Unit 7 Acute Coronary Syndromes/EKG Flashcards
When speaking of location in the heart, where is the base and where is the apex?
Base = Top Apex = Bottom
What is ejection fraction and the norm?
Percentage of blood leaving your heart each time it contracts.
Normal EF is > 60 %
< 40% = left ventricle dysfunction and PT needs to be on ACE inhibitors
What is the pericardium?
Membrane enclosing the heart
What are the main coronary arteries of the heart and which one being obstructed usually results in MI and Death?
Left Coronary Artery
Right Coronary Artery
Circumflex Artery (branches laterally off of left coronary artery)
Left Anterior Descending Artery (branches downward from left coronary artery)
Left Coronary Artery block = MI or Death
What is the pacemaker of the heart? What is it’s rate? If it does not initiate what takes over and the rate, and if THAT fails, what takes over and the rate?
SA node is pacemaker of heart 60-100, if it fails
AV node takes over 40-60, if it fails,
Ventricle will take over 20-40.
Definite the following terminologies. Starling's Rule. Stroke Volume Paroxysmal nocturnal dyspnea (PND; what's it an early sign of?) Prelaod Afterload
Starling’s rule = stroke volume increases in response to increase in the volume of blood in ventricles
Stroke Volume = amount of blood ejected with each beat (~70mL)
PND is a sensation of shortness of breath that awakens the patient; early sign of L sided HF
Preload = Degree of stretch in ventricles before systole/ amount of blood in heart at end of diastole
Afterload = pressure heart has to pump against (amount of resistance the left side of the heart has to overcome in order to eject blood)
What is the common side effect of a patient taking an ACE Inhibitor?
Dry cough
“pril” medications
Where is the apical pulse found?
MCL 5th intercostal space
What is the nemonic to help remember order of auscultating heart sounds?
All Physicians
Earn
To
Much
What narrows and blocks the coronary arteries?
Atherogenesis, (disorder of artery wall that clumps WBCs)
Plaque formation
Endothelial injury
What are the normal LDL and HDL levels?
LDL < 130
HDL > 45
What are modifiable and non-modifiable risk factors for CAD?
Modifiable:
- Smoking
- Dyslipidemiea
- HTN
- Diabetes (A1C < 7)
- Obesity
- Lack of Exercise
- Personality
- Stress
Non-Modifiable:
- Sex
- Age
- Family Hx
CAD/HF is the leading cause of death for who?
Men tend to manifest CAD how many years prior?
Who has the highest incident of CAD?
Who has the earliest age onset?
Women
10 years
White middle aged men
AA’s
What is angina relieved with?
Rest and nitroglycerin
What are Acute Coronary Syndromes? How long do the episodes last?
Unstable Angine (change in duration of pain/ not relieved usual way anymore, needs treatment)
STEMI (A Myocardial Infarction, ST elevation)
NSTEMI (Sub-endorcadial MI, no ST elevation)
Sudden Cardiac Death (usually left main coronary artery blocked)
> 30 min episodes not relieved by nitroglycerin
What are diagnostic studies for CAD? What is used for diagnosis?
Blood work (H/H, Lipid profile, CRP, Homocysteine level EKG Echocardiogram CXR Nuclear Stress Test Cardiac catheterization
-12 lead EKG
What are pharmacological interventions for CAD?
- Anti-platelets
- Nitrates
- Beta blockers “olol”
- Lipid lower agents “statin”
- Calcium channel blockers “ide and ine”
- ACE inhibitors “prils”
What are the surgical interventions for CAD?
PTCA - catheter through femoral artery, balloon inflates to compress plaque and open vessel
PCI - catheter, balloon, plus stent at the end
Regarding EKG’s, what is Ischemia associated with? Injury? Necrosis?
Ischemia - ST depression and T wave inversion
Injury - ST elevation and T wave inversion
Necrosis - abnormal Q wave
Describe women and heart disease.
