Week 3B: Initial Assessment of CAD Flashcards
WWYD: a pt presents with what you expect is a heart attack. What would you focus on in your initial assessment? (5)
-Baseline VS + 12-lead ECG in 10’
-Assessment of chest pain
-Associated symptoms
-Physical assessment
-Medications
What are some other steps in an initial assessment of a pt with a suspected heart attack (following the initial 5)? (4)
Personal and family Hx, environmental factors, psychosocial Hx, pt attitudes and believes about health and illness (do not get these while they are unstable, this is not top of priority list)
How many minutes must you do you ECG within once the patient presents to the ER?
10
How frequently do you take a patients EKG?
15-30’ over 2-4hr
What is an ST depression?
Lack of oxygenation, permanent damage can be avoided if we respond appropriately!
Lack of “motivation” because you’re depressed
What is an ST elevation?
More than just schema, this is indicative of infra and permenant death of heart tissue. We would proceed with an echo
What are the stages of an assessment and the diagnostic studies we perform?
12-lead ECG (in 10’ q15-30/2-4h)
Cardiac monitor
Chest Xray
Coronary angiography
Exercise stress test
Echocardiogram
Explain a cardiac angiography
Assess: Coronary arteries
Looks at: Pressure in cardiac chambers, valve function, ventricular function
Use a dye to take photos via radial or femoral access threaded up to the aorta.
What does a stress test tell us?
Ischemia, ST segment changes, arrhythmia, functional capacity, efficacy of surgical intervention
Who cannot receive a stress test?
Elderly, with mobility issues
What does an echo assess?
Myocardial structures, ventricular function, effusions, thrombus, ischemia
What are the lab values we’re assessing in our cardio work-up?
Serum cardiac markers, C-reactive protein, lipid profile, blood glucose, electrolytes, kidney function
What are the serum cardiac markers?
Troponin, serum creatinine kinase, myoglobin
Do serum cardiac markers rapidly change in your system?
No. They take time to elevate and they’re examined in a “trending” manner
Troponin
Two subsets: cTnT, cTn1
Greater specificity than CK-MB
Levels rise 3-12hr
Peak 1-2days
Return to normal over 5-10 days
Serum Creatinine Kinase
Fractionated into bands
Rises 3-12hrs, peaks in 24
Return to normal after 2-3 days
Pt presents with chest pain, what could be the diagnosis
Stable or unstable angina, myocardial infarction
A patient presents with pain that lasts 3-5 minutes and responds well to nitro. There is usually no pain at rest and there is a ST segment depression on the ECG.
Chronic stable angina: Episodes are predictable and Brought on by precipitating factors, so we can time medications well. A disease grounded in supply and demand. Decrease load.
What are the variants of stable angina?
Silent ischemia, nocturnal angina, angina decubitus, and variant
Silent ischemia
Asymptomatic, diabetes mellitus
Nocturnal Angina
At night, not always while sleeping. Wear nitro patches at night
Angina decubitus
Chest pain while lying down. Relieved by standing or sitting
Variant angina
At rest or in response to spasm of major artery. Seen in clients w. Hx migraine, raynaids, not necessarily CAD, relieved by moderate exercise
A pt presents with chest pain that is new, occurs at rest and is also becoming worse. It is not relieved by rest and nitro does not work. This patient also has anxiety and indigestion.
Unstable angina. Associated with deterioration of plaque, can lead to MI or return to a stable lesion. Increases in frequency, duration, or severity.
What causes a myocardial infarction?
Severe and prolonged decrease in oxygen supply. This leads to necrosis. Usually associated with acute coronary thrombosis.
Is it more severe the lower on an artery the area of necrosis is?
No. The higher up on the artery it is, the more muscle it feeds and the worse the situation.
Zone of injury vs. zone of ischemia
Ischemia is the area deprived of oxygen but it is salvageable. The zone of injury is an area with compromised oxygen delivery but this is still salvageable.
A Pt presents with severe and immobilizing chest pain, position change and NO does not relieve their discomfort. They are not diabetic. There is initially an increase in glucose, BP and HR, and then there is a decline. There is pulmonary edema as you can hear crackles in their lungs. There are S3 and S4 lung sounds as well. They also have a fever.
MI
If a diabetic patient is having an MI, they will experience more pain than a non-diabetic patient (T/F)
False. A diabetic patient might not experience any pain at all!
What is the diagnostic criteria for a patient with an MI?
2/3 needed
-Chest pain more than 30’
-ECG-Q waves/ST elevation/Twave inversion
-Serum cardiac markers (troponin T, Creatinine kinase)
Which has an ST elevation: STEMI or NSTEMI?
STEMI (duh)
Which has elevated serum markers, STEMI or NSTEMI?
Both
Which leads to an elevation in serum markers, NSTEMI or unstable angina?
NSTEMI (eventually) and in NSTEMI there is an ST depression or T-wave inversion
