingual 0.4mg
Q3-5min × 3 until pain relief/ hypotension
Type of MI nitroglycerin is Contradicted in…
RV MI
Nitroglycerin
Contraindicated
SBP…..
HR ….
Type of recent medication…
SBP 100 or 90 TEACHER WILL DISCUSS
HR <50 or >100
Phosphodiesterase inhibitor
Sildenfanil
Vardenfamil
Tadafil
When to evaluate fir hypotension with nitroglycerin administration….
Before & After
Types of Reperfusion Therapy (3)
Indications (3)
1.Pharmacological Therapy:
Thrombolytics (Clot-Busting Drugs): Medications like alteplase, reteplase, or tenecteplase are used to dissolve blood clots.
Indicated in specific situations like ischemic stroke or STEMI (ST-Elevation Myocardial Infarction).
- Mechanical Therapy:
Percutaneous Coronary Intervention (PCI): A procedure where a catheter with a balloon is inserted into a blocked coronary artery to restore blood flow, often followed by stent placement.
Mechanical Thrombectomy: A procedure to remove a clot, commonly performed in patients with acute ischemic stroke.
- Coronary Artery Bypass Grafting (CABG):
A surgical method to create a new pathway for blood flow around blocked arteries.
Indications:
Acute Myocardial Infarction (AMI): Especially STEMI.
Acute Ischemic Stroke: When initiated within a specific time window.
Peripheral Arterial Occlusion: To save ischemic limbs.
Angina therapies (4)
Aspirin
B blocker (First Line Therapy)
CCB
Nitroglycerin
Reperfusion therapy -
Progresses to an acute coronary syndrome (ACS), such as a myocardial infarction (MI) (STEMI or NSTEMI), or when angina is caused by a complete coronary artery
Actions:
DECREASES HR WHICH DECREASES O2 DEMAND AND PREVENTS ISCHEMIA
SHORT TERM- Increase EF after 1-3 months of use
Blocks excessive Sympathetic NS stimulation
Prolongs diastole filling time
Prevents remodeling arrhythmias
Medication….
Beta-Blockers
OLOL
SE in Beta-Blockers (OLOL)
(6)
Bradycardia
Hypotension
Fluid retention
Fatigue
Impotence
Masks Hypoglycemia
BB & CCB mostly go together for angina problems…
False
Caution combining them
Verapamil
Diltiazem
Amlodipine
This type of med….
These SE….
CCB
Peripheral Edema
Hypotension/ Dizzy
Bradycardia
Constipation
Action
Decreased oxygen demand
Vasodilation reduces ventricular wall stress
Decreased HR amd contractility (Increased Oxygen Supply)
Dilate Coronary Arteries
Reverse Vasospasms
CCB
Diltiazem
Verapamil
Amlodipine
Morphine Sulfate
Action: Binds with Kappa & mu pain receptors to produce analgesia
Dosing….
2 - 4 mg
Every 5 - 15 min
up to 8mg can be used
How should the ST segment look on an ECG…
What if its not…
Flat & even with the baseline
STEMI
ST segment elevation >1mm in 2 or more continous ECG leads
Complete Block of Coronary Artery
Rapid Reperfusion required
NSTEMI
ST Depression or T wave Inversion
Partial blockage
BOTH WILL HAVE TROPONIN LEVELS ELEVATED >0.04
Due to myocardial infarction- necrosis- due to lack of oxygen
ST segment elevation >1mm in 2 or more continous ECG leads
This problem…
STEMI
ST Elevation Myocardial Infarction
Complete Heart Block
Rapid Reperfusion required
Describe how a NSTEMI will look…
ST Depression/ T wave inverted
Tissue Perfusion
Timely Reperfusion
Percutaneous Coronary Intervention (PCI)
_____ Minutes first contact
_____ Minutes of EC door
Fibrinolytics
_____ minutes of EC door
90 Minutes first contact
[Provided in Class] Minutes of EC door
Fibrinolytics
30 minutes of EC door
Alteplase (tPA):
Tenecteplase:
Reteplase:
Which type of medication…
Do what…
For which problems…(3)
Fibrinolytics aka thrombolytics
Disolve blood clots by breaking down fibrin
Used for:
ST-Elevation Myocardial Infarction (STEMI)
Pulmonary embolism (PE)
Ischemic stroke
Purpose:
Diagnose and evaluate heart conditions (e.g., coronary artery disease, valve function, or heart defects).
Can be used to perform therapeutic interventions, such as angioplasty.
Procedure…
Cardiac Catheterization:
Purpose:
Reopen narrowed or blocked coronary arteries.
