Acute Coronary Syndrome

Thrombolytic Therapy Procedure

Draw blood to obtain baseline lab values and start 2-3 lines for IV therapy Depending on drug selected, therapy is given in one IV bolus or over time (30-90 min)

Transmyocardial Laser Revascularization

Indirect revascularization procedure Advanced CAD who are NOT candidates for traditional CABG and have persistent angina despite maximum medical therapy Procedure: Use of a high-energy laser to create channels in the heart muscle to allow blood flow to ischemic areas Can be done using a left thoracotomy approach or in combo with CABG surgery Adjunctive therapy when bypass grafts cannot be placed

Recovery Phase I: Hospitalization

Activity level depends on severity of angina or MI. Patient may initially sit up in bed or a chair, perform range-of-motion exercises and self-care (e.g., washing, shaving), and progress to ambulation in hallway and limited stair climbing. Attention focuses on management of chest pain, anxiety, dysrhythmias, and complications.

Pain

Occurs with increasing frequency and is easily provoked by minimal or no exertion, during sleep, or even at rest.

STEMI

Totally blocked by a thrombus and blood flow is restricted

Myocardial Infarction: Gender Differences

Women seen to have first MI at older age, often have more comorbidities Women seek medical attn later in CV disease process and often more ill on presentation UA is first heart event for women most often Women: more "silent" MIs Women: more disability after CV event

The nurse is caring for a patient recently returning from cardiac catheterization after a severe myocardial infarction (MI). In discussing the plan of care with the patient, which statement is most appropriate to describe care for the immediate post procedure period? "I can assist you onto the bedpan if you need help." "I will need to assist you when you walk in the hall." "We will start with your cardiac rehabilitation tomorrow." "You are not allowed to sit in a chair for at least 2 weeks."

"I can assist you onto the bedpan if you need help." --- Use of a bedpan is based on patient preference and is appropriate care after a large MI to avoid extra movement that could stress the myocardium.

Indication Criteria for Thrombolytic Therapy

(1) Chest pain less than 12 hours w/ 12-lead ECG finding consistent with acute STEMI (2)No absolute contraindications Pts. w/ chest pain lasting 12-24 hrs. with ECG changes supporting STEMI may be considered for therapy

Nursing Interventions

-Upright position -Nasal cannula >93% -Assess O2 status -Est. IV line -Nitro, morphin, supplemental O2 to reduce chest pain -ECG monitoring -Vital signs -Intake and output -Lung and heart sounds

Initial Therapy after MI

-V nitroglycerin -Aspirin -β-adrenergic blockers -Anticoagulation

A patient comes to the emergency department with complaints of chest pain. The initial ECG shows ST-segment elevation in more than three leads. Which intervention should the nurse perform first? Obtain a chest x-ray and complete blood count (CBC). Administer oxygen and nitrates. Establish a peripheral intravenous (IV) line. Ask patient to rate the severity of the pain.

Administer oxygen and nitrates. --- A patient with an ST-segment-elevation myocardial infarction (STEMI) requires oxygen to decrease the amount of damage to the myocardium and nitrates to increase coronary blood flow.

The emergency department receives a report from a paramedic who is transporting a patient with chest pain that is unrelieved by three sublingual nitroglycerin tablets. Which priority collaborative care intervention should be implemented on the patient's arrival? Administration of morphine intravenously A 12-lead ECG to determine areas of injury in the myocardium Administration of β-blocker to block catecholamine effects on the myocardium Laboratory tests for myocardial proteins to determine myocardial injury

Administration of morphine intravenously --- Administration of morphine will decrease pain. This is the priority intervention at this time.

Thrombolytic (fibrinolytic) Therapy TX

Aims to limit infarction size by dissolving the thrombus in the coronary artery and prepare the heart muscle for reperfusion

Contraindications for Thrombolytic Therapy: ABSOLUTE

Any history of intracranial hemorrhage Known structural or vascular abnormality (e.g., arteriovenous malformation) Known intracranial neoplasm (primary or metastatic) Recent (within past 3 months) ischemic stroke Significant closed-head or facial trauma within past 3 months Intracranial or intraspinal surgery within past 2 months Severe uncontrolled hypertension Active internal bleeding or bleeding diathesis (excluding menstruation) Suspected aortic dissection

A patient is being discharged with prescriptions for aspirin and clopidogrel after percutaneous coronary intervention (PCI) to treat acute coronary syndrome. The patient wants to know why these medications need to be taken if the artery is open after the stent was placed. Which is the best response? These medications are to help relieve any post procedure pain. Aspirin and clopidogrel can prevent another clot from forming. Aspirin and clopidogrel help relax the artery so the stent can stay in place. These medications should not be used because of an increased risk of bleeding.

