Week 8: Cardiac Emergencies.. Part 2 Flashcards
progressive inflammatory disorder of arterial wall that is characterized by focal lipid rich deposits of atheroma that remain clinically silent until they become large enough to impair tissue perfusion
atherosclerosis
Includes
STEMI
Non-STEMI
Unstable Angina
-Leading cause of Death in the US
Age:
Increased age-disease process begins early and develops gradually.
Gender:
Highest for middle-aged white caucasian
Race:
Caucasian males highest risk
Genetic:
Inherited tendencies for atherosclerosis
Coronary Artery Disease
modifiable risk factors for CAD
- Tobacco
- Hypertension
- Physical Activity
- Obesity
- Dyslipidemia
- Diabetes
- Stress
- ETOH abuse
- HRT
Hypertensive crisis
higher than 180/higher than 110
high blood pressure stage 2
160 or higher/100 or higher
high blood pressure stage 1
140-159/90-99
prehypertension
120-139/80-89
Where do we want our patients with CAD for BP
less than 120/less than 180
where do we want BMI?
19-24
optimal total cholesterol and ldl, HDL,TC/HDL
total: less than 160
LDL: less than 100
HDL: above 45
TC/HDL: less than 3
HIgh HDL promotes
promotes collateral circulation in the heart (creating new vessels around blocked vessels naturally)
most used to treat lipid levels
Statins: effects LDL, HDL, and triglycerides
what do omega fatty acids help with?
triglycerides
How does diet affect LDL, HDL, TG
LDL: lowers it
HDL: little effect
TG: lowers it
what does exercise really help with regards to HDL, LDL, TG?
really helps HDL and TG
Type of angina?
Pain w/exertion-relief w/rest
stable Angina
Type of Angina?
Pain onset w/ rest
Caused by vasospams
Prinzmetal’s
type of angina?
Pain onset w/rest
Precursor to AMI
unstable angina
type of angina?
Unrecognized
Silent agina
causative factors of Angina
- Physical exertion
- Temperature extremes
- Strong emotions
- Heavy meal
- Tobacco use
- Sexual activity
- Stimulants
- Circadian rhythm patterns
Treatment of stable angina?
- etiology: Myocardial ischemia
- Symptoms: episodic, aggravated with exercise, relieved w/NTG
- Treatment: NTG, beta blockers, ca+ channel blockers, ACE inhibitors
Unstable angina treatment
- etiology: ruptured or thickened plaque with platelet and fibrin thrombus
- symptoms: increasing episodes, occurs with rest and exercise, not relieved with NTG
- treatment: NTG, tPA, morphine (dilates vessels), ASA
Prinzmetals angina treatment
- etiology: Coronary vasospasams
- symptoms: Occurs at rest, Triggered with smoking, May have ST elevation,
AV Block or Ventricular arrhythmias - Treatment: Ca+ Channel Blockers
Patho of mycocardial infarct
- Rupture of plaque
- Ischemia within 10 seconds
- Hypoxia and lack of glucose
- Anaerobic activity
- inability to polarize: Ventricular remodeling
Stemi vs NonStemi
- ST elevation= stemi. Elevation in the t “firemans cap”
- ST depression= non-stemi.
manifestations of heart attack
- Appearance: Anxious, restless, pallor, diaphoresis
- Blood Pressure/Pulses
- Breathing
- JVD (Jugular Vein Distension)
- Auscultation/heart and lung
- Abnormal heart sounds S3, S4
- Shortness of Breath (SOB): Orthopnea
- Chest Discomfort: Pleuritic-point tenderness?, Localized vs. diffuse, Palpitaion
APQRST evaluation of chest pain
A= Associated Symptoms Dyspnea, nausea, diaphoresis, palpitations, feeling of impending doom
P= Precipitating Factors Exertion, Cold Exposure, meals, movement
Relieved by: rest, NTG, or position?
