CAD, Angina, and MI Lecture notes (completed)

Atheromas

Fatty deposits that accumulate within the vessels.

Chronic Endothelial Injury

Caused by factors such as hypertension, tobacco use, hyperlipidemia, diabetes, and toxins, leading to a damaged endothelium.

Fatty Streak

Stage of atherosclerosis where lipids accumulate and migrate into the smooth muscle cells.

Fibrous Plaque

Collagen covers the fatty streak, narrowing the vessel lumen and reducing blood flow.

Complicated Lesion

Involves plaque rupture and thrombus formation, potentially leading to total occlusion of the vessel.

Major Vessels in Coronary Circulation

Circumflex artery, Aorta, Right coronary artery, and Left coronary artery.

Collateral Circulation

Arterial anastomoses within coronary circulation that increase to provide adequate blood and oxygen when blockages develop slowly, but are insufficient during increased workload.

What can cause spasming of coronary arteries?

Cocaine

What is C-reactive Protein (CRP)?

A nonspecific marker of inflammation that shows chronic elevations associated with unstable plaques and oxidation of LDL cholesterol; many patients with CAD show increased CRP levels.

What is considered high cholesterol?

200 mg/dL. or higher

What are the optimal levels for High-Density Lipoproteins (HDL) in males and females?

> 40 mg/dL for males, > 50 mg/dL for females; high levels prevent lipid accumulation.

What is the critical value for Low-Density Lipoproteins (LDL)?

130 mg/dL; high levels increase atherosclerosis.

What is the significance of Fasting Triglycerides?

Important for assessing cardiovascular risk, should be less than 150 mg/dL

What is the treatment goal for hypertension?

The treatment goal for hypertension is to maintain blood pressure below $130/80\,mmHg$; individualized targets for patients over 65 years.

What defines Stage 1 Hypertension (HTN)?

Stage 1 Hypertension is defined as blood pressure readings of $130-139/80-89\,mmHg$.

What defines Stage 2 Hypertension (HTN)?

Stage 2 Hypertension is defined as blood pressure readings greater than $140/90\,mmHg$.

What is considered elevated blood pressure?

Elevated blood pressure is defined as 120-129/<80 mmhg

What are the effects of Tobacco Use on coronary artery disease (CAD)?

Tobacco use causes increased catecholamine release, raises LDL, lowers HDL, and increases oxygen radicals and carbon monoxide. Second-hand smoke increases CAD risk by 25%-30%.

What does the DASH Eating Plan emphasize?

It emphasizes vegetables, fruits, whole grains, fat-free or low-fat dairy, fish, poultry, beans, nuts, seeds, and vegetable oils while limiting fatty meats, whole milk, full-fat dairy, sugar-sweetened beverages, sweets, and sodium intake.

What should be decreased in nutritional therapy recommendations?

Saturated fats, cholesterol, red meat, egg yolks, and whole milk.

What should be increased in nutritional therapy recommendations?

Complex carbohydrates, fiber (whole grains, fruits, vegetables), and Omega-3 fatty acids.

What is the recommended total fat intake for a healthy diet?

25%-35% of total calories.

What are the physical fitness recommendations for cardiovascular health?

Engage in 30 minutes of moderate intensity exercise most days of the week to help with weight reduction, lower systolic blood pressure by over 10%, and increase HDL cholesterol.

What are the ECG changes seen during ischemia?

Shows ST segment depression and/or T wave inversion during the ischemic episode; returns to normal once blood flow is restored and pain is relieved.

Prinzmetal’s Angina

A type of angina that often occurs at rest due to a spasm of a major coronary artery, seen in patients with histories of migraines, tobacco use, and Raynaud’s phenomenon.

Silent Ischemia

Ischemia that occurs without subjective symptoms, often associated with diabetic neuropathy and confirmed by ECG changes.

What is the action of Short-Acting Nitrate Therapy (Sublingual NTG)?

It dilates peripheral and coronary blood vessels.

How should Sublingual NTG be administered?

Do not swallow saliva until the pill is dissolved. It may be repeated every 5 minutes for a maximum of 3 doses.

What should you do if pain persists after the first dose of Sublingual NTG?

Call 911.

When can Sublingual NTG be used as prophylaxis?

It can be used before emotionally stressful situations or sexual intercourse.

What are some side effects of Short-Acting Nitrate Therapy?

Headache (treat with Tylenol/acetaminophen) and orthostatic hypotension.

What is a Long-Acting Nitrate used for?

