Acute coronary syndrome

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?

"You are having decreased blood flow to part of the heart."

Thrombolytic Therapy complications

A major concern with thrombolytic therapy is reocclusion of the artery. The site of the thrombus is unstable, and formation of another clot or spasm of the artery may occur. Therefore IV heparin therapy is started. If another clot develops, the patient will have similar complaints of chest pain, and ECG changes will return. Patients receiving thrombolytic therapy should be moved to a facility with PCI capabilities as soon as possible so PCI can be performed if thrombolytic therapy fails. The major complication of thrombolytic therapy is bleeding. Ongoing nursing assessment is essential. Minor bleeding (e.g., surface bleeding from IV sites or gingival bleeding) is expected and controlled by applying a pressure dressing or ice packs.

Which statement best describes acute coronary syndrome (ACS)?

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.

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.

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?

Administer oxygen and nitrates.

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

UA gender differences

After age 75, the incidence of MI in men and women equalizes. Men present more frequently than women with an acute MI as the first manifestation of CAD. Men develop greater collateral circulation than women. Men have larger-diameter coronary arteries than women. Vessel diameter is inversely related to risk of restenosis after interventions. Standard screening for risk of sudden cardiac death is more predictive in men. Women seek medical attention for symptoms of UA more often than men.

absolute contraindications for thrombolytic therapy

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?

Aspirin and clopidogrel can prevent another clot from forming.

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.

CABG surgery and PCI are considered palliative treatment for CAD and not a cure.

CABG surgery consists of the placement of arterial or venous grafts to provide blood flow between the aorta or other major arteries and the heart muscle distal to the blocked coronary artery (or arteries). Requires a sternotomy (opening of the chest cavity) and cardiopulmonary bypass (CPB). Studies have shown improved patient outcomes, quality of life, and survival after CABG surgery.

Location of Pain in UA and MI

Common locations of pain are epigastric, substernal, and retrosternal regions. The pain may radiate to the neck, jaw, and arms or to the back. Pain may occur while the patient is active or at rest, asleep or awake; it commonly occurs in the early morning hours.

Anger and Hostility

Commonly expressed as, "Why did this happen to me?" May be directed at family, staff, or medical regimen

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

Coronary revascularization with CABG surgery is recommended for patients who (Hillis, 2011):

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.

Thrombolytic Therapy procedure

Draw blood to obtain baseline laboratory values and start two or three lines for intravenous (IV) therapy. Depending on the drug selected, therapy is given in one IV bolus or over time (30 to 90 minutes).

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

Anxiety and Fear

Fears long-term disability and death Overtly manifests apprehension, restlessness, insomnia, tachycardia Less overtly manifests increased verbalization, projection of feelings onto others, hypochondriasis Fears activity Fears recurrent chest pain, heart attacks, and sudden death

What is a primary difference in the clinical manifestations of acute coronary syndrome between men and women?

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).

Realistic Acceptance

Focuses on optimum rehabilitation Plans changes compatible with altered cardiac function Actively engages in lifestyle changes to address modifiable risk factors

Relative contraindications for thrombolytic therapy

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

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?

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.

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." 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.

Initial drug therapy after an MI includes

IV nitroglycerin, aspirin, β-adrenergic blockers, and anticoagulation (e.g., clopidogrel). Systemic anticoagulation may be achieved with low-molecular-weight heparin (LMWH) given subcutaneously or IV unfractionated heparin (UH). If PCI is anticipated, glycoprotein IIb/IIIa inhibitors may be used. Angiotensin-converting enzyme (ACE) inhibitors are added for some patients after an MI. Calcium channel blockers may be used if the patient is already taking adequate doses of β-blockers or does not tolerate these blockers.

Thrombolytic Therapy indications

Inclusion criteria for thrombolytic therapy are (1) chest pain less than 12 hours with 12-lead ECG findings consistent with acute STEMI and (2) no absolute contraindications. Patients with chest pain lasting 12 to 24 hours with ECG changes supporting STEMI may be considered for thrombolytic therapy (Levine, 2015).

Dependency

Is totally reliant on staff Is unwilling to perform tasks or activities unless approved by health care provider Wants to be monitored by ECG at all times Is hesitant to leave the intensive care or telemetry unit or hospital

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?

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.

