Coronary Artery Disease and Acute Coronary Syndrome

Non-modifiable risk factors

• Age

• Sex

• Family history/ genetics

• Ethnicity

Modifiable

• Elevated serum lipids

• Hypertension

• Smoking

• Physical inactivity

• Obesity

• Nutrition

• Comorbid Conditions

Angina

• Clinical manifestation of ischemia

• Results from imbalance of supply of blood to heart and O2 demand

Supply

• Heart rate

• Coronary Perfusion Pressure

  • Pressure that drives blood forward for coronary perfusion

• O2 concentration

• Coronary vessel diameter

Demand

• Basal requirements

• Heart rate

• Preload/afterload

  • Force that stresses the cardiac muscle prior to contraction. This is the volume of blood that fills the heart from venous return

  • The amount of pressure the heart needs to exert to eject the blood to circulation

• Contractility

Location of pain

May present differently in female pt and those with diabetes

PQRST

P - Precipitating events

• What were you doing when it started?

Q- Quality of Pain

• What does it feel like? Pressure/dull/sharp/ squeezing

R- Region

• Where is it located? Can you point to it? Does it radiate?

S- Severity of pain

• Scale of 0-10 how bad is it?

T - Timing

• When did it start? Has it changed (better/ worse)? Have you had this before?

Stable Angina

• Typically provoked by exertion or stress

• Reversible

• Last 5-10 minutes

• Relieved by rest and NTG ( Nitroglycerin)

• No change in frequency, duration, or precipitation factors in preceding 60 days

• Associated with a stable atherosclerotic

Unstable angina

• Occurs at rest or awakens the pt from sleep

• Longer duration >15 minutes

• Frequency and intensity of pain increases

• Unpredictable Pattern

• associated with rupture of a plaque, results in platelet aggregation, clot formation, and vasoconstriction

Stable Angina Tx

• Modification of risk factors

• Revascularization (Percutaneous Coronary Intervention, Coronary Artery Bypass Graft)

• Medications

  • Antiplatelet

    • Asprin

    • Clopidogrel

  • Nitrates

    • SL NTG/Long acting

    • NTG patch

      • Make sure to remove old patches/ paste each evening and make sure to wear gloves when handling

    • Tolerance to long nitrates can develop and pt should have a nitrate free period

  • ACE/ ARBS, BB, CCB

  • Lipid Lowering medications

Medication teaching for NTG

• Keep in original bottle

• Protect from light

• Replace every 6 months

• Avoid storing in temp extremes

Take 1 if pain not relieved in 5 mins, seek further evaluation and can take up for 3 times. Should tingle under tongue and keep with you at all times

Ischemia

ST depression

• Decreased perfusion

Injury

ST segment elevation

Will resolve in hours to days with development of inverted T waves or pathologic Q waves if reperfusion is not done quickly. Inverted T waves may resolve, Q waves will always be here if they develop

• Damage to cells causing elevated troponin

Troponin

Released by damaged heart muscle, increased with more damage - heart specific

CK-MB

Creatine kinase-MB distinguishes between heart and skeletal muscle damage (CK level)

Chest pain - What to do

• Assess Client including vital signs

• Administer NTG as ordered

• Notify provider if pain persists ( or if no new onsent/ no NTG order)

• Obtain 12 lead EKG stat if pain unrelieved or changed

• Code chart to client’s bedside

• Common medication orders

  • NTG 0.4 mg sublingual q 5 min x 3 dpses prn if systolic BP>100

  • If no chest pain relief morphine 2 mg IV q 5 min prn to a max of 10mg over 2 hrs

STEMI

• Caused by occlusive thrombus

• ST elevation in leads facing infarct

• Elevation of cardiac markers

• Development of pathologic Q wave if not treated quicklu

• TX

  • Urgent PCI or antithrombolytics

  • Goal is to revascularize within 90 mins

NON-STEMI

• Caused by non-occlusive thrombus

• No ST elevation

• May see ST depression or T wave inversion

• Elevation of cardiac markers

• Tx

  • Cardiac cath within 12-72 hours Tx as needed

Complications of Acute MI

• Dysrhythmias

• Heart failure

• Cardiogenic Shock

• Pericarditis

• LV wall aneurysm

• Papillary Muscle Dysfunction or rupture

• Ventricular- Septal Wall Rupture

• LV Free wall rupture

Tx for MI

• Fibrinolytics - STEMI only

• Percutaneous Coronary Intervention (PCI)

