angina, MI, cardiogenic shock

angina

type of chest pain (CP) or discomfort that occurs when the heart does not get enough oxygen

can be a symptom of CAD

stable angina **

most common

occurs during physical exercise or stress and is relieved with rest or medication

usually predictable and lasts a few minutes

tell patient to rest first before taking nitroglycerin

unstable angina **

more serious

can happen at rest or with minimal exertion

unpredictable and can last longer

can indicate increased risk of heart attack

relieved by nitroglycerin

does not get relieved by rest because it can happen at rest

variant angina (X)

occurs due to spasms in the coronary arteries 

happens at rest and can be severe

may go away on its own or with meds 

manifestations and diagnostics of angina

• chest pain/discomfort

• radiation of pain to shoulder, neck, and jaw (think they are having a heart attack)

• SOB

• diaphoresis

• nausea

• lightheadedness

• fatigue

• weakness

do H&P (how long has it been hurting, what were you doing, is it radiating, rate pain)

ECG is important

do cardiac labs (troponins, CK-MB, CPK),  stress test on treadmill or with thalium, and ECHO

labs should all be NEGATIVE

thalium stress test

radioactive iodine test used to increase the heart rate and investigates if angina was caused by stress

troponins vs. CPK vs. CK-MB

indicates cardiac muscle breakdown due to insufficient oxygen

vs.

indicates muscle breakdown in the body

vs.

enzymes released when there is cardiac damage

in what condition is elevated troponins expected?

chronic renal failure

nitroglycerine

short acting nitrate used for angina

comes in IV, sublingual, and paste (use gloves)

causes hypotension - check their BP before every dose

patient should take 3 doses, 5 minutes apart, before going to ED

isosorbide dinitrate

long acting nitrate used for angina

patient takes these every day

beta blockers

reduces workload by slowing HR and decreasing BP

reduces frequency of angina

calcium channel blockers

relaxes and widens coronary arteries

improving blood flow and reducing chest pain

useful in variant angina

aspirin

anti-platelet aggregator used to reduce risk of blood clots

full 325mg dose given in hospital

nursing interventions for angina

• monitor vital signs

• monitor pain levels

  • location, duration, triggers

• evaluate for other symptoms of HF, arrhythmias, MI

• monitor for adverse reactions of medications

• educate on med adherence and recognizing symptoms of an MI

• lifestyle modification (exercise, diet, weight management, smoking cessation, stress management)

myocardial infarction

total occlusion of one or more coronary arteries resulting in ischemia and death of myocardial tissues

atherosclerosis is most common cause - accumulations can cause direct obstruction or break off, causing platelet aggregation at the site of injury and formation of a thrombus

MI risk factors

• family history of CAD

• hypertension and smoking

• blood cholesterol levels

• obesity

• diabetes

• high sensitivity C-reacting protein

  • an inflammatory marker

• hyperhomocysteinemia - elevated RBCs

MI (STEMI and NSTEMI) manifestations

• gender variability

• chest pain or crushing pressure **

  • radiating to left arm, shoulder, or jaw in males

  • “elephant sitting on my chest”

• fatigue, SOB

• sweating and pallor

• indigestion

• n/v

• females can have upper back and epigastric pain

diagnostics for MI

• H&P

• cardiac enzymes*

  • troponins and CK-MB will elevated

• ECG* - tells you if its a STEMI or not

• CT angiography - sees if there is a blockage

  • do not do in a STEMI because of time

• ECHO

• chest radiograph

STEMI vs. NSTEMI

ST elevation in 2 or more leads = EMERGENCY, get them in the cath lab within 90 minutes

monitor them for cardiogenic shock, pulmonary edema (pink frothy sputum), and HF

vs.

elevated troponins without ST elevation

treat with meds like heparin, Clopidogrel (stronger than aspirin), and aspirin

emergency treatment of STEMI

1. ABCs

2. surgery 

   1. PCI or PTCA

3. medications

percutaneous coronary intervention (PCI) and percutaneous transluminal coronary angioplasty (PTCA)

non-surgical procedure used for STEMIs that uses a catheter to place a small stent to open a blood vessel

is inserted into groin or arm

balloon is inflated with the stent over it, plaque is pushed to the walls and the balloon is deflated so the stent remains in place

we want to assess VS, puncture site, and pulses on side of puncture site

check for infection, bleeding, hematoma

use doppler if needed; if pulse cannot be felt → notify provider

cardiogenic shock

dysfunction in systolic or diastolic function of the heart → reduced cardiac output, stroke volume, and BP

need to have a some kind of heart problem

leads to decreased cardiac function and perfusion

is the leading cause of MI (especially STEMIs)

can be caused by:

• cardiac tamponade

• ventricular hypertrophy

• cardiomyopathy

• dysrhythmias (fix)

• valvular stenosis or regurgitation (fix with surgery)

• ventricular septal rupture (fix with surgery)

• tension pneumothorax (only exception)

cardiogenic shock manifestations

• tachycardia

• hypotension

• narrowed pulse pressure ex. 110/90

• decreased cap. refill 

• crackles and tachypnea

• peripheral hypoperfusion

  • cyanosis, pallor, weak pulses, cool and clammy

  • gets worse →

• decreased urine output = decreased renal perfusion

• anxiety, confusion, agitation = impaired cerebral perfusion

how is IV nitroglycerin used in cardiogenic shock

reduces afterload by dilating coronary arteries, improving cardiac output

monitor them closely due to route

dobutamine *

increases the heart’s contractility → improves cardiac output

norepipnephrine

vasopressor used if there is low blood pressure to improve perfusion

keeps BP stable

Milrinone

inotropic agent used in cardiogenic shock sometimes

can improve heart function by increasing contractility and decreasing afterload

diuretics

med given for pulmonary edema if it occurs in cardiogenic shock

used to remove excess fluid → improves lung function

intra-aortic balloon pump (IABP)

mechanical support device used in cardiogenic shock

helps improve blood flow to the coronary arteries by inflating during diastole and deflating during systole

improves perfusion and decreases heart workload

ventricular assist devices (VAD)

mechanical support device used in cardiogenic shock

is a mechanical pump that helps pump the blood from the heart to the rest of the body

usually used by patients waiting for a heart transplant

extracorporeal membrane oxygenation (ECMO)

mechanical support device used in cardiogenic shock (last ditch effort)

provides cardiac and respiratory support by oxygenating the blood from outside of the body and returning it to circulation

used in severe cases when other treatments are not sufficient 

nursing interventions for cardiogenic shock

• monitor VS

  • hypotension, tachycardia, low urine output

• monitor for dysrhythmias

• lab monitoring

  • lactate - if tissues are having a perfusion problem

  • electrolyte imbalance

  • renal function

  • cardiac biomarkers

• fluid and electrolyte management

  • 1L of fluids before vasopressors but not too much

• oxygenation