Aspirin and clopidogrel can prevent another clot from forming. --- After PCI, the patient is treated with dual antiplatelet agents until the intimal lining can grow over the stent and provide a smooth vascular surface that will inhibit thrombus formation.

The nurse administers morphine as ordered to a patient experiencing chest pain of 9 on a scale of 10 that is unrelieved by three doses of nitroglycerin. Which assessment finding would be most concerning? Distended neck veins Increased pain rating Decreased blood pressure Oxygen saturation of 93% with oxygen administered via nasal cannula

Distended neck veins --- Distended neck veins indicate heart failure resulting from myocardial infarction, making this the most concerning finding.

The nurse is caring for a patient who arrives in the emergency department with complaints of chest pain. Which nursing intervention is a priority for this patient? Elevate the head of bed. Start an intravenous (IV) line. Provide calming reassurance. Administer thrombolytic therapy.

Elevate the head of bed.--- Elevating the head of bed places the patient in an upright position to maximize oxygenation and promote myocardial perfusion.

Collaborative care for ACS

Focuses on stabilizing the patient in crisis, treating pain, and eliminating the coronary arterial blockage.

Contraindications for Thrombolytic Therapy: RELATIVE

For streptokinase, prior treatment within the past 6 months Active peptic ulcer disease Current use of oral anticoagulants Pregnancy Prior ischemic stroke (>3 months ago) Dementia Known intracranial pathology not covered in absolute contraindications Noncompressible vascular punctures Recent (within 2-4 weeks) internal bleeding Major surgery (<3 weeks) History of chronic, severe, poorly controlled hypertension Significant hypertension on presentation (systolic blood pressure [SBP] >180 mm/Hg or diastolic blood pressure [DBP] >110 mm/Hg) Traumatic or prolonged (>10 min) cardiopulmonary resuscitation

PCI anticipated drug might be used

Glycoprotein IIb/a Inhibitors

Thrombolytic (fibrinolytic) Therapy Goal

Goal is to admin thrombolytic agent within 30 minutes of arrival to ER

On entering a patient's room, the nurse sees the patient clutch his chest, and he states he is in pain. Which nursing interventions are priorities? (select all that apply) Have the patient rate the pain on a number scale. Determine when the pain started. Ask the patient to describe his pain. Question the patient about the location of the pain. Assess when the patient last received pain medication.

Have the patient rate the pain on a number scale. -- Asking the patient with chest pain to describe the severity of the pain using a number scale is a priority nursing intervention to help determine whether the pain is cardiac in origin. Determine when the pain started.-- Asking the patient with chest pain when the pain started is a priority nursing intervention to help determine whether the pain is cardiac in origin. Ask the patient to describe his pain.-- Asking the patient with chest pain to describe the quality of the pain is a priority nursing intervention to help determine whether the pain is cardiac in origin. Question the patient about the location of the pain.-- Asking the patient with chest pain about the location and possible radiation of pain is a priority nursing intervention to help determine whether the pain is cardiac in origin.

Thrombolytic (fibrinolytic) Therapy Indications

Indicated for patients with a STEMI Advantages include its availability and rapid admin when a facility doesnt have a interventional cardiac cath lab or too far away

Severe LV Dysfunction may require addition of....

Intra-aortic balloon pump (IABP) therapy and/or Inotrope (e.g., dobutamine) Small percentage of pts. may require emergent coronary artery bypass graft (CABG) surgery.

MIDCAB

Left anterior descending or right coronary artery an approach to surgical treatment that does not involve a sternotomy and CPB. Requires several small incisions between the ribs or a mini-thoracotomy Thoracoscope or robotic assistance is used to dissect the internal mammary artery (IMA) from the chest. Mechanical stabilizer immobilizes operative site. The IMA is then sutured to the left anterior descending or right coronary artery Some patients undergo hybrid procedures in which they have a MIDCAB for the left anterior descending artery and a PCI of a second or third artery at a later time.

OFCAB

Less than 20% of CABG procedures Median sternotomy to access all coronary vessels. Performed on a beating heart (no CPB) using mechanical stabilizers Associated with less blood loss, less renal dysfunction, less postoperative atrial fibrillation, and fewer neurological complications. Primarily patients with multiple comorbidities for whom CPB should be avoided

The surgeon has explained the coronary artery bypass graft (CABG) procedure to a patient. Afterward the patient asks the nurse why he "just can't get more stents." How can the nurse explain the difference between these procedures? Recovery time for CABG is shorter than that for percutaneous coronary intervention (PCI). The CABG procedure is safer than having stents. CABG will result in better control of your chest pain. Long-term benefits are expected to be better with CABG.

