Acute Coronary Syndromes Quiz 2

Placement of Coronary Artery Stent

A stent is an expandable meshlike structure designed to keep the vessel open after balloon angioplasty. Because stents are thrombogenic, many different types of drugs are used to prevent platelet aggregation within the stent. Drugs commonly used during PCI are unfractionated heparin (UH) or low-molecular-weight heparin (LMWH), a direct thrombin inhibitor (e.g., bivalirudin [Angiomax]), and/or a glycoprotein IIb/IIIa inhibitor (e.g., eptifibatide [Integrilin]). After PCI, the patient is treated with dual antiplatelet drugs (e.g., aspirin [indefinitely] and clopidogrel) up to 12 months or longer, until the intimal lining grows over the stent and provides a smooth vascular surface. There are two types of stents: bare metal stents (BMS) and drug-eluting stents (DES)

Myocardial Infarction

■Nausea and vomiting -Reflex stimulation of the vomiting center by severe pain -Vasovagal reflex ■Fever -Up to 100.4° F (38° C) in first 24-48 hours -Systemic inflammatory process caused by heart cell death

Complications of Myocardial Infarction

■Heart failure -Occurs when pumping power of heart has diminished -Left-sided HF ■Mild dyspnea, restlessness, agitation, slight tachycardia initially -Right-sided HF ■Jugular venous distention, hepatic congestion, lower extremity edema

Coronary artery disease

■Includes stable angina, acute coronary syndromes ■Ischemia -Insufficient oxygen supply to meet requirements of myocardium ■Infarction -Necrosis or cell death that occurs when severe ischemia is prolonged and decreased perfusion causes irreversible damage to tissue

Interprofessional Care Acute Coronary Syndrome

■Initial interventions -12-lead ECG -Upright position -Oxygen - keep O2 sat > 93% -IV access -Nitroglycerin (SL) and ASA (chewable) -Statin -Morphine

Acute Coronary Syndrome

Relationships among coronary artery disease, chronic stable angina, and acute coronary syndrome. When ischemia is prolonged and not immediately reversible, acute coronary syndrome (ACS) develops. ACS includes the spectrum of UA, non-ST-segment-elevation myocardial infarction (NSTEMI), and ST-segment-elevation myocardial infarction (STEMI). When patients first present with chest pain, ST-elevations on the 12-lead ECG are most likely indicative of a STEMI. The ECG should always be compared to a previous ECG whenever possible. For patients with chest pain who do not show ST-elevation or ST-T wave changes on the ECG, it is difficult to distinguish between UA and NSTEMI until serum cardiac biomarkers are measured. On the cellular level, the heart muscle becomes hypoxic within the first 10 seconds of a total coronary occlusion. Heart cells are deprived of oxygen and glucose needed for aerobic metabolism and contractility. Anaerobic metabolism begins and lactic acid accumulates. In ischemic conditions, heart cells are viable for approximately 20 minutes. Irreversible heart damage starts after 20 minutes if there is no collateral circulation.

Clinical Manifestations of CAD Chronic Stable Angina

■Intermittent chest pain that occurs over a long period with same pattern of onset, duration, and intensity of symptoms ■Few minutes in duration ■ST segment depression and/or T-wave inversion ■Control with drugs •Chronic stable angina refers to chest pain that occurs intermittently over a long period of time with a similar pattern of onset, duration, and intensity of symptoms.

Chronic Stable Angina interprofessional care

■Lipid lowering drugs -Statins (↓ cholesterol) ■Atorvastatin (Lipitor), Pravastatin (Pravachol) -Fibrates (↓ triglycerides) ■Gemfibrozil (Lopid) -Niacin (Vitamin B3) ■↓ cholesterol

Chronic Stable Angina interprofessional care

■Long-acting nitrates -To reduce angina incidence -Main side effects: headache, orthostatic hypotension -Methods of administration ■Oral ■Nitroglycerin (NTG) ointment ■Transdermal controlled-release NTG

Internal Mammary Artery and saphenous vein grafts

•The internal mammary artery (IMA) is the most common artery used for bypass graft. It is left attached to its origin (the subclavian artery) but then dissected from the chest wall. Next, it is anastomosed (connected with sutures) to the coronary artery distal to the blockage. •Saphenous veins are also used for bypass grafts. The surgeon endoscopically removes the saphenous vein from one or both legs. A section is sutured into the ascending aorta near the native coronary artery opening and then sutured to the coronary artery distal to the blockage. The use of antiplatelet and statin therapy after surgery improves vein graft patency.