Long-Acting (isosorbide mononitrate) is used to reduce the frequency of angina and is available as oral sustained-release, ointment, or transdermal patches.

What are Calcium Channel Blockers (diltiazem) used for?

They are used to decrease coronary spasms, especially in Prinzmetal’s angina.

12-lead ECG

The first component for diagnosing angina or myocardial infarction (MI); identifies ST segment elevations or depressions.

Cardiac Catheterization

Used to identify and localize coronary artery disease (CAD); allows visualization of blockages and potential intervention via Percutaneous Coronary Intervention (PCI), including balloon angioplasty and stents.

What are Laboratory Studies in the context of coronary artery disease?

Includes cardiac biomarkers, lipid panels, and C-reactive protein (CRP).

What are the types of Imaging used in diagnosing coronary artery disease?

Chest x-ray, Echocardiogram, and Calcium-score screening heart scan.

Pre-Procedure Care for Cardiac Catheterization

1. Check for sensitivity to contrast media/dye. 2. Assess renal function (serum creatinine) as dye is nephrotoxic. 3. Withhold food and fluids for 6-12 hours before. 4. Assess baseline vital signs, heart/breath sounds, peripheral pulses, and extremity sensation/temperature. 5. Explain the procedure, including anesthesia use and the feeling during dye injection.

Post-Procedure Care for Cardiac Catheterization

Frequently assess circulation distal to insertion site (peripheral pulses, color, sensation). Monitor vital signs, pain sources, ECG, renal function, and promote fluid intake. Check for hematoma, bleeding, and keep the affected extremity straight.

What develops when ischemia is prolonged and not immediately reversible?

Acute Coronary Syndrome (ACS), which encompasses unstable angina and myocardial infarction.

What are the characteristics of Unstable Angina (UA)?

New onset pain, occurs at rest or shows a worsening (crescendo) pattern, is unpredictable, and lasts > 10 minutes.

What manifestations are commonly seen in women with Unstable Angina?

Often more vague symptoms like fatigue, dyspnea, indigestion, and anxiety.

What ECG changes may occur in Unstable Angina?

May show transient ST depression and/or T wave inversion.

How does Stable Angina differ from Unstable Angina?

Stable Angina is episodic, lasts 2-5 minutes, occurs on exertion, and is relieved by rest; Unstable Angina is severe, lasts > 10 minutes, occurs at rest, and is unpredictable.

What immediate care should be provided for someone experiencing Unstable Angina?

Position the patient upright, apply oxygen (O2 sat goal > 93%), assess vital signs and heart/breath sounds, continuous ECG monitoring, obtain cardiac biomarkers, and provide pain relief (NTG or IV opioids).

What is STEMI (ST-segment elevation MI)?

Thrombus causes total occlusion of the artery, leading to T wave inversion and pathologic Q waves developing within a few hours to days.

What is NSTEMI (Non-ST segment elevation MI)?

Thrombus causes partial occlusion, showing ST depression or T wave inversion on the initial ECG.

What are the atypical presentations of Myocardial Infarction in women and the elderly?

Atypical chest pain or discomfort, fatigue, weak or numb extremities, dizziness, palpitations, shortness of breath, indigestion, confusion or change in mental status.

What happens during Sympathetic Nervous System (SNS) stimulation?

Release of catecholamines leads to diaphoresis, increased heart rate (HR), blood pressure (BP), and peripheral vasoconstriction (pale, clammy, cool skin).

Cardiovascular Effects of Myocardial Infarction

Initially increased HR/BP, followed by BP drop due to decreased CO; S3/S4 heart sounds, JVD, and peripheral edema indicate RV dysfunction; crackles indicate LV dysfunction.

Gastrointestinal Effects of Myocardial Infarction

Nausea and vomiting due to vasovagal reflex; fever up to 100.4°F within the first 24 hours due to systemic inflammation from cell death.

Renal Effects of Myocardial Infarction

Decreased renal perfusion leading to decreased urine output.

What happens by the 4th day of the healing process after a myocardial infarction?

Proteolytic enzymes (neutrophils and macrophages) begin removing necrotic tissue.

What occurs at 10-14 days after a myocardial infarction?

The new scar tissue is still thin/weak, making the myocardium highly vulnerable to stress and dysrhythmias.

How can necrotic zones be identified after a myocardial infarction?

Necrotic zones are identifiable by nuclear scanning or ECG changes.

Why must the myocardium be monitored after a myocardial infarction?

The myocardium is vulnerable to stress, posing a risk for dysrhythmias, so the patient must be monitored carefully as activity levels increase.