Long-term benefits are expected to be better with CABG. --- Studies have shown improved patient outcomes, quality of life, and survival after CABG surgery if stent placement is not successful.

Complications of Thrombolytic Therapy

Major concern: Reocclusion of the artery BLEEDING Site of thrombus is unstable, and formation of another clot or spasm of the artery may occur. Therefore, IV heparin is started If another clot develops, the patient will have similar complaints of chest pain, and ECG changes will return. should be moved to a facility with PCI capabilities as soon as possible so PCI can be performed if thrombolytic therapy fails

Pain Patterns/ Locations UA and MI

Mid sternum, left shoulder and down both arms, neck and arms Substernal radiating to neck and jaw, substernal radiating down left arm Epigastric radiating to neck, jaw, and arms Intrascapular

A patient is complaining of angina that has increased in intensity. The patient's vital signs are as follows: blood pressure 94/52, heart rate 122, respiratory rate 20, temperature 99.9, and oxygenation saturation 93%. An electrocardiogram for the patient shows elevated ST segment in leads II and III. Which intervention has the highest priority in the nursing management of this patient? Administration of heparin per protocol Notification of the health care provider Administration of a β-blocker per protocol Administration of antiplatelet therapy per protocol

Notification of the health care provider--- Notifying the health care provider is highest priority because ST-segment elevation usually requires percutaneous coronary intervention to restore myocardial perfusion. The health care provider determines the need for immediate PCI.

Coronary Revascularization: CABG Surgery Candidates

PT.s WHO: -Do not respond to medical management -Have left main coronary artery or three-vessel disease -Are not candidates for PCI (e.g., blockages are long or difficult to access) -Have not responded to PCI and continue to have chest pain. -CABG may also be the option for patients with diabetes, LV dysfunction, or chronic kidney disease. Considered palliative TX of CAD, not cure

Nursing Management for ACS

Pain assessment and relief, careful observation of signs and symptoms, promotion of rest and comfort, and teaching stress reduction strategies.

A patient has been diagnosed with acute coronary syndrome. Which assessment findings would the nurse expect to see?(Select all that apply) Pain occurs at rest. Pain only occurs after activity. Pain may radiate to other areas. Severe, immobilizing chest pain. Pain resolves with nitroglycerin.

Pain occurs at rest. ---The pain from acute coronary syndrome may occur while the patient is active or at rest, asleep or awake. Pain may radiate to other areas. --- The pain from acute coronary syndrome may radiate to the neck, lower jaw, and arms or to the back. Severe, immobilizing chest pain. --- Pain from acute coronary syndrome usually lasts for 20 minutes or longer, is more severe than usual chest pain, and may be described as immobilizing.

NSTEMI

Partially blocked by a thrombus

Which patients are more likely to require off-pump coronary artery bypass (OPCAB) surgery instead of coronary artery bypass graft (CABG) surgery? (Select all that apply) Patient with renal complications whose urine output is 50 mL per day Patient with left ventricular heart failure, obesity, and poor wound healing Patient with history of an ischemic stroke who has difficulty using the right arm Patient with diabetes mellitus whose blood glucose level ranges from 70 to 150 mg/dL Patient with failed percutaneous coronary intervention (PCI) who has continued chest pain

Patient with renal complications whose urine output is 50 mL per day--- OPCAB is associated with less renal dysfunction and would be more likely to be used for a patient with current renal dysfunction. Patient with left ventricular heart failure, obesity, and poor wound healing--- OPCAB is used for patients with multiple comorbidities because of decreased complications when compared with CABG. Patient with history of an ischemic stroke who has difficulty using the right arm --- OPCAB is associated with fewer neurological complications and would be more likely to be used for a patient with a history of ischemic stroke, since neurological deficits may already be present.

CABG Surgery

Placement of arterial or venous grafts to provide blood flow between aorta and other major arteries and the heart muscle distal to blocked coronary artery Requires a sternotomy (opening of chest cavity) and cardiopulmonary bypass (CPB) Improve pt outcomes, quality of life, and survival after surgery

Unstable angina is considered an emergency because of which pathophysiological occurrence? Platelet aggregation blocks the artery. Fatty streaks form a plaque on the arterial wall. Platelet destruction causes myocardial ischemia. Plaques narrow the arterial wall causing infarction.

Platelet aggregation blocks the artery. --- Unstable angina results from a ruptured plaque that causes platelet aggregation, which forms a thrombus. The thrombus can partially block blood flow to the heart resulting in myocardial injury, making this a medical emergency.

