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3.0 - ABSN NUR 405 CV I Content > Acute Coronary Syndrome (ACS) > Flashcards

Acute Coronary Syndrome (ACS) Flashcards

1
Q

ACS continuum

ACS -> 1. unstable angina or 2. acute MI

A

ECG changes (ST elevation) present -> elevated troponin = STEMI

ECG changes absent (no ST elevation) -> elevated troponin -> NSTEMI (heart damage present)

ECG changes absent -> normal troponin -> unstable angina (no heart damage)

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2
Q

Unstable angina facts

A
  1. Often occurs at rest-usually more than 20 minutes duration
  2. New-onset that markedly limits physical activity
  3. Increasing angina more frequent, longer in duration, and occurs with less exertion than stable/previous angina
  4. Poorly relieve by rest or nitroglycerin
  5. May have associated symptoms
  6. Unpredictable and is an emergency
  7. No elevations in serum troponin
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3
Q

Women and atypical angina s/s

A

Fatigue (most prominent)
SOA
Indigestion
Anxiety

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4
Q

Anginal pain

A

Precipitated by exertion/stress
Relieved by rest/nitroglycerin
Lasts < 15 minutes

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5
Q

MI pain

A

Occurs without cause, often in early morning
Relieved only by opioids
Last 20 minutes or longer
Frequently presents with associated symptoms (n/v, diaphoresis, dyspnea, anxiety/fear, dysrhythmias)

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6
Q

MI facts

A

Process takes time (cells can stand ischemia x 20 minutes before cell death)

Subendocardium layer affected earliest (takes 4-6 hours for entire thickness of heart muscle to necrose)

The location correlates with the involved coronary circulation (i.e., blockage in the left anterior descending coronary artery causes damage to the left ventricle)

MIs are described based on location of damage (anterior, inferior, lateral, septal or posterior)

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7
Q

What does MI Pain feel like?

A

Severe, immobilizing chest pain not relieved by rest, position changes, or nitrates (hallmark of MI)

Persistent & described as heaviness, pressure, tightness, burning, constriction, and crushing

Women/patients with diabetes mellitus may have different or no symptoms (silent MI)

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8
Q

Complications of MI

A
  1. Dysrhythmias (most common complication; most common cause of pre-hospital death; reason patients must be on telemetry)
  2. Heart failure (occurs from the reduced pumping action of heart; occurs esp. with damage to the left ventricle)
  3. Cardiogenic shock (low BP/decreased perfusion due to severe left-ventricular failure; if occurs, high mortality rate)
  4. Papillary muscle dysfunction (consequence: new murmur noted)
  5. Pericarditis (occurs 2-3 days after acute MI; consequence: new pericardial friction rub)
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9
Q

Pericardial friction rub

A

High-pitched, scratchy grating sound heard best with the patient sitting and leaning forward and while holding their breath at end of expiration; indicative of pericarditis; caused by friction between the inflamed pericardial surfaces

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10
Q

How can you differentiate between pericardial friction rub (heart) and a pleural friction rub (lungs)?

A

Have patient hold their breath. If you still hear the rub, it is cardiac.

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11
Q

Diagnostic testing for ACS: EKG

A

Used to r/o or confirm unstable angina/MI

Look for changes in the QRS complex, ST segment & T wave

STEMI = “ST Elevated Myocardial Infarction” 
NSTEMI = “Non-ST Elevated Myocardial Infarction”

STEMI – more extensive infarct
NSTEMI or UA = transient thrombosis/incomplete
occlusion

Serial EKGs may be ordered, as ischemia & infarction can change over a matter of a few hours

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12
Q

ST elevation vs. depression in relation to the isoelectric line on an EKG

A

Normal: ST segment along the isoelectric line
ST elevation: ST segment above the isoelectric line
ST depression: ST segment below the isoelectric line

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13
Q

Ischemia vs infarction

A

Ischemia: reduced (but not obstructed) blood flow

Infarction: obstructed blood supply causing local tissue death

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14
Q

ST elevation vs depression

A

ST elevation occurs with infarction (this is permanent)

ST depression occurs with ischemia

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15
Q

Diagnostic testing for ACS: serum cardiac markers

A

Serum troponin has greater sensitivity & specificity than CK-MB & myoglobin. Troponin increases in 2-3 hrs, returns to baseline in 10-14 days.

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16
Q

STEMI

A
  1. ST segment elevation
  2. QRS usually pathologic (wide)/develops over hours
  3. T wave peaked, then inverted
  4. Troponin elevated
  5. Size of infarct larger
  6. Poor outcomes
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17
Q

NSTEMI

A
  1. ST segment depressed or normal
  2. QRS normal
  3. T wave inverted
  4. Troponin elevated
  5. Size of infarct smaller
  6. Better outcomes
18
Q

Progression of an acute MI

A

Ischemia (lack of O2 to cardiac tissue represented by ST depression, T wave inversion or both) -> injury -> infarction (death of tissue represented by a pathological Q wave)

19
Q

ACS initial assessment

A

Consider diagnosis w/ chest discomfort, SOA or other suggestive symptoms; women, older patients & patients with DM may have atypical presentations.

