Week 1 - Cardiovascular Flashcards
Coronary Artery Disease
CAD - _______ disorder
▪ Atherosclerosis
▪ Gruel/fatty mush - hard
▪ Asymptomatic or chronic ______ angina (chest pain)
▪ Effects __________
▪ Depends on heart’s ability to generate CO.
CAD - blood vessel disorder
▪ Atherosclerosis
▪ Gruel/fatty mush - hard
▪ Asymptomatic or chronic stable angina (chest pain)
▪ Effects perfusion
▪ Depends on heart’s ability to generate CO.
Right Coronary Artery (RCA)
▪ Right Atrium
▪ Right Ventricle
▪ SA Node (55%)
▪ AV Node (90%)
▪ Posterior Left Ventricle
Cardiac Output (CO)
Process of ______
Heart’s ability to generate CO
______ distribution to tissues.
Process of perfusion
Heart’s ability to generate CO
Blood distribution to tissues.
▪ Cardiovascular Disease (CVD) is the leading cause of death worldwide.
▪ By 2030, expected to account for ___ million deaths.
▪ Several disorders:
▪ ____(most common type)
▪ Leading cause of death in US
▪ Cerebrovascular disease
▪ Peripheral artery disease
▪ By 2030, expected to account for 22.2 million deaths.
▪ Several disorders:
▪ CAD (most common type)
▪ Leading cause of death in US
▪ Cerebrovascular disease
▪ Peripheral artery disease
Coronary Artery Disease
Huge issue in the US
Very costly (procedures, meds, etc).
Huge issue in the US
Very costly (procedures, meds, etc).
Non-modifiable risk factors for CAD
▪ Age
▪ Gender
▪ Ethnicity
▪ _______ predisposition
▪ ________ history
▪ Age
▪ Gender
▪ Ethnicity
▪ Genetic predisposition
▪ Family history
Major modifiable risk factors for CAD
▪ Elevated serum ______
▪ Hypertension
▪ Cigarette smoking/tobacco
▪ Physical _________
▪ ________
Contributing modifiable risk factors for CAD
▪ Diabetes Mellitus
▪ Stress and behavior patterns
▪ Metabolic syndrome (obesity, HTN, elevated triglycerides, serum lipids, and elevated FSBG).
▪ Substance abuse
▪ Elevated homocysteine levels
Major modifiable risk factors for CAD
▪ Elevated serum lipids
▪ Hypertension
▪ Cigarette smoking/tobacco
▪ Physical inactivity
▪ Obesity
Contributing modifiable risk factors for CAD
▪ Diabetes Mellitus
▪ Stress and behavior patterns
▪ Metabolic syndrome (obesity, HTN, elevated triglycerides, serum lipids, and elevated FSBG).
▪ Substance abuse
▪ Elevated homocysteine levels
CAD - Health Promoting Behaviors
▪ ID High Risk Persons
▪ Modify Risk Factors
▪ Control ____ (Diuretics, B-blockers, ACE I, etc.)
▪ Increase physical ________ (30-60 min 5/week)
▪ Improve _____ (DASH)
▪ Stop _________, limit ETOH
▪ Cholesterol lowering drugs (statins)
▪ Antiplatelet therapy (ASA, Plavix)
▪ ID High Risk Persons
▪ Modify Risk Factors
▪ Control BP (Diuretics, B-blockers, ACE I, etc.)
▪ Increase physical activity (30-60 min 5/week)
▪ Improve diet (DASH)
▪ Stop smoking, limit ETOH
▪ Cholesterol lowering drugs (statins)
▪ Antiplatelet therapy (ASA, Plavix)
▪ Ischemic coronary events occur when there is a mismatch between ____________________________
blood demand and blood supply
CAD vs ACS
CAD
▪ Angina Pectoris
▪ Stable
▪ Unstable
▪ Prinzmetal (Variant)
ACS
▪ Myocardial Infarction
▪ NSTEMI
▪ STEMI
CAD
▪ Angina Pectoris
▪ Stable
▪ Unstable
▪ Prinzmetal (Variant)
ACS
▪ Myocardial Infarction
▪ NSTEMI
▪ STEMI
ACS - Acute coronary syndrome
Chronic Stable Angina
▪ CAD is chronic and __________ disease
▪ Asymptomatic patients may develop chronic stable chest pain (angina)
▪ O2 demand greater than ________ results in myocardial __________
▪ Angina= clinical manifestation
▪ 1 or more arteries are blocked 70% or more by atherosclerotic plaque
▪ 50% or more for left main coronary artery
▪ CAD is chronic and progressive disease
▪ Asymptomatic patients may develop chronic stable chest pain (angina)
▪ O2 demand greater than O2 supply results in myocardial ischemia
▪ Angina= clinical manifestation
▪ 1 or more arteries are blocked 70% or more by atherosclerotic plaque
▪ 50% or more for left main coronary artery
Chronic Stable Angina cont.
▪ Intermittent chest pain occurs over a _____ period of time with similar pattern of onset, duration, and intensity of symptoms
▪ Onset: physical ________, stress, or emotional ______
▪ Accurate assessment important: _______
▪ May deny pain; have pressure, heaviness, or discomfort in chest; may be accompanied by dyspnea or fatigue; no change with position or breathing
▪ Intermittent chest pain occurs over a long period of time with similar pattern of onset, duration, and intensity of symptoms
▪ Onset: physical exertion, stress, or emotional upset
▪ Accurate assessment important: PQRST
▪ May deny pain; have pressure, heaviness, or discomfort in chest; may be accompanied by dyspnea or fatigue; no change with position or breathing
Common Locations and Patterns of
Angina or MI
Chronic Stable Angina cont.
▪ Duration of pain: _________
▪ Subsides when precipitating factor resolved
▪ Rest, calm down, sublingual __________ (SL NTG)
▪ Generally ________ and controlled with drugs
▪ Ischemic changes on 12-lead ECG—ST segment depression or T wave inversion
▪ ECG returns to normal when blood flow _________ and pain relieved
▪ Duration of pain: few minutes
▪ Subsides when precipitating factor resolved
▪ Rest, calm down, sublingual nitroglycerin (SL NTG)
▪ Generally predictable and controlled with drugs
▪ Ischemic changes on 12-lead ECG—ST segment depression or T wave inversion
▪ ECG returns to normal when blood flow restored and pain relieved
Chronic Stable Angina cont.
▪ Silent Ischemia
▪ Ischemia that occurs in absence of any subjective __________
▪ Associated with diabetic neuropathy
▪ Confirmed by ____ changes Same prognosis as ischemia with pain
▪ Silent Ischemia
▪ Ischemia that occurs in absence of any subjective symptoms
▪ Associated with diabetic neuropathy
▪ Confirmed by ECG changes Same prognosis as ischemia with pain
Chronic Stable Angina - Types of Angina
▪ Prinzmetal’s Angina (_______ angina, vasospastic angina)
▪ _____; occurs at rest; with without increased physical demand
▪ History of migraine headaches, Raynaud’s phenomenon, and heavy smoking
▪ Spasm of a major coronary artery with or without CAD
▪ Contributing factors: increased levels of certain substances, exposure to medications that narrow blood vessels, or exposure to _____ weather
▪ Treatment:
▪ Moderate exercise, ______________ blockers and/or nitrates, stop use of offending substances
▪ May ________ spontaneously
▪ Prinzmetal’s Angina (variant angina, vasospastic angina)
▪ Rare; occurs at rest; with without increased physical demand
▪ History of migraine headaches, Raynaud’s phenomenon, and heavy smoking
▪ Spasm of a major coronary artery with or without CAD
▪ Contributing factors: increased levels of certain substances, exposure to medications that narrow blood vessels, or exposure to cold weather
▪ Treatment:
▪ Moderate exercise, calcium channel blockers and/or nitrates, stop use of offending substances
▪ May disappear spontaneously
Chronic Stable Angina - Types of Angina
__________ angina
▪ Coronary microvascular disease or dysfunction (MVD)
▪ Chest pain occurs in the absence of significant CAD or coronary spasm of a major coronary artery
▪ Related to myocardial ischemia from atherosclerosis or spasm of distal coronary branches
▪ More common in women; physical exertion
▪ Prevention and treatment follows CAD recommendations
Microvascular
Nursing Care - Chronic Stable Angina
▪ Goal of treatment is to reduce O2 _______ and/or increase O2 ________
▪ Assessment and diagnostic studies
▪ Manage _________
▪ Goal of treatment is to reduce O2 demand and/or increase O2 supply
▪ Assessment and diagnostic studies
▪ Manage anxiety
Nursing Care - Chronic Stable Angina Goals:
▪ ______ relief
▪ Immediate and appropriate treatment
▪ Preservation of heart muscle if MI suspected
▪ Effective coping with illness-associated ________
▪ Participation in a rehabilitation plan
▪ Reduction of risk factors
▪ Pain relief
▪ Immediate and appropriate treatment
▪ Preservation of heart muscle if MI suspected
▪ Effective coping with illness-associated anxiety
▪ Participation in a rehabilitation plan
▪ Reduction of risk factors
Nursing Care - Chronic Stable Angina
▪ Acute care
Patient with angina
▪ Position _______; apply oxygen
▪ Assess: VS; heart and breath sounds
▪ Continuous _____ monitor; 12-lead ECG
▪ Pain relief—NTG; IV opioid if needed
▪ Obtain cardiac biomarkers
▪ Obtain chest ______
▪ Provide support; reduce _______
▪ Acute care
Patient with angina
▪ Position upright; apply oxygen
▪ Assess: VS; heart and breath sounds
▪ Continuous ECG monitor; 12-lead ECG
▪ Pain relief—NTG; IV opioid if needed
▪ Obtain cardiac biomarkers
▪ Obtain chest x-ray
▪ Provide support; reduce anxiety
Nursing Care - Chronic Stable Angina
Patient teaching
▪ CAD, angina
▪ How to identify and avoid _________ factors
▪ Reducing modifiable risk factors
▪ Diet
▪ Physical activity to maintain ideal body ______
▪ Medications
▪ Psychological support
▪ CAD, angina
▪ How to identify and avoid precipitating factors
▪ Reducing modifiable risk factors
▪ Diet
▪ Physical activity to maintain ideal body weight
▪ Medications
▪ Psychological support
Nursing Care - Chronic Stable Angina: Drug Therapy
▪ _______
▪ Short-acting _______
▪ Dilate peripheral and coronary arteries and collateral vessels
▪ Sublingual ___________ (SL NTG) or translingual spray
▪ Give 1 tablet or 1 to 2 metered sprays
▪ Relief in ___ minutes; duration 30 to 40 minutes
▪ If symptoms unchanged after 5 minutes, call EMS
▪ May cause: headache, dizziness, flushing, orthostatic hypotension
▪ Patient teaching: proper use and storage
▪ Prophylactic use
▪ Aspirin
▪ Short-acting nitrates
▪ Dilate peripheral and coronary arteries and collateral vessels
▪ Sublingual nitroglycerin (SL NTG) or translingual spray
▪ Give 1 tablet or 1 to 2 metered sprays
▪ Relief in 5 minutes; duration 30 to 40 minutes
▪ If symptoms unchanged after 5 minutes, call EMS
▪ May cause: headache, dizziness, flushing, orthostatic hypotension
▪ Patient teaching: proper use and storage
▪ Prophylactic use
Nursing Care - Chronic Stable Angina: Drug Therapy
▪ Long-acting _______
▪ Reduce frequency of angina, treat Prinzmetal’s angina
▪ Main side effect: ________
▪ Tolerance can develop- schedule 14-hour nitrate-free period every day
▪ Methods of administration
▪ Oral
▪ Nitroglycerin (NTG) ointment
▪ Transdermal controlled-release NTG
▪ Long-acting nitrates
▪ Reduce frequency of angina, treat Prinzmetal’s angina
▪ Main side effect: headache
▪ Tolerance can develop- schedule 14-hour nitrate-free period every day
▪ Methods of administration
▪ Oral
▪ Nitroglycerin (NTG) ointment
▪ Transdermal controlled-release NTG
Nursing Care - Chronic Stable Angina: Drug Therapy
▪ Angiotensin-converting enzyme (ACE) inhibitors and
angiotensin receptor blockers (ARBs)
▪ _________ and reduced blood volume
▪ Prevent or reverse ventricular remodeling
▪ β-Adrenergic blockers
▪ Decrease myocardial __________, HR, SVR, and BP
▪ Side effects: bradycardia, hypotension, wheezing, GI
effects; weight gain, depression, fatigue, sexual dysfx
▪ Contraindicated: severe bradycardia, acute
decompensated HF
▪ Cautious use: asthma, diabetes
▪ Angiotensin-converting enzyme (ACE) inhibitors and
angiotensin receptor blockers (ARBs)
▪ Vasodilation and reduced blood volume
▪ Prevent or reverse ventricular remodeling
▪ β-Adrenergic blockers
▪ Decrease myocardial contractility, HR, SVR, and BP
▪ Side effects: bradycardia, hypotension, wheezing, GI
effects; weight gain, depression, fatigue, sexual dysfx
▪ Contraindicated: severe bradycardia, acute
decompensated HF
▪ Cautious use: asthma, diabetes
Nursing Care - Chronic Stable Angina: Drug Therapy
▪ Calcium channel blockers (CCBs)
▪ Systemic ________ with reduced SVR, reduced myocardial contractility, coronary vasodilation, reduced HR
