CAD

Stable angina

Chest pain/discomfort with activity. Typically linked to fixed plaques. Predictable. Symptoms often alleviated with rest and/or medication (nitro).

Unstable angina

Can occur at rest. Acute decrease in coronary blood flow. Usually prolonged and may not be relieved with rest or medication. Initial phase of acute coronary syndrome (ACS). Precursor to MI.

Most common time for MI

midnight to 8 am (increase in cortisol and SNS)

Prinzmetal’s or variant angina

Caused by coronary spasm rather than plaque. Atherosclerotic changes may be present. (more common in women and less dangerous)

not all chest pain is caused by cardiac ischemia. Other potential causes?

Aortic dissection, Pericarditis, GI problems (PUD, GERD e.g.), Pleuritic pain, Pulmonary embolism

Aortic dissection signs

ripping chest pain

Pericarditis sign

relief of chest pain by position (leaning forward)

Myocardial Infarction (MI)

Destruction of heart muscle from lack of oxygenated blood supply.

Acute Coronary Syndromes

Unstable angina, Non-STEMI, STEMI

Non-STEMI

not completely occulted no ST elevation

STEMI

completely occulted ST elevation (transmural)

Possible complications of MI

Dysrythmias, Heart Failure, Cardiogenic Shock

Myocardial Infarction (MI) Manifestations

Chest pain (use PQRST method), radiating to lt shoulder/arm, jaw, btwn shoulder blades, upper back, dyspnea, nausea/vomiting, diaphoresis, fatigue

Right coronary artery MI (RCA—inferior, posterior wall) Manifestations

jugular vein distension (JVD), hypotension, bradycardia, heart blocks more likely. Clear lung sounds

Right coronary artery MI

inferior, posterior wall

Left coronary artery MI

LAD—anterior wall

Left coronary artery MI (LAD—anterior wall) Manifestations

Dyspnea, pulmonary congestion, tachycardia, hypertension quickly progressing to hypotension. Lethal rhythms are more likely to develop.

Left coronary artery MI (CIRC—posterior, lateral wall) Manifestations

bradycardia, heart blocks more likely.

MI atypical presentation

Women (neck shoulder, jaw, abdominal, pain) geriatric population (dyspnea, syncope, weakness, confusion) , diabetes (nervous system damage – dyspnea fatigue GI)

RCA feeds

SA node and right ventricle

MI GOLD standard Diagnostics

12 lead EKG! (NSTEMI vs. STEMI)

MI Cardiac enzymes

(CK-MB Troponin) ( > 0.4 ng/ml)

CK-MB

The standard of care is to draw blood every 6–8 hours for the first 24 hours. levels increase 4–9 hours after an injury or heart attack, peak at 6–10 hours, and return to normal within 1–2 days.

Troponin

Blood samples are usually drawn twice, 6–8 hours apart, to determine cardiac-specific levels. levels can remain elevated for up to 4–7 days for __ I, and 10–14 days for _ T.

MI Additional potential diagnostics

CBC, COAGs & other labs, CXR, Echo

Inferior MI

leads II, III, aVF

Anterior MI

V leads

V1-2

Septal (LAD)

V3-4

Anterior (LAD)

V5-6

Lateral (Circumflex)

Goals for MI Care

Oxygenation, Pain control. Dilation of coronary vessels, Prevention of clot formation, Decrease cardiac workload, REPERFUSION Maintain Cardiac Output!

MI Patient Care

ABCs, oxygen for sat <90%, Anticipate cardiac arrest, 12 lead EKG and continuous cardiac monitor, IV access (2 large bore IVs), Collect labs, CXR, Quick H & P, Fibrinolytic check list

MI Medications

ASA, Possible heparin, Possible P2Y12 inhibitor, Nitroglycerin, Morphine, Possible beta blocker, Possible PCI, thrombolytic, CABG

MI Medications ASA

160-325 mg (chew), Rectal if N/V

MI Medications Possible P2Y12 inhibitor

Ticegralor (Brilenta), Clopidogrel (Plavix)

MI Medications Nitroglycerin

0.4 mg SL Q 5 minutes X 3, Change to IV after 3 doses if pain not controlled, Ask about PDE5 inhibitor use within past 24-48 hrs

Nitroglycerin Ask about PDE5 inhibitor

Sildenafil (Viagra) and Vardenafil (Levitra)—24 hrs, Tadalafil (Cialis)—48 hrs

MI Medications Nitroglycerin With caution or hold with

inferior MI, With caution or hold with hypotension (SBP < 90 mm Hg), bradycardia, or marked tachycardia (ACLS) Increased risk for cardiac decompensation

MI Medications Morphine

2-10 mg IV Q 5-30 minutes IV for pain not responding to nitroglycerin (Narcan for OD)—Fentanyl alternative

MI Medications Possible fluid challenge for

inferior MI, 200-300ml NS at a time, monitor BP CVP if possible, JVD and pulm crackles,

MI Medications Possible beta blocker

not for Heart block, low HR, low BP, can help decrease heart work load

For right MI give

fluid

For Left MI give

Nitro

Cath lab for percutaneous coronary intervention (PCI) ASAP for STEMI

door to balloon time 90 minutes! Patient Care

Fibrinolytic Therapy

For STEMI when PCI unavailable within 90 minutes, Within 12 hours of symptom onset

