Cardiac; CAD and ACS

chronic endothelial injury

• 1st sequence in plaque buildup

• injury to inside of the vessel

fatty streak

• 2nd sequence in plaque buildup

• lipids accumulate and migrate into smooth muscle cells

• starts to narrow vessel

fibrous plaque

• 3rd sequence in plaque buildup

• vessel becomes even more narrow & blood flow is reduces

• fissures (breaks in vessels) can develop

complicated lesion

• final stage in plaque buildup

• plaque ruptures and blood clot forms as platelets swarm the area

• clot can also break off and travel

collateral circulation

• arterial anastomoses (connections) the body makes in the coronary circulation

• may be more functioning and have less symptoms bc body compensates

• may not be adequate enough for rapid onset CAD

what can angina pain be

• pressure “elephant on my chest” and increased WOB

• squeezing, heavy

• choking or suffocated

• indigestion/burning - easily brushed off

• rarely sharp or stabbing

where can angina pain occur

• mid sternum and subternum

• shoulders, down the arms

• epigastric pain

• dental pain in women

• intrascapular

stable angina

• oxygen demand ?

• ischemia is ? pt can take ?

• angina occurs when ?

• hypoxic within ?

• progressive disease

• oxygen demand is greater than the supply = myocardial ischemia

• reversible ischemia (can take nitro and usually calms down )

• angina happens when arteries are blocked 75%

• hypoxic within 10 seconds of occlusion

chronic stable angina

• is ?

• duration

• EKG?

• control with

• Intermittent chest pain that occurs over a long period with the same pattern of onset, duration, and intensity of symptoms

• 5 to 15 minute duration

• EKG may show ST segment depression (doesn't return to isoelectric line) and/or T-wave inversion (goes down instead of up)

• Control with nitro and decreased movement

managing angina

• first line of med?

• what does it do

• when to call EMS

• how many doses? how much time in between

• may also use ?

• nitroglycerin - first line (short acting)

• dilates blood vessels & increases O2 supply

• if no relief in 5 minutes, call EMS

• if some relief repeat q5min for max of 3 doses

• may also use prohpylactially before physical activity

long acting nitrates

• reduces angina incidene

• may cause headache and orthostatic hypotension

• always assess BP before and after administering

• hold if systolic BP is under 90

silent ischemia

• associated with?

• confirmed by ?

• ischemia w/o subjective symptoms

• associated w/ diabetic nueropathy

• confirmed with ECG changes at yearly physical

prinzmetals (variant ) angina is when ?

• common cause ?

• s/s ?

• occurs at rest from spam of a major coronary artery (cocaine common cause)

• can occur w/ or w/o CAD

• not precipitated by increased O2 demand

• chest pain with marked transient ST segment elevation (comes and goes)

what are the first organs affected by CAD

• signs ?

• labs ?

• kidneys, decreased blood flow = renal failure

• decreased UO

• increased BUN and creatine

what is ordered for someone coming in with angina

• baseline vitals and assessment first

• start IV

• 12 lead ECG

• possible CXR

• cardiac labs (troponin and CKMB)

• ECHO - looks at ejection fraction and valve function

• calcium-score screening heart scan - not emergent, looks at calcium deposits

• cardiac catheterization

what is troponin

• how long does troponin stay high

• cardiac enzyme that is released in blood when the heart is damaged

• rises in first 1-3 hours after

• stays high in first 1-2 weeks

other meds for angina

• beat blockers

• calcium channel blocker s

• aspirin

lipid lowering drugs

• statins - inhibit cholesterol synthesis, decrease LDL, increase HDL

• - monitor for liver damage and myopathy (check liver enzymes and muscle function )

• Zetia - decrease absorption of dietary and biliary cholesterol

acute coronary syndrome

• is ?

• occurs when?

• women ?

• how do we dx

• 3 categories

• any condition caused by a sudden, reduced blood flow to the heart muscle

• occurs at rest

• symptoms may be atypical in women

• must do ECG to determine what kind it is:

• unstable angina

• Non-ST elevation MI - partial blockage

• ST elevation MI - full blockage , emergency!

how do we treat STEMI vs Non STEMI

• STEMI - immediately goes to Cath lab

• Non-stemi - treat according to symptoms , give O2 if less than 92%, if symptoms are severe then go to Cath lab

clinical manifestations of MI

• initially raised HR and BP, then BP drops in response to drop in CO

• crackles

• JVD

• abnormal heart sounds - S3 or S4, or new murmur

• GI symptoms

• low grade temp

cardiac angiography

• dx test used to visualize blood flow in the heart

• same nursing implications at Cardiac catheterization

post catheter care

• what are we checking how often ?

• force?

• bed? position?

