Cardiovascular - ACS

What is atherosclerosis?

The buildup of fatty plaques (atheromas) in arterial walls that narrow the vessel lumen.

How does atherosclerosis lead to coronary artery disease (CAD)?

Plaque narrows coronary arteries, reducing blood flow to the myocardium and causing ischemia.

What is myocardial ischemia?

Reduced blood flow and oxygen supply to the myocardium that is usually reversible.

What is myocardial infarction (MI)?

Irreversible myocardial cell death caused by prolonged ischemia.

What is the difference between ischemia and infarction?

Ischemia is reversible reduced blood flow; infarction is irreversible tissue death.

What is angina pectoris?

Reversible myocardial ischemia without myocardial cell death.

How does plaque rupture cause ACS?

Plaque ruptures → platelet aggregation → thrombus formation → partial or complete coronary artery occlusion.

What laboratory value distinguishes angina from MI?

Troponin.

What is the troponin level in angina?

Normal.

What is the troponin level in MI?

Elevated.

What are the nonmodifiable risk factors for CAD?

Age, sex, family history, race/ethnicity.

What are the major modifiable risk factors for CAD?

Hyperlipidemia, hypertension, diabetes, smoking, obesity, inactivity, poor diet, chronic stress.

What LDL level increases CAD risk?

130 mg/dL.

What HDL level increases CAD risk?

What causes chronic stable angina?

Fixed atherosclerotic plaque.

When does stable angina occur?

Predictably with exertion.

How long does stable angina usually last?

Less than 15 minutes.

How is stable angina relieved?

Rest or nitroglycerin.

What ECG changes occur with stable angina?

Usually none.

What is the troponin level in stable angina?

Normal.

What causes unstable angina?

Plaque rupture with thrombus formation.

When can unstable angina occur?

At rest or unpredictably.

How long does unstable angina usually last?

More than 15 minutes.

Is unstable angina relieved by nitroglycerin?

Poorly relieved or not relieved.

What ECG changes occur with unstable angina?

ST depression.

What is the troponin level in unstable angina?

Normal.

Why is unstable angina considered an emergency?

It can rapidly progress to myocardial infarction.

What three conditions make up Acute Coronary Syndrome (ACS)?

Unstable angina, NSTEMI, and STEMI.

What causes NSTEMI?

Partial coronary artery occlusion with myocardial cell death.

What ECG finding occurs in NSTEMI?

ST depression.

What troponin finding occurs in NSTEMI?

Elevated.

What causes STEMI?

Complete coronary artery occlusion.

What ECG finding occurs in STEMI?

ST elevation.

What troponin finding occurs in STEMI?

Markedly elevated.

Which ACS condition requires immediate reperfusion?

STEMI.

What is the door-to-balloon goal for PCI?

Within 90 minutes.

What are the classic symptoms of MI?

Crushing chest pain, diaphoresis, dyspnea, nausea, anxiety, pallor, cool clammy skin, pain lasting >30 minutes.

What is Levine's sign?

A clenched fist over the chest indicating cardiac chest pain.

How do HR and BP initially change during an MI?

Increase.

How do HR and BP change later during an MI?

Blood pressure and cardiac output decrease.

How may women present during an MI?

Jaw pain, neck pain, back pain, fatigue, nausea, with less chest pain.

How may older adults present during an MI?

Confusion or altered mental status.

How may diabetic patients present during an MI?

Silent MI with little or no chest pain.

Who commonly has atypical MI presentations?

Women, older adults, and diabetics.

What is the gold-standard biomarker for MI?

Troponin I/T.

When does troponin begin to rise?

3–4 hours.

When does troponin peak?

4–24 hours.

How long does troponin remain elevated?

7–21 days.

How often are serial troponins obtained?

Every 3–6 hours.

When does CK-MB rise?

4–8 hours.

When does CK-MB return to normal?

3–4 days.

When does myoglobin rise?

1–3 hours.

What ECG finding indicates STEMI?

ST elevation.

What ECG finding indicates NSTEMI?

ST depression with T-wave inversion.

What ECG finding suggests ischemia?