▪ Side effects: fatigue, headache, dizziness, flushing, hypotension, peripheral edema
▪ Enhance action of digoxin
▪ Lipid-lowering drugs
▪ Sodium Current Inhibitor
▪ Used when inadequate response to other antianginal drugs
▪ Side effects: dizziness, nausea, constipation, HA
▪ Calcium channel blockers (CCBs)
▪ Systemic vasodilation with reduced SVR, reduced myocardial contractility, coronary vasodilation, reduced HR
▪ Side effects: fatigue, headache, dizziness, flushing, hypotension, peripheral edema
▪ Enhance action of digoxin
▪ Lipid-lowering drugs
▪ Sodium Current Inhibitor
▪ Used when inadequate response to other antianginal drugs
▪ Side effects: dizziness, nausea, constipation, HA
Chronic Stable Angina - Diagnostic studies
▪ 12-lead ECG
▪ Lab studies: cardiac biomarkers, lipid profile, CRP
▪ Chest x-ray
▪ Echocardiogram
▪ Exercise stress test
▪ Electron beam computed tomography
▪ Coronary computed tomography anigography
▪ 12-lead ECG
▪ Lab studies: cardiac biomarkers, lipid profile, CRP
▪ Chest x-ray
▪ Echocardiogram
▪ Exercise stress test
▪ Electron beam computed tomography
▪ Coronary computed tomography anigography
Chronic Stable Angina
Cardiac ___________ —“gold standard” to identify and localize CAD
▪ Visualize blockages (diagnostic)
▪ Open blockages (interventional)
▪ Percutaneous coronary intervention (PCI)
▪ Balloon angioplasty
▪ Intracoronary stents (Figs. 37-6 and 37-7)
▪ Bare metal stent (BMS)
▪ Drug-eluting stent (DES)—prevent neointimal hyperplasia
catheterization
Chronic Stable Angina
▪ Stent placement procedure & post procedure drugs
▪ Used to prevent platelet _________ & stent
_________
▪ During PCI: unfractionated ________ or low-molecular weight heparin, a direct thrombin inhibitor and/or GP lIb/IIIa inhibitor
▪ After PCI: ______ antiplatelet therapy (DAPT)
▪ Aspirin and clopidogrel
▪ Stent placement procedure & post procedure drugs
▪ Used to prevent platelet aggregation & stent
thrombosis
▪ During PCI: unfractionated heparin or low-molecular weight heparin, a direct thrombin inhibitor and/or GP lIb/IIIa inhibitor
▪ After PCI: dual antiplatelet therapy (DAPT)
▪ Aspirin and clopidogrel
Chronic Stable Angina
Nursing management: Cardiac catheterization and
percutaneous coronary intervention (PCI) Assess:
▪ Allergy (contrast dye)
▪ Baseline assessment: VS, pulse ox, heart and breath sounds, neurovascular
▪ Laboratory studies
▪ Administer drugs
▪ Patient education: procedure and postprocedure
Nursing management: Cardiac catheterization and
percutaneous coronary intervention (PCI) Assess:
▪ Allergy (contrast dye)
▪ Baseline assessment: VS, pulse ox, heart and breath sounds, neurovascular
▪ Laboratory studies
▪ Administer drugs
▪ Patient education: procedure and postprocedure
Chronic Stable Angina
Nursing management: Cardiac catheterization and
percutaneous coronary intervention (PCI) See: Box
Postprocedure (RN):
▪ Compare assessments to preprocedure
▪ Assess catheter insertion site for ________, bleeding, bruit every 15 minutes for first hour, then agency policy
▪ ECG for dysrhythmia; chest pain or other pain
▪ IV infusion of antianginals
▪ Monitor for complications
▪ Education: discharge care and drugs; signs and symptoms to report to HCP
Nursing management: Cardiac catheterization and
percutaneous coronary intervention (PCI) See: Box
Postprocedure (RN):
▪ Compare assessments to preprocedure
▪ Assess catheter insertion site for hematoma, bleeding, bruit every15 minutes for first hour, then
agency policy
▪ ECG for dysrhythmia; chest pain or other pain
▪ IV infusion of antianginals
▪ Monitor for complications
▪ Education: discharge care and drugs; signs and symptoms to report to HCP
Coronary Surgical Revascularization: Chronic Stable Angina
▪ Coronary artery bypass ______ (CABG) Surgery
rec. for patients who:
▪ Do not respond well to medical management
▪ Have left main coronary artery or 3-vessel disease
▪ Are not candidates for PCI
▪ Continue to have chest pain after PCI.
▪ CABG may be an option for patients with diabetes, LV dysfunction, and/or CKD
graft
[last resort or if issues with LMCA]
RCA and LCA are
right and left coronary arteries
Coronary Surgical Revascularization: Chronic Stable Angina
Traditional CABG Surgery
▪ 1 or more arterial or venous grafts placed from
aorta/branch to heart muscle distal to _________
▪ Grafts: internal mammary (thoracic) artery (IMA or
ITA), saphenous vein, and/or radial artery
▪ Sternotomy and cardiopulmonary bypass (CPB)
blockage
Coronary Surgical Revascularization: Chronic Stable Angina
▪ _________ _________e direct coronary artery bypass (MIDCAB)
▪ Small incisions between ribs or mini-thoracotomy;
mechanical stabilization
▪ Off-pump coronary artery bypass (OPCAB)
▪ Median sternotomy; no CPB; fewer complications
Minimally invasiv
Coronary Surgical Revascularization: Chronic Stable Angina
▪ Totally endoscopic coronary artery bypass (TECAB)
▪ ________ CABG; limited bypass grafting
▪ Transmyocardial laser revascularization
▪ Left thoracotomy approach
▪ Laser creates channels to get blood flow to ischemic
areas
▪ Used for patients with advanced CAD who are not
candidates for CABG
Robotic
Atherosclerosis - the buildup of fats, cholesterol and other substances in and on the artery walls. This buildup is called _______ which can cause arteries to narrow, blocking blood flow. The plaque also can burst, leading to a blood clot.
plaque
Postoperative Care after CABG Surgery
▪ ICU for __________ for:
▪ Hemodynamic monitoring
▪ Arterial line for BP monitoring
▪ Pleural and mediastinal chest tubes
▪ Continuous ECG
▪ Endotracheal tube to ventilator
▪ Epicardial pacing wires
▪ Urinary catheter
▪ Nasogastric tube
24 to 48 hours
CABG Surgery: Postoperative Complications
▪ CPB
▪ Systemic inflammation
▪ Bleeding and anemia
▪ Fluid and electrolyte imbalances
▪ Infection
▪ Hypothermia
▪ Dysrhythmias, especially _________
▪ Wound care
▪ Chest wound
▪ Harvest site
▪ CPB
▪ Systemic inflammation
▪ Bleeding and anemia
▪ Fluid and electrolyte imbalances
▪ Infection
▪ Hypothermia
▪ Dysrhythmias, especially atrial fibrillation
▪ Wound care
▪ Chest wound
▪ Harvest site
CABG Surgery: Postoperative Complications
▪ ______ management
▪ Prevent VTE
▪ Early _________
▪ SCD
▪ Respiratory complications
▪ Splinting
▪ Incentive spirometry
▪ Postoperative cognitive dysfunction (POCD)
▪ Pain management
▪ Prevent VTE
▪ Early ambulation
▪ SCD
▪ Respiratory complications
▪ Splinting
▪ Incentive spirometry
▪ Postoperative cognitive dysfunction (POCD)
Acute Coronary Syndrome
▪ Prolonged _________; not immediately reversible;
includes:
▪ Non-ST elevation acute coronary syndrome
▪ Unstable angina and non-ST segment elevation myocardial infarction (NSTEMI)
▪ ST-segment-elevation myocardial infarction (STEMI)
ischemia
Acute Coronary Syndrome
▪ Presentation of chest pain
▪ ST _________ on 12-lead ECG are most likely STEMI
▪ Compare to previous ECG
▪ ST elevation = potentially ________ myocardial injury
▪ UA or NSTEMI—may or may not have ST segment
depression and/or T wave inversion
▪ If not, evaluate serum cardiac biomarkers
▪ Presentation of chest pain
▪ ST elevations on 12-lead ECG are most likely STEMI
▪ Compare to previous ECG
▪ ST elevation = potentially reversible myocardial injury
▪ UA or NSTEMI—may or may not have ST segment
depression and/or T wave inversion
▪ If not, evaluate serum cardiac biomarkers
Acute Coronary Syndrome
▪ Total coronary occlusion: cellular response to O2
and glucose deprivation
▪ Heart muscle hypoxic within _______
▪ Anaerobic metabolism, increased lactic acid
▪ Heart cells viable ___ minutes; damage irreversible if no collateral circulation
▪ If reperfused, aerobic metabolism and contractility restored and cellular repair begins
▪ Total coronary occlusion: cellular response to O2
and glucose deprivation
▪ Heart muscle hypoxic within 10 seconds
▪ Anaerobic metabolism, increased lactic acid
▪ Heart cells viable 20 minutes; damage irreversible if no collateral circulation
▪ If reperfused, aerobic metabolism and contractility restored and cellular repair begins
Acute Coronary Syndrome - Etiology & Pathophys.
▪ Deterioration of once stable plaque leads to
_______, platelet aggregation and thrombus
▪ Result
▪ Partial occlusion of coronary artery: UA or NSTEMI
▪ Total occlusion of coronary artery: STEMI
rupture
ACS: Unstable Angina (UA)
Chest pain:
▪ New onset; occurs at rest; or with increasing frequency, duration, or less effort than chronic stable angina pattern
▪ May be first clinical sign of CAD
▪ Pain lasting > ___ minutes
▪ __________; needs immediate treatment
▪ ECG may show ST depression and/or T wave inversion = ischemic changes
Chest pain:
▪ New onset; occurs at rest; or with increasing frequency, duration, or less effort than chronic stable angina pattern
▪ May be first clinical sign of CAD
▪ Pain lasting > 10 minutes
▪ Unpredictable; needs immediate treatment
▪ ECG may show ST depression and/or T wave inversion = ischemic changes
ACS: Myocardial Infarction (MI)
▪ ST-elevation and Non-ST-elevation MI
▪ Result of abrupt _________________ through a coronary artery with a thrombus caused by platelet aggregation, causing irreversible myocardial cell death (necrosis) Preexisting CAD
▪ STEMI—occlusive thrombus; ST elevation in leads facing infarction
▪ NSTEMI—non-occlusive thrombus
stoppage of blood flow
MI: STEMI and NSTEMI
▪ STEMI
▪ Emergency; artery must be opened within 90 minutes with either PCI or __________
▪ NSTEMI
▪ ____ within 12 to 72 hours
▪ STEMI or NSTEMI
▪ Echocardiogram—hypokinesis or akinesis of infarcted areas
▪ Degree of LV dysfunction depends on area of heart and size of infarction
▪ STEMI
▪ Emergency; artery must be opened within 90 minutes with either PCI or thrombolytic
▪ NSTEMI
▪ PCI within 12 to 72 hours
▪ STEMI or NSTEMI
▪ Echocardiogram—hypokinesis or akinesis of infarcted areas
▪ Degree of LV dysfunction depends on area of heart and size of infarction
SA node - cluster of cells [__________ of heart] - initiates HR
pacemaker
AV node - ensures ______ for adequeate CO & bloodflow
delay
MI: STEMI and NSTEMI
▪ Evolution of MI—hours to a few days
▪ Subendocardium—ischemic first
▪ Entire thickness of heart muscle necrotic in 4-6 hours; Partial occlusion by thrombus—up to 12 hours
▪ MI described by location—anterior, inferior, lateral,
septal or posterior wall
▪ Location of MI and ECG changes correlate with involved coronary artery (Table 37-13)
▪ Severity of MI influenced by collateral circulation
▪ Women often undertreated; worse outcomes
▪ Evolution of MI—hours to a few days
▪ Subendocardium—ischemic first
▪ Entire thickness of heart muscle necrotic in 4-6 hours; Partial occlusion by thrombus—up to 12 hours
▪ MI described by location—anterior, inferior, lateral,
septal or posterior wall
▪ Location of MI and ECG changes correlate with involved coronary artery (Table 37-13)
▪ Severity of MI influenced by collateral circulation
▪ Women often undertreated; worse outcomes
Clinical Manifestations of MI
Pain
▪ Severe chest pain not _________ by rest, position change, or nitrate administration
▪ Heaviness, pressure, tightness, burning, constriction, or crushing
▪ Common locations: substernal or ________
▪ May radiate to neck, lower jaw, arms, back
▪ Often occurs in early morning; greater than ___ min.
▪ _________ in women and older adult
▪ No pain if cardiac neuropathy (diabetes)
Pain
▪ Severe chest pain not relieved by rest, position change, or nitrate administration
▪ Heaviness, pressure, tightness, burning, constriction, or crushing
▪ Common locations: substernal or epigastric
▪ May radiate to neck, lower jaw, arms, back
▪ Often occurs in early morning; greater than 20 min.