Pain may

Radiate to the neck, jaws, and arms or to the back Active or at rest, asleep or awake Commonly occurs in early mornings

Thrombolytic Therapy: Signs of Reperfusion

Reperfusion: coronary artery that was blocked is opened and blood flow is restored to the heart muscle Signs: (1)Return of the ST segment to baseline on ECG (most reliable) (2)Resolution of chest pain and an early, rapid rise of the serum cardiac biomarkers within 2 hrs of therapy, peaking within 12 hours (3)Presence of reperfusion dysrhythmias (accelerated idioventricular rhythm) is a less reliable sign of reperfusion. These dysrhythmias are generally self-limiting and do not require aggressive TX

A patient diagnosed with myocardial infarction is transferred to the intensive care unit (ICU) for observation after percutaneous coronary intervention (PCI) with stent placement in the right circumflex artery. The nurse will assess for effectiveness of the intervention by monitoring for which changes? Decreased cardiac enzymes to baseline Coagulation values within normal limits Resolution of ST-elevation changes on a 12-lead ECG Increased peripheral pulses indicative of reperfusion

Resolution of ST-elevation changes on a 12-lead ECG--- Opening of the affected coronary artery allows perfusion manifested by resolution of ST elevation on a 12-lead ECG.

The Emergency Medical Service (EMS) was called to assess a person who had collapsed. The patient's electrocardiogram (ECG) has been transmitted to the emergency department for interpretation and intervention. Which results would require the patient's immediate transport for diagnostic cardiac catheterization? U wave ST elevation ST depression T-wave inversion

ST elevation--- ST elevation indicates myocardial infarction and requires immediate intervention.

Myocardial Infarction: Pain Symptoms

Severe/ persistent chest pain not relieved by rest or nitrates is the hallmark of an MI Pain: heaviness, pressure, burning, crushing, tightness, or constriction Pain usually lasts 20 min. or more and is more severe than usual angina Epigastric pain pt. may take antacids without relief

Medications

Sublingual nitroglycerin (SL NTG) and asprin (chewable) if not administered before arrival into ER Morphine sulfate is given for pain UNRELIEVED by nitroglycerin

A male patient diagnosed with acute ST-segment-elevation myocardial infarction (STEMI) is receiving thrombolytic therapy. Which assessment finding by the nurse would require immediate intervention? A decreased ST-segment elevation compared with previous ECG tracings. An idioventricular rhythm 30 minutes after the thrombolytic infusion. The skin is pale and cool with bilateral pedal pulses faintly palpable. The patient reports the pressure in his chest has diminished in severity.

The skin is pale and cool with bilateral pedal pulses faintly palpable. --- Bleeding is a complication associated with thrombolytic therapy. Skin that is pale and cool, in association with faint peripheral pulses, can indicate low blood pressure related to major bleeding, which requires immediate intervention.

Which statement describes how unstable angina differs from chronic stable angina? Unstable angina has a random onset. Stable angina is not relieved by resting. Stable angina requires immediate treatment. Unstable angina does not change in intensity.

Unstable angina has a random onset. --- Unstable angina differs from chronic stable angina because it is not predictable and can have a random onset.

Continuous ECG Monitoring to...

detect premature ventricular contractions (PVCs) or ventricular tachycardia that can lead to ventricular fibrillation in pt. who had MI Monitor ST segment shift up or down Silent ischemia may occur

Bare metal stent (BMS) or drug-eluting stent (DES)

is inserted into the blocked coronary artery.

A patient has just been diagnosed with a myocardial infarction. The patient has begun to cry and is verbalizing doubts about being able to care for her family. How would the nurse approach the patient to address these concerns? "Can you tell me what your concerns are? I have time." "Can I call the chaplain or someone from your family to be with you?" "Everyone goes through this process, and I have been told it doesn't last long." "I can suggest a support group for you when you are discharged home."

"Can you tell me what your concerns are? I have time." --- Asking the patient to be specific about concerns gives the nurse the opportunity to assist.

A patient comes to the emergency department with complaints of chest pain, and heart monitoring is initiated. The nurse notes T-wave inversion on the electrocardiogram (ECG). The patient questions the nurse about what this means. Which is the nurse's best response? "T-wave inversion means you are having a heart attack." "You are having decreased blood flow to part of the heart." "The ECG shows you have an area of dead tissue on the heart." "This indicates a zone of injury on your heart that is causing pain."

"You are having decreased blood flow to part of the heart." --- This is the most appropriate response because T-wave inversion indicates a zone of ischemia resulting from decreased blood flow to part of the heart.