Myocardial Infarction Healthing Process

■10 to 14 days after MI, scar tissue is still weak ■Heart muscle vulnerable to stress ■Monitor patient carefully as activity level increases

Sudden Cardiac Death Nursing/Interprofessional Care

■24-hour Holter monitoring ■Exercise stress testing ■Signal-averaged ECG ■Electrophysiologic study (EPS) ■Implantable cardioverter-defibrillator (ICD) •Antidysrhythmic drugs •LifeVest

Nursing Management Acute Coronary Syndrome

■Acute Care -Anxiety reduction ■Identify source and alleviate ■Patient teaching important -Emotional and behavioral reaction ■Maximize patient's social support systems ■Consider open visitation

Nursing Management Acute Coronary Syndrome

■Acute Care ■Pain: nitroglycerin, morphine, oxygen ■Continuous monitoring •ECG •ST segment •Heart and breath sounds •VS, pulse oximetry, I and O ■Rest and comfort •Balance rest and activity •Begin cardiac rehabilitation

Complications of myocardial Infarction

■Dressler syndrome -Pericarditis and fever that develops 1 to 8 weeks after MI -Chest pain, fever, malaise, pericardial friction rub, arthralgia -High dose aspirin is treatment of choice •Dressler syndrome is pericarditis and fever that develop 1 to 8 weeks after MI.

Interprofessional Care Acute Coronary Syndrome

■Drug therapy -IV nitroglycerin (NTG) -Morphine -β-adrenergic blockers -ACE inhibitors -Antidysrhythmic drugs -Lipid-lowering drugs -Stool softeners

Complications of Myocardial Infarction

■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

Nursing Management Acute Coronary Syndrome

■Evaluation -Stable vital signs -Relief of pain -Decreased anxiety -Realistic program of activity -Effective management of therapeutic regimen

Acute Myocardial Infarction

•Acute myocardial infarction in the posterolateral wall of the left ventricle. This is demonstrated by the absence of staining in the areas of necrosis (white arrow). Note the scarring from a previous anterior wall myocardial infarction (black arrow). •The majority of MIs affect the LV and are usually described based on the location of damage (e.g., anterior, inferior, lateral, septal, or posterior wall infarction). The location of the MI and ECG changes correlate with the involved coronary artery. •For example, in most people, the right coronary artery provides blood to the inferior and posterior LV walls. Blockage of the right coronary artery results in an inferior wall and/or posterior wall MI. Anterior wall infarctions result from blockages in the left anterior descending artery. Blockages in the left circumflex artery usually cause lateral LV wall MIs. Damage can occur in more than one location, especially if more than one coronary artery is involved (e.g., anterolateral MI). Right ventricular MIs are much less common and treated differently than LV MIs. •Not everyone develops collateral circulation, but if present, the degree of collateral circulation influences the severity of the MI. An individual with a long history of CAD may develop good collateral circulation to provide the area surrounding the infarction site with a blood supply. This is one reason why a younger person may have a more serious first MI than an older person with the same degree of blockage.

Locations and Patterns of Angina and MI

•Although most angina pain occurs substernally, it may radiate to other locations, including the jaw, neck, shoulders, and/or arms. •Many people with angina complain of indigestion or a burning sensation in the epigastric region. •The sensation may also be felt between the shoulder blades. •Often people who complain of pain between the shoulder blades or indigestion type pain dismiss it as not being heart related. •Some patients, especially women and older adults, report atypical symptoms of angina including dyspnea, nausea, and/or fatigue. •This is referred to as angina equivalent.

Chronic stable Angina types of angina

•In microvascular angina, chest pain occurs in the absence of significant CAD or coronary spasm of a major coronary artery. •In these patients, chest pain is related to myocardial ischemia associated with atherosclerosis or spasm of the small distal branch vessels of the coronary microcirculation.

Chronic Stable Angina types of angina

•Prinzmetal's angina (variant angina) is a rare form of angina that often occurs at rest and not with increased physical demand. •Strong contraction (spasm) of smooth muscle in the coronary artery results from increased intracellular calcium. •Factors causing coronary artery spasm include increased myocardial oxygen demand and increased levels of certain substances (e.g., tobacco smoke, alcohol, amphetamines). •When spasm occurs, the patient experiences angina and transient ST-segment elevation. •The pain may occur during rapid-eye-movement (REM) sleep when myocardial oxygen consumption increases or when exposed to cold temperatures. •The pain may be relieved by moderate exercise, with SL NTG, or it may disappear spontaneously. •Cyclic, short bursts of pain at a usual time each day may also occur with this type of angina. •Calcium channel blockers and/or nitrates are used to control the pain, as well as stopping any offending substances.