Restore blood flow to the heart muscle.
Procedure:
A balloon-tipped catheter is advanced to the site of the blockage.
The balloon is inflated to compress the plaque against the artery wall.
Angioplasty a type of (Percutaneous Coronary Intervention, PCI)
Why are anticoagulants held and aspirin given before cardiac Catheterization…
Holding anticoagulants reduces bleeding risk during cardiac catheterization, while aspirin is maintained to prevent arterial clot formation (Due to Trauma in the vessel from the procedure), ensuring the safety and success of the procedure.
Pre-Procedure Cardiac Catheterization
Nurses responsibilities…
Informed Consent: Ensure the patient understands the procedure, risks, and benefits.
Fasting: Ensure the patient has been NPO (nothing by mouth) for 6–8 hours before the procedure.
Medication Review:
Withhold
Anticoagulants (e.g., warfarin, DOACs).
Nephrotoxic Drugs Metformin
Administer prescribed medications such as aspirin or clopidogrel if ordered.
Baseline Assessments:
Vital signs.
Peripheral pulses (especially in the affected limb).
ECG and blood work (e.g., coagulation profile, renal function).
Intra-Procedure Care:
Cardiac Catheterization
Monitor Patient Status, how….
Continuous ECG monitoring for arrhythmias
Activity Restrictions:
Post cardiac Catheterization
Activity Restrictions:
For Femoral Access: Keep the leg straight and immobilized for 4–6 hours to prevent bleeding.
For Radial Access: Elevate the wrist slightly, and avoid heavy lifting for 24–48 hours.
Inflating a small balloon inside a coronary artery to compress plaque against the artery walls and improve blood flow.
Angioplasty
Angioplasty may or may not involve the placement of a stent.
Common PCI techniques: (4)
Percutaneous Coronary Intervention (PCI):
Balloon Angioplasty: Inflating a balloon to open a blocked artery.
Stent Placement: Inserting a metal mesh device to keep the artery open after angioplasty (most common in modern PCI).
Atherectomy: Removing plaque using specialized devices.
Thrombectomy: Removing blood clots during acute coronary syndromes.
Pathway for Cardiac Catheterization
(2)
Femoral Access: Femoral artery → iliac artery → abdominal aorta → thoracic aorta.
Radial Access: Radial artery → brachial artery → subclavian artery → aortic arch.
Cardiac Catheterization
Fluoroscopy….
Contrast Dye: Injected through the catheter to make the coronary arteries visible on X-ray.
Fluoroscopy: Real-time X-ray imaging helps the physician visualize the catheter’s path.
rtPA (Activase)
reteplase (Retavase)
tenecteplase (TNKase)
- This type of medication…
- Absolute & Relative Contraindications (3)
- Action….
- Fibrinolytics
- Absolute: Recent Major Bleeding & Preggers
Relative: Hypertension (SBP>180 or DBP > 110
- Dissolves thrombi in the coronary arteries to restore blood flow.
Class:
Fibrinolytics
Exp.
rtPA(Activase)
reteplase(Retavase)
tenecteplase (TNKase)
Contraindications:
2. Absolute: Recent Major Bleeding & Preggers
Relative: Hypertension (SBP>180 or DBP > 110
Action:
Dissolves thrombi in the coronary arteries to restore blood flow.
Indications/ Treats (1)
Time frame….
STEMI
Door to needle 30 minutes
P2Y12 aka ADP Inhibitors
Exp.
Clopidogrel (Plavix)
Prasugrel (Effient)
Ticagrelor (Brilinta)
Cangrejos (Kangreal)
Action: Reduces Platelet function
Uses: Decrease sudden cardiac death due to thrombosis
ALERT….
Caution…. (3)
SE…. (2)
Alert: Need cardiology approval to stop med
Caution: Age>75
Hx of stroke
Stop 7 days before surgery
SE: Bleeding, stroke
ROSC…
Return of Spontaneous Circulation
Only intervention shown to improve neurological outcome and decrease mortality in Cardiac Arrest patients who dont Regain Consciousness after ROSC….
Therapeutic hypothermia
32 - 34 / 89.6 - 93.2
Therapeutic hypothermia
32 - 34 C / 89.6 - 93.2 F
Only intervention shown to improve neurological outcome & decrease mortality following patients who Dont Regain Consciousness after ROSC following cardiac arrest.
Adverse SE…. (6)
Fluid / electrolyte imbalance
Arrhythmias
Insulin resistance
Shivering
Coagulation
Pain / sedation concerns
NSTEMI
Chest Pain
ST Depression _____
T wave _____
Transient (<20 min) ST elevation
What level of Cardiac Markers (Troponin) determines diagnosis….
