Acute Coronary Syndrome: Unstable Angina, NSTEMI, and STEMI

most highly specific cardiac markers

Troponin

deterioration of once stable plaque -> rupture -> platelet aggregation-> thrombus **Cause of instability is not understood-may be some form of inflammation

acute coronary syndrome

two types of troponin

-cardiac specific troponin T (cTnT) -cardiac specific troponin I (cTnI)

what do you need to do prior to and during administration of thrombolytic therapy?

-draw blood to obtain baseline values -start at least 2 IVs -complete all other invasive procedures prior to administration -given as IV bolus over 30-60 ominutes dependent on drug selected -document start of therapy and monitor

heart becomes hypoxic within ___________ seconds of occlusion- anaerobic metabolism kicks in and lactic acid starts to accumulate

10

NSTEMI needs cardiac cath within

12-72 hours

irreversible damage to the heart occurs within ______________ minutes

20

necrosis of entire thickness of myocardium takes __________ to _________ hours, or even up to _______________

4-6 12

STEMI needs cardiac cath within

90 minutes

advantages of PCI over _____________: -faster reperfusion -alternative to surgical intervention -performed with local anesthesia -ambulation shortly after procedure -decrease length of stay -return to work sooner

CABG

cardiac biomarker specific to myocardial cells and helps to quantify myocardial damage (0-3 ng/mL= normal)

CK-MB band

diagnostic studies including interpreting and monitoring __________________ findings

EKG

caused by a NONOCCLUSIVE thrombus -does NOT cause ST elevation -EKG may not show ST/T wave changes -treatment is more lax: cardiac cath. within 12-72 hours (thrombolytics are not indicated- because it is a nonocclusive clot)

NSTEMI

severe, immobilizing chest pain not relieved by rest, position change or nitrate administration -heaviness, pressure, tightness, burning, constriction, crushing -substernal, retrosternal, epigastric, neck, jaw, arms -more common in AM -atypical in women and elderly -no pain if cardiac neuropathy

PAIN=Hallmark of MI

first line treatment for STEMI (stent or drug-eluding stent)

PCI

____________________ stimulation -catecholamines are released -diaphoresis (sweating) -vasoconstriction -ashen, clammy skin, cool to touch

SNS

caused by an OCCLUSIVE thrombus -ST elevation -considered medical emergency -artery must be opened within 90 minutes to restore blood flow and oxygen to the heart -need intervention: PCI or thrombolytic therapy

STEMI

total occlusion of CA

STEMI

partial occlusion of CA

UA or NSTEMI

proteins that are released into the blood from necrotic heart muscle: -troponin -creatine kinase -CK-MB band -myoglobin

cardiac biomarkers

goal is to reopen occluded artery and limit the infarction size

cardiac cath

very important part of nursing management following MI that works towards restoration of optimal state of function *divided into phases

cardiac rehab

type of troponin- more hydrophobic- appears in blood in a different type of form and is smaller

cardiac specific troponin I (cTnI)

type of troponin- higher overall tissue concentration and free sodal plasmic concentration than other one **appear in blood of patient with acute MI as a mixed complex

cardiac specific troponin T (cTnT)

______________________ manifestations of MI -initially increased in HR and BP, then decrease in BP, secondary to decrease in CO -crackles' -JVD -abnormal heart sounds (distant, S3 or S4, holosystolic murmur)

cardiovascular

inclusion criteria for thrombolytic therapy

chest pain less than 12 hours with EKG findings consistent with acute STEMI **reduces mortality if given within 6 hours