MIDCAB

MIDCAB offers patients with disease of the left anterior descending or right coronary artery an approach to surgical treatment that does not involve a sternotomy and CPB. The technique requires several small incisions between the ribs or a mini-thoracotomy. A thoracoscope or robotic assistance is used to dissect the internal mammary artery (IMA) from the chest. A mechanical stabilizer immobilizes the 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.

Denial

May have history of ignoring signs and symptoms related to heart disease Minimizes severity of medical condition Ignores activity restrictions Avoids discussing illness or its significance

Safety Alert: Thrombolytic Therapy

Minor or major bleeding can occur with thrombolytic drugs. Establish two or three IV lines before thrombolytic therapy is started. 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.

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. 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.

Depression

Mourns loss of health, altered body function, and changes in lifestyle Realizes seriousness of situation Begins to worry about future implications of health problem Shows signs of withdrawal, crying, apathy May be more evident after discharge

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 priorityin the nursing management of this patient?

Notification of the health care provider

A patient has been diagnosed with acute coronary syndrome. Which assessment findings would the nurse expect to see?

Pain occurs at rest. Pain may radiate to other areas. Severe, immobilizing chest pain.

Which patients are more likely to require off-pump coronary artery bypass (OPCAB) surgery instead of coronary artery bypass graft (CABG) surgery?

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

Unstable angina is considered an emergency because of which pathophysiological occurrence?

Platelet aggregation blocks the artery.

How does acute coronary syndrome cause injury to the heart?

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.

Acute Nursing Interventions

Position the patient in an upright position unless contraindicated, and administer oxygen by nasal cannula to keep oxygen saturation above 93%. Assess oxygenation status frequently, especially if the patient is receiving oxygen. Establish an IV line to provide route for emergency drug therapy. Provide nitroglycerin, morphine, and supplemental oxygen as needed to eliminate or reduce chest pain. Maintain continuous ECG monitoring. Dysrhythmias need to be identified and treated quickly. Assess vital signs frequently.Evaluate intake and output and perform physical assessment to detect deviations from the patient's baseline parameters. Assess lung and heart sounds and observe for evidence of early heart failure (e.g., dyspnea, tachycardia, pulmonary congestion, distended neck veins).

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?

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?

ST elevation

MI pain symptoms

Severe and persistent chest pain not relieved by rest or nitrate administration is the hallmark of an MI. Pain is usually described as a heaviness, pressure, burning, crushing, tightness, or constriction. The pain usually lasts for 20 minutes or more and is more severe than usual angina. When epigastric pain is present, the patient may take antacids without relief.

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.

OFCAB

The OPCAB procedure uses a median sternotomy to access all coronary vessels. OPCAB is performed on a beating heart (no CPB) using mechanical stabilizers. OPCAB is associated with less blood loss, less renal dysfunction, less postoperative atrial fibrillation, and fewer neurological complications. It is estimated that less than 20% of CABG procedures are OPCAB procedures. OPCAB is primarily used for patients with multiple comorbidities for whom CPB should be avoided (Bojar, 2011).

UA pain symptoms

The chest pain associated with UA is new in onset, occurs at rest, or has a worsening pattern. The patient without previously diagnosed angina describes pain that has progressed rapidly in the past few hours, days, or weeks, often including pain at rest.

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?

The skin is pale and cool with bilateral pedal pulses faintly palpable.

transmyocardial laser revascularization

Transmyocardial laser revascularization is an indirect revascularization procedure. It is used for patients with advanced CAD who are not candidates for traditional CABG surgery and who have persistent angina despite maximum medical therapy. The procedure involves the use of a high-energy laser to create channels in the heart muscle to allow blood flow to ischemic areas. The procedure can be done using a left thoracotomy approach or in combination with CABG surgery. It is used as an adjunctive therapy when bypass grafts cannot be placed.

Which statement describes how unstable angina differs from chronic stable angina?

Unstable angina has a random onset.

Thrombolytic Therapy signs of reperfusion

When reperfusion occurs (e.g., the coronary artery that was blocked is opened and blood flow is restored to the heart muscle), several clinical signs may be seen. The most reliable sign is the return of the ST segment to baseline on the ECG. Other signs include a resolution of chest pain and an early, rapid rise of the serum cardiac biomarkers within 3 hours of therapy, peaking within 12 hours. The presence of reperfusion dysrhythmias (e.g., accelerated idioventricular rhythm) is a less reliable sign of reperfusion. These dysrhythmias are generally self-limiting and do not require aggressive treatment.