ST Depression > 0.5mm
T wave Inversion
> 0.04 ng/mL (or 40 ng/L)
NSTEMI (Non-ST-Elevation Myocardial Infarction)
Or
UA (Unstable Angina)
Definition Partial blockage of a coronary artery causing myocardial injury with elevated cardiac biomarkers (e.g., troponin).
Partial blockage causing ischemia but without myocardial injury (normal)
NSTEMI or UA…..
ECG Changes May show ST depression or T-wave inversion.
May show similar changes, but often normal.
NSTEMI or UA….. Symptoms
Chest pain or discomfort, similar to UA but may persist longer and occur at rest.
Chest pain or discomfort, typically at rest or worsening over time. May be new onset or a change in stable angina.
NSTEMI or UA…..Risk
Higher risk of progressing to a STEMI or further myocardial damage.
Indicates high risk but no myocardial cell death yet.
Top = NSTEMI
Bottom = UA
NSTEMI Initial treatment: Acute Pain
911 / EMS - Call for help
ASA 165 - 325mg, antiplatelet (Clopidogrel)
Nitroglycerin SL
IV if on going
O2, IV, Monitor, Morphine
ECG
H&P
Blood draw cardiac marker
Tissue Perfusion Interventions:
Anti-ischemic therapy (6)
Bedrest
Oxygen
Nitroglycerin
Beta-Blockers
CCB
ACE/ARB
Continous Nitroglycerin
Indications (3)
Chest pain (Angina)
Hypertension
Pulmonary Edema
Heparin
Bolus IV then continuous infusion to maintain therapeutic level
- What is Normal (in regular person)
- Low intensity
- High intensity
- 25 - 35 second saPTT (Activated Partial Thromboplastin Time): (Someone not recieving Heparin)
- Low Intensity 55 - 75 / 60 - 80 aPTT (Activated Partial Thromboplastin Time):
- High intensity 80 - 100 aPTT (Activated Partial Thromboplastin Time):
What is a critical Heparin coagulation time.
> 120 sec
What is a critical Heparin coagulation time.
> 120 sec
What is a critical Heparin coagulation time.
> 120 sec
ELISA test is used for…
Describe the health problem it is looking for….
HIT
Heprin Induced Thrombocytopenia
HIT is more about clotting risk than bleeding.
Requires immediate action to prevent serious complications like stroke, PE, or limb ischemia.
Future anticoagulation regimens should avoid heparin altogether.
Define
Thrombocytopenia/ Thrombocytosis
Thrombocytopenia<150,000
Thrombocytosis>450,000
Enoxaparin (Lovenox)
Class: Low-Molecular-Weight Heparin (LMWH).
Mechanism of Action: Inhibits clotting factors Xa and IIa (thrombin), with a greater effect on factor Xa.
Uses:
Prevention and treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE).
Acute coronary syndromes (e.g., unstable angina, NSTEMI, STEMI).
Labs to monitor…
Route: Subcutaneous (SC) injection.
None
However, anti-Xa levels can be monitored in certain cases (e.g., renal impairment).
Bivalirudin
Class: Direct Thrombin Inhibitor (DTI).
Mechanism of Action: Binds directly to thrombin (factor IIa), preventing fibrin formation, platelet activation, and clot stabilization.
Uses:
Anticoagulation in patients undergoing percutaneous coronary intervention (PCI).
Alternative to heparin in patients with HIT or at risk for HIT.
Route: Intravenous (IV) infusion.
Monitoring….
Monitoring:
Activated clotting time (ACT) or activated partial thromboplastin time (aPTT) may be used for monitoring.
Argatroban
Class: Direct Thrombin Inhibitor (DTI).
Mechanism of Action: Inhibits thrombin (factor IIa) directly, preventing clot formation.
Uses:
Anticoagulation in patients with HIT.
Alternative anticoagulant for PCI in patients with HIT.
Route: Intravenous (IV) infusion.
Monitoring…..
Key Notes…
aPTT is monitored to maintain therapeutic levels (1.5–3 times baseline).
Key Notes:
Metabolized in the liver; no dose adjustment needed for renal impairment but caution in hepatic dysfunction.
Short half-life (~40–50 minutes).
Fondaparinux
Class: Factor Xa Inhibitor (Synthetic Pentasaccharide).
Mechanism of Action: Selectively inhibits factor Xa, interrupting the coagulation cascade.
Uses:
Prevention and treatment of DVT and PE.
Alternative anticoagulant in patients with HIT.
Route: Subcutaneous (SC) injection.
