AH II: Exam II (ACS, AMI, HF, CMP, Infections)

Cardiac Output (CO)

Bloodflow thru heart/min

• HR x SV = 4-8 LPM

Cardiac Index

CO relative to body SA

• Normal: 2.5-4 L/min/m²

*better indicator of cardiac function than CO

Preload (L)

stretch placed on ❤ muscle fibers (preexisting circulating volume)

Afterload (SVR)

Resistance against which the heart muscle must pump

Ejection Fraction

blood pumped per contraction / available blood

NICOM

pt raise head/legs 45° →

• if ↑ SV → tx w/ fluids

• if SV (—) → tx w/ vasopressors

ARTERIOsclerosis

normal age-related BV thickening/hardening

ATHEROsclerosis

Plaque formation @ arterial wall

1. atheroma @ media intima → inflammation

2. Lesion becomes fibrous/calcified → occlusion

a. severity factors: site & % (S/S appear @ 75-80% occlusion)

*usually @ coronary, renal & femoral arteries → #1 CVD risk

CAD Risk Factors

NON-MODIFIABLE:

• Age

• Male/post-menopausal (r/t estrogen)

• Heredity

• POC → later dx

MODIFIABLE:

• Hyperlipidemia

• HTN

• T2DM

• Metabolic syndrome, obesity, holiday heart syndrome

• smoking

• stress

• exercise

Chest pain pipeline

EKG

• determine if STEMI or non-STEMI

LABS/PIV

• CBC (ax anemia, inflammation, etc)

• BMP (ax electrolytes for ❤ fxn, renal fxn to determine meds)

• CPK, BNP, troponin (presence indicates damaged cells leaked into circulation)

• Coags

Angina Pectoris

No EKG evidence of AMI

• stable vs unstable

Stable Angina

known cause → temporary Δ in ❤ bloodflow

TX:

• Rest

• Nitroglycerine (NTG)

  • Vasodilator → ↓ BP

• Exercise

Acute Coronary Syndrome (ACS)/Unstable Angina: MoA

≥ 40% occlusion → angina pectoris becomes UNSTABLE → STEMI

Acute Coronary Syndrome (ACS)/Unstable Angina: S/S

S/S

• ↑ pain, frequency

• ↓ provocation

• unrelieved by rest/nitro, > 5 mins

Acute Coronary Syndrome (ACS)/Unstable Angina: Diagnostics

DX

• Stress test: exercise (treadmill) vs chemical (Dobutamine, Adenosine, Thallium)

• Cardiac Computed Tomography Angiography (CCTA): visualize BV’s w/ scan & no ischemia

  • Pre-procedure β-blockers (PO/IV metoprolol) → HR 60

  • Nitro paste/spray

Acute Coronary Syndrome (ACS)/Unstable Angina: Treatment

TX

Acute (MONA)

• M: Morphine (↓ catecholamines, pain, anxiety)

• O: Oxygen (if < 95%, increase PRN)

• N: Nitroglycerin (vasodilation)

• A: Aspirin (antiplatelet)

Ongoing (anti-lipemics)

• HMG-CoA “—statins”: ↓ cholesterol synthesis @ liver

• Ezetimibe (Zetia): ↓ cholesterol absorption @ small intestine

• Nicotinic acid (Niacin): ↓ triglyceride synthesis → ↑ LDL synthesis

• BP control

• daily aspirin (ASA)

Acute Myocardial Infarction (AMI)/ STEMI/ Heart attack: MoA

Atherosclerosis/vasospasm/trauma/ARDS → occlusion → ischemia → myocardial necrosis (infarction)

TYPES: inferior wall, R ventricular, Anterior & Septal, Lateral wall, Posterior wall

Acute Myocardial Infarction (AMI)/ STEMI/ Heart attack: S/S

S/S

MEN

• sudden, severe substernal chest pain w/ radiation to jaw, shoulder, neck, arm not relieved by rest/nitro

• pain anxiety → HF → SOB/dyspnea

• Catecholamine release → Tachycardia + diaphoresis, HTN

• ↓ perfusion + coronary irritability → Dysrhythmias

WOMEN

• Silent ischemia: dizziness, SOB, fatigue

• No radiation

• GI S/S: epigastric/back pain, nausea

Acute Myocardial Infarction (AMI)/ STEMI/ Heart attack: Diagnostics

DX

EKG

• Zone of Ischemia (viable cells): T-wave inversion

• Zone of Injury (potentially viable): STEMI alert

• Zone of Infarction (non-viable): Q waves

Labs

• ↑ troponin, CK-MB, C-reactive protein

• anemia

Acute Myocardial Infarction (AMI)/ STEMI/ Heart attack: Pharm Treatment

TX

ACUTE

• MONA

  • M: Morphine Sulfate (vasodilation, ↓ cardiac workload & anxiety)

  • O: Oxygen (2-4 LMP nasal cannula)

  • N: Nitroglycerin SL (vasodilation, ↓ cardiac workload & anxiety)

    • GLOVES, mx HYPOtension, aka Isordil/Imdur

  • A: ASA (antiplatelet)

• β-blockers (“—olol”) → ↓ HR & cardiac workload (mx HF)

  • Emergent & long-term tx

• Ca-Channel blockers: vasospasm tx & vasodilation

• 2B3As (Integrilin, Aggrastat): px NEW clots

• Anticoagulants (Lovenox, Heparin, Atrixtra): px NEW clots

• Thrombolytics (Alteplase): destroy all EXISTING clots

  • Ix: last option

LONG-TERM

• Antiplatelets: Plavix (clopidogrel), Brilinta (ticagrelor)

• ACE inhibitors: ↓ PVR → ↓ cardiac workload → px HF

• Colace: px vasovagal response

• Antilipemics

Acute Myocardial Infarction (AMI)/ STEMI/ Heart attack: Non-Pharm Treatment

Cardiac Cath (femoral/radial)

• Left: heart pressures, visualize coronary arteries and L heart, EF

• Right: heart pressures, visualize R heart, CO

Percutaneous Coronary Intervention (PCI): dilate BV w/ inflated balloon

Atherectomy: rotating blade cleans artery

Stent: wire mesh keeps artery open

Acute Myocardial Infarction (AMI)/ STEMI/ Heart attack: Nursing considerations

Positioning

• Supine w/ leg extended for 4-6 hrs

• No heavy lifting for 1 week

Assessment (Q15 × 4, Q30 × 4, Q1H x 4)

• VS, peripheral pulses

• Site check (infection, bleeding, pain, drainage, dressing, etc.)

Hydration

• protect kidneys from dye from catheterization

HF Staging (ACC/AHA, NYHA)

CLASS A/1:

ID pts @ risk

• DM, CAD, HTN

• Education & lifestyle changes

CLASS B/2:

Structural changes/no symptoms

• History of MI

• Valve regurgitation

• Left ventricular hypertrophy documented by EKG or Echo

Treatment

• Diuretic, BB, ACE, CCB

CLASS C/3:

Symptomatic w/ ordinary physical activity

• CHF tx: ↑ meds, add digoxin

CLASS D/4:

End-Stage Heart Disease

• symptoms @ rest & any physical activity

• tx: transplant eval, end-of-life care