MI gender differences

Women are older than men when seen with first MI and often have more comorbidities. Women seek medical care later in the cardiovascular disease process and often are more ill on presentation than men. First heart event for women is more often UA than MI. Women experience more "silent" MIs compared with men. Women report more disability after a cardiac event than men.

UA is

chest pain that is new in onset, occurs at rest, or has a worsening pattern. The patient with chronic stable angina may develop UA, or UA may be the first clinical sign of CAD. Chronic stable angina is predictable, but UA may be random and can lead to myocardial infarction (MI), a medical emergency. The patient with previously diagnosed chronic stable angina will describe a significant change in the pattern of angina.

Treatment of ACS can include

coronary revascularization surgery. Possible options are CABG surgery, minimally invasive direct coronary artery bypass (MIDCAB), off-pump coronary artery bypass (OPCAB), and transmyocardial laser revascularization.

Perform a physical assessment to detect

detect deviations from the patient's baseline findings. Assess heart and lung sounds for any evidence of early heart failure (e.g., dyspnea, tachycardia, pulmonary congestion, distended neck veins). In addition to routine measurement of vital signs, monitor intake and output.

Continuous ECG monitoring should be done to

detect premature ventricular contractions (PVCs) or ventricular tachycardia that can lead to ventricular fibrillation in a patient who has had an MI. Dysrhythmias need to be identified and treated quickly. During the initial period after MI, ventricular fibrillation is the most common lethal dysrhythmia. In many patients, PVCs or ventricular tachycardia can precede this dysrhythmia. Assess the patient for reinfarction or ischemia by monitoring the ST segment for shifts above or below the baseline of the ECG. Silent ischemia can occur without clinical symptoms such as chest pain. Its presence places a patient at higher risk for adverse outcomes and even death. If the nurse notes ST-segment changes, the physician should be notified.

The most important nursing interventions for an acute coronary event are

encouraging the patient to rest, provision of supplemental oxygen even if saturation is stable without it, and administration of morphine to control pain and reduce the workload of the heart.

Emergent PCI is

first-line treatment for patients with confirmed STEMI (e.g., ST elevation on the ECG and/or positive cardiac biomarkers). The goal is to open the blocked artery within 90 minutes of arrival to a facility that has an interventional cardiac catheterization laboratory. In this case, the patient undergoes cardiac catheterization to locate and assess the severity of the blockage(s), determine the presence of collateral circulation, and evaluate left ventricular (LV) function. During the procedure, a bare metal stent (BMS) or drug-eluting stent (DES) is inserted into the blocked coronary artery. Patients with severe LV dysfunction may require the addition of intra-aortic balloon pump (IABP) therapy and/or an inotrope (e.g., dobutamine). A small percentage of patients may require emergent coronary artery bypass graft (CABG) surgery.

Psychosocial responses to ACS are varied, and the nurse should know how to

identify each. The nurse should ask the patient to be specific about concerns and take the opportunity to assist or offer emotional support: Denial, anger and hostility, anxiety and fear, dependency, depression, realistic acceptance

After the initial pain assessment, nursing interventions for the patient with ACS include

physiological monitoring, promotion of rest and comfort, alleviation of stress and anxiety, and understanding of the patient's emotional and behavioral reactions. Proper management of these priorities decreases the oxygen requirements of a compromised myocardium. In addition, the nurse should institute measures to avoid the hazards of immobility while encouraging the patient to rest.

It is important to promote

rest and comfort for patients with any degree of myocardial injury. Bed rest may be ordered for the first few days after an MI that involves a large portion of the ventricle so the myocardium can heal. A patient with an uncomplicated MI (e.g., angina resolved, no signs of complications) may rest in a chair within 8 to 12 hours after the event. The use of a commode or bedpan is based on the patient's preference.

When ischemia is prolonged and not immediately reversible, ACS develops and encompasses the

spectrum of UA, NSTEMI, and STEMI.

ACS is caused by

the decline of a once stable atherosclerotic plaque. The previously stable plaque ruptures, releasing substances into the vessel. This causes platelet aggregation and thrombus formation. The vessel may be partially blocked by a thrombus (manifesting as UA or NSTEMI) or totally blocked by a thrombus (manifesting as STEMI), and blood flow is restricted. What causes the plaque to suddenly become unstable is not well understood, but systemic inflammation is thought to play a role. Patients with suspected ACS need immediate hospitalization. Pain occurs with increasing frequency and is easily provoked by minimal or no exertion, during sleep, or even at rest.

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."