(ACS) Acute Coronary Syndrome (nSTEMI, STEMI, UNSTABLE ANGINA)

Unstable Angina (UA)

• new in onset

• Occurs ________or during sleep

• Occurs with increasing frequency, duration, or less effort than the patients usual chronic stable angina

• Usually lasts at least _________

• UNPREDICTABLE

At rest, 10 min

Non-ST-Elevation MI (NSTEMI)

Caused by- ________________

• does NOT cause ST segment elevation

• ECG may show ST depression &/or T wave inversion

• Pts will usually undergo cardiac Catherization within ________

• Thrombolytic therapy is ___________________

Nonocclusive thrombus, 12-72 hrs, not a treatment option

ST-Elevation MI (STEMI)

Caused by- ________________

Myocardial cell death occurs

ST segment elevation

Occlusive thrombus

First line STEMI treatment : ________________

if available, must occur within _______ of arrival to ED

Percutaneous coronary intervention, 90 min

STEMI treatment (if PCI not available)

______________ : must occur within ________ of arrival to ED

Thrombolytic therapy, 30 min

MI chest pain: persistent

• Heavy, pressure, tight, burning, constricted, or crushing

• Common locations: _____________or _________

• May radiate to neck, lower jaw, arms, or back

• Often occurs in early morning

Substernal, epigastric

MI chest pain usually lasts

20 min or longer

MI chest pain:

Atypical symptoms:____________

Discomfort, weakness, nausea, indigestion, SOB

patients with ______ may have silent (asymptomatic) MIs

Diabetes

MI clinical manifestations for Older patients:

• _____________

• SOB

• _____________

• _____________

• Dysrhythmia

Change in mental status, pulmonary edema, dizziness

Clinical manifestations of MI:

SNS stimulation:

• __________

• Increased HR & BP

• vasoconstriction of peripheral blood vessels (Skin may be ______, ________, or cool)

Diaphoresis, ashen, clammy

Clinical manifestations of MI:

Nausea & vomiting:

Severe pain causes reflex stimulation of the vomiting center

• ___________ in area of infarcted heart muscle

Vasovagal reflex

Clinical manifestations of MI: Fever

May last ____________

Death of heart cells cause systemic inflammatory process

4-5 days

Often given to limit remodeling after Mi

ACE inhibitors

Complications of MI: Dysrhythmias

Occurs in 80-90% of pts after MI

• _____ & ______ are the most common cause of death in prehospital period

• Bradycardia

• ________

VT, VF, PVCs

Complications of MI: dysrhythmias, _______, _________

Heart failure, Cardiogenic shock

Complications of MI: Papillary muscle dysfunction or rupture

treatment: reduce afterload with __________ &/or ______

Immediate surgery to repair or replace mitral valve

Nitroprussidd, IABP

Complications of MI: Ventricular Septal Wall Rupture & LV free wall rupture

• may cause HF, Cardiogenic shock

• Treatment→ _________

Emergency surgical repair

• mild to severe chest pain that increases with inspiration, coughing, and movement of upper body

• May occur 2-3 days after MI

Pericarditis

pericarditis & fever that develops 1-8 weeks after MI

• may be autoimmune reaction to necrotic heart muscle

• May have pericardial friction rub & pericardial effusion

Dressler syndrome

Dressler syndrome treatment

High dose aspirin

Diagnostics of ACS:

ECG, AND ________

Echocardiogram

Worsening myocardial contractility

Hypokinesis

Standard to identify MI: Cardiac-Specific Troponin

• serial sets are drawn over _______

24 hrs

MI: cardiac biomarker- less sensitive than Troponin

Creatine Kinase MB

Patients w/ STEMI must have cardiac cath w/ PCI within ____ mins of arrival at ED

90

Patients w/ UA or NSTEMI usually have cardiac cath during hospitalization to diagnose & evaluate extent of disease; they do NOT need emergent cath

• usually within _____-_____hrs after arrival to hospital

• PCI may be done during diagnostic cath if appropriate

12-72

Management of ACS:

• Always assess & monitor ABCs.

• Position patient _______ unless contraindicated.

• Give O2 by __________ or __________ mask.

• Obtain baseline vital signs, including O2 saturation.

• Auscultate heart & breath sounds.

• Obtain 12-lead ECG.

• Insert 2 IV catheters.

• Assess pain using PQRST mnemonic (Table 37.8).

• Medicate for pain as ordered (e.g., nitroglycerin, morphine).

Upright, nasal cannula, nonrebreather

Management of ACS:

Start continuous ECG monitoring.

• Obtain baseline blood work.

• Obtain portable chest x-ray.

• Assess for contraindications for antiplatelet, anticoagulant, or thrombolytic therapy, as appropriate.

• Give _______ for heart-related chest pain unless contraindicated.

• Give a high-dose _______.

• Give antidysrhythmic drugs for life-threatening dysrhythmias.

Aspirin, statin

ACS: Ongoing monitoring

Assess & record response to drugs (e.g., decrease in chest pain) & re-medicate or titrate drugs (e.g., _________) as needed.

nitroglycerin

ACS: ongoing monitoring

Anticipate need for intubation if ___________ is evident.

• Prepare for CPR & defibrillation if cardiac arrest is evident.

• Anticipate need for transcutaneous pacing for symptomatic bradycardia or _________.

Respiratory distress, heart block

Management of ACS: cardiac catheterization

Diagnostic functions:

• _________ blockage

• Assess _________ of blockage

• Determine presence of ____________

• Evaluate LV function

Locate, severity, collateral circulation

Management of ACS: cardiac catheterization

Therapeutic functions:

• Balloon angioplasty

• Insert ______ or ______ into blocked coronary artery

Bare metal stent, DES

Post-Op care after CABG

• ICU for first ____-____ hrs

• Hemodynamic monitoring

• __________ for continuous BP monitoring

• Pleural & mediastinal _____________ for chest drainage

• Continuous ECG monitoring

• Mechanical ventilation

24-48, arterial line, chest tubes

Post-Op care after CABG

• Epicardial pacing wires for emergency pacing of the heart is for _________

• Urinary cath

• NGT for gastric decompression

Temp pacemaker

Potential complications after CABG

• Systemic inflammation

• Bleeding & anemia

• F&E imbalances

• Infection

• Hypothermia

• Dysrhythmias (A. Fib)

  • _____________should be started at least 24 hrs. before surgery & restarted ASAP

• __________________________

Beta blockers, postoperative cognitive dysfunction

Management of ACS: thrombolytic therapy

Indicated only for pts with _______ who cannot have an emergent cardiac cath

STEMI

Management of ACS: Thrombolytic Therapy

Inclusion criteria:

• Chest pain <______ & ECG findings show a STEMI

• Must have NO absolute contraindications

12 hrs

Management of ACS: Thrombolytic Therapy:

What are the most important Absolute contraindications?

Bleeding, uncontrolled HTN

Management of ACS: Thrombolytic Considerations:

• BEFORE starting:

  • - draw blood for baseline lab values

  • - start _________IV lines_

  • - Perform all other _______________

• Regularly assess _____________ for changes that could indicate cerebral bleeding

• MAIN COMPLICATION —> ___________

2-3, invasive procedures, neuro, bleeding

ACS: drug therapy

• quickly reduces cardiac workload & ischemia

• Titrate infusion to chest pain

IV nitroglycerin

ACS: drug therapy

Reduces cardiac O2 demand

Treats acute chest pain

Morphine

ACS: drug therapy: Antidysrhythmics (if needed)

CCB, Beta blockers

ACS: drug therapy

T or F ?

Stool softeners used

T