AH3 CAD/ACS

CAD clinical manifestations: (3)

1. stable angina

2. unstable angina

3. prinzmetal’s angina

what distinguishes stable (3) from unstable angina (4)?

stable: (3)

1. CP with activity

2. linked to fixed plaque

3. relieved by meds and rest

unstable: (4)

1. CP at rest (and activity)

2. most concerning

3. marks the start of ACS

4. treated as emergency

what causes Prinsmetal’s angina?

• when does it typically occur?

a variant of unstable angina caused by coronary spasms rather than plaque (but atherosclerotic changes are present)

→ occurs @ rest and in clusters b/w midnight and 8AM

What labs would you want to draw for CAD? (7)

1. total cholesterol

2. triglycerides

3. LDL

4. HDL

5. CK (creatinine kinase)

• ⬆= muscle damage

6. CK-MB (mostly in heart muscle)

• ⬆= HEART muscle damage

7. troponin

Whats the gold standard diagnostic test for CAD?

• what does it help determine?

Coronary Angiography (left sided heart cath)

→ determines if PTCA/Stent placement is an option

(Percutaneous Transluminal Coronary Angioplasty aka Percutaneous Coronary Intervention)

What happens during PTCA? (3)

1. catheter w/ small ballon on its tip advanced through femoral/radial artery to area with plaque

2. ballon inflated, then deflated to open lumen of artery

3. once opened, stent advances to location to hold artery open and maintain blood flow

What defines Coronary Artery Bypass Grafting (CABG):

• arteries (chest/arms) or veins (legs) are grafted to bypass blocked coronary arteries while cardiopulmonary bypass (CBP) maintains perfusion

  • heart is stopped during this to provide bloodless field to work in

whats a complication of CAD?

Acute coronary syndrome (ACS)

• aka MI

• STEMI vs NSTEMI

Key differences b/w STEMI and NSTEMI:

STEMI: (BAAAD)

1. infarction w/ complete obstruction of blood flow

NSTEMI:

1. ischemia w/ partial obstruction

Aside from classic chest pain, what other symptoms should nurse watch for in MI? (5)

1. epigastric discomfort

2. pain b/w shoulders and jawline

3. diaphoresis

4. syncope

5. SOB

What cardiac biomarkers specific to myocardium and stays elevated the longest?

Troponin I: NL: < 0.04 ng/mL (MI: > 0.04)

• rises 3-6 hrs

• peaks 14-20 hrs

• stays elevated 1-2 weeks

Troponin T: NL: <0.01 ng/mL

• rises: 3-4 hrs

• peaks: 12-24 hrs

• stays elevated 2-3 weeks

NSTEMI vs STEMI ECG changes:

NSTEMI:

• ST depression

STEMI:

• ST elevation

emergent treatment bundle for STEMI at presentation: (4)

1. aspirin

2. nitroglycerin

3. morphine

4. O2 if < 90%

Whys aspirin given 1st in ACS?

Whats the 2 doses?

Key note when taking aspirin?

Given first to disable platelet aggregation

• initial dose: 325 mg CHEWED

• 2nd: 81 mg indefinitely

NOTE: dont take with other NSAIDS!!

What does nitro do?

What to monitor for?

Contraindications: (2)

Nitro is a vasoDILATOR

Monitor: hypotension, HA

Contraindicated: (2)

1. right ventricular MI

2. use of PDE-5 inhibitors aka Viagra

How is Nitro given?

Sublingual 0.4 mg q5mins x3

How is morphine dosed in ACS? (3)

1. used as adjunct to nitro (also vasodilator)

2. small doses!!!

• 1-2 mg IV q5-15 mins if CP not relived by Nitro

3. AVOID in right ventricular MI

whats the door-to balloon time goal for STEMI treated w/ PCI?

90 mins!!!

What are signs of a retroperitoneal bleed/Hematoma??? (RBH) (5)

catheter injures femoral artery → blood leaks into retroperitoneal space (behind abdominal organs)

1. hypotension

2. tachycardia (may be masked by beta blockers)

3. abdominal distention

4. back/groin pain (LATE)

5. flank ecchymosis (LATE)

how would u treat a retroperitoneal hematoma?

1. hold pressure

2. percutaneous intervention w/ balloon tamponade

3. blood transfusion

Indications (2) for fibrinolytic therapy and whats the biggest risk?

indications: (2)

1. pain < 6 hrs with STEMI

2. ST elevation > 1 mm in 2+ leads

risk: BLEEDING!!!

• stop anticoags

• monitor PT/INR

• monitor fibrinogen, urine output, BUN/Cr

• give cryoprecipitate and platelets

• NO punctures, invasive devices

If unable to get to cath lab in time, what would u give for a STEMI? (2)

1. TNKase (tenecteplase)

• 5 sec bolus; no infusion or 2nd bolus

  • weight based dose, no more than 50 mg

2. rtPA (Activase)

• bolus followed by infusion

Big 5 discharge meds after ACS? (5)

1. ASA—indefinitely

2. P2Y12 receptor blockers

• at least 1 yr!!

3. BB—indefinitely

4. Statin—indefinitely

5. ACE-I (or ARB)

• EF < 40% or anterior MI

How should P2Y12 inhibitor typically be continued after ACS, and why does this matter for teaching?

At least 1 year

• continuing dual antiplatelet therapy for full yr is critical

  • stopping early = stent thrombosis

3 major complications of CAD:

1. MI (aka ACS)

2. HF

• ⬇CO

• left ventricle cant function

3. Arrhythmias

• can lead to asystole, bradycardia, heart blocks