Post menopausal women risk of MI quadruples
Women suffer more silent MI’s, less classical symptoms
Women report more disability after cardiac event then Men
What are other causes of ACS?
Marfan’s Syndrome (connective tissue disorder, narrow arteries)
Coronary artery vassospasm
Coronary arterial stenosis
What is CABG?
coronary artery bypass grafting
What is the gold standard intervention for an acute MI?
PCI and the goal is to perform it within 90 minutes from the times of chest pain.
What essentially happens in ACS?
Severe and abrupt cessation of blood supply (O2) leads to ischemia
Ischemia when persists then causes injury
Cell death results if O2 supply is not restored which is irreversible
This is leads to necrosis which again is irreversible
How are MI’s classified?
- Wall thickness affected
1. Transmural (STEMI)
2. Subendocardial (non-transmural, NSTEMI) - Coronary artery involved (LAD anterior wall, LCA lateral wall, RCA inferior and posterior wall)
- From 12 lead EKG
- Ventricle Involved
What do each of the 12 leads correspond with?
Anteroseptal/Anterior = V1, V2, V3, V4
Inferior = 2, 3, aVf
Lateral = 1, avl, V5, V6
Posterior = V2
What do Tombstone ST’s signify?
What do Fireman’s hat signify?
Tombstone = Anterior MI
Fireman’s hat = Inferior MI
What are factors affecting a MI?
Location of infarct
Degree of infarct
Collateral circulation (older PT’s have better collateral circulation)
Describe angina pain vs MI pain.
Angina pain:
- Goes away in < 30 min
- Precipitated by exercise
- No damage to the heart
- Relieved by rest and nitroglycerin
MI pain:
- > 30 min episode
- Radiates to other parts of the body
- Not relieved by rest or nitroglycerin
What are diagnostic lab tests for a MI?
CPK (creatininephosphokinase, 55-175 normal)
Troponin (VERY early rise and peak, elevated for ~10 days
LDH (lactase dehydrogenase)
BNP (normal < 100, with HF > 1000’s!!
What diagnostic procedures can be done for MI’s?
Chest X-ray
Echocardiogram
Cardiac Catheterization:
- Check for shellfish allergies since it uses contrast
- Post procedure PT lays flat 4-6 hrs, neurovascular checks
What are nursing interventions for a PT with chest pain?
- O2 therapy
- VS monitoring
- 12 lead EKG
- Multiple IV access
- Medications: aspirin, plavix, nitroglycerin, lovenox
- Thrombolytics
- Sx
- Interventional cardiology (PCI)
- Bedrest with gradual increase of activity
What are pharmacological Rx’s for MI/Chest Pain/CAD?
- Vasodilators (Nitrates, Hydralazine)
- Anti platelet (asa, plavix)
- Beta blockers ( “olol”)
- Opioid analgesics (morphine)
- Anticoagulants
- ACEis (prils)
- Statins
- Stool softeners
- Anxiolytics
What is a thrombolytic? Describe.
Purpose is to cause the dissolution of the clot resulting in re-profusion. “Clot buster”
With effective Rx:
- Abrupt cessation of pain
- Reprofusion of arrhythmias
- Normalization of ST’s
ex: tPA
What is the selection criteria for thrombolytics?
Age
Pain criteria (pain last > 1 hr not relieved by nitro
Time from onset of pain to initial evaluation with 6 hrs
EKG - ST elevation in at least 2 LEADS
What are contraindications for thrombolytics?
Bleeding disorder
Hemorrhagic stroke
Recent surgical procedure
Peptic ulcer/ GI bleed/ hemoptysis
Uncontrolled HTN
Serious or advanced illness
Pregnancy
What are major complications of thrombolytics?
Hemorrhage
Stroke
COMA (altered MS, pupils early indication something is wrong)
What is IABP and what does it do?