▪ Atypical in women and older adult
▪ No pain if cardiac neuropathy (diabetes)
Clinical Manifestations of MI
Sympathetic nervous system stimulation
▪ Release of catecholamines
▪ _________
▪ _______ HR and BP
▪ _____________ of peripheral blood vessels
▪ Skin: ashen, clammy, and/or cool to touch
Sympathetic nervous system stimulation
▪ Release of catecholamines
▪ Diaphoresis
▪ Increased HR and BP
▪ Vasoconstriction of peripheral blood vessels
▪ Skin: ashen, clammy, and/or cool to touch
Clinical Manifestations of MI
Cardiovascular
▪ Initially, increased HR and BP, then reduced BP (secondary to decrease in CO)
▪ Decreased renal perfusion leads to decreased ______ output
▪ ________ (LV dysfunction)
▪ Jugular venous distention, hepatic engorgement, peripheral edema (RV dysfunction)
▪ Abnormal heart sounds
▪ S3 or S4
▪ New _______: holosystolic
Cardiovascular
▪ Initially, increased HR and BP, then reduced BP (secondary to decrease in CO)
▪ Decreased renal perfusion leads to decreased urine output
▪ Crackles (LV dysfunction)
▪ Jugular venous distention, hepatic engorgement, peripheral edema (RV dysfunction)
▪ Abnormal heart sounds
▪ S3 or S4
▪ New murmur: holosystolic
Clinical Manifestations of MI
▪ Nausea and vomiting
▪ Reflex stimulation of the vomiting center by ______________
▪ Vasovagal reflex
▪ Fever
▪ Up to 100.4° F (38° C) in first 24 to 48 hours; up to 4 to 5 days
▪ Systemic inflammatory process caused by heart cell death
severe pain
CO =
cardiac output
CO = ________ [formula]
SV x HR
MI Healing Process
▪ Inflammatory process: within _______, leukocytes infiltrate the area of cell death; enzymes released
▪ Proteolytic enzymes of neutrophils and macrophages begin to remove necrotic tissue by fourth day resulting in thin wall
▪ Catecholamine-mediated lipolysis and glycogenolysis resulting in increased glucose
▪ Necrotic zone identifiable by ECG changes
▪ Collagen matrix laid down—scar tissue
▪ Inflammatory process: within 24 hours, leukocytes infiltrate the area of cell death; enzymes released
▪ Proteolytic enzymes of neutrophils and macrophages begin to remove necrotic tissue by fourth day resulting in thin wall
▪ Catecholamine-mediated lipolysis and glycogenolysis resulting in increased glucose
▪ Necrotic zone identifiable by ECG changes
▪ Collagen matrix laid down—scar tissue
CO is the amount of _________________
blood pumped per minute
MI Healing Process
▪ 10 to 14 days after MI, scar tissue is still _____
▪ Heart muscle vulnerable to stress
▪ Monitor patient carefully as activity level increases
▪ By 6 weeks after MI, _____ tissue has replaced necrotic tissue
▪ Area is said to be healed, but less compliant
▪ Ventricular remodeling
▪ Normal myocardium will hypertrophy and dilate in an attempt to compensate for infarcted muscle
▪ 10 to 14 days after MI, scar tissue is still weak
▪ Heart muscle vulnerable to stress
▪ Monitor patient carefully as activity level increases
▪ By 6 weeks after MI, scar tissue has replaced necrotic tissue
▪ Area is said to be healed, but less compliant
▪ Ventricular remodeling
▪ Normal myocardium will hypertrophy and dilate in an attempt to compensate for infarcted muscle
Complications of MI
▪ ___________
▪ Most common complication
▪ Present in 80% to 90% of MI patients
▪ Can be caused by ischemia, electrolyte imbalances, or SNS stimulation
▪ VT and VF are most common cause of death in
prehospitalization period
▪ Dysrhythmias
▪ Most common complication
▪ Present in 80% to 90% of MI patients
▪ Can be caused by ischemia, electrolyte imbalances, or SNS stimulation
▪ VT and VF are most common cause of death in
prehospitalization period
Complications of MI
▪ Heart failure—decreased pumping power
▪ Left-sided HF
▪ Mild ________, restlessness, agitation, or slight
tachycardia; pulmonary congestion on x-ray, S3
sounds, crackles, paroxysmal nocturnal dyspnea, and orthopnea
▪ Right-sided HF
▪ Jugular venous ________, ________ congestion, lower
extremity _______
▪ Left-sided HF
▪ Mild dyspnea, restlessness, agitation, or slight
tachycardia; pulmonary congestion on x-ray, S3
sounds, crackles, paroxysmal nocturnal dyspnea, and orthopnea
▪ Right-sided HF
▪ Jugular venous distention, hepatic congestion, lower
extremity edema
Complications of MI
▪ _________ shock—decreased O2 and nutrients related to:
▪ Severe LV failure, papillary muscle rupture, ventricular septal rupture, LV free wall rupture, right ventricular infarction
▪ Requires aggressive management to:
▪ Increased _____ delivery, decreased O2 demand, and prevent complications
▪ Associated with a high _______ rate
▪ Cardiogenic shock—decreased O2 and nutrients related to:
▪ Severe LV failure, papillary muscle rupture, ventricular septal rupture, LV free wall rupture, right ventricular infarction
▪ Requires aggressive management to:
▪ Increased O2 delivery, decreased O2 demand, and prevent complications
▪ Associated with a high death rate
Complications of MI
▪ _________ muscle dysfunction or rupture
▪ Causes acute and massive mitral valve regurgitation; new systolic murmur
▪ Aggravates an already compromised LV results in decreased CO resulting in rapid clinical deterioration
▪ Left Ventricular ___________
▪ Myocardial wall is thin; bulges out during contraction; may rupture and hide thrombi
▪ Leads to HF, dysrhythmias, and angina
▪ Papillary muscle dysfunction or rupture
▪ Causes acute and massive mitral valve regurgitation; new systolic murmur
▪ Aggravates an already compromised LV results in decreased CO resulting in rapid clinical deterioration
▪ Left Ventricular Aneurysm
▪ Myocardial wall is thin; bulges out during contraction; may rupture and hide thrombi
▪ Leads to HF, dysrhythmias, and angina
Complications of MI
▪ Ventricular septal wall ________ and left ventricular free wall ________
–New, loud systolic ________
– HF and cardiogenic shock
– Emergency repair
– Rare condition associated with high death rate
▪ Ventricular septal wall rupture and left ventricular free wall rupture
▪ New, loud systolic murmur
▪ HF and cardiogenic shock
▪ Emergency repair
▪ Rare condition associated with high death rate
Complications of MI
▪ Pericarditis
▪ Inflammation of visceral &/or parietal __________
▪ Mild to severe chest pain
▪ Increases with inspiration, coughing, movement of upper body
▪ Relieved by sitting in ________ position
▪ Pericardial friction rub, fever, decreased BP, ECG changes
▪ Treat with high dose ________
▪ Pericarditis
▪ Inflammation of visceral &/or parietal pericardium
▪ Mild to severe chest pain
▪ Increases with inspiration, coughing, movement of upper body
▪ Relieved by sitting in forward position
▪ Pericardial friction rub, fever, decreased BP, ECG changes
▪ Treat with high dose aspirin
Complications of MI
▪ _______ syndrome
▪ Pericarditis and fever that develops 1 to 8 weeks after MI; possibly autoimmune
▪ Chest pain, fever, malaise, pericardial friction rub,
arthralgia, increased WBC and sedimentation rate
▪ High dose aspirin is treatment of choice
Dressler
Acute Coronary Syndrome Diagnostic Studies
▪ Detailed health _________
▪ 12-lead ____
▪ Compare new ECG to previous ECG
▪ Changes in QRS complex, ST segment, and T wave
▪ Distinguish between STEMI and NSTEMI/UA
▪ Serial ECGs reflect evolution of MI
▪ Detailed health history
▪ 12-lead ECG
▪ Compare new ECG to previous ECG
▪ Changes in QRS complex, ST segment, and T wave
▪ Distinguish between STEMI and NSTEMI/UA
▪ Serial ECGs reflect evolution of MI
Acute Coronary Syndrome Diagnostic Studies
Serum cardiac biomarkers
▪ _______ released after ___ (Table 31-6)
▪ Cardiac-specific troponin T (cTNT)
▪ Cardiac-specific troponin I (cTNI)
— Increased _____ hours after onset of MI
— Peak at ______ hours
— Return to baseline over _____ days
▪ Biomarkers negative for UA; positive for NSTEMI
▪ Cardiac-specific troponins are better indicators of MI than CK-MB or myoglobin
Acute Coronary Syndrome Diagnostic Studies
Serum cardiac biomarkers
▪ Proteins released after MI (Table 31-6)
▪ Cardiac-specific troponin T (cTNT)
▪ Cardiac-specific troponin I (cTNI)
— Increased 4 to 6 hours after onset of MI
— Peak at 10 to 24 hours
— Return to baseline over 10 to 14 days
▪ Biomarkers negative for UA; positive for NSTEMI
▪ Cardiac-specific troponins are better indicators of MI than CK-MB or myoglobin
what is NSTEMi/ STEMI?
ST elevation MI
Chest pain assessment
Severity
when did it start
radiation?
Severity
when did it start
radiation?
Unstable Angina and MI Diagnostic Studies
Cardiac catheterization
▪ Within 90 minutes for patients with a STEMI or receive __________ therapy within 30 minutes (if no PCI available)
▪ Within 12 to 72 hours for patients with UA or NSTEMI
▪ May have PCI, medical therapy, or referral for CABG depending on findings
Cardiac catheterization
▪ Within 90 minutes for patients with a STEMI or receive thrombolytic therapy within 30 minutes (if no PCI available)
▪ Within 12 to 72 hours for patients with UA or NSTEMI
▪ May have PCI, medical therapy, or referral for CABG depending on findings
Acute Coronary Syndrome - Emergency care
▪ 12-lead _____
▪ _________ position
▪ Oxygen—keep O2 sat > __%
▪ IV access
▪ Nitroglycerin (SL) and +___ (chewable)
▪ Morphine
▪ Statin
▪ 12-lead ECG
▪ Upright position
▪ Oxygen—keep O2 sat > 93%
▪ IV access
▪ Nitroglycerin (SL) and ASA (chewable)
▪ Morphine
▪ Statin
Acute Coronary Syndrome
▪ ECG shows ST elevation leading to cardiac _______ for PCI or thrombolytic therapy
▪ ECG shows ST depression or T-wave inversion leading to ______ care or telemetry unit
▪ Dysrhythmias—treat as per agency
▪ Monitor serum biomarkers
▪ ECG shows ST elevation leading to cardiac cath lab for PCI or thrombolytic therapy
▪ ECG shows ST depression or T-wave inversion leading to critical care or telemetry unit
▪ Dysrhythmias—treat as per agency
▪ Monitor serum biomarkers
M.P.’s ECG shows significant ST elevation.
▪ What evidence-based intervention would you expect to prepare M.P. to undergo within 90 minutes of arrival to the ED?
PCI
Nursing Care Acute Coronary Syndrome
▪ UA and NSTEMI
▪ ______
▪ Glycoprotein IIb/IIIa inhibitors before or during PCI
▪ STEMI
▪ Glycoprotein IIb/IIIa inhibitors during PCI
▪ UA and NSTEMI
▪ Heparin
▪ Glycoprotein IIb/IIIa inhibitors before or during PCI
▪ STEMI
▪ Glycoprotein IIb/IIIa inhibitors during PCI
ACS acute care
Admit to ICU/_______ unit
▪ Monitor VS and pulse oximetry
▪ Continuous ____
▪ Serial 12-lead ECGs
▪ Serial cardiac biomarkers
▪ Bed rest/ limit activity for _________ ; increase gradually
Admit to ICU/telemetry unit
▪ Monitor VS and pulse oximetry
▪ Continuous ECG
▪ Serial 12-lead ECGs
▪ Serial cardiac biomarkers
▪ Bed rest/ limit activity for 12 to 24 hours; increase gradually
ACS acute care cont.
▪ ______ —UA and NSTEMI
▪ DAPT—NSTEMI and UA with stent
▪ Aspirin—UA
▪ Cardiac ____________ —UA and NSTEMI
▪ Medical management, PCI, or CABG
▪ __________ therapy—STEMI
▪ Emergent PCI
▪ _________ therapy
▪ Heparin—UA and NSTEMI
▪ DAPT—NSTEMI and UA with stent
▪ Aspirin—UA
▪ Cardiac Catheterization—UA and NSTEMI
▪ Medical management, PCI, or CABG
▪ Reperfusion therapy—STEMI
▪ Emergent PCI
▪ Thrombolytic therapy
Acute Care: Emergent PCI
▪ Emergent PCI is first treatment with confirmed _______
▪ Goal: open ____________ within 90 minutes of arrival to facility with cardiac catheterization lab; BSM or DES
▪ If severe LV dysfunction—IABP and/or inotropes
▪ Emergent CABG
▪ Emergent PCI is first treatment with confirmed STEMI
▪ Goal: open blocked artery within 90 minutes of arrival to facility with cardiac catheterization lab; BSM or DES
▪ If severe LV dysfunction—IABP and/or inotropes
▪ Emergent CABG
Acute Care: Emergent PCI cont.