  • With or without stent

  • Heparin or IIB/IIA inhibitors (eptifibatide)

  • Coronary artery bypass graft

Fibrinolytc therapy

Only for STEMI MI and no access to PCI

• Clot busters

• Tenecteplase, alteplase; give IV

• Indications: CP <12 hours, STEMI

• Contraindications

  • Severe HTN

  • H/O ICH

  • Intracranial surgery <2 months

  • Ischemic stroke < 2 months

  • Aortic dissection

  • Brain tumor

  • Active bleeding

• Markers of reperfusion

  • Significant relief of pain

  • Reduction of ST segment elevation

  • Abrupt increase in cardiac enzymes

• Rescue PCI if thrmobyltics fail

Major complication is bleeding

Reciprocal changes

ST elevation in one sets of lead are accompanied by ST- segment depressions in the opposite (reciprocal) leads

Contiguous leads

ECG leads that are anatomically next to each other and reprsent the general area of the heart

ST elevation

• STEMI

ST depression

Myocardial ischemia

• NON STEMI

LDL

Delivers cholesterol

HDL

Removes cholesterol from the bloodstream

• “Good cholesterol”

MI S/S

• Heart palpitations

• Chest pain that radiates to left arm

• SOB

• Nausea

• Ashy, clammy, and cool skin

• Initial increase in HR and BP followed by decrease

• Crackles in lungs

• Jugular vein distension

• Fever

• Weakness

• Anxiety

Statins

Thought to be associated with plaque stabilization, showed decrease in major adverse cardiac event post MI

Medications

• Morphine

• NTG

• Antiplatelets

• Beta Blockers

• Ace inhibitors

• Stool softeners

PCI pre- procedure

• Baseline assessment

• Allergies

  • Shellfish

  • Contrast dye

    • Precautions with metformin

• NPO

• Informed Consent

• Teaching

• Access radial versus femoral artery

Goal is to reopen artery within 90 minutes of presentation

Cardiac Catheterization

Look at arteries and figure out what is needed

PCI

Angioplasty

• Treating blockages

PCI - Post Procedure

• V/S q15 min for 1 hours, then q30 for 1 hour then every hour

• Assess pain

  • May still have some chest pain after

• Monitor puncture site/compression device

• Circulation to extremity

• Hydration

• Bedrest 2-8 hours, extremity straight

• Caution with bending after BR

• Monitor ECG

  • For improving ST elevation and decreasing cardiac enzymes

• Anticoagulation - ASA/ Clopidogrel

  • Low-dose aspirin and antiplatelet 1-12 months depending on type of stent

Coronary Artery Bypass Graft (CABG) - Revascularization Surgery

Indications

• failed medical management

• Continued chest pain after PCI

• Presence of 3 vessel disease

• Disease of the left main coronary artery

CABG Post-op nursing care

• V/S

• Heart rhythm

• Surgical sites

• Chest tube output

• Pain

• Cognitive status

• Fluid volume management

• Pulmonary toileting

• Early ambulation

• Sternal precautions

Usually ICU for 24-48 hours

Hospitalized 3-5 days

Sternal Precautions

• No tub baths x 4-6 weeks

• Do not use arms to push up from chair

• Do not lift > 4-10lbs for 4-6 weeks

• Do not push/pull

• Avoid driving x 4-6 weeks

Discharge planning

• Pt and family teaching

  • Medications

    • Do not stop antiplatelets untill instructed by provider

  • Sternal precautions

• Exercise

• Resumption of sexual activity

  • Do not take erectile dysfunction drugs ex sildenafil with nitrates for a risk of hypotension

• Coping with anxiety

• Cardiac rehabilitation

• Reduction of risk factors