Monitoring….
Key notes…
No routine monitoring required, as it has a predictable anticoagulant effect.
Key Notes:
Contraindicated in severe renal impairment (CrCl <30 mL/min).
Long half-life (~17 hours), allowing once-daily dosing.
Ezetimide
Action….
Prevents cholesterol absorption in the Small Intestine
Lowers cholesterol
Used for people who cannot tolerate statins
SE (5) & Nurse Considerations (5)
Giving Fibrinolytics
(Alteplase, Tenecteplase, Reteplase)
Side Effects of Thrombolytics
Bleeding: Includes intracranial, gastrointestinal, and wound-site bleeding.
Allergic Reactions: Rash, itching, or rare anaphylaxis.
Hypotension: Common systemic effect.
Reperfusion Arrhythmias: Occurs during restored blood flow.
Nausea, Vomiting, Fever, and Chills.
Nursing Considerations
Assess for Contraindications: Recent surgery, bleeding disorders, or severe hypertension.
Baseline Data: Obtain vital signs, neurological status, and labs (CBC, PT/INR, aPTT, fibrinogen).
Monitor Closely: Watch for bleeding, changes in LOC, and arrhythmias during and after infusion.
Avoid Invasive Procedures: Minimize venipunctures and catheter use.
Educate Patient: Emphasize avoiding activities that increase bleeding risk.
Big difference between NSTEMI & UA
NSTEMI involves myocardial injury with necrosis, shown by elevated troponins (>0.04)
Unstable Angina involves ischemia without necrosis, so troponins remain normal.
Proper differentiation is crucial as it influences management and prognosis.
Meds
Stable Angina…..
Unstable Angina….
Prinzmetal Angina…
Stable Angina
Aspirin
BB
CCB
Nitroglycerin
Statins
Unstable Angina
Dual Antiplatelet (Aspirin and clopidogrel)
Anticoagulant
ACE
BB
Nitroglycerin
Statins
Prinzmetal Angina
CCB
Nitrates
NSTEMI or STEMI
Require urgent Reperfusion (Thrombolytics/ PCI)
STEMI
Why not give BB with Prinzmetal Angina…
BB can worse the spasm and occulude vessel
Eptifibatide (Integrilin)
Abciximab (ReoPro)
Tirofibran (Aggrastat)
Type of medication….
Action….
Use…
Antiplatelets
Action:
Inhibits platelet aggregation by preventing fibrin binding with platelet.
Eptifibatide (Integrilin)
Tirofibran (Aggrastat)
NSTEMI & Unstable Angina
(PCI, including stenting) – During and after the procedure
Abciximab (ReoPro)
STEMI & NSTEMI
PCI with Stenting or Balloon Angioplasty – Reduces ischemic complications
Eptifibatide (Integrilin)
Abciximab (ReoPro)
Tirofibran (Aggrastat)
Antiplatelets med
Action:
Prevent fibrin from binding with platelet.
Indications:
- Treats….
- Abciximab can treat….
- Give these meds in combination befire PCI…
- Not intended for ____ if not planned…
- Adverse SE
- UA/NSTEMI
- Abciximab only can treat STEMI
- Aspirin, Clopidogrel, Heparin / Bivalirudin
- PCI - This medication is used in High Risk patients who are prone to Thrombosis.
- Bleeding
RC Dysrhthmias
Refactory Cardiogenic Dysrhythmias
Causes…(4)
Challenge (1)
Treatment (3)
Causes
Myocardial infarction (MI).
Heart failure (HF).
Electrolyte imbalances (e.g., hypokalemia, hypomagnesemia).
Drug toxicity (e.g., digoxin, antiarrhythmics).
Challenge
Resistant to antiarrhythmic drugs (e.g., amiodarone, lidocaine).
Treatment
Often requires advanced interventions like defibrillation, cardioversion, or mechanical support (e.g., ECMO, ventricular assist devices).
Refractory Cardiogenic Heart Failure (RC Heart Failure)
Cause..(3)
Challenge: (1)
Treatment: (3)
Cause
End-stage heart failure.
Acute decompensation due to MI or severe valve disease.
Chronic conditions like dilated cardiomyopathy or hypertrophic cardiomyopathy.
Challenge
Nonresponsive to Medications: Standard diuretics, inotropes, or vasodilators may not work.
Treatment
Mechanical circulatory support (e.g., intra-aortic balloon pump, left ventricular assist device).
Heart transplantation in eligible patients.
Palliative care for symptom management in end-stage cases.