• V/s , and check distal pulses q15 min for first hour

• check insertion site for bleeding or hematoma formation

• force fluids PO or IV to clear out contrast dye

• bed rest and supine, keep extremity straight for 2-6 hrs, after 2-6hrs

• after 2-6 hrs HOB above 30 degrees

• if percutaneous seals used can be out of bed earlier (2 hours)

why are the initial interventions for someone coming in with ACS

• 12 lead ECG within first 10 min

• get IV access

• semi fowlers

• MONA (morphine, oxygen if less than 92%, nitro, aspirin)

what can be placed in the Cath lab

• if chest pain worsens

• percutaneous coronary intervention (stent)

• ballon angioplasty- inflates and opnes stent

• if chest pain worsens, it may mean the stent failed and vessel becomes reoocluded

what dysrhythmias can occur post ACS?

• most common is afib - quivering atria

• watch for V-tach and V- fib , life threatening, call code !

• treat with antidysrythmIc meds

what can be done for unstable angina and NSTEMI

• aspirin, heparin, glycoprotein inhibitors

• coronary angiography with PCI (stent) once stable

tx for STEMI

• what procedure ? in what time frame ?

• meds ?

• last resort ?

• emergent PCI

• goal - within 90 minutes of admission

• ballon angioplasty

• anticoagulants to decrease chance of clot formation (stent increases chance of clot forming bc its a foreign object)

• last resort CABG

thrombolytic therapy

• only done for ? if what is not available

• how does it work

• may cause ?

• route

• time frame

• C/I

• monitor for ?

• done for certain STEMI patients only if PCI not available

• meds that stop infarction process by dissolving the thrombus

• may cause significant bleeding issues

• given IV

• done within the first hour of admission

• C/I - GI ulcer , causes GI bleeding

• monitor for bleeding, check Iv site, and filet

what happens to the myocardium after a MI

• ventricular remodling

• muscle hypertrophy and the chambers become smaller in attempt to compensate for dead muscle

what other meds are given for ACS

• beta blockers

• ACE inhibitors

• statins

• stole softeners to avoid straining - bearing down may cause rupture of stent or incision

complications after MI

1. heart failure from damage to muscle

• ECHO needs after MI to asses EF and valve function

• also asses kidney function, those are affected by HF first

2. cariogenic shock - heart not pumping and not perfusing body

3. acute pericarditis - edema in pericardial space from damage

when would someone need a Coronary Artery Bypass Graft

• presence of left main coronary artery disease

• three vessel disease (all main 3 coronary arteries are blocked )

• PCI won’t work b lesions are too long or difficult to access

• failed PCI with ongoing chest pain

• diabetes

• when long term benefits of CABG are better than a PCI

Coronary Artery Bypass Graft

• what is it ?

• requires ?

• other option ?

• complication ?

• veins and arteries are used as grafts to creates new vessels in the heart for blood flow

• requires sternotomy (cuts sternum) and cardiopulmonary bypass (pumps and oxygenates blood during surgery)

• also a minimally invasive option

• high BP can rupture sutures after surgery

post CABG

• where is the patient

• hemodynamic monitoring ?

• cardiac monitoring ?

• respiratory?

• urinary ?

• GI?

• ICU for first 24-36 hour because ….

• A-line - checks Bp every minute

• chest tubes monitored hourly for drainage

• pulmonary artery catheter

• continuous ECG

• ET tube with mechanical vent

• epicardial pacing wires

• foley

• NG tube - surgery causes Gi slowing , tube relives pressure and can also start enteral feeding if needed

epicardial pacing wires

• wires placed in the heart that come out thru the chest wall and are isolated by gauze

• monitors dysrryhthmias and can be hooked up to a pacing machine to manually pace heart

complications from cardiopulmonary bypass

• bleeding / anemia from damage to RBCs and platelets

• fluid and electrolyte imbalances , especially K+

• hypothermia bc blood is cooled as it passes through bypass machine - pt should be warmed

• infection

post op CABG nursing care

• monitor for dysrhythmias - fib common

• asses for any bleeding, fluid & electrolyte status, temp

• monitor surgical site for any edema

• monitor donor site

• pain management, DVT prevention, CDB/ spirometer , same for any surgery

• try to reorient if confused, use mittens to avoid pt ripping out any lines

Physical activity post CABG

• METs or Borg scale to asses ability to do ADLs

• monitor HR

• low level stress test before d/c

• isometric vs isotonic (taught by pt)

resumption of sexual activity

• include when teaching about physical activity

• can resume in 7-10 days post MI or when pt can climb 2 flights of stairs

• nitrates can be taken before prophylactically

• ED drugs contraindicated with nitrates - both drop BP drastically

Sudden Cardiac Death is ?

• loss of?

• causes?

• what test

• unexpected death from cardiac causes (and brought back)

• abrupt disruption in cardiac function → loss of CO and cerebral blood flow

• most commonly caused by dysrhythmias

• can also be caused by structural heart disease and conduction disturbances (pacemaker)

• no signs or symptoms if not occurring with MI

• Electrophysiologic study done - cardiac catheterization that tests the heart electrical signals