▪ Advantages of PCI versus CABG
▪ Faster _________
▪ Local anesthesia
▪ Ambulatory sooner
▪ ______ of stay shorter (reduced costs)
▪ Faster return to work
▪ Complications of PCI
▪ Dissection or ______ of artery
▪ Abrupt artery closure
▪ Acute stent thrombosis
▪ Failure to cross blockage
▪ Extended infarct
▪ Advantages of PCI versus CABG
▪ Faster reperfusion
▪ Local anesthesia
▪ Ambulatory sooner
▪ Length of stay shorter (reduced costs)
▪ Faster return to work
▪ Complications of PCI
▪ Dissection or rupture of artery
▪ Abrupt artery closure
▪ Acute stent thrombosis
▪ Failure to cross blockage
▪ Extended infarct
Acute Care: Thrombolytic Therapy
▪ Indicated for _______
▪ Advantages: availability and rapid administration (if
not PCI-capable)
▪ May transfer if PCI can be done within 120 minutes
▪ Goals:
▪ Limit size of infarction
▪ Administer IV within 30 minutes of arrival
STEMI
Acute Care: Thrombolytic Therapy
▪ Thrombolytic—IV administration of selected medication to open blocked arteries by ____ of thrombus/clot; concern for bleeding with other sites
▪ Inclusion criteria:
▪ Chest pain less than ______ and 12 lead shows STEMI
▪ No absolute contraindications
Acute Care: Thrombolytic Therapy
▪ Thrombolytic—IV administration of selected medication to open blocked arteries by lysis ofthrombus/clot; concern for bleeding with other sites
▪ Inclusion criteria:
▪ Chest pain less than 12 hours and 12 lead shows STEMI
▪ No absolute contraindications
Acute Care: Thrombolytic Therapy
Procedure
▪ Prior to administration:
▪ Obtain baseline ____
▪ ____ lines for IV therapy
▪ Complete any invasive procedures
▪ Administer IV bolus or infusion
▪ Monitor heart rhythm, VS, and pulse ox
▪ Assess heart, lungs, and neuro status
Procedure
▪ Prior to administration:
▪ Obtain baseline labs
▪ 2 to 3 lines for IV therapy
▪ Complete any invasive procedures
▪ Administer IV bolus or infusion
▪ Monitor heart rhythm, VS, and pulse ox
▪ Assess heart, lungs, and neuro status
Acute Care: Thrombolytic Therapy cont.
▪ Reperfusion occurs
▪ ST segment returns to _______
▪ No chest pain
▪ Early, rapid rise of serum biomarkers; peak within 12 hours
▪ Reperfusion dysrhythmias—less reliable
▪ Major concern—reocclusion
▪ IV heparin
▪ Monitor for chest pain and ECG changes
▪ Major complication—__________
▪ Reperfusion occurs
▪ ST segment returns to baseline
▪ No chest pain
▪ Early, rapid rise of serum biomarkers; peak within 12 hours
▪ Reperfusion dysrhythmias—less reliable
▪ Major concern—reocclusion
▪ IV heparin
▪ Monitor for chest pain and ECG changes
▪ Major complication—bleeding
Drug Therapy - Acute Coronary Syndrome
Suspected ACS
▪ Antiplatelet therapy, IV NTG, atorvastatin
NSTEMI or UA
▪ Anticoagulation and glycoprotein IIb or IIIa
MI
▪ DAPT, Aspirin, B-blockers, calcium channel blockers, ACE inhibitors, and/or nitrates
Suspected ACS
▪ Antiplatelet therapy, IV NTG, atorvastatin
NSTEMI or UA
▪ Anticoagulation and glycoprotein IIb or IIIa
MI
▪ DAPT, Aspirin, B-blockers, calcium channel blockers, ACE inhibitors, and/or nitrates
Drug Therapy cont. - Acute Coronary Syndrome
▪ IV __________ (NTG)
▪ __________
▪ β-Adrenergic blockers
▪ ACE inhibitors and ARBs
▪ Antidysrhythmic drugs
▪ Lipid-lowering drugs
▪ Aldosterone antagonists
▪ Stool softeners
▪ IV nitroglycerin (NTG)
▪ Morphine
▪ β-Adrenergic blockers
▪ ACE inhibitors and ARBs
▪ Antidysrhythmic drugs
▪ Lipid-lowering drugs
▪ Aldosterone antagonists
▪ Stool softeners
Nutritional Therapy - Acute Coronary Syndrome
▪ Initially NPO
▪ Progress to low _____, low saturated- ____ and low ____________
Progress to low salt, low saturated- fat and low cholesterol
Nursing Assessment - __________ data ACS
▪ Health history
▪ CAD/chest pain/angina/ MI
▪ Valve disease
▪ Heart failure/cardiomyopathy,
▪ Hypertension, diabetes, anemia, lung disease, hyperlipidemia
▪ Medications
▪ History of present illness
Subjective
Nursing Assessment cont. ACS
________ data: Functional health patterns
▪ Health-perception–health management family history
▪ Nutritional–metabolic- Indigestion/heartburn; nausea/vomiting
▪ Elimination- Urinary urgency or frequency; Straining at stool
▪ Activity–exercise- Palpitations, dyspnea, dizziness, weakness
▪ Cognitive–perceptual- Chest pain
▪ Coping–stress tolerance- Stress, depression, anger, anxiety
Subjective data: Functional health patterns
▪ Health-perception–health management family history
▪ Nutritional–metabolic- Indigestion/heartburn; nausea/vomiting
▪ Elimination- Urinary urgency or frequency; Straining at stool
▪ Activity–exercise- Palpitations, dyspnea, dizziness, weakness
▪ Cognitive–perceptual- Chest pain
▪ Coping–stress tolerance- Stress, depression, anger, anxiety
Nursing Assessment cont. ACS - _________ data
▪ General - Anxious, fearful, restless, distressed
▪ Integumentary - Cool, clammy, pale skin
▪ Cardiovascular - Tachycardia or bradycardia, pulse deficit, pulsus alternans, dysrhythmias, S3, S4, increased or decreased BP, murmur
Objective
Clinical Problems ACS
▪ Impaired ______ function
▪ Pain
▪ Anxiety
▪ Activity _________
▪ Impaired cardiac function
▪ Pain
▪ Anxiety
▪ Activity intolerance
Nursing Management: ACS
▪ Pain
▪ ____, morphine, O2
▪ Monitoring
▪ ECG: v-fib, PVCs, VT, ST segment
▪ Physical assessment, VS, I & O, O2
▪ _____ and comfort
▪ Bed rest, gradual increase in activity; promote relaxation; rehabilitation
▪ Pain
▪ NTG, morphine, O2
▪ Monitoring
▪ ECG: v-fib, PVCs, VT, ST segment
▪ Physical assessment, VS, I & O, O2
▪ Rest and comfort
▪ Bed rest, gradual increase in activity; promote relaxation; rehabilitation
Nursing Management: ACS
▪ ________
▪ Explore fears and concerns; provide education
▪ Emotional and behavioral reactions
▪ Psychosocial responses Support systems
▪ Patient _________
▪ Assess literacy and learning needs; consider timing
▪ Anxiety
▪ Explore fears and concerns; provide education
▪ Emotional and behavioral reactions
▪ Psychosocial responses Support systems
▪ Patient teaching
▪ Assess literacy and learning needs; consider timing
Nursing Management: ACS
▪ Physical activity
▪ Regular schedule for optimal physio functioning and psychological well-being
▪ Metabolic equivalent (MET) units
▪ Increase ________ gradually; check HR; FITT formula
▪ Limit isometric exercise; Valsalva maneuver
▪ Women; less adherence due to caregiver role; also consider fatigue and depression
activity
Nursing Management: ACS
▪ Cardiac __________ to restore optimal function:
▪ Physiological
▪ Psychological
▪ Mental
▪ Spiritual
▪ Economic
▪ Vocational
▪ Outpatient or home-based
▪ Cardiac rehabilitation to restore optimal function:
▪ Physiological
▪ Psychological
▪ Mental
▪ Spiritual
▪ Economic
▪ Vocational
▪ Outpatient or home-based
Angina standard treatment =
Nitro sublingual q 5 mins [MAX = 3 doses]
Nursing Management: ACS
Resumption of sexual activity
▪ Sexual counseling important
▪ Include when discuss other physical activity
▪ Erectile dysfunction drugs contraindicated with ________
▪ Prophylactic ________ before sexual activity
▪ When to avoid sex
▪ Typically _______ days post MI or when patient can climb two flights of stairs or walk briskly
Resumption of sexual activity
▪ Sexual counseling important
▪ Include when discuss other physical activity
▪ Erectile dysfunction drugs contraindicated with nitrates
▪ Prophylactic nitrates before sexual activity
▪ When to avoid sex
▪ Typically 7 to 10 days post MI or when patient can climb two flights of stairs or walk briskly
Expected outcomes:
▪ Maintain stable signs of adequate ___
▪ Have relief of _____ and/or shortness of breath
▪ reduced _______ and increased sense of self-control
▪ Achieve realistic program of activity
▪ Describe the disease process, measures to reduce risk factors, and rehabilitation activities necessary to manage the therapeutic regimen
▪ Maintain stable signs of adequate CO
▪ Have relief of pain and/or shortness of breath
▪ reduced anxiety and increased sense of self-control
▪ Achieve realistic program of activity
▪ Describe the disease process, measures to reduce risk factors, and rehabilitation activities necessary to manage the therapeutic regimen
Sudden Cardiac Death (SCD) Etiology and Pathophys.
▪ Abrupt, unexpected death from cardiac causes; occurs within ____ of symptom onset; ~350,000 annually (reduced due to ICDs)
▪ Acute ventricular _________ (e.g., VT, VF) causes disruption in cardiac function, resulting in loss of CO and cerebral blood flow
▪ Most commonly caused by:
▪ CAD
▪ Structural heart disease
▪ Conduction disturbances
▪ Abrupt, unexpected death from cardiac causes; occurs within 1 hour of symptom onset; ~350,000 annually (reduced due to ICDs)
▪ Acute ventricular dysrhythmia (e.g., VT, VF) causes disruption in cardiac function, resulting in loss of CO and cerebral blood flow
▪ Most commonly caused by:
▪ CAD
▪ Structural heart disease
▪ Conduction disturbances
Sudden Cardiac Death (SCD) Clinical Manifestations and Complications
▪ Symptoms within one hour: angina, palpitations, dizziness, or lightheadedness
▪ SCD occurs with:
▪ Prior (old) MI—most common
▪ Acute MI
▪ If survive, increased risk of another event due to electrical instability from scarred muscle; referred for ICD after 40 days medical therapy
▪ Symptoms within one hour: angina, palpitations, dizziness, or lightheadedness
▪ SCD occurs with:
▪ Prior (old) MI—most common
▪ Acute MI
▪ If survive, increased risk of another event due to electrical instability from scarred muscle; referred for ICD after 40 days medical therapy
Sudden Cardiac Death
▪ Diagnostic workup: rule out or confirm ___
▪ Serial cardiac biomarkers
▪ Serial ECGs
▪ Cardiac catheterization
▪ PCI or CABG, if indicated
▪ Electrophysiology Study (EPS)
▪ Outpatient monitor; Mobile Cardiac Outpatient
Telemetry (MCOT); implanted monitor
▪ Diagnostic workup: rule out or confirm MI
▪ Serial cardiac biomarkers
▪ Serial ECGs
▪ Cardiac catheterization
▪ PCI or CABG, if indicated
▪ Electrophysiology Study (EPS)
▪ Outpatient monitor; Mobile Cardiac Outpatient
Telemetry (MCOT); implanted monitor
Sudden Cardiac Death
Prevent recurrence:
▪ Implantable cardioverter-________ (ICD)
▪ Amiodarone
▪ Wearable cardioverter-defibrillator (LifeVest—bridge to ICD or heart transplant
▪ Education:
▪ CPR and defibrillation with AED; ACLS
defibrillator
Sudden Cardiac Death
Psychosocial adaptation
▪“Brush with death”
▪“Time bomb” mentality
▪ Anxiety, anger, depression
▪ Additional issues
▪ Driving restrictions
▪ Role reversal
▪ Change in occupation
▪ Provide __________ support
Psychosocial adaptation
▪“Brush with death”
▪“Time bomb” mentality
▪ Anxiety, anger, depression
▪ Additional issues
▪ Driving restrictions
▪ Role reversal
▪ Change in occupation
▪ Provide emotional support
Infective Endocarditis (IE)
Disease of the __________, innermost layer of the heart, and the heart valves
IE is associated with a ____ prognosis and a decreased life expectancy
Increase in the number of cases of IE largely related to an increase in _________
Disease of the endocardium, innermost layer of the heart, and the heart valves
IE is associated with a poor prognosis and a decreased life expectancy
Increase in the number of cases of IE largely related to an increase in IV drug use
Important cardiac markers are
troponin
CK-MB
Myoglobin
Symptoms of left vs right HF
left side- more pulmonary/respiration
right side- more circulatory/cardiac- edema/vein distention
Infective Endocarditis (IE) Classification
By ______
-IV drug use (IVDA IE), fungal IE
By _____ of involvement
-Prosthetic valve endocarditis (PVE)
Subacute form affects those with preexisting valve disease
Acute form affects those with _______ valves
By cause
-IV drug use (IVDA IE), fungal IE
By site of involvement
-Prosthetic valve endocarditis (PVE)
Subacute form affects those with preexisting valve disease
Acute form affects those with healthy valves
Infective Endocarditis (IE) Causative Organisms
_________ most common
- Staphylococcus aureus (about 50%)
-Streptococcus viridans
- Coagulase Negative Staphylococci
Colonizers of the oropharynx
- HACEK organisms (Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella)
Bacterial most common
- Staphylococcus aureus (about 50%)
-Streptococcus viridans
- Coagulase Negative Staphylococci
Colonizers of the oropharynx
- HACEK organisms (Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella)
Risk factors of infective endocarditis
-History of IE
-IV _________
-Prosthetic valve
-Health care–associated infection from use of an intravascular device
- Methicillin-resistant S. aureus (MRSA)
-Renal dialysis
-History of IE
-IV drug use
-Prosthetic valve
-Health care–associated infection from use of an intravascular device
- Methicillin-resistant S. aureus (MRSA)
-Renal dialysis
IE Occurs in 3 stages
Bacteremia
Adhesion
Vegetation
Bacteremia
Adhesion
Vegetation
IE - Vegetation
Fibrin, leukocytes, platelets, and microbes
Stick to the valve or endocardium
Parts break off and enter circulation (embolization)
Left-sided vegetation can move to brain, kidneys, spleen, and extremities
Right-sided vegetation can move to lungs (PE)
Fibrin, leukocytes, platelets, and microbes
Stick to the valve or endocardium
Parts break off and enter circulation (embolization)
Left-sided vegetation can move to brain, kidneys, spleen, and extremities
Right-sided vegetation can move to lungs (PE)
IE S&S - Nonspecific, involve multiple organ systems
Fever
Chills
Weakness
Malaise
Fatigue
Anorexia
Fever
Chills
Weakness
Malaise
Fatigue
Anorexia
IE S&S Subacute form
Arthralgias
Myalgias
Back pain
Abdominal discomfort
Weight loss
Headache
Clubbing of fingers
Arthralgias
Myalgias
Back pain
Abdominal discomfort
Weight loss
Headache
Clubbing of fingers
IE S&S Vascular manifestations
Splinter hemorrhages in nail beds
Petechiae
Osler’s nodes on fingertips or toes
Janeway’s lesions on fingertips, palms, soles of feet, and toes
Roth’s spots
Splinter hemorrhages in nail beds
Petechiae
Osler’s nodes on fingertips or toes
Janeway’s lesions on fingertips, palms, soles of feet, and toes
Roth’s spots
IE S&S cont.