Q= Quality Heaviness, tightness, sharp, stabbing, burning
R= Region, Radiation, Risk Factors Radiates to: arm, jaw, back, below diaphram
Region: substernal, left lateral, right chest
Risk factors: HTN, DM, Obesity, Dyslipidemia, Smoking
S= Severity Rate pain on scale 0-10
T= Timing Onset and duration of pain, nocturnal?, constant? Intermittent?
inferior area of damage
Right Coronary Artery
Leads II, III, AVF (see st elevation)
anterior area of damage
Left Anterior Descending
Leads V1-V4 (st elevations)
lateral area of damage
Circumflex
Leads I, AVL, V5, V6 (st elevations)
CPK and Troponin
CPK MB: rises 4-8 hours, peaks 12-24, remains elevated for a day
Troponin: (breakdown in cardiac muscle) rises in 3 hours, peaks 12-18 hours, stays elevated for 14 days
Troponin t: 0.1 or less micrograms per liter
Troponin I: less than 10 micrograms
angiogram
- View coronary arteries
- Incr. risk if done after MI
- Need creatinine: Dye can cause renal failure
Echocardiogram
Safe, non-invasive, wall motion abnormalities
C-Reactive protein
Produced by liver w/ inflammation
Rules out stable angina
Good o get pt. baseline
Reference range
Low- < 1.0 mg/dL
Average- 1.0-3.0 mg/dL
High- > 3.0 mg/dL
normal BUN
10-20
normal creatinine
0.5-1.1
normal creatinine clearance
130-170 ml/min
myoglobin
- Peak levels occur 1-4 hours
- Doubling in 2 hours ++ MI
- Reference range: < 90 mcg/L
nursing immediate action for MI
- Pt. placed in semi-fowlers position
- ECG and Cardiac Enzyme Assessment
- IV line started (at least 18 guage)
- ASA 325 mg given: Four baby ASA, Clopidogrel (Plavix) 300 mg (becomes an issue if they need to go to surgery)
- Oxygen
- Beta Blockers
- ACE inhibitors (if CHF present): watch out for asthma patients
-NTG titrate to releive chest pain but keep SBP above 90 mm/Hg
- start drip 5 mics per min, can titrate as high as 400
- Works as a vasodilator
- Decreases peripheral resistance
- Increased coronary blood flow
Heparin vs Lovenox
- Neither lyse the clot only prevents new clots
- Heparin increased risk of HTP
- Lovenox longer more predictable action
- Not preferred if Surgery anticipated
cardiac catheterization
- Procedure which involves placement of a catheter into RT or LT side of heart.
- Invasive
- Coronary angiography is often included together with cardiac catheterization
- Diagnostic procedure and/or
- a therapeutic procedure
- Adults & Children
PTCA
- This procedures provides the doctor with a “road map” of the arteries in the heart
- To find any areas of blockage in the arteries that supply the heart with blood.
- May also look at the valves, chambers & heart muscle
- Can help in making decisions about the treatment of heart disease.
Relative contraindications for cardiac cath
- Peptic Ulcer
- Anticoagulants
- Ischemic stroke
- Dementia
- Recent surgery
- Internal bleeding recent
absolute contraindications to cardiac cath
- Internal Bleeding
- Cerebral Aneurysm
- AV malformation
- Previous Cerebral Hemorrhage
- Pregnant
- CVA recent
- Uncontrolled HTN
- Aortic Dissection
- Traumatic CPR
Catheter can be introduced through?
- femoral, brachial or carotid artery to the knob of the aorta for coronary arteries
- It may be advanced to the left heart to look at the LT ventricle
Balloon Angioplasty/PTCA
- Balloon Angioplasty is a technique used to dilate an area of arterial blockage with the help of a balloon catheter.
- It is a way of opening a blocked blood vessel
- Not highly effective, can rupture wall of vessel, or the plaque can just move right back
stent placement
- Usually a metal stent is placed in the opened artery to make sure restenosis does not reoccur
- Following the procedure, the balloon is deflated and additional x-rays are taken to determine how much blood flow has increased.