3 Phases of Activity Intolerance
Describe…
Phase 1: Hospitalization
Nurse & PT supervise progressive ambulation
Phase 2: Convalescence
Outpatient cardiac rehab
Phase 3: Long Term Conditioning
Independent
RC Dysrhthmias
Inferior: leads to…
Anterior leads to…
Inferior SA & AV Blocks which lead to (BRADYCARDIA & BLOCKS)
Anterior Damage to interventricular septum and conduction pathways (Ventricular irritability and bundle branch blocks (BBBs).)
Inotropes are medications that affect the contractility of the heart muscle.
Positive inotropes increase the strength of heart contractions, improving cardiac output.
Examples: (3)….
Negative inotropes reduce contractility but are not used in refractory cardiogenic (RC) heart failure.
Dobutamine, Milrinone, Dopamine (at moderate doses).
Intra-Aortic Balloon Pump (IABP)
Does…
When does it Inflate / Deflate…
The IABP is a mechanical device that provides Temporary circulatory support
Inflating during diastole: Increases coronary artery perfusion.
Deflating just before systole: Reduces afterload and cardiac workload.
Can most patients with CVD have sex
Yes
Reperfusion therapy
Fibrinolytics with in….
PCI with in….
Fibrocystic 30 min
PCI 90 min
Death occurs in patients with non-critical disease
Name (2)
Unstable plaque
Abnormal coronary flow reserve
A 72-year-old male presents with five hours of substernal chest pain and pressure despite taking three sublingual nitroglycerin. You order an EKG. What findings on the EKG would indicate that this patient is potentially a candidate for thrombolytic therapy?
A. Ventricular tachycardia
B. ST-segment elevation of at least 1 mm in two or more contiguous leads
C. ST-segment depression of at least 2mm in any precordial lead
D. Atrial fibrillation with a rapid ventricular response
B. ST-segment elevation of at least 1 mm in two or more contiguous leads
The answer is B. “Fibrinolytic therapy is indicated for patients with STEMI (as a reperfusion option) if time to treatment is <6 to 12 hours from symptom onset, and the ECG has at least 1-mm ST-segment elevation in two or more contiguous leads.”
Chest pain, elevated Troponin levels and ST segment depression. What is the findings…
A. STEMI
B. NSTEMI
C. USA
D. Angina
B. NSTEMI
An ICD (Implantable Cardioverter-Defibrillator) is….
Medical device used to monitor and treat abnormal heart rhythms (arrhythmias) that may cause sudden cardiac arrest
Most common cause of Stable Angina
A. Rupture of fatty plaque within a coronary artery
B. Fatty plaque within the coronary artery that has cause it to stiffen (Atherosclerosis)
C. Thrombus formation within a coronary artery
D. Vasospasm of a coronary artery.
Most likely cause of Stable Angina is:
B. Fatty plaque within the coronary artery that has cause it to stiffen (Atherosclerosis)
Unstable Angina
A. Rupture of fatty plaque within a coronary artery
Cause of MI
C. Thrombus formation within a coronary artery
Cause of Prinzmetal Angina
D. Vasospasm of a coronary artery.
Antidote for Heparin
Antidote for Warfarin
Protamine Sulfate
Vitamin K
* teach pt to have consistent intake of Vitamin K
Normal CK levels
Adult Men: 52–336 U/L
Adult Women: 38–176 U/L
Describe abnormal
Which type of meds will these levels be checked….
Mild Elevation (up to 5 times normal):
Strenuous exercise
Minor muscle injuries
Infections
Certain medications (e.g., statins)
Moderate Elevation (5–10 times normal):
Myositis (muscle inflammation)
Rhabdomyolysis (severe muscle breakdown)
Muscular dystrophies
Myocardial infarction (MI)
CHECK WHEN TAKING STATINS
Describe clotting values for
Heparin / Lovenox
Warfarin/ Coumadin
Heparin appt
Normal 25 - 35 seconds
Therapeutic value 1.5 - 2.5 times higher
60 - 80 seconds
Lovenox (low molecular weight heparin) does not have a value to consider.
Warfarin
INR
Normal Range (without warfarin): 0.8–1.1
Therapeutic Range:
For most conditions (e.g., atrial fibrillation, DVT, PE): 2.0–3.0.
For mechanical heart valves or recurrent embolism: 2.5–3.5
&
Prothrombin Time (PT)
Purpose: Evaluates blood clotting time, often used in conjunction with INR.
Normal Range (without warfarin): 11–13.5 seconds.
Therapeutic Range (with warfarin): 1.5–2.5 times the normal PT value.
16.5 - 21 sec or 28 - 34
Consideration: An elevated PT may indicate an increased risk of bleeding.