Serum Cardiac Biomarkers After MI

•Serum cardiac biomarkers are proteins released into the blood from necrotic heart muscle after an MI. •These biomarkers are important in the diagnosis of MI. The onset, peak, and duration of levels of these biomarkers are shown in this graph. •Cardiac-specific troponin has two subtypes: cardiac-specific troponin T (cTnT) and cardiac-specific troponin I (cTnI). •CK levels begin to rise at about 6 hours after an MI, peak at about 18 hours, and return to normal within 24 to 36 hours. The CK enzymes are fractionated into bands. The CK-MB band is specific to heart muscle cells and help to quantify myocardial damage. •Myoglobin is released into the circulation within 2 hours after an MI and peaks in 3 to 15 hours.

Myocardial Infarction From Occlusion

•The acute MI process evolves over time. •The earliest tissue to become ischemic is the subendocardium (the innermost layer of tissue in the heart muscle). •If ischemia persists, it takes approximately 4 to 6 hours for the entire thickness of the heart muscle to become necrosed. •If the thrombus is not completely blocking the artery, the time to complete necrosis may be as long as 12 hours.

Chronic stable angina interprofessional care

■Goal: ↓ O2 demand and/or ↑ O2 supply ■Short-acting nitrates -Dilate peripheral and coronary blood vessels -Give sublingually or by spray -If no relief in 5 minutes, call EMS; if some relief ,repeat every 5 minutes for maximum 3 doses -Patient teaching -Can use prophylactically

Nursing Management Chronic Stable Angina

■Acute Intervention -Upright position -Supplemental oxygen -Assess vital signs -12-lead ECG -Administer NTG followed by an opioid analgesic, if needed -Assess heart and breath sounds If your patient experiences angina, perform the following measures: 1.Position patient upright unless contraindicated and apply supplemental oxygen. 2.Assess vital signs. 3.Obtain a 12-lead ECG. 4.Provide prompt pain relief first with NTG followed by an opioid analgesic if needed 5.Assess heart and breath sounds. The patient will most likely be anxious and may have pale, cool, clammy skin.

Complications of Myocardial Infarction

■Acute pericarditis -Inflammation of visceral and/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 -ECG changes

Nursing Management Acute Coronary Syndrome

■Ambulatory Care -Cardiac rehabilitation -Patient and caregiver teaching -Physical activity ■METs scale ■Monitor heart rate ■Low-level stress test before discharge ■Isometric versus isotonic activities

Nursing Management Chronic Stable Angina

■Ambulatory Care -Provide reassurance -Patient teaching ■CAD and angina ■Precipitating factors for angina ■Risk factor reduction ■Drugs

Nursing Management Acute Coronary Syndrome

■Ambulatory Care -Resumption of sexual activity ■Teach when discuss other physical activity ■Erectile dysfunction drugs contraindicated with nitrates ■Prophylactic nitrates before sexual activity ■When to avoid sex ■Typically 7-10 days post MI or when patient can climb two flights of stairs

Chronic Stable Angina interprofessional care

■Angiotensin-converting enzyme inhibitors (ACE) and angiotensin receptor blockers (ARBs) ■β-Blockers ■Calcium channel blockers •Patients with chronic stable angina who have an ejection fraction [EF] of 40% or less, diabetes, hypertension, or chronic kidney disease should take an ACE inhibitor (e.g., lisinopril [Zestril]) indefinitely, unless contraindicated. Patients with chronic stable angina and a normal EF, diabetes, and one other CAD risk factor should also take an ACE inhibitor to decrease the risk of MI, stroke and death.

Myocardial Infarction Healing Process

■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

Nursing Management Acute Coronary Syndrome

■CABG: postoperative nursing care -Assess patient for bleeding -Monitor hemodynamic status -Assess fluid status -Replace blood and electrolytes PRN -Restore temperature -Monitor for atrial fibrillation (which is common)

Nursing Management Acute Coronary Syndrome

■CABG: postoperative nursing care -Surgical site care ■Radial artery harvest site ■Leg incisions ■Chest incision -Pain management -DVT prevention -Pulmonary hygiene -Cognitive dysfunction

CHRONIC stable angina nursing interprofessional care

■Cardiac catheterization/coronary angiography -Visualize blockages (diagnostic) -Open blockages (interventional) ■Percutaneous coronary intervention (PCI) ■Balloon angioplasty ■Stent