Unstable Angina: Gender Differences

75 YOA+: MI incidence in men and women equalize Men present more with acute MI Men develop greater collateral circulation than women Men have larger coronary arteries Women seek medical attn for symptoms more than men

Safety Alert: Thrombolytic Therapy

Minor or major bleeding may occur Establish two or three IV lines before starting If signs and symptoms of major bleeding occur (e.g., drop in blood pressure [BP], increase in heart rate [HR], sudden change in the patient's mental status, blood in the urine or stool), STOP the drug and notify the health care provider.

Which statement best describes acute coronary syndrome (ACS)? ACS is the progression of untreated ischemia. ACS is the equalization of oxygen demand and supply. ACS is the development of a stable atherosclerotic plaque. ACS is the first clinical sign of systemic atherosclerotic disease

ACS is the progression of untreated ischemia.--- When ischemia is prolonged and not immediately reversible, ACS develops and encompasses the spectrum of unstable angina, non-ST-segment-elevation myocardial infarction, and ST-segment-elevation myocardial infarction.

Unstable Angina: Pain Symptoms

At rest or has worsening patterns Pt. with previously diagnosed angina describes pain that has prolonged rapidly in the past few hours, days, or weeks, often pain at rest

ACS is caused by the decline of a once stable----

Atherosclerotic plaque - the previously stable plaque ruptures, releasing substances into the vessel. This causes plaque aggregation and thrombus formation.

Recovery Phase II: Early Recovery

Begins after the patient is discharged. Usually lasts from 2-12 weeks and is conducted in an outpatient facility. Activity level is gradually increased under the supervision of the cardiac rehabilitation team and with ECG monitoring. Team may suggest that activity (e.g., walking) be initiated at home. Information regarding risk factor reduction is provided at this time.

Common Pain Locations for MI and UA

Epigastric Substernal Retrosternal

What is a primary difference in the clinical manifestations of acute coronary syndrome between men and women? Men experience more disability after myocardial infarction than women. The initial cardiac event for men is more often unstable angina than myocardial infarction. More women than men present with acute myocardial infarction as the first sign of coronary artery disease. Fewer women than men manifest the "classic" signs and symptoms of unstable angina or myocardial infarction.

Fewer women than men manifest the "classic" signs and symptoms of unstable angina or myocardial infarction. --- Fewer women than men manifest the "classic" signs and symptoms of a cardiac event. Women are more likely to have nontypical symptoms (e.g., fatigue, shortness of breath, indigestion, anxiety).

Emergency Percutaneous Coronary Intervention (PCI)

First line treatment for pts. with confirmed STEMI (e.g., ST elevation on ECG and/or positive cardiac biomarkers)

The nurse is caring for a patient who returns to the unit after percutaneous coronary intervention (PCI). Which intervention is a priority on the patient's arrival on the unit? Monitor the ECG for heart rate and rhythm. Check the sternal incision for bleeding. Assess recovery from general anesthesia. Ensure that intravenous (IV) fluids are infusing.

Monitor the ECG for heart rate and rhythm. --- Because PCI is used to open a blocked artery in patients with segment-elevation myocardial infarction, the priority nursing intervention is to assess the ECG for changes after the procedure.

Goal of Percutaneous Coronary Intervention (PCI)

Open blocked artery within 90 minutes of arrival

How does acute coronary syndrome cause injury to the heart? Collateral circulation develops from a thrombus that obstructs blood flow. Platelets adhere to the plaque, occluding blood flow to the myocardium. A plaque narrows the blood vessel causing increased blood flow to the myocardium. Blood flow to the myocardium is partially blocked, resulting in myocardial inflammation.

Platelets adhere to the plaque, occluding blood flow to the myocardium. --- A thrombus develops from platelets that adhere to the plaque, resulting in lack of blood flow to the myocardium distal to the blockage, which causes necrosis.

PQRST Chest Pain

Precipitating events Quality Radiation Severity Timing

Cause of ACS

Prolonged ischemia resulting in unstable angina (UA), non-ST-segment-elevation myocardial infarction (NSTEMI), and STEM.

Recovery Phase III: Late Recovery

Takes place 12+ weeks after hospital discharge and involves a long-term maintenance program. Individual physical activity programs are designed and implemented at home, a local gym, or the rehabilitation center. Patient and caregiver may restructure lifestyles and roles. Therapeutic lifestyle changes should become lifelong habits. Medical supervision is still recommended.

Coronary angiography with possible percutaneous coronary intervention (PCI) is ...

considered once patient is stable and angina is controlled, or if angina returns or increases in severity

Cardiac Catheterization

to locate and assess severity of blockage(s), determine presence of collateral circulation, and eval left ventricular (LV) function.