New or worsening systolic ________ in most pts
Heart _________
Manifestations secondary to septic embolism
-Central nervous system
-Extremities
-Spleen
-Kidneys
New or worsening systolic murmur in most pts
Heart failure
Manifestations secondary to septic embolism
-Central nervous system
-Extremities
-Spleen
-Kidneys
IE diagnostics
Health history
Laboratory tests
Blood cultures
CBC with differential
ESR, C-reactive protein (CRP)
Echocardiography
Duke criteria
Health history
Laboratory tests
Blood cultures
CBC with differential
ESR, C-reactive protein (CRP)
Echocardiography
Duke criteria
IE care -
Prophylactic __________ treatment for select patients having
Certain ________ procedures
Respiratory tract incisions
Tonsillectomy and adenoidectomy
Surgical procedures involving infected skin, skin structures, or musculoskeletal tissue
Prophylactic antibiotic treatment for select patients having
Certain dental procedures
Respiratory tract incisions
Tonsillectomy and adenoidectomy
Surgical procedures involving infected skin, skin structures, or musculoskeletal tissue
IE care
Accurate identification of _________
Blood cultures
IV __________ (long-term)
Repeat blood cultures
Valve replacement if needed
Antipyretics
Fluids
Rest
Accurate identification of organism
Blood cultures
IV antibiotics (long-term)
Repeat blood cultures
Valve replacement if needed
Antipyretics
Fluids
Rest
IE assessment
________ data
Health history
Valvular, congenital, or syphilitic heart disease
Previous endocarditis
Staph or strep infection
Drugs—Immunosuppressive therapy
Recent surgeries and procedures
Subjective data: Functional health patterns
IVDA
Alcohol use
Weight changes
Chills
Hematuria
Exercise intolerance, weakness, fatigue
Cough, DOE, orthopnea, palpitations
Night sweats
Pain, headache, joint, or muscle tenderness
Subjective data
Health history
Valvular, congenital, or syphilitic heart disease
Previous endocarditis
Staph or strep infection
Drugs—Immunosuppressive therapy
Recent surgeries and procedures
Subjective data: Functional health patterns
IVDA
Alcohol use
Weight changes
Chills
Hematuria
Exercise intolerance, weakness, fatigue
Cough, DOE, orthopnea, palpitations
Night sweats
Pain, headache, joint, or muscle tenderness
IE ________ data
Arthralgia and myalgias
Petechiae
Splinter hemorrhages
Osler’s nodes
Janeway’s lesions
objective
IE clinical problems
Impaired __________
Infection
Fatigue
Substance use
cardiac output
IE planning - Overall goals include
Normal or baseline function
Ability to perform ADLs without ________
Understanding of the treatment plan to prevent recurrence
fatigue
IE Health promotion
Patient teaching
need to avoid people with _________
Avoidance of stress and fatigue
Plan rest periods
Good _____ hygiene
Schedule regular ______ visits
Prophylactic __________
Drug rehabilitation
Patient teaching
need to avoid people with infections
Avoidance of stress and fatigue
Plan rest periods
Good oral hygiene
Schedule regular dental visits
Prophylactic antibiotics
Drug rehabilitation
IE Ambulatory care
Antibiotic therapy for ______
Assess home setting
Monitor laboratory data, including blood cultures
Assess IV lines
Coping strategies
Adequate rest
Moderate activity
Compression stockings
ROM exercises
Deep breath and cough every 2 hours
IE Ambulatory care
Antibiotic therapy for 4 to 6 weeks
Assess home setting
Monitor laboratory data, including blood cultures
Assess IV lines
Coping strategies
Adequate rest
Moderate activity
Compression stockings
ROM exercises
Deep breath and cough every 2 hours
IE patient teaching
Monitor body _____________
Signs and symptoms of complications
Nature of disease and how to reduce risk of reinfection
Stress follow-up care, good nutrition, prompt treatment of common infections
Signs and symptoms of infection
Need for prophylactic antibiotic therapy
temperature
IE - Expected outcomes are that the patient will
Maintain adequate tissue and organ ________
Maintain normal body ________
Report an increase in physical and emotional ________
Maintain adequate tissue and organ perfusion
Maintain normal body temperature
Report an increase in physical and emotional comfort
Valvular Heart Disease - one or more of the heart valves do not ________________
open or close properly
Valvular Heart Disease -
Stenosis (constriction/narrowing)
-Valve opening is ______
-________ blood flow is impeded
-_________ differences on the two sides of the valve reflect degree of stenosis
-Valve opening is smaller
-Forward blood flow is impeded
-Pressure differences on the two sides of the valve reflect degree of stenosis
Valvular Heart Disease
Regurgitation (incompetence or insufficiency)
Incomplete closure of valve leaflets
Results in backward flow of blood
Incomplete closure of valve leaflets
Results in backward flow of blood
Mitral Valve Stenosis
Most common cause is _______________
Scarring of valve leaflets and chordae tendineae
Contractures develop with adhesions between commissures of the leaflets
rheumatic heart disease
Mitral Valve Stenosis
Results in __________ blood flow from left atrium to left _________
Increased left atrial pressure and volume
Increased pulmonary vasculature pressure
Risk for atrial _________
Results in decreased blood flow from left atrium to left ventricle
Increased left atrial pressure and volume
Increased pulmonary vasculature pressure
Risk for atrial fibrillation
Mitral Valve Regurgitation
Normal valve function depends on intact:
Mitral leaflets
Mitral annulus
Chordae tendineae
Papillary muscles
Normal valve function depends on intact:
Mitral leaflets
Mitral annulus
Chordae tendineae
Papillary muscles
Mitral Valve Stenosis - Clinical manifestations
Exertional dyspnea
Loud S1
_________ murmur
Fatigue
Palpitations
Hoarseness, hemoptysis
Atrial fibrillation with risk for ______
Exertional dyspnea
Loud S1
Diastolic murmur
Fatigue
Palpitations
Hoarseness, hemoptysis
Atrial fibrillation with risk for stroke
Mitral Valve Regurgitation
_______ caused by:
MI
Chronic rheumatic heart disease
Mitral valve prolapse
Ischemic papillary muscle dysfunction
IE
Damage
Mitral Valve Regurgitation
_________ valve closure
_______ flow of blood
Acute MR
-__________ edema
-Untreated- cardiogenic shock
Chronic MR
-Left atrial enlargement, ventricular dilation, eventual ventricular hypertrophy, decreased CO
Incomplete valve closure
Backward flow of blood
Acute MR
-Pulmonary edema
-Untreated- cardiogenic shock
Chronic MR
-Left atrial enlargement, ventricular dilation, eventual ventricular hypertrophy, decreased CO
Mitral Valve Regurgitation
Acute clinical manifestations
Thready peripheral pulses
Cool, clammy extremities
Chronic clinical manifestations
__________ for years
Weakness, fatigue, palpitations, dyspnea
Progress to orthopnea, paroxysmal nocturnal dyspnea
Peripheral edema
Audible S3, murmur
Mitral Valve Regurgitation
Acute clinical manifestations
Thready peripheral pulses
Cool, clammy extremities
Chronic clinical manifestations
Asymptomatic for years
Weakness, fatigue, palpitations, dyspnea
Progress to orthopnea, paroxysmal nocturnal dyspnea
Peripheral edema
Audible S3, murmur
Mitral Valve Prolapse
Abnormality of mitral valve leaflets and the papillary muscle or chordae
>Leaflets prolapse back into left atrium during _______
Usually benign with valve closing effectively
Potential complications
Unknown cause but genetic link in some
systole
Mitral Valve Prolapse
Confirmed with echocardiography - M-mode or 2-D
Clinical manifestations
Most patients _______ for life
Only ___% with symptoms
Murmur d/t regurgitation
Severe MR uncommon
Confirmed with echocardiography - M-mode or 2-D
Clinical manifestations
Most patients asymptomatic for life
Only 10% with symptoms
Murmur d/t regurgitation
Severe MR uncommon
Mitral Valve Prolapse - Clinical manifestations
[only 10% get symptoms]
____________ can cause palpitations, light-headedness, and syncope
Infective endocarditis
Chest ____ unresponsive to nitrates
Treat symptoms with _________
Valve surgery for MR
Dysrhythmias can cause palpitations, light-headedness, and syncope
Infective endocarditis
Chest pain unresponsive to nitrates
Treat symptoms with β-blockers
Valve surgery for MR
Mitral Valve Prolapse
Patient teaching important
Antibiotic prophylaxis if MR present
Take drugs as prescribed
Healthy diet; avoid _______
Avoid OTC stimulants
Exercise
When to call HCP or EMS
Patient teaching important
Antibiotic prophylaxis if MR present
Take drugs as prescribed
Healthy diet; avoid caffeine
Avoid OTC stimulants
Exercise
When to call HCP or EMS
Aortic Valve Stenosis
___________ aortic stenosis (AS) generally found in childhood, adolescence, or young adulthood
In adults, can be degenerative or caused by _________ fever
Congenital aortic stenosis (AS) generally found in childhood, adolescence, or young adulthood
In adults, can be degenerative or caused by rheumatic fever
Aortic Valve Stenosis
-_________ of blood flow from left ventricle to aorta
-Left ventricular hypertrophy and increased myocardial oxygen ___________
-Decreased CO leads to decreased tissue __________, pulmonary hypertension, and HF
>Poor prognosis if ___________
-Obstruction of blood flow from left ventricle to aorta
-Left ventricular hypertrophy and increased myocardial oxygen consumption
-Decreased CO leads to decreased tissue perfusion, pulmonary hypertension, and HF
>Poor prognosis if left untreated
Aortic Valve Stenosis - Clinical manifestations
Angina
Syncope
Exertional ________
Angina
Syncope
Exertional dyspnea
Aortic Valve Stenosis - Auscultatory findings
Normal to soft S1
Decreased or absent ___
Systolic ________ with radiation to the carotids
Prominent S4
Normal to soft S1
Decreased or absent S2
Systolic murmur with radiation to the carotids
Prominent S4
Aortic Valve Stenosis
Poor prognosis if symptomatic and not corrected
Use ____________ cautiously
–Reduces preload and BP
–Can worsen chest pain
Poor prognosis if symptomatic and not corrected
Use nitroglycerin cautiously
–Reduces preload and BP
–Can worsen chest pain
The nurse is caring for a patient with aortic stenosis. For what should the nurse assess the patient?
Systolic murmur
Pericardial friction rub
Diminished or absent S4
Low-pitched diastolic murmur
Systolic murmur
Aortic Valve Regurgitation
Acute AR
IE, trauma, or aortic dissection
Life-threatening _________
_______ AR
Rheumatic heart disease, congenital bicuspid aortic valve, syphilis, connective tissue problem, or post-surgical cause
Acute AR
IE, trauma, or aortic dissection
Life-threatening emergency
Chronic AR
Rheumatic heart disease, congenital bicuspid aortic valve, syphilis, connective tissue problem, or post-surgical cause
Aortic Valve Regurgitation
_________ blood flow from ascending aorta into left ventricle
With chronic AR, left ventricular dilation and hypertrophy
Decrease in myocardial __________
__________ hypertension and right ventricular failure
Backward blood flow from ascending aorta into left ventricle
With chronic AR, left ventricular dilation and hypertrophy
Decrease in myocardial contractility
Pulmonary hypertension and right ventricular failure
Aortic Valve Regurgitation
Clinical manifestations of acute AR-
Severe ________
Chest pain
Hypotension
__________ shock
Life-threatening ________
Severe dyspnea
Chest pain
Hypotension
Cardiogenic shock
Life-threatening emergency
Aortic Valve Regurgitation
Clinical manifestations of chronic AR-
May be asymptomatic for _______
Exertional dyspnea, orthopnea, paroxysmal dyspnea
Angina
________________ pulse if severe
Soft or absent S1
S3 or S4
Murmur
May be asymptomatic for years
Exertional dyspnea, orthopnea, paroxysmal dyspnea
Angina
Water-hammer pulse if severe
Soft or absent S1
S3 or S4
Murmur
Tricuspid Valve Stenosis
Usually caused by _____________
Clinical manifestations-
-Fluttering discomfort in _____
-Fatigue
-Right upper quadrant pain
Usually caused by rheumatic fever
Clinical manifestations-
-Fluttering discomfort in neck
-Fatigue
-Right upper quadrant pain
Pulmonary Regurgitation
Often ____________
Crescendo-decrescendo murmur
Potential causes
-Pulmonary ___________
-Surgical repair of tetralogy of Fallot (TOF)
-Congenital valve disease
Can cause RV dilation.