Intra Aortic Balloon Pump
Decreases O2 demand, Increases O2 supply
- Inserted through femoral artery
- Intermittin inflation (check for blockage)
- PT needs foley to monitor urine output and to make sure balloon is not blocking renal artery
- PT needs to lay flat
What is the goal of cardiac rehabilitation and the three phases?
Goal = well being pf PT
Phase 1 = CCU admission to transfer/discharge
Phase 2 = discharge to convalescence and home
Phase 3 = Long term recovery and conditioning. Involvement of community rehabilitation program
What are complications of MI’s?
Sudden death
Arrhythmias
Heart Failure
Pump Failure
Papillary muscle dysfunction
Dressler’s syndrome (pleural pericardial effusion ~6 weeks after MI)
Ventricular aneurysm and rupture
What is the core measure for a MI?
PCI within 90 minutes of arrival to hospital
Thrombolytic therapy Received Within 30 Minutes of Hospital Arrival
Aspirin at admission and discharge
ACEi’ (prils) and ARBs (artan)
Statin prescribed at discharge
Describe Sudden cardiac death.
What are the causes?
What are the interventions?
Unexpected collapse with cardiopulmonary arrest
Causes: Massive MI, dysrhythmias, LV outflow obstruction
Statistically most don’t survive
Rx:
-EMS immediate CPR, ACLS, PTCA, IABP, CABG
-Therapeutic hypothermia
Briefly describe broken heart syndrome.
Presents like MI, except arteries are normal
Triggered by stressful event
What is the time frame of one small box on an EKG?
What about one big box (5 small boxes)
1 small box = .04 seconds
1 big box (5 small boxes) = .20 seconds
In 1st degree heart block on an EKG, what length is shortened and what is the PR interval regarding it?
The T to P break (where EKG ends and starts again)
PR interval is > .20
What wave represents arterial depolarization leading to arterial contraction?
P wave
What is the inner layer of the heart called?
endocardium
What is myoglobin?
Heme protein that transports oxygen
What is CRP (C-reactive protein)?
Protein released in blood during inflammatory states
What medication is given to PT’s who are allergic to Aspirin?
clopidogrel (Plavix)
What lead is the most common used for continuous cardiac monitoring?
Lead 2
How do you calculate HR on an EKG strip?
- Count the number of small boxes in between R-R intervals and divide them from 1500.
- Another method is to count the number of QRS complexes in one minute, or in 6 seconds and multiply by 10
What does depolarization mean? Re-polarization?
Depolarization = Contraction
Re-polarization = Relaxation
What does the R-R measure on an EKG?
P-P?
R-R measures ventricular rate
P-P measures arterial rate
What is the normal PR interval, normal QRS, and QT interval?
PR interval normal is .12-.20
QRS normal < .12
QT interval normal .36-.44 (2 large boxes plus or minus one small box)
Explain what each associated pattern corresponds with. P wave. PR segment. QRS complex. T wave. Isoelectric line.
p wave = atrial depolarization
pr segment = Delay at AV node
QRS complex = ventricular depolarization
T wave = ventricular re-polarization
Isoelectric line = no electric activity
What are the causes of Sinus Tachycardia and what is the treatment? What does the rate have to be?
Rate has to be > 100
Causes: -Tachypnea -Elevated BP -Pain/fever -Excersise -Stimulant use: Caffeine Tobacco Medications
Treatment: Anti-anxiety meds if anxious, fluid replacement, If in pain give pain med, essentially treat the cause- notify nurse
What are the causes of Sinus Bradycardia and what is the treatment? What does the rate have to be?
Rate has to be < 60
Causes:
- Is PT an athlete?
- Meds such as beta blockers, CCB, digoxin
Treatment:
- Treat cause
- Atropine if symptomatic (stimulates SA node)
- Pacemaker
What are the causes and treatments of A-fib?
