Week 1: Acute Coronary Syndrome

Coronary Artery Disease

• what is it

• Risk factors (11)

• s/s (7)

• TX (7)

• DX (7) (4 are labs)

• PT Education (9)

CAD: Narrowing of the coronary arteries d/t atherosclerosis (plaque build-up in arteries from cholesterol deposits)

Risk Factors:

• smoking and alcohol use

• HTN

• overweight/obesity

• diabetes

• high cholesterol

• stress

• sedentary lifestyle

• Family Hx

• Advanced age

• race (African American)

• gender (male)

Symptoms:

• May show no s/s

• chest pain that goes away with rest

• diaphoresis

• SOB

• Heartburn

• n/v

• fatigue

DX:

• EKG

• Stress test

• cardiac catheterization

• Labs: HDL >60 and LDL <100 (cholesterol), triglycerides <150, total cholesterol: <200

TX:

• Right away MONA (Morphine, O2, Nitroglycerin, Aspirin)

• Antihypertensives

• atherectomy: removal of plaque from artery

• percutaneous coronary intervention (PCI): unblocks arteries to restore blood flow with balloon and possible stent placement

Patient Education:

• Smoking cessation

• Moderate exercise 3-4 times/week

• stress management

• weight managment

• monitor HR and BP

• Diet: low sodium, low saturated fat, increase fiber and fruits and veggies

A myocardial infarction (MI) is commonly known as what?

Heart attack

When someone is presenting with crushing chest pain what should you always assume until proven otherwise

MI

MI: Treatment and diagnostic

• DX (imaging, procedures, labs, ect..) (3)

• TX (8) (right away 4, later on 4)

DX:

• 12 lead ECG!!!

• Troponins (now, 2hrs, and 4 hrs) (follow trend might not increase for a while)

• chest x-ray

TX:

Right away: MONA (Morphine, O2, Nitroglycerin (can give 1 up to 3x Q5mins), Aspirin(chewable))

Later on: BASH (Beta blockers, Ace inhibitors, Statins, IV Heparin)

STEMI vs NSTEMI

Clinical Manifestations of Acute coronary syndrome (ACS): Unstable angina-

_____ blockage

• describe (3)

• what to keep in mind in terms of different presentations in different populations

• what on a ECG = ischemic changes (2)

• is this life threatening

temporary blockage

1. new pain, onset with ordinary physical activity

2. OCCURS AT REST, usually prolonged (> 10 minutes)

3. increased angina that is more frequent and longer in duration

Keep in mind:

• Some women, older adults, and diabetics may not have chest pain but present with exertional symptoms (triggered or caused by physical or mental effort) of jaw, neck, arm; fatigue, nausea, unexplained worsening of exertional dyspnea

*ST depression and/or T wave inversion = ischemic change!!!

*Needs immediate treatment!!!

Clinical Manifestations of ACS Myocardial Infarction – _____ blockage

• describe

• s/s (6)

• location (2)

• may radiate to (5)

• typically lasts how long

• Drive mnenomnic for MI presentation

• when does it often occur

• Atypical presentation in what populations? (3)

• other s/s (4)

Prolonged blockage

MI: Severe chest pain not relieved by rest, position change, or nitrate administration

• Heaviness, pressure, tightness, burning, constriction, crushing

• Substernal or epigastric

• May radiate to neck, lower jaw, arms, back, may follow ulnar nerve to pinky

• TYPICALLY LASTS > 20 MINUTES (CRUSHING, GRIPPING, HEAVINESS

DRIVE: (Diaphoresis, Radiation, I won’t get burned (burning), Vomiting, Exertion)

Often occurs in early morning

Atypical in women, elderly and diabetics (No pain if cardiac neuropathy)

Other s/s – JVD, HF, decline in BP, and Increased temperature up to 100.4 F (38C)

Unstable Angina and MI: Diagnostic Studies

• DX procedures, imaging labs, ect… (2) (what testing is only done on stable patients and what other criteria? (1))

• Serum cardiac Biomarkers (3)