Complications of Myocardial Infarction

■Cardiogenic shock -Occurs because of ■Severe LV failure, papillary muscle rupture, ventricular septal rupture, LV free wall rupture, right ventricular infarction -Requires aggressive management ■Associated with a high death rate

Clinical Manifestations of ACS Myocardial Infarction

■Cardiovascular -Initially, ↑ HR and BP, then ↓ BP (secondary to ↓ in CO) -Crackles -Jugular venous distention -Abnormal heart sounds ■S3 or S4 ■New murmur

Clinical Manifestations of ACS Myocardial Infarction

■Catecholamine release and stimulation of SNS -Release of glycogen -Diaphoresis -Increased HR and BP -Vasoconstriction of peripheral blood vessels -Skin: ashen, clammy, and/or cool to touch

Nursing Management Acute Coronary Syndrome

■Complications related to CPB -Bleeding and anemia from damage to RBCs and platelets -Fluid and electrolyte imbalances -Hypothermia as blood is cooled as it passes through the bypass machine -Infections

Unstable Angina and MI Diagnostic Studies

■Coronary angiography -For patients with a STEMI -Not for patients with UA or NSTEMI ■Pharmacologic stress testing -For patients with abnormal but nondiagnostic ECG and negative biomarkers Coronary Angiography

Nursing Management Acute Coronary Syndrome

■Coronary revascularization: CABG -ICU for first 24-36 hours -Pulmonary artery catheter -Intraarterial line -Pleural/mediastinal chest tubes -Continuous ECG -ET tube with mechanical ventilation -Epicardial pacing wires -Urinary catheter -NG tube

Nursing Management Acute Coronary Syndrome

■Coronary revascularization: PCI -Monitor for recurrent angina -Frequent VS, including cardiac rhythm -Monitor catheter insertion site for bleeding -Neurovascular assessment -Bed rest per institutional policy

Interprofessional Care Acute Coronary Syndrome

■Coronary surgical revascularization -Failed medical management -Presence of left main coronary artery or three-vessel disease -Not a candidate for PCI (e.g., blockages are long or difficult to access) -Failed PCI with ongoing chest pain -History of diabetes mellitus, LV dysfunction, chronic kidney disease

Unstable Angina and MI Diagnostic Studies

■Detailed health history ■12-lead ECG -Compare to previous ECG -Changes in QRS complex, ST segment, and T wave -Distinguish between STEMI and NSTEMI -Serial ECGs reflect evolution of MI

Chronic Stable Angina interprofessional care

■Diagnostic studies -Chest x-ray -12-lead ECG -Laboratory studies -Echocardiogram -Exercise stress test -EBCT -CCTA

Sudden Cardiac Death Nursing/Interprofessional Care

■Diagnostic workup to rule out or confirm MI -Cardiac biomarkers -ECGs -Treat accordingly ■Cardiac catheterization ■PCI or CABG

Interprofessional Care Acute Coronary Syndrome

■NSTEMI -Reperfusion therapy ■Emergent PCI -Treatment of choice for confirmed STEMI -Goal: 90 minutes from door to catheter laboratory -Balloon angioplasty + stent(s) -Many advantages over CABG

Clinical manifestation of ACS Unstable Angina

■New in onset ■Occurs at rest ■Increase in frequency, duration, or with less effort ■Pain lasting > 10 minutes ■Needs immediate treatment ■Symptoms in women often under-recognized •Unstable angina (UA) is chest pain that is new in onset, occurs at rest, or occurs with increasing frequency, duration, or with less effort than the patient's chronic stable angina pattern. The pain typically lasts 10 minutes or more.

Sudden Cardiac Death (SCD)

■No warning signs or symptoms if no MI ■Prodromal symptoms if associated with MI -Chest pain, palpitations, dyspnea -Death usually within 1 hour of onset of acute symptoms

Nursing Management Chronic Stable Angina and ACS

■Nursing Assessment: Objective Data -Anxious, fearful, restless, distressed -Cool, clammy, pale skin -Tachycardia or bradycardia -Pulsus alternans -Pulse deficit -Dysrhythmias -S3, S4, ↑ or ↓ BP, murmur

Nursing Management Chronic Stable Angina and ACS

■Nursing Assessment: Subjective Data -Family history -Indigestion/heartburn; nausea/vomiting -Urinary urgency or frequency -Straining at stool -Palpitations, dyspnea, dizziness, weakness -Chest pain -Stress, depression, anger, anxiety

Nursing management chronic stable angina and ACS

■Nursing Assessment: Subjective Data -Health history ■CAD/chest pain/angina/ MI ■Valve disease ■Heart failure/cardiomyopathy, ■Hypertension, diabetes, anemia, lung disease, hyperlipidemia -Drugs -History of present illness

Nursing Management Chronic Stable Angina and ACS

■Nursing Diagnoses -Decreased cardiac output -Acute pain -Anxiety -Activity intolerance -Ineffective health management

Interprofessional Care Acute Coronary Syndrome

■Nutritional therapy -Initially NPO -Progress to ■Low salt ■Low saturated fat ■Low cholesterol •Initially, patients may be NPO (nothing by mouth), except for sips of water, until stable (e.g., pain free, nausea resolved). •You advance the diet as tolerated to a low-salt, low-saturated fat, and low-cholesterol diet.