Fibrinolytic Therapy Absolute contraindications

Symptoms suggest aortic dissection (ripping pain), Active bleeding (not menses), Any prior intracranial bleeding, Known structural cerebral lesions, Significant closed head trauma within past 3 months

Fibrinolytic Therapy Relative contraindications

Hypertension (treat BP then give), Ischemic stroke within 3 months (possible brain bleed) then no but if Ischemic stroke within the past 3 hours yes

Fibrinolytic Therapy medications

Alteplase (Activase), retaplase (Retavase), TNKase (Tenecteplase)

Nursing care for fibrinolytics

2 large bore IVs. Clotting studies, Monitor VS and neuro status, Monitor for bleeding, Monitor for signs of reperfusion

fibrinolytics Monitor for signs of reperfusion

No pain, Sudden burst of V tach, ST segment resolution, Early peak cardiac biomarkers (avg is 24 want before that)

Post MI Care—CAD care Lifestyle changes!

Diet (whole food, plant based, low saturated fat, balanced salt intake) Activity (increased HDL, decreased triglycerides, BP and weight control, decreased inflammation, increased heart strength, BG control, helps with smoking cessation) Smoking cessation, ETOH reduction

Post MI Care—CAD care

Diet, Activity, ) Smoking cessation, ETOH reduction Screening and treatment for depression, Stress management, Cardiac rehabilitation programs

Cardiac rehabilitation programs

Medically supervised program to improve heart health after MI, heart surgery, PCI, out patient (multidisciplinary)

Post MI Care Medications

Managing clotting (anticoag), Reducing endothelial damage (statins) BP control (BB, ACE, ARB), BG considerations, Relieving symptoms (Nitro)

Coronary Artery Bypass Graft (CABG)

Healthy artery or vein used for bypass, Cardiopulmonary bypass machine used during procedure, May be done after failed PCI or may be procedure of choice in some situations.

CABG Post-operative care Airway, ventilator related care

Dexmedetomidine (Precedex), Extubation goal? 6 hr post

CABG Post-operative Vital signs and hemodynamics

Systemic inflammation, Cardiac output maintenance, heart failure potential

CABG Post-operative Arterial line

BP too low vessel collapse, BP too hig bleeding risk, PA catheter, Support blood pressure and HD status (IV fluids, inotropes, vasodilators, vasoconstrictors, diuretics)

CO/CI (cardiac output) –

4-8L/min

PVR

(<250 dynes*sec/cm5) pulmonary VR

SVR

900-1400 dynes/sec/cm

SVO2

(60-75%) mixed venous oxygen saturation how oxygenated is the blood before the lungs (how much oxygen was use in the body)

MAP

70-100 mmHg (constant perfusion pressure) KEEP ABOVE 65

CVP Central Venus pressure + SVC

2-6 mmHg (preload of R side)

PA (pulmonary artery)

25/10 mmHg (quarter over dime) (Left heart preload indirect)

PCWP (PAOP)

6-12 mmHg

CABG Post-operative Cardiac rhythm monitoring

ST elevation – reoccultion, A fib and AV block common,

CABG Post-operative Assess heart tones

Muffled – tamponade , S3 (bell) volume overload

S3

Kentucky, systolic, cause by fluid overload

CABG Post-operative Monitor for cardiac tamponade

muffled heart sounds, distended Neck viens, decrease BP (distance, distended, decreased)

CABG Post-operative Monitor

breath sounds and O2 sat, Monitor temp, gradually rewarm (Warm fluids, blankets, air flow (Baer Hugger) , Assess neuro status (stroke), Hourly intake and output (renal function, CO) , Skin color, temp, pulses, cap refill

CABG Post-operative Chest tube care

color, hourly output, Pleural, Mediastinal Sudden increase in output? Hemorage (bright red) Sudden decrease? Clotting off pressure to, Tamponade risk

CABG Post-operative Chest tube Report

more than 200 ml in a 2-hour period.

CABG Post-operative Labs

CBC (WBCs, Hgb & Hct, platelet count (heavy heparinized during surgery), Elytes, (watch for high K low Ca) BUN & Creatinine, Blood glucose, Coagulation studies (Possible protamine administration) , Possible TEG

CABG Post-operative

Incision assessment and wound care, Splint with CDB, ICS use after extubated , Pain medication (not too much) , Early mobilization (OOB to chair within 24 hrs, Ambulate TID first Post operative day)

CABG Post-operative Transfer from ICU

Pa cath, cordis, art line removed, May transfer with chest tubes, Pacer wires remain

Pacer wires removal

RN can pull pacing wires, don’t if there is ANY resistance (dependent on how long they have been in) if cant pull HCP will clip

CABG Discharge Teaching Wound care and preventing/monitoring for infection

HCP Prescribed, Report separation, purulent drainage, movement, Wash with soap and H20, Avoid lotions and creams, Avoid tight clothes, Cushion with pillow, Possible leg incision (elevated, keep clean, TEDs), Dietary considerations; Prevention of constipation . Daily weight, Ted hose

CABG Discharge Teaching Sternal precautions

Weight limits (not > 10 lbs), No arms over head, bending at waste, vigorous activity, ALSO, avoid push/pull, support with CDB, sleep on back for several weeks, arms close to body for 6-8 wks

CABG Discharge Medication teaching

Pain medication (give stool softener no straining), ASA, Lipid lowering drug, Beta blocker

CABG Discharge Activity

as tolerated, Cardiac rehab, Sex when comfort allows (HCP clearance is best)