Causes:
- Heart disease
- Pulmonary disease
- Excessive alcohol or caffeine
Treatment:
-Anticoagulation w/ asa, heparin, warfarin
-HR control using, beta-blockers, CCB (cartizem), Digoxin
(seeking to get to 60-100 w/o conversion)
-Rhythm control
amiodarone (anti-arrhythmic for abnormal rhythms)
OR with,
Cardioversion
uses electricity or chemical means for rhythm control (dronedarone)
OR with,
Ablation (radio frequency destroying tissue in the pathways that cause abnormal rhythm)
What is the treatment for Supra-ventricular Tachycardia (PSTV)? Is the rhythm technically regular or irregular? What are the causes?
Rhythm is normal! Just ventricle firing extremely fast. Can’t measure PR interval. Can’t tell if P or T wave.
Causes: chronic health problems, high levels of heart medications
Treatment:
-Physical maneuver affecting the vagus nerve called Valsalva maneuver. (PT takes deep breath and then bears down with mouth closed)
-Rx [adenosine] which reduces the normal flow of electrical impulses through the AV node.
Given very quickly
Half life of 2 minutes
6mg, 12mg, 12mg
-Cardioversion
When are PVC (premature ventricular contractions) dangerous and you’d want to report to MD?
- > five in a minute
- Two or more in a row
- Multifocal (coming from different areas)
- R wave on T wave (R on T)
When are PVC’s in a rhythm considered Ventricular tachycardia?
When there are 4 or more
What are the causes and treatments of PVC? What will the PT feel?
Causes:
- Caffeine
- Electrolyte imbalance (hypo/hyperkalemia, hypomagnesium)
- Ischemia/hypoxia
(PT will feel lightheadedness)
Treatment:
- Replace electrolytes
- Rx, amiodarone
- lidocaine/novocain
What is the treatment for ventricular tachycardia? What is seen in V-Tach?
- Oxygen
- Lidocaine
- Rx, amiodarone
(mix in solution and give rapidly) - Cardioversion
- Restoring electrolyte imbalances
QRS one after the other. No pauses.
What are the causes and treatment for Ventricular Fibrillation? What are the most common signs of V-Fib?
Causes:
- Acute MI
- Electrolyte disturbances
- Drugs
Treatment:
- ASSESS UNRESPONSIVENESS
- Call 911/code blue
- Initiate CPR
- Defibrillation
- Medications: epinephrine, amiodarone, lidocaine, vasopressin
Most common signs:
- Absent peripheral pulses
- Unconscious
What are causes and treatments of Asystole?
Causes:
- Acute MI
- Cardiac Arrest
Treatment:
- ASSESS UNRESPONSIVENESS
- Call 911/code blue
- Initiate CPR
- Defibrillation
- Medications: epi, amiodarone, lidocaine, vasopressin
What medication for a PT is monitored on telemetry and why?
Digoxin because they could slip into a 1st degree heart block due to digoxin toxicity
What is the treatment for 3rd degree heart block?
Atropine first (to try and increase heart rate)
Pacemaker
What is considered 1st degree and 3rd degree heart block?
1st degree = PR interval >.20
3rd degree = more p waves than QRS’s
What is the therapeutic effect of nitroglycerin and how do you know it was effective? What is the initial standard dose?
Dilates blood vessels
Decreases O2 demand
Effective if pain is relieved
50mg/250mL
What EKG reading would you expect with digoxin toxicity and why?
1st degree heart block.
SA impulse is delayed to the AV, longer PR interval.
Where are the SA and AV node located in the heart?
Sa node is at the junction of the aorta and RA
AV is in the intraarterial septum
How can you tell if an EKG rythmn is regular or irregular?
The interval between the R waves would be regular or irregular
Does does BNP indicate?
Hear failure
BNP normal < 100, with HF > 1000’s!!
helps combat adh and aldosterone to prevent overload of fluid
What is MONA for?
MI Interventions
Morphine
Oxygen
Nitrates
Aspirin
What does an S3 heart sound indicate?
Left-sided heart failure