Troponin I or T

The biomarker of choice for heart injury; rises in 4-6 hours, peaks at 10-24 hours, and lasts 10-14 days. Normal troponin T level is 0 to 0.2 ng/mL.

Myoglobin

Limited use as a biomarker; rises in $2$ hours and peaks in $3-5$ hours. Helps differentiate unstable angina (UA) from non-ST segment elevation myocardial infarction (NSTEMI).

What is the first step in the management of Acute Coronary Syndrome?

Run a 12 lead ECG FIRST!!!

What are examples of antiplatelet medications used in Acute Coronary Syndrome?

Aspirin, clopidogrel, ticagrelor.

What is the target for aPTT monitoring when using anticoagulants like Heparin?

1.5-2.5 times normal.

What is the purpose of beta-blockers in the management of Acute Coronary Syndrome?

To decrease BP, slow HR, and reduce myocardial oxygen demand.

What is the goal for administering thrombolytic therapy for STEMI?

Administer within 30 minutes of arrival.

What is the first-line treatment for STEMI?

Coronary angiography (PCI).

What dietary changes should be made post-Acute Coronary Syndrome?

Gradually progress from NPO to small, easily digested, low-salt, low-saturated-fat, and low-cholesterol meals.

What should be monitored for Warfarin?

Monitor PT/INR; PT goal is 1.5 times the normal; INR goal is 2.0-3.0.

What is the first-line treatment for STEMI?

Percutaneous Coronary Intervention (PCI).

What is the goal time for PCI to be achieved?

The goal is 'door to catheter lab' in 90 minutes.

What methods does PCI use?

Balloon angioplasty and stents.

Why do patients need dual antiplatelets after PCI?

To prevent thrombosis, as stents are thrombogenic; this is required for up to 12 months or longer.

Coronary Artery Bypass Grafting (CABG)

Creates new routes around narrowed and blocked arteries, allowing sufficient blood flow to deliver oxygen to the heart muscle.

Indications for CABG

Failed medical management, left main coronary artery or three-vessel disease, failed PCI with ongoing pain, or if long-term benefits of CABG outweigh PCI.

CABG Procedure

Requires a sternotomy and cardiopulmonary bypass (CPB) machine, using grafts from the internal mammary artery, saphenous vein, or radial artery.

What is the focus of preoperative care before a CABG procedure?

Assess electrolytes, gather baseline nursing data (pulses, $HR$, neuro), withhold aspirin, and maintain $NPO$ at midnight.

What should be monitored postoperatively after a CABG?

Monitor surgical sites (chest and harvest sites like legs/radial).

How can airway and gas exchange be promoted postoperatively after a CABG?

Assess breath sounds, encourage the use of incentive spirometer, and teach splinting (holding a pillow over the incision) during coughing/deep breathing.

What are ways to prevent DVT postoperatively?

Implement early ambulation and use compression devices.

What is the target urine output for monitoring fluid balance and kidney function postoperatively?

The target urine output should be > 30 cc/hour.

What are some complications of the CABG procedure that nurses must assess for?

Includes pulmonary issues such as atelectasis, pleural effusion, pneumonia, as well as cardiac instability, dysrhythmias, neuro changes, fluid imbalance, fever, immobility, and sleep disturbance.

Pulsus alternans

Alternating weak and strong heartbeats.

Pulse deficit

Difference between beats of the heart and pulse.

Objective data in nursing assessment for MI

Includes anxiety, cool clammy skin, tachycardia/bradycardia, dyspnea, and the need for cardiac monitoring.

What is the Valsalva Maneuver?

A forced expiration against a closed glottis that occurs when intrathoracic pressure increases and blood return to the heart decreases.

What are potential outcomes of the Valsalva Maneuver?

It can produce sinus bradycardia, dysrhythmias, and syncope.

What may be ordered to prevent complications from the Valsalva Maneuver?

Stool softeners (like docusate sodium [Colace]) may be ordered to prevent straining.

What is Cardiogenic Shock?

A severe complication where the heart cannot pump enough blood to vital organs, characterized by very low BP, low urine output, rapid/weak pulse, and confusion.

What are the common dysrhythmias associated with myocardial infarction?

Dysrhythmias occur in 80%-90% of patients and include Premature Ventricular Contractions (PVCs), Ventricular Tachycardia (VT), and Ventricular Fibrillation (VF), which are the most common causes of death.

What may develop after a myocardial infarction?

Bradycardia may develop after MIs.

What is heart failure in the context of myocardial infarction?

Heart failure occurs when the heart cannot supply enough blood for the body's needs.