- usually covered in a heparanized solution
prevention of re-stenosis
- Lifestyle Change
- Healthy diet
- adequate exercise
- No Smoking
- Medicine coated stents (apirin, plavix, cholesterol medicine)
ablation
INDICATIONS
- Atrial Fibrillation
- Atrial Flutter
- AV Nodal Reentrant Tachycardia
- AV Reentrant Tachycardia
- Atrial Tachycardia
Most often, cardiac ablation is used to treat rapid heartbeats that begin in the upper chambers, or atria, of the heart. As a group, these are know as supraventricular tachycardias, or SVTs. Types of SVTs are:
Minimally invasive treatment for arrhythmias
Live fluoroscopy and angiography techniques are used along with special electro physiologic equipment and catheters
minimally invasive CABG
- Minimally invasive surgery does not use CPB
- Smaller incision
- Emerging as a replacement for conventional CABG
- Starting in 1990’s, MIDCAB has gained popularity
- Usually conducted for LIMA to LDA grafts
Advantages
- no sternotomy or CPB
- operating time is 2-3 hours
- recovery time 1-2 weeks
- effectiveness 90%
- incision only 10cm
- reduced need for blood transfusion
- less time on anesthesia
- less pain
- less expensive
problem with MIDCAB
- New instruments must be developed
- Requires highly skilled surgeon and learning curve for surgeons limits number performed
- Small incision
- Beating heart
- Blood in field
- Can only be used with patients having blockages in one or two coronary arteries on the front of the heart
- Attempts at operating on other arteries have been moderately successful, but requires even greater skill and practice
Port access CABG
- Uses CPB
- Balloon catheter system for aortic occlusion and cardioplegic arrest
- 5-8 cm left anterior thoracotomy incision
- No sternotomy!!!
- uses LIMA
Benefits:
- Bloodless field
- Heart arrested
- allows more accurate anastomoses than MIDCAB
- Smaller incision than CABG
- No sternotomy
Drawbacks
- Uses CPB
- Technically very difficult
Nursing management for all CABG patients
*Most important thing we look at is hemodynamics
- Assess for signs of hemodynamic compromise
- Hypotension
- Decreased cardiac output
- Shock
- Monitor VS, ECG, MAP (70-110 mm Hg)
- I&O – fluid and electrolyte imbalance
- Early weaning from ventilator
- Monitor ABGs
- Encourage effective post-operative pulmonary toileting
- Chest splintingPain management
- Pharmacological management
- Assess chest tube drainage
- Encourage early ambulation
- Monitor for complications of procedure
- Advance diet as tolerated
- Cardiac diet
- Emotional support of patient and family
pulmonary toileting
- good oral care every 2 hours
- when extubated: incentive spirometer, turning, ambulating, sitting up, deep breathing and coughing, splinting with binder and pillow, pre-medication
chest tubes for open heart
- medial-stinal chest tubes placed right behind heart
- drain excess fluid and blood that comes off
- several hundred the first hour is normal, want to see drainage steadily decreases and goes from sanguinous to sero-sanguinous. Also dump a lot of fluid when the sit up as well
- If getting a lot of blood, do an H&H, if less than 6 transfuse
- Also think about auto-transfusion. Chest tube has an extra chamber. Take the blood draining off and put back in. Big problem with this is hyperkalemia (bc of K+ bath of heart with surger)
Post operative dysrhythmias
- Hypothermia (warming)
- Anesthetics
- Electrolyte imbalance
- Acidosis
- MI
- normally given lanoxin (iv version of digoxin) IV psuh
treatment of CO/CI decreased, PCWP decreased
Inotropic support (increase contractility of the heart, dobutamine! 5mics per kg) & replacement Fluid
treatment of SVR decreased
(means periphery is dilated) Check for Hypothermia (vasodilation related to temperatures) or volume issues
discharge planning and teaching for CABG
- What to expect at home
- Pain in your chest around the incision area
- Swelling in the leg at harvest site
- Itchiness or tingling feeling at incision site
- Weakness
- Cardiac rehabilitation
- Lifestyle & diet modification
- Smoking cessation
- Cardiac diet (Low salt, low cholesterol, low fat)