• Procedures (1) (when is this procedure used 3)

DX for angina and MI:

• 12-lead ECG, distinguish between STEMI and NSTEMI)

• stress testing: for STABLE patients with abnormal but non-diagnostic ECG and negative biomarkers

Biomarkers:

• cardiac specific troponin (cTnT, cTnl, Hs-cTn)

• creatine kinase (CK-MB)

• myoglobin

Procedures:

• coronary angiography (heart Cath or cardiac cath):

For patients with a STEMI, US, and STEMI

critical physiological thresholds and clinical treatment window standards for MI:

• 20 minutes

• 30 minutes

• 90 minutes

20 minutes:

• Irreversible myocardial injury begins

30 minutes:

• door to needle goal

• thrombolytics should be started within 30 minutes If PCI cannot be performed promptly and the patient is an appropriate candidate

90 minutes:

• door-to-balloon goal

• Percutaneous Coronary Intervention / PCI) should be performed to manually inflate a balloon and clear the arterial blockage within 90 minutes of arriving at a capable hospital.

• Restoring blood flow within this window significantly preserves heart function and survival rates.

Acute Coronary Syndrome: interprofessional care

• common care plan interventions (3)

• interventions/tx for UA or NSTEMI (2)

• what is to monitor (1)

common care plan interventions:

• Ongoing monitoring

• Treat dysrhythmias

• Frequent vital sign monitoring

• Bed rest/limited activity for 12–24 hours

• Stool softeners

UA or NSTEMI interventions:

Dual antiplatelet therapy (ASA (asprin), ticagrelor (tye-ka-ga-lor) recommended over clopidogrel) and heparin

• Cardiac catheterization with PCI once stable

Heparin Nomogram:

• measuring therapeutic effectiveness aPtt, anti-Xa Assay

Interprofessional Care Acute Coronary Syndrome- STEMI

• Emergent Reperfusion therapys (3)

• think about time requrments

• tx of choice for STEMI

• what is only for patients with STEMI

• conrdications (1)

Coronary artery bypass graft surgery (CABG) surgery

• procedure to restore blood flow to areas of your heart

Emergent PCI (Percutaneous Cardiac Intervention)

• Treatment of choice for confirmed STEMI

• Goal: 90 minutes from door to catheter laboratory

• Balloon angioplasty + stent(s)

• Many advantages over CABG

Thrombolytic therapy - tenectaplase, alteplase

• Only for patients with a STEMI

• Agencies that do not have cardiac catheterization resources

• Given IV within 30 minutes of arrival to the ED

• Patient selection critical

• What are the absolute contraindications? (wounds)

Thrombolytic therapy –

• used for (1)

• drugs (2)

• what to monitor (2)

• how many IV’s should you start

• best sign of reperfusion?

• what should be done prior to procedure

• what is used to prevent re-occlusion

• used for STEMI

• drugs: tenectaplase, alteplase

• Draw blood and start 2–3 IV sites

• Complete invasive procedures prior

• Administer according to protocol

• Monitor closely for signs of bleeding

• Assess for signs of reperfusion: Return of ST segment to baseline best sign

• IV heparin to prevent re-occlusion (nomogram)

Acute Coronary Syndrome

Nursing Management

A patient who has chest pain is admitted to the emergency department (ED), and all of the following are ordered. Which order should the nurse arrange to be completed first?

a. Chest X-ray

b. Troponin level

c. Electrocardiogram ECG

d. Insertion of a peripheral IV

C

A patient is admitted to the coronary care unit following a cardiac arrest and successful cardiopulmonary resuscitation. When reviewing the health care provider’s admission orders, which order should the nurse question?

a. Oxygen at 4 L/min per nasal cannula to keep sats >93%

b. Morphine sulfate 2 mg IV every 10 minutes until chest pain is relieved

c. Tissue plasminogen activator (tPA) 100 mg IV infused over 3 hours

d. IV nitroglycerin at 5 mcg/minute and increase 5 mcg/minute every 3 to 5 minutes PRN for chest pain

C