Often symptomatic
Crescendo-decrescendo murmur
Potential causes
-Pulmonary hypertension
-Surgical repair of tetralogy of Fallot (TOF)
-Congenital valve disease
Can cause RV dilation.
Pulmonary Regurgitation
Almost always _________
Causes right ventricular hypertension and hypertrophy
Clinical manifestations
Syncope
Dyspnea
Angina
Often asymptomatic until adulthood
Almost always congenital
Causes right ventricular hypertension and hypertrophy
Clinical manifestations
Syncope
Dyspnea
Angina
Often asymptomatic until adulthood
Valvular Heart Disease - Diagnostic Studies
History and physical assessment
Real-time 3-D echocardiography
TEE
Doppler color flow
Chest x-ray
ECG
Heart catheterization
History and physical assessment
Real-time 3-D echocardiography
TEE
Doppler color flow
Chest x-ray
ECG
Heart catheterization
Valvular Heart Disease - Interprofessional Care
Conservative therapy
-Dependent on valve involved and disease _________
-Prevent exacerbations of HF, pulmonary edema, thromboembolism, and recurrent RF and IE
-Prophylactic ___________ therapy to prevent recurrent RF and IE
-Dependent on valve involved and disease severity
-Prevent exacerbations of HF, pulmonary edema, thromboembolism, and recurrent RF and IE
-Prophylactic antibiotic therapy to prevent recurrent RF and IE
Valvular Heart Disease - Interprofessional Care cont. Conservative management
Drugs to treat/control HF
Vasodilators (e.g., nitrates, ACE inhibitors)
Positive inotropes (e.g., digoxin)
Diuretics
β-blockers
Low sodium diet
For atrial dysrhythmias
-Calcium channel blockers, β-blockers
-Anti-dysrhythmic drugs
-Anticoagulation therapy for A-fib
Drugs to treat/control HF
Vasodilators (e.g., nitrates, ACE inhibitors)
Positive inotropes (e.g., digoxin)
Diuretics
β-blockers
Low sodium diet
For atrial dysrhythmias
-Calcium channel blockers, β-blockers
-Anti-dysrhythmic drugs
-Anticoagulation therapy for A-fib
Valvular Heart Disease - Interprofessional Care cont.
-Percutaneous transluminal balloon valvuloplasty (PTBV)
–Split open fused commissures
–Treats mitral, tricuspid, and pulmonic, and AS
–Balloon-tipped catheter inserted via femoral artery
–Inflated to separate valve _________
leaflets
Valvular Heart Disease - Interprofessional Care - Surgical therapy
Valve _______
-Preferred surgical procedure
-Lower operative mortality rate than replacement
-May not restore total valve function
Valve __________
Valve repair
-Preferred surgical procedure
-Lower operative mortality rate than replacement
-May not restore total valve function
Valve replacement
Valvular Heart Disease - Interprofessional Care - Valve repair
Commissurotomy (valvulotomy)
Closed
Open (more common)
Valvuloplasty
Open
Minimally invasive
Annuloplasty
Commissurotomy (valvulotomy)
Closed
Open (more common)
Valvuloplasty
Open
Minimally invasive
Annuloplasty
Valvular Heart Disease - Interprofessional Care - Valve replacement
Mechanical (artificial)
More durable, last _______
Risk of thromboembolism
Require long-term __________
Biologic (tissue)
Bovine, porcine, and human
More natural blood flow
No anticoagulation required
Less _______
Mechanical (artificial)
More durable, last longer
Risk of thromboembolism
Require long-term anticoagulation
Biologic (tissue)
Bovine, porcine, and human
More natural blood flow
No anticoagulation required
Less durable
VHD assessment
Subjective data
Medical history
IVDA, fatigue
Palpitations, weakness, activity intolerance, dizziness, fainting
DOE, cough, hemoptysis, orthopnea, PND
Angina or atypical chest pain
Objective data
Fever
Diaphoresis, flushing, cyanosis, clubbing, peripheral edema
Crackles, wheezes, hoarseness
S3 and S4
Dysrhythmias
Increase or decrease in pulse pressure
Hypotension
Water-hammer or thready peripheral pulses
Hepatomegaly, ascites
Weight gain
Subjective data
Medical history
IVDA, fatigue
Palpitations, weakness, activity intolerance, dizziness, fainting
DOE, cough, hemoptysis, orthopnea, PND
Angina or atypical chest pain
Objective data
Fever
Diaphoresis, flushing, cyanosis, clubbing, peripheral edema
Crackles, wheezes, hoarseness
S3 and S4
Dysrhythmias
Increase or decrease in pulse pressure
Hypotension
Water-hammer or thready peripheral pulses
Hepatomegaly, ascites
Weight gain
VHD - clinical problems
Impaired cardiac function
Fatigue
Fluid imbalance
Impaired cardiac function
Fatigue
Fluid imbalance
VHD - Patient goals
Normal heart function
Improved activity tolerance
Understanding of the disease process and health maintenance measures
Normal heart function
Improved activity tolerance
Understanding of the disease process and health maintenance measures
VHD - Health promotion
Early treatment of streptococcal ______
Prophylactic antibiotics for patients with history
Teach patient symptoms to report
Early treatment of streptococcal infections
Prophylactic antibiotics for patients with history
Teach patient symptoms to report
VHD
Individualize rest and exercise
Limit activities that cause fatigue and _________
Discourage _______ use
Ongoing cardiac assessments to monitor drug effectiveness
Monitor INR for patient on anticoagulants
Individualize rest and exercise
Limit activities that cause fatigue and dyspnea
Discourage tobacco use
Ongoing cardiac assessments to monitor drug effectiveness
Monitor INR for patient on anticoagulants
VHD Patient teaching
______ actions and side effects
Importance of prophylactic _________ therapy
Information related to ___________ therapy
When to seek medical care
Drug actions and side effects
Importance of prophylactic antibiotic therapy
Information related to anticoagulation therapy
When to seek medical care
VHD - Follow-up care
Notify HCP for —
Signs of infection, HF, or bleeding
Monitor ____ level if on Warfarin
INR _____
Planned invasive or _______ work
Medical-alert device or bracelet
Notify HCP for —
Signs of infection, HF, or bleeding
Monitor INR level if on Warfarin
INR 0.8-1.0
Planned invasive or dental work
Medical-alert device or bracelet
VHD - Expected patient outcomes
Maintain adequate tissue and organ perfusion
Achieve fluid balance
Achieve optimal level of activity
Describe disease process and measures to prevent complications
Maintain adequate tissue and organ perfusion
Achieve fluid balance
Achieve optimal level of activity
Describe disease process and measures to prevent complications
MONA =
Morphine
Oxygen
Nitroglycerin
Aspirin
INR should be
under 1
[0.8-1]
if INR is larger than 1, blood is ________
thinning
________ angina - shorter, responds to NTG
________ angina - longer duration & does not respond to NTG
stable angina - shorter, responds to NTG
unstable angina - longer duration & does not respond to NTG
If husband is having chest pain, instruct wife to
CALL 911
Woman & older adults may have _______________________ MI
If a female with HPN and no other sx, check EKG
atypical or asymptomatic
Pain assessment- PQRST
provocation
quality
Radiation/region
Severity
Timing
PCI within _____
thrombolytic therapy within _____
PCI within 90 mins
thrombolytic therapy within 30 mins
Aspirin reduces _________________
platelet aggregation
________ is the more sensitive cardiac biomarker
Troponin
If Pt has a PCI, if there is new ______ pain, or changes in BP or neuro, check the escalation [could be issue in kidney or another occlusion in heart/arteries]
back
ER - chest pain- first do:
EKG ASAP
______ pain always concern (pain is subjective)
Chest
Cardizem- for ________
angina
Metoprolol tartrate is short-acting and is usually taken at least _____ a day.
Metoprolol succinate ER (extended-release) is longer-acting and normally taken _____ a day.
Both medications are FDA approved for treating HTN and chest pain (angina).
Metoprolol tartrate is short-acting and is usually taken at least twice a day.
Metoprolol succinate ER (extended-release) is longer-acting and normally taken once a day.
Both medications are FDA approved for treating HTN and chest pain (angina).
who is at the highest risk for developing atherosclerotic heart disease (i.e. risk factors)
White males, then black
genetics/ family history
older
HTN, diabetes, obesity, smoking, sedentary
Describe the atherosclerosis process and what is going on in terms of stable angina/unstable angina/MI (fatty streak to partial occlusion to complete occlusion)
Atherosclerosis begins with the formation of fatty streaks, where lipids collect in the _____________, forming yellow streaks. [no symptoms]
Over time, fibrous plaques develop as cholesterol and lipids accumulate, thickening the arterial wall and narrowing the blood flow. This partial blockage can lead to _______________, where chest pain occurs during activity and resolves with rest.
If the plaque becomes unstable, it may rupture, triggering clot formation (thrombus). A partial blockage from a clot can cause _____________, where chest pain is unpredictable and happens even at rest.
A complete blockage of the artery results in ________________, where blood flow stops entirely, causing permanent heart muscle damage.
Atherosclerosis begins with the formation of fatty streaks, where lipids collect in the arterial walls, forming yellow streaks. [no symptoms]
Over time, fibrous plaques develop as cholesterol and lipids accumulate, thickening the arterial wall and narrowing the blood flow. This partial blockage can lead to stable angina, where chest pain occurs during activity and resolves with rest.
If the plaque becomes unstable, it may rupture, triggering clot formation (thrombus). A partial blockage from a clot can cause unstable angina, where chest pain is unpredictable and happens even at rest.
A complete blockage of the artery results in myocardial infarction (MI), where blood flow stops entirely, causing permanent heart muscle damage.
Identify the ECG changes associated ST-Elevated MI’s.
Define and differentiate between a STEMI and NSTEMI (non-ST elevated MI)
STEMI:
ST-segment elevation
Full-thickness myocardial damage
Urgent treatment (PCI or thrombolysis)
NSTEMI:
No ST-segment elevation
ST-segment depression or T-wave inversion
Partial-thickness myocardial damage
Medical therapy and possible PCI
What are some common dysrhythmias that occur after heart surgery or valve surgery?
Atrial fibrillation (AFib)
Ventricular arrhythmias
Bradycardia
Supraventricular tachycardia (SVT)
Heart block
?
Review nursing diagnoses that pertain to patients with valve disorders and/or ACS
Nursing Diagnoses for Valve Disorders:
Decreased Cardiac Output
Activity Intolerance
Risk for Ineffective Tissue Perfusion
Excess Fluid Volume
Ineffective Breathing Pattern
Risk for Infection
Nursing Diagnoses for Acute Coronary Syndrome (ACS):
Acute Pain
Decreased Cardiac Output
Ineffective Tissue Perfusion
Anxiety
Activity Intolerance
Risk for Ineffective Coping
Risk for Fluid Imbalance
The water hammer pulse is a _________ pulse with rapid systolic rising and diastolic collapse that can be appreciated at either the radial, ulnar or brachial artery.
bounding
_________ lesions are a rare but important clinical sign of infective endocarditis that can appear as painless, flat, erythematous macules on the palms and soles of the feet.
Janeway
_____ nodes are red purple, slightly raised, tender lumps, often with a pale center.
Osler
_________ hemorrhages are red, brown, or purple streaks of blood that appear under the nail plate and run in the direction of nail growth.
Splinter
Cardiac Output (CO) is the amount of ____________________________________, calculated by multiplying the stroke volume (amount of blood pumped per beat) by the heart rate.
blood pumped by the heart per minute
The cardiac index (CI) is an assessment of the ______________ value based on the patient’s size. To find the cardiac index, divide the cardiac output by the person’s body surface area (BSA). The normal range for CI is 2.5 to 4 L/min/m2
cardiac output
Preload (CVP and PWCP):
Represents the degree of ventricular _________ before contraction, essentially the “filling pressure” of the heart. Increased preload (higher CVP or PWCP) generally leads to increased stroke volume and therefore, increased CO due to the Frank-Starling mechanism, where more stretch results in a stronger contraction.
stretching
- Afterload (SVR and PVR):
Represents the __________ the heart must overcome to eject blood, primarily influenced by systemic vascular resistance (SVR) and pulmonary vascular resistance (PVR). Increased afterload (higher SVR or PVR) decreases stroke volume and therefore, CO, as the heart has to work harder to push against greater resistance
resistance
Heart Rate (HR):
The number of times the heart beats per minute.
A higher heart rate directly increases _____ as more blood is pumped out per unit time, assuming stroke volume remains constant
The number of times the heart beats per minute.
A higher heart rate directly increases CO as more blood is pumped out per unit time, assuming stroke volume remains constant
Contractility:
The force of __________________, determined by the intrinsic strength of the cardiac muscle. Increased contractility leads to increased stroke volume and therefore, increased ___, as the heart pumps more blood with each beat.
The force of ventricular contraction, determined by the intrinsic strength of the cardiac muscle. Increased contractility leads to increased stroke volume and therefore, increased CO, as the heart pumps more blood with each beat.