12-lead EKG within 10 minutes of arrival (repeat every 10-15 mins if non-diagnostic, but suspicion remains)

20
Q

STEMI EKG

A

STEMI = ST segment elevation in two anatomically contiguous leads

21
Q

NSTEMI or unstable angina EKG

A

NSTEMI or UA = ST depressions or deep T wave inversions without Q waves or possibly no EKG changes

22
Q

ACS initial interventions

A

Assess/stabilize ABCs
Position patient upright to support oxygenation
Administer oxygen (NC initially)
Obtain V.S., including O² sat
Attach cardiac monitor (continuous telemetry)
Monitoring for dysrhythmias & ST changes
Establish IV access

23
Q

More ACS initial interventions

A

Give ASA 325 (chew/swallow)

Assess pain using PQRST

For pain:

  1. Give 3 SL NTG (0.4 mg) one at a time, spaced 5 minutes apart for persistent chest pain (monitor BP)
  2. Give morphine sulfate (2-4 mg IVP q 5-15 mins) for unacceptable, persistent discomfort

Obtain baseline lab work (cardiac markers, electrolytes esp. K, Ca, and Mg, H&H; possibly coags)

Monitor heart (murmur, gallop or rubs?) & lung sounds (crackles may be heard with left HF from left ventricle infarction)

24
Q

What may patients need instead of nitroglycerin if their BP is too low?

A

Morphine; morphine eases the workload on the heart (decreases preload and afterload) and also decreases anxiety

25
Q

What is nitroglycerin?

A

A potent coronary vasodilator

26
Q

PQRST assessment of angina

A

Precipitating events
(What precipitated?)

Quality of pain
(Feel like? Ache? Squeeze? etc)

Radiation of pain
(Where is the pain?)

Severity of pain
(1-10 scale)

Timing
(When did it begin?)

27
Q

Three reperfusion strategies for a blockage

A
  1. Emergent percutaneous coronary intervention (PCI)-for STEMI or NSTEMI
  2. Thrombolytic (fibrinolytic) therapy-for STEMI
  3. Coronary artery bypass graft (CABG)-for patients with DM, 3 or more-vessel disease, or when blockage unreachable by catheter
28
Q

Percutaneous Coronary Intervention (PCI)

A

First-line of treatment for patients with confirmed MI

Goal: open within 90 minutes of ED arrival

First must perform a cardiac cath to locate blockage(s), assess the severity of blockage(s), determine the presence of collateral circulation (compensatory/alternate circulation around a blockage), and evaluate left ventricular function

29
Q

Which location for heart cath is required to assess the coronary arteries?

A

LEFT heart cath

30
Q

Percutaneous coronary intervention (aka angioplasty or balloon procedure) steps

A

LEFT cardiac cath –> blockage located –> deflated balloon catheter placed at the occlusion site in the coronary artery –> balloon inflated –> plaque flattened –> patency of coronary artery reestablished

31
Q

PCI: advantages

A

Alternative to surgical intervention

Performed with local anesthesia rather than general anesthesia

Patient is ambulatory shortly after procedure

Length of hospital stay = 1-3 days (4-6 days with CABG)

Can return to work sooner

Currently, more PCIs are performed than CABGs.

32
Q

PCI: Nursing Care

A

Similar to cardiac cath; monitor closely for manifestations of myocardial ischemia, such as chest pain/EKG changes, dysrhythmias or hemodynamic instability

Patient typically on dual antiplatelet therapy (ASA & heparin, for instance)

Vascular sheath removal usually 4-6 hours after procedure (manual pressure x 20 minutes esp. if arterial puncture); check site & distal circulation.

33
Q

Thrombolytic therapy

A

AKA clot blusters

Fibrinolytics used to dissolve thrombi in coronary arteries- restores myocardial blood flow

May be administered during cardiac catheterization

Most effective when administered within 6 hours of coronary event

Goal: start within 30 minutes of ED admission

Important: Monitor for BLEEDING post-administration

34
Q

Examples of fibrinolytics/clot busters

A

Tissue Plasminogen Activator (t-PA)

Reteplase (Retavase)

35
Q

Thrombolytic therapy contraindications

A

History of intracranial hemorrhage

Recent abdominal surgery or stroke

Any active bleeding (excluding menses)

36
Q

Reasons for coronary artery bypass graft (CABG)

A

Elective vs emergency

37
Q

CABG procedure

A

Graft anastomosed distal and proximal to blockage to bypass it

38
Q

CABG grafts options

A

May involve grafts using the internal mammary artery or a harvested saphenous vein

39
Q

CABG complications

A

Stroke
Myocardial infarction
Infection (sternal wound, vein harvest sites)
Dysrhythmias
Pleural effusion
Pericardial effusion
Cardiac tamponade (fluid accumulation in the pericardium)
Renal failure

40
Q

ACS ongoing care

A

Continuous monitoring with telemetry

Rest & comfort-activity restrictions

Help examine source of anxiety & address

For anxiety teach at patient’s level-not from pre-packaged program

Help deal with emotional and behavioral reactions

Patient teaching – timing is important; start where the patient “is”

Teaching regarding resumption of sexual activity

41
Q

ACS going home

A

Refer to “Cardiac Rehabilitation” program in community:
Physiologic
Psychological
Mental
Spiritual
Economic
Vocational

3.0 - ABSN NUR 405 CV I Content (7 decks)

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