T-wave inversion.

What additional diagnostic tests evaluate CAD?

Chest X-ray, echocardiogram, CT coronary angiography, and cardiac catheterization.

What does MONA stand for?

Morphine, Oxygen, Nitroglycerin, Aspirin.

When is oxygen indicated in ACS?

Only if SpO₂ is below 90%.

Why is routine oxygen no longer recommended?

It has no benefit and may worsen outcomes if oxygen saturation is normal.

Why is morphine given during ACS?

Relieves severe pain and decreases myocardial oxygen demand.

How does nitroglycerin reduce cardiac workload?

Venous dilation decreases preload and arterial dilation decreases afterload.

How is nitroglycerin administered during ACS?

Every 5 minutes for up to 3 doses.

What should a patient do if chest pain continues after the FIRST nitroglycerin dose?

Call 911 immediately.

When should nitroglycerin NOT be given?

If systolic BP is less than 90 mmHg.

What are common side effects of nitroglycerin?

Headache, hypotension, orthostatic hypotension.

How should nitroglycerin tablets be stored?

In the original dark, dry, airtight container and replaced every 6 months.

Why must nitroglycerin patches be removed before defibrillation?

To prevent burns.

What aspirin dose is given during ACS?

162–325 mg chewed.

Why is aspirin chewed?

For rapid antiplatelet action.

Should aspirin be prescribed PRN after MI?

No, it is taken daily.

What are the major actions of beta blockers after MI?

Decrease HR, BP, contractility, oxygen demand, infarct size, and mortality.

What are common beta blocker side effects?

Bradycardia, hypotension, bronchospasm, masking hypoglycemia.

Which patients should generally avoid beta blockers?

Patients with active asthma or COPD.

When should ACE inhibitors be started after MI?

Within 24 hours.

Which patients especially benefit from ACE inhibitors?

Patients with EF less than 40%.

Why are statins prescribed after MI?

Lower LDL and stabilize plaques.

Why is heparin administered during ACS?

To prevent formation of new clots.

What medications are included in dual antiplatelet therapy (DAPT)?

Aspirin plus a P2Y12 inhibitor such as clopidogrel or ticagrelor.

How long should DAPT continue after stent placement?

12 months.

What laboratory value monitors heparin therapy?

aPTT.

What is the antidote for heparin?

Protamine sulfate.

What laboratory value monitors warfarin?

INR.

What is the therapeutic INR for warfarin?

2–3.

What is the antidote for warfarin?

Vitamin K.

What bleeding precautions should patients on anticoagulants follow?

Soft toothbrush, electric razor, avoid NSAIDs unless prescribed, monitor for bleeding.

What is the preferred reperfusion therapy for STEMI?

PCI with balloon angioplasty and drug-eluting stent.

When are thrombolytics used?

If PCI is unavailable and STEMI symptoms began within 12 hours.

What is the door-to-needle goal for thrombolytics?

Within 30 minutes.

What is the major complication of thrombolytics?

Hemorrhagic bleeding and stroke.

What are common indications for CABG?

Multivessel disease, left main disease, or complex coronary lesions.

What is the FIRST nursing priority during an acute MI?

Pain relief.

What is the most common cause of death after MI?

Dysrhythmias.

What are the first nursing actions during ACS?

12-lead ECG within 10 minutes, IV access, telemetry, aspirin, nitroglycerin, and pain control.

What should be assessed before cardiac catheterization?

Contrast allergy, informed consent, distal pulses, IV access, NPO status, baseline vital signs.

What should be monitored after cardiac catheterization?

Bleeding, hematoma, distal pulses, sensation, temperature, color, and vital signs.

What are signs of retroperitoneal bleeding after catheterization?

Back pain, flank pain, and hypotension.

When should activity be stopped after MI?

If HR increases >20 bpm above baseline, SBP rises >15 mmHg, or fatigue/dyspnea develops.

What medications are typically lifelong after MI?

Aspirin and statins.

What is the smoking priority after MI?

Smoking cessation is the highest priority modifiable risk factor.

What BP goal should post-MI patients know?

Less than 130/80 mmHg.