CAD is divided into 1) and 2)

chronic stable angina and acute coronary syndrome

_________________ of MI -pain -SNS stimulation -CV -nausea and vomiting -fever

clinical manifestations

________________________ : -heart failure -cardiogenic shock -papillary muscle dysfunction -ventricular aneurysm -ventricular rupture -acute pericarditis -Dressler's Syndrome

complications

_______________ for thrombolytic therapy: -active internal bleeding or bleeding -history of intracranial hemorrhage -recent ischemic stroke -sever uncontrolled HTN -intracranial/intraspinal surgery

contraindications

cardiac biomarker that is an enzyme found in heart tissue and skeletal muscle, with a small amount in the brain *renal patients of raptomyolosis usually have an elevated level of this- we don't want to see this high in anyone -levels rise about 6 hours post MI, peak at 18 hours, and return to normal within 24-36 hours

creatine kinase

________________________ studied: -exercise or pharmacologic stress testing -echocardiogram -cardiac cath

diagnostic

__________________ therapy -IV nitro -morphine sulfate -beta adrenergic blockers -ACE inhibitors -antidysrhythmic -cholesterol-lowering drugs -stool softeners

drug

participation in early _______________ results in: -reduced all-cause mortality ranging from 15-28% -reduced cardiac mortality from 26-31% -reduced CV events -reduced readmission rates to hospital -a strong dose-response relationship between number of sessions and long-term outcomes -improved adherence with preventative medications -improved function and exercise capacity -improved quality of life -improved modifiable risk factors

immediate outpatient cardiac rehabilitation

______________________ interventions: -semi fowler's position -oxygen -IV access (need fast relief of drugs) -pain assessment (morphine or NTG) -Nitroglycerin (SL) and ASA (chewable) **know if they've already take -Morphine (if not relieved by NTG) -Labs, CXR

initial

result of sustained ischemia (>20 minutes), causing irreversible myocardial cell death (necrosis) -80-90% secondary to thrombus -ischemia starts in the subendocardium (innermost layer of tissue in cardiac muscle) -loss of contractile finction

myocardial infarction

cardiac biomarker that is an early index of damage to myocardium **release 2 hours post MI, peaks 3-15 hours **lacks cardiac specifity and role of diagnosing MI is limited **level should be 90 or less mcg/L

myoglobin

phase of cardiac rehab: (inpatient) -assessment and mobilization, education on risk factors and a discharge plan

phase I

phase of cardiac rehab: (immediate outpatient) -exercise, risk factor reduction, reduce morbidity/mortality, improve function and QOL and build confidence

phase II

phase of cardiac rehab: -maintenance program with follow up

phase III

what is a pathologic Q wave an indicator of

previous MI

assess for _________________ -look for return of ST segment to baseline -resolution of chest pain -early, rapid rise of cardiac biomarkers within 3 hours of therapy -monitor for reperfusion dysrhythmias -major concern= reocclusion of artery) *start heparin infusion

reperfusion

we must teach about resumption of _____________________ -when it is appropriate- typically 7-10 days post MI (when you can climb two flights of steps without chest pain or dyspnea) -may use prophylactic nitrates prior to engaging -when to avoid: following heavy meal, extremely tired/stressed, after excessive alcohol use -erectile dysfunction drugs are contraindicated with nitrates

sexual activity

nursing assessment for MI: ________________________ -health history (including family history) -medications -history of present illness

subjective data

alteplase and streptokinase are two drugs used in

thrombolytic therapy

therapy reserved for patient with STEMI that aims to limit the infarction size by dissolving the thrombus before establishing reperfusion -given via IV- alteplase or Steptokinase

thrombolytic therapy

want to see these levels very LOW typically under <0.01 -high levels represent indication of MI -levels increase 4-6 hours after onset of MI, peak 10-24 hours, and return to baseline in 10-14 day -should be completed in sets (every 6 hours X3)

troponin

new in onset, occurs at rest, worsening pattern, unpredictable, EKG changes (ST depression of T wave inversion) **Considered a medical emergency **symptoms in women may be more vague (generally fatigue)

unstable angina

acute coronary syndrome is divided into 1) 2)

unstable angina NSTEMI STEMI

reflex stimulation of the _____________ center by sever pain *vasovagal reflex-initiated from area of infarcted MI

vomittung

within what time frame do you want to administer thrombolytic therapy

within 30 minutes of arriving in the ER