Interprofessional Care Acute Coronary Syndrome

■Ongoing monitoring -Treat dysrhythmias -Frequent vital sign monitoring -Bed rest/limited activity for 12-24 hours ■UA or NSTEMI -Dual antiplatelet therapy and heparin -Cardiac catheterization with PCI once stable

Clinical Manifestations of ACS Myocardial Infarction

■Pain -Severe chest pain not relieved by rest, position change, or nitrate administration ■Heaviness, pressure, tightness, burning, constriction, crushing ■Substernal or epigastric ■May radiate to neck, lower jaw, arms, back -Often occurs in early morning -Atypical in women, elderly -No pain if cardiac neuropathy (diabetes)

Complications of Myocardial Infarction

■Papillary muscle dysfunction or rupture -Causes mitral valve regurgitation -Aggravates an already compromised LV → rapid clinical deterioration ■Left ventricular aneurysm -Myocardial wall becomes thinned and bulges out during contraction -Leads to HF, dysrhythmias, and angina

Sudden Cardiac Death Nursing/Interprofessional Mgmt

■Patient teaching ■Psychosocial adaptation -"Brush with death" -"Time bomb" mentality -Additional issues ■Driving restrictions ■Role reversal ■Change in occupation

Nursing Management Chronic Stable Angina and ACS

■Planning: Overall goals -Relief of pain -Preservation of heart muscle -Immediate and appropriate treatment -Effective coping with illness-associated anxiety -Participation in a rehabilitation plan -Reduction of risk factors

Acute Coronary Syndrome Etiology and Pathophysiology

■Result -Partial occlusion of coronary artery: UA or NSTEMI -Total occlusion of coronary artery: STEMI

Clinical Manifestations of ACS Myocardial infarction (MI)

■ST-elevation and non-ST-elevation ■Result of abrupt stoppage of blood flow through a coronary artery, causing irreversible myocardial cell death (necrosis) -Preexisting CAD -STEMI - occlusive thrombus -NSTEMI - non-occlusive thrombus

Chronic Stable Angina types of angina

■Silent ischemia -Ischemia that occurs in absence of any subjective symptoms -Associated with diabetic neuropathy -Confirmed by ECG changes

Interprofessional Care Acute Coronary Syndrome

■Thrombolytic therapy -Draw blood and start 2-3 IV sites -Complete invasive procedures prior -Administer according to protocol -Monitor closely for signs of bleeding -Assess for signs of reperfusion ■Return of ST segment to baseline best sign ■IV heparin to prevent reocclusion

InterProfessional Care Acute Coronary Syndrome

■Thrombolytic therapy -Only for patients with a STEMI ■Agencies that do not have cardiac catheterization resources -Given IV within 30 minutes of arrival to the ED -Patient selection critical •Thrombolytic (fibrinolytic) therapy is only indicated for patients with a STEMI. It offers the advantages of availability and rapid administration in agencies that do not have an interventional cardiac catheterization laboratory or one is too far away to transfer the patient safely.

Interprofessional Care Acute Coronary Syndrome

■Traditional coronary artery bypass graft (CABG) surgery -Requires sternotomy and cardiopulmonary bypass (CPB) -Uses arteries and veins for grafts ■The internal mammary artery (IMA) is most common artery used for bypass graft

Sudden Cardiac Death (SCD)

■Unexpected death from cardiac causes - almost 400,000 annually ■Abrupt disruption in cardiac function, resulting in loss of CO and cerebral blood flow ■Most commonly caused by -Ventricular dysrhythmias -Structural heart disease -Conduction disturbances

Complications of Myocardial Infarction

■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

Myocardial Infarction Healing Process

■Within 24 hours, leukocytes infiltrate the area of cell death ■Proteolytic enzymes of neutrophils and macrophages begin to remove necrotic tissue by fourth day → thin wall ■Necrotic zone identifiable by ECG changes ■Collagen matrix laid down