Key points to remember:
- Direct relationship: Increased preload, heart rate, and contractility generally lead to increased ____.
- Inverse relationship: Increased afterload typically leads to decreased ___
- Clinical application: By monitoring CO and CI, healthcare providers can assess the overall cardiac function and identify potential issues related to preload, afterload, heart rate, or contractility
- Direct relationship: Increased preload, heart rate, and contractility generally lead to increased CO.
- Inverse relationship: Increased afterload typically leads to decreased CO.
- Clinical application: By monitoring CO and CI, healthcare providers can assess the overall cardiac function and identify potential issues related to preload, afterload, heart rate, or contractility
Fluids increase _______
diuretics decrease preload, dopamine
CA channel blockers improve __________
Fluids increase preload
diuretics decrease preload, dopamine
CA channel blockers improve contractility
An accurate central venous pressure (CVP) measurement needs to be taken with the patient __________ and the transducer aligned with the phlebostatic axis. The number (normal CVP is 2–6 mmHg) indicates right ventricular function and systemic fluid status
lying supine
Reasons why CVP may be elevated are:
- ____________ increases venous return
- Heart failure or pulmonary artery _________ limiting venous outflow
- Positive pressure breathing due to straining.
- Over hydration increases venous return
- Heart failure or pulmonary artery stenosis limiting venous outflow
- Positive pressure breathing due to straining.
A reason why CVP may be decreased is:
* _____________ shock.
Hypovolaemic
CVCs have potentially serious complications:
* Pneumothorax
* Bloodstream infections
* Thrombosis
- Pneumothorax
- Bloodstream infections
- Thrombosis
CVCs have potentially serious complications: CONT.
- _________ – placing the catheter usually requires the patient adopting a Trendelenburg or at least supine position. This may be difficult in pregnancy as it may cause aortocaval compression.
- Air ________ – lines attached to a CVC must be kept air free
- __________ and formation of a haematoma.
- Misplacement – placing the catheter usually requires the patient adopting a Trendelenburg or at least supine position. This may be difficult in pregnancy as it may cause aortocaval compression.
- Air embolus – lines attached to a CVC must be kept air free
- Haemorrhage and formation of a haematoma.
Cardiac Output = Heart Rate x Stroke Volume
Cardiac Output: Amount of ________________
blood pumped by the heart
Heart Rate: How many times the heart _______ in a set amount of time
contracts
Stroke volume: Volume of blood pumped ______________________
OUT of the LV during systolic contraction
- Valvular regurgitation - ________ flow of blood
- Valvular incompetence or insufficiency - incomplete _______ of the leaflets
- Valvular regurgitation - backward flow of blood
- Valvular incompetence or insufficiency - incomplete closure of the leaflets
- Valvular stenosis
- Impediment of ________ blood flow due to restricted valve orifice
- Valvular constriction, narrowing
forward
Mitral Valve Regurgitation
Cause: Rheumatic disease, aging, endocarditis, collagen vascular disease, papillary muscle dysfunction
Management: vasodilators, diuretics, nitrates, anticoagulants, IABP
Cause: Rheumatic disease, aging, endocarditis, collagen vascular disease, papillary muscle dysfunction
Management: vasodilators, diuretics, nitrates, anticoagulants, IABP
Mitral Valve Regurgitation
ACUTE Symptoms: Pulmonary edema, shock, thready pulses, cool and clammy extremities
CHRONIC Symptoms: Asymptomatic or vague, weakness, general malaise, dyspnea, orthopnea, peripheral edema, S3 heart sound, loud holosystolic murmur at apex (heard during systole)
ACUTE Symptoms: Pulmonary edema, shock, thready pulses, cool and clammy extremities
CHRONIC Symptoms: Asymptomatic or vague, weakness, general malaise, dyspnea, orthopnea, peripheral edema, S3 heart sound, loud holosystolic murmur at apex (heard during systole)
Mitral Valve Stenosis
Cause: smaller valve area, resulting in increased LA and Pulm pressure (usually due to rheumatic heart disease)
Symptoms: dyspnea, A Fib/Palpitations, chest pain, diastolic murmur, high risk for emboli
Management: Restrict Na+ intake, diuretics, nitrates, beta-blockers, digitalis, calcium antagonist, anticoagulants, surgery
Cause: smaller valve area, resulting in increased LA and Pulm pressure (usually due to rheumatic heart disease)
Symptoms: dyspnea, A Fib/Palpitations, chest pain, diastolic murmur, high risk for emboli
Management: Restrict Na+ intake, diuretics, nitrates, beta-blockers, digitalis, calcium antagonist, anticoagulants, surgery
Aortic Valve Regurgitation
Cause: rheumatic fever, systemic hypertension, Marfan syndrome, syphilis, rheumatoid arthritis, aging, or discrete subaortic stenosis.
Symptoms: Chest pain, Dyspnea/DOE, orthopnea, paroxysmal nocturnal dyspnea
Management: inotropic agents, ACE Inhibitors, diuretics,nitrates
Cause: rheumatic fever, systemic hypertension, Marfan syndrome, syphilis, rheumatoid arthritis, aging, or discrete subaortic stenosis.
Symptoms: Chest pain, Dyspnea/DOE, orthopnea, paroxysmal nocturnal dyspnea
Management: inotropic agents, ACE Inhibitors, diuretics,nitrates
Aortic Valve Stenosis
Cause: Calcification of the leaflets of the valve (valve doesn’t open properly)
Symptoms: Angina pectoris, Syncope, Dyspnea/DOE, S4 heart sound, Systolic crescendodecrescendo murmur, S/S for LV systolic failure
Management: Use nitroglycerin with caution, low Na diet, antiHTN, anti- arrhythmetics, digitalis, diuretics, ACE Inhibitors, surgery
Cause: Calcification of the leaflets of the valve (valve doesn’t open properly)
Symptoms: Angina pectoris, Syncope, Dyspnea/DOE, S4 heart sound, Systolic crescendodecrescendo murmur, S/S for LV systolic failure
Management: Use nitroglycerin with caution, low Na diet, antiHTN, anti- arrhythmetics, digitalis, diuretics, ACE Inhibitors, surgery
Anticoagulants Prevent systemic and pulmonary ________
emboli
Digoxin, cardioversion, beta blockers, amiodarone - Prevent _____________
dysrhythmias
Valve Replacement
Mechanical
* Pro: _________ lasting, more _______, good for younger patients
* Con: higher risk of blood clots, lifelong __________ therapy, hemorrhage or stroke risk, hear clicking, valve failure
Biological
* Pro: low _____ risk, no anticoagulant therapy needed, better for _________
* Con: can calcify just like original tissue, replacement needed every 7-10 years, risk for endocarditis
Mechanical
* Pro: longer lasting, more durable, good for younger patients
* Con: higher risk of blood clots, lifelong anticoagulant therapy, hemorrhage or stroke risk, hear clicking, valve failure
Biological
* Pro: low clot risk, no anticoagulant therapy needed, better for elderly
* Con: can calcify just like original tissue, replacement needed every 7-10 years, risk for endocarditis
The nurse obtains a health history from a 65-year-old patient with a prosthetic mitral valve who has symptoms of infective endocarditis. Which question by the nurse is most appropriate?
a) Do you have a history of heart attack?
b) Is there a family history of endocarditis?
c) Have you had any recent immunizations?
d) Have you had dental work done recently?
d) Have you had dental work done recently?
Dental procedures place this patient at risk for IE. The other options are not risk factors.
after receiving report on 4 patients, the nurse should first see…
a) Patient with acute pericarditis who has a pericardial friction rub
b) Patient who has just returned to the unit after balloon valvuloplasty
c) Patient with hypertrophic cardiomyopathy w/ HR of 116
d) Patient who had a mitral valve replacement and is due for their scheduled
anticoagulant
b) Patient who has just returned to the unit after balloon valvuloplasty
- This patient needs to be assessed for post procedure complications, like
bleeding and hypotension. While the other patients also need to be assessed,
their findings are consistent with their diagnoses and do not require urgent
attention.
Left Coronary Artery (LCA)
*Left anterior descending
* Anterior LV, Lateral LV, Anterior 2/3 of septum
*Left circumflex
* LA, Posterior LV, SA node 45%, AV node 10%
*Left anterior descending
* Anterior LV, Lateral LV, Anterior 2/3 of septum
*Left circumflex
* LA, Posterior LV, SA node 45%, AV node 10%
CAD risk factors
non-mod
* Age
* Gender (sex from genetic chromosomes)
* Ethnicity
* Genetic predisposition
* Family history
mod
* Elevated serum lipids
* HTN
* Smoking
* Inactivity
* Obesity
non-mod
* Age
* Gender (sex from genetic chromosomes)
* Ethnicity
* Genetic predisposition
* Family history
mod
* Elevated serum lipids
* HTN
* Smoking
* Inactivity
* Obesity
CAD comorbidities
- DM
- Stress
- Metabolic syndrome
- Substanceabuse
- Elevated homocysteine levels
- DM
- Stress
- Metabolic syndrome
- Substanceabuse
- Elevated homocysteine levels
Angina types
________: Chest pain is intermittent and predictable
________/Prinzmetal: Coronary artery spasm
________: acute and unpredictable
Stable can turn into unstable
Angina types
Stable: Chest pain is intermittent and predictable
Variant/Prinzmetal: Coronary artery spasm
Unstable: acute and unpredictable
Stable can turn into unstable
Stable angina: Chest pain is intermittent and _________
- Occurs with _________ and stops when activity is stopped.
- Controlled with ______
Stable angina: Chest pain is intermittent and predictable
- Occurs with activity and stops when activity is stopped.
- Controlled with meds
Variant/Prinzmetal angina: Coronary artery spasm
- Occurs at _____
- Treated with ______________ blockers
- Occurs at rest
- Treated with calcium channel blockers
Unstable angina: acute and unpredictable
- ________, constricting pain
- Risk for ___
- Squeezing, constricting pain
- Risk for MI
HEART ATTACKS: stemi/nstemi
- NSTEMI = non-ST elevation MI
- Transient thrombosis or incomplete coronary artery occlusion
- STEMI = ST elevation MI
- Extensive and complete coronary artery occlusion
- Q-Wave MI: pathologic Q-wave seen after a complete infarction
- Can indicate a prior MI
- NSTEMI = non-ST elevation MI
- Transient thrombosis or incomplete coronary artery occlusion
- STEMI = ST elevation MI
- Extensive and complete coronary artery occlusion
- Q-Wave MI: pathologic Q-wave seen after a complete infarction
- Can indicate a prior MI
when developing a teaching plan for a 61-yo male with
the following risk factors for cad, the nurse should focus on the…
A) family history of CAD
B) Increased risk associated with the patient’s gender
C) Increased risk of CVD as people age
D) Elevation of the patient’s LDL level
Elevation of the patient’s LDL level
This is the only MODIFIABLE risk factor listed
which information given by a patient admitted with chronic stable angina will help the nurse confirm this diagnosis?
A) the patient states, “The pain wakes me up at night.”
B) The patient rates the pain at 3/10
C) The patient states an increase in pain frequency over the past week
D) The patient states the pain resolves with one sublingual nitroglycerin tablet
The patient states the pain resolves with one sublingual nitroglycerin tablet
Chronic stable angina is typically relieved by rest or nitroglycerin.
a patient who has had chest pain for several hours is admitted with a diagnosis of ‘rule out acUTe mi.’ Which lab test should the nurse monitor to help determine whether the patient has had an ami?
a) Myoglobin
b) Homocysteine
c) CRP
d) Cardiac specific troponin
D) Cardiac specific troponin
Troponin levels increase for approx. 4-6 hours after MI and
are highly specific indicators for MI. Myoglobin, though released, lacks specificity.
Heparin is ordered for a patient with an nstemi. What is
the purpose of this medication?
a) Heparin enhances platelet aggregation
b) Heparin decreases coronary artery plaque size
c) Heparin prevents the development of new clots in the coronary arteries
d) Heparin dissolves clots that are blocking blood flow in the coronary arteries
C) Heparin prevents the development of new clots in the coronary arteries
- Heparin helps prevent the conversion of fibrinogen to fibrin and
decreases coronary artery thrombosis due to blood thinning
abilities. It does not dissolve already existing clots (“clotbusting”)
a patient admitted to the ed with chest pain is diagnosed with a stemi following a 12-lead ekg. What question should the nurse ask to determine whether the patient is a candidate for thrombolytic therapy?
a) Do you have allergies?
b) Do you take aspirin daily?
c) What time did your chest pain begin?
d) Can you rate your pain on a 0 to 10 scale?
C) What time did your chest pain begin?
- Time is muscle!
- Thrombolytic therapy should be started within 6 hours of the
onset of the MI, and knowing when the pain began can help
determine this
__________
NEED TO MONITOR: BP, HR, I&O, WEIGHT, (possibly) K+ LEVELS
DIURETICS
ANTI-PLATELET
- _________ or Plavix
- Monitor for S/S of ________
Aspirin
bleeding
ANTIDYSRHYTHMIC/antiarrhythmic
Used to prevent abnormal cardiac _________ such as atrial fibrillation, atrial flutter, ventricular tachycardia, and ventricular fibrillation
Works by blocking sodium, potassium, and ________ channels in the heart muscles
Used to prevent abnormal cardiac rhythms such as atrial fibrillation, atrial flutter, ventricular tachycardia, and ventricular fibrillation
Works by blocking sodium, potassium, and calcium channels in the heart muscles
The patient has used sublingual nitroglycerin (NTG) and various longactingnitrates butnow has an ejection fraction of 38% and is considered at a high risk for a cardiac event. Which medication would first be added for vasodilation and to reduce ventricular remodeling?
a. Captopril
b. Clopidogrel (Plavix)
c. Diltiazem (Cardizem)
d. Metoprolol (Lopressor)
a. Captopril would be added. It is an angiotensin-converting enzyme (ACE) inhibitor that vasodilates and decreases endothelial dysfunction and may prevent ventricular remodeling. Clopidogrel (Plavix) is an antiplatelet agent used as an alternative for a patient unable to use aspirin. Diltiazem (Cardizem), a calcium channel blocker, may be used to decrease vasospasm but is not known to prevent ventricular remodeling. Metoprolol (Lopressor) is a β-adrenergic blocker that inhibits sympathetic nervous stimulation of the heart
During treatment with reteplase ( retavase) for a patient with
a STEMI, which finding should most concern the nurse?
a. Oozing of blood from the IV site
b. BP of 102/60 mm Hg with an HR of 78 bpm
c. Decrease in the responsiveness of the patient
d. Intermittent accelerated idioventricular rhythms
c. Decreasing level of consciousness (LOC) may reflect hypoxemia
resulting from internal bleeding, which is always a risk with thrombolytic therapy. Oozing of blood is expected, as are reperfusion dysrhythmias. BP is low but not considered abnormal because the pulse is within normal range. Idioventricular dysrhythmias are common with reperfusion.
When the patient who is diagnosed with an MI is not relieved of chest pain with IVNTG, which medication will the nurse expect to be used?
a. IV morphine sulfate
b. Calcium channel blockers
c. IV administration of amiodarone
d. Angiotensin-converting enzyme (ACE) inhibitors
a. Morphine sulfate decreases anxiety and cardiac workload as a
vasodilator and reduces preload and myocardial O2 onsumption, which relieves chest pain. Calcium channel blockers, amiodarone, and angiotensin-converting enzyme (ACE) inhibitors will not relieve chest pain related to an MI.
What is the rationale for using docusate sodium (Colace) for a patient after an MI?
a. Relieves cardiac workload
b. Minimizes vagal stimulation
c. Controls ventricular dysrhythmias
d. Prevents the binding of fibrinogen to platelets
b. Docusate sodium (Colace) is a stool softener, which prevents
straining and provoking dysrhythmias. It does not do any of the other options. Antidysrhythmics are used to control ventricular dysrhythmias; morphine sulfate is used to decrease anxiety and cardiac workload; and glycoprotein IIb/IIIa inhibitors and antiplatelets prevent the binding of fibrinogen to platelets.
A patient who has hypertension just had an MI. Which type of medication should the nurse expect to be added to decrease the
cardiac workload?
a. ACE inhibitor
b. β-adrenergic blocker
c. Calcium channel blocker
d. Angiotensin II receptor blocker (ARB)
b. It is recommended that patients with hypertension and after an MI be on β-adrenergic blockers indefinitely to decrease oxygen demand. They inhibit sympathetic nervous stimulation of the heart; reduce heart rate, contractility, and BP; and decrease afterload. Although calcium channel blockers decrease heart rate, contractility, and BP, they are not used unless the patient cannot tolerate β-adrenergic blockers. ACE inhibitors and angiotensin II receptor blockers (ARBs) are used for vasodilation.
Which drugs would the nurse expect to be prescribed for patients with a mechanical valve replacement?
a. Oral nitrates
b. Anticoagulants
c. Atrial antidysrhythmics
d. β-adrenergic blocking agents
b. Patients with mechanical valves have an increased risk for
thromboembolism and require long-term anticoagulation to prevent systemic or pulmonary embolization. Nitrates are contraindicated for the patient with aortic stenosis because an adequate preload is necessary to open the stiffened aortic valve. Antidysrhythmics are used only if dysrhythmias occur and β-adrenergic blocking drugs may be used to control the heart rate if needed.
2 atrioventricular valves
___
___
2 semilunar valves
___
___
2 atrioventricular valves
Mitral
Tricuspid
2 semilunar valves
Aortic
Pulmonic
Diastole: The heart ___________, and the chambers _____________
relaxes
fills with blood
Systole: The heart ________, pumping blood out to the body and lungs.
contracts
CAD-
______ streaks form early but don’t cause symptoms.
Fibrous _______ develop, partially blocking arteries and causing stable angina.
Plaque _________ leads to clots, causing unstable angina (partial block) or MI (complete block).
Fatty streaks form early but don’t cause symptoms.
Fibrous plaques develop, partially blocking arteries and causing stable angina.
Plaque rupture leads to clots, causing unstable angina (partial block) or MI (complete block).
Identify and discuss the current labs, diagnostic tests, and drug therapies used in treating patients with ACS (including management of the patient post-PCI)
Coronary artery disease (CAD) is a type of blood vessel disorder in the general category of ___________.
atherosclerosis
The term athero sclerosis comes from 2 Greek words: athere, meaning “gruel or fatty mush,” and skleros, meaning “hard.”
Atherosclerosis begins as soft deposits of fat that harden with age, often referred to as “______________ of the arteries.” Atherosclerosis can occur in any artery in the body. When the atheromas (fatty deposits) form in the coronary arteries, the disease is called CAD.
Arteriosclerotic heart disease (ASHD), cardiovascular heart disease (CVHD), ischemic heart disease (IHD), coronary heart disease (CHD) are other terms used to describe CAD.
hardening
difference between stable & unstable angina
Nitro, 3 doses, 5 mins – if no relief, it is likely ________ angina
unstable
Women & older adults are sometime ___________ in the event of an MI. If pt is female with high BP and other issues but no other symptoms (no chest pain, no fatigue, no dizziness, no shortness of breath), push for an EKG or other intervention to make sure nothing is going on with the heart if the high BP is a new change for the pt. Women are higher risk for mortality with anything cardiac related b/c of the atypical symptoms.
asymptomatic
DAPT- ______________ therapy- includes aspirin and plavix. Aspirin works to inhibit platelet aggregation. Aspirin will always be used for pts that have chest pain or stemi or nstemi. Aspirin fx is to reduce platelet aggregation.
Dual anti platelet
Cardiac biomarkers: ___________, _______, troponin levels. Troponin is the most sensitive, the most reliable indicator and used when trending and monitoring.
Myoglobin, CK-MB
MONA:
MONA: morphine, oxygen, nitroglycerin, aspirin (inhibits platelet aggregation)
What does aspirin do
reduce platelet aggregation
Pt has PCI and comes to your unit,
monitor pt– site of intervention (right femoral site PCI, do right pedal pulse checks).
If pt suddenly starts complaining about back pain, has changes in BP, has changes in neuro status– something is going on with this pt and it needs to be investigated and escalated b/c if they had a PCI, something could have ruptured, they could be bleeding internally, they can have a reocclusion of another valve or other area of the heart/ artery so escalate if you see a change in these conditions.
Back pain and hypotension are big ones to watch out for– indicative of something going on with the ________ or something getting ready to happen with another part of the valve or arteries in the heart.
kidneys
patient comes in with chest pain. What do you do first?
____ ! Set bed up, get them on O2, may need morphine, may need nitro or aspirin but priority is ECG so we can figure out what’s going on
ECG
ST segment depression Myocardial _________
ST segment elevation Myocardial _________
ST segment depression Myocardial ischemia
ST segment elevation Myocardial infarction
If your pt comes back to your unit after they have received TPA (clot buster) and they have ______ in the catheter, something is wrong. There is some bleeding happening somewhere that needs to be cauterized. Anything abnormal needs to be reported. Pts receiving these meds are at increased risk for bleeding. Every site needs to be monitored - gums, urethra, wherever they have IVs or central lines - these can be sites for bleeding.
blood
Med for 2 types of angina is ________ .
cardizem
[Calcium channel blocker]
CABG - Ex: pt had CABG, now they have JVD, BP isn’t looking right, what is happening?
Fluid is accumulating somewhere & something is not going right. Indicative of CABG failing so blood may be leaking out to other parts of the body. Report to DR right away. They will likely want to do pericardiocentesis to remove fluid.
Fluid is accumulating somewhere & something is not going right. Indicative of CABG failing so blood may be leaking out to other parts of the body. Report to DR right away. They will likely want to do pericardiocentesis to remove fluid.
Pts with a-fib will use something also, an ___________ medication for rest of life. Coumadin or xarelto are most common.
anti coagulation
You have a patient with CAD and want them to have more of a healthy lifestyle, it’s important to meet the patient where they are, work with them to develop individualized/customized care for them. Work with ___________ to establish a wellness plan.
the patient
Aortic stenosis - encourage pts to slowly increase _______ w/in their capabilities
activity
IS angina or UA longer?
UA is longer
Anytime patient is outside the hospital setting and they feel anything abnormal than what they were feeling prior to _______ immediately
, call 911
Stable angina responds well to ________ !
nitrates
Acute MI: ______ ventricle is the most important part of the heart, and has the most important role and function of the heart.
left
Class: Diuretics
Action: Removes excess fluid from the body by increasing urine output.
Indications: Heart failure, hypertension, edema.
Side Effects: Dehydration, electrolyte imbalances, low blood pressure.
Nursing Considerations: Monitor fluid status, electrolytes, and blood pressure.
Class: Beta-blockers
Action: Blocks adrenaline effects on the heart, reducing heart rate and blood pressure.
Indications: Hypertension, arrhythmias, heart failure.
Side Effects: Low heart rate, fatigue, dizziness.
Nursing Considerations: Monitor heart rate and blood pressure, don’t abruptly stop.
Calcium Channel Blockers (e.g., Amlodipine, Diltiazem)
Class: Calcium channel blockers
Action: Relaxes blood vessels and reduces heart workload.
Indications: Hypertension, angina, arrhythmias.
Side Effects: Swelling, low blood pressure, dizziness.
Nursing Considerations: Monitor blood pressure and heart rate, caution with older adults.
ACE Inhibitors (e.g., Enalapril, Lisinopril)
Class: ACE inhibitors
Action: Blocks a substance that narrows blood vessels, lowering blood pressure.
Indications: Hypertension, heart failure, post-heart attack.
Side Effects: Cough, high potassium, low blood pressure.
Nursing Considerations: Monitor kidney function, potassium levels, and blood pressure.
Vasodilators (e.g., Nitroglycerin)
Class: Vasodilators
Action: Expands blood vessels, reducing heart’s workload.
Indications: Angina, heart failure, high blood pressure.
Side Effects: Headache, low blood pressure, dizziness.
Nursing Considerations: Monitor blood pressure, avoid sudden position changes.
Positive Inotropes (e.g., Dopamine, Dobutamine, Epinephrine, Digoxin)
Class: Positive inotropes
Action: Increases heart contractility and output.
Indications: Shock, heart failure, bradycardia.
Side Effects: Arrhythmias, high blood pressure, nausea.
Nursing Considerations: Monitor heart rate, blood pressure, and ECG.
Antidysrhythmics (e.g., Amiodarone)
Class: Antidysrhythmics
Action: Regulates heart rhythm by stabilizing electrical impulses.
Indications: Arrhythmias.
Side Effects: Lung damage, liver issues, thyroid problems.
Nursing Considerations: Monitor ECG, lung function, and liver enzymes.
Platelet Inhibitors (e.g., Aspirin, Clopidogrel)
Class: Platelet inhibitors
Action: Prevents platelets from sticking together to form clots.
Indications: Prevent strokes, heart attacks.
Side Effects: Bleeding, stomach upset.
Nursing Considerations: Monitor for signs of bleeding, avoid in active bleeding conditions.
Statins (e.g., Atorvastatin, Simvastatin)
Class: Statins
Action: Lowers cholesterol levels.
Indications: Hyperlipidemia, prevention of heart disease.
Side Effects: Muscle pain, liver damage, digestive issues.
Nursing Considerations: Monitor liver function and muscle pain.
Anticoagulants (e.g., Warfarin, Heparin, Apixaban)
Class: Anticoagulants
Action: Prevents blood clot formation.
Indications: Deep vein thrombosis, pulmonary embolism, atrial fibrillation.
Side Effects: Bleeding, bruising.
Nursing Considerations: Monitor INR/PT (for warfarin), watch for signs of bleeding.
- Aortic Stenosis
Cause: Narrowing of the aortic valve, often from aging or birth defects.
Symptoms: Chest pain, fainting, shortness of breath.
Treatment: Meds (e.g., beta-blockers), surgery (valve replacement).
Valve Types:
Mechanical: Lasts longer but needs blood thinners.
Biological: Shorter lifespan, no blood thinners.
Patient Teaching: Watch for chest pain and dizziness, take meds as prescribed. - Mitral Stenosis
Cause: Narrowing of the mitral valve, usually from past rheumatic fever.
Symptoms: Shortness of breath, fatigue, swelling.
Treatment: Meds (e.g., diuretics, blood thinners), surgery (valve repair or replacement).
Valve Types:
Mechanical: Lasts longer but needs blood thinners.
Biological: Shorter lifespan, no blood thinners.
Patient Teaching: Watch for swelling and difficulty breathing, follow-up regularly. - Mitral Regurgitation
Cause: Leaky mitral valve, often due to heart disease or infection.
Symptoms: Fatigue, shortness of breath, swollen ankles.
Treatment: Meds (e.g., ACE inhibitors), surgery (repair or replacement).
Valve Types:
Mechanical: Needs blood thinners.
Biological: No blood thinners, but not as durable.
Patient Teaching: Monitor for swelling and tiredness, take medications as directed.
