CAD and Acute Coronary Syndrome

Question 1

CAD

Answer 1

coronary artery disease

a progressive atherosclerotic disorder of the coronary arteries that results in narrowing or complete occlusion of one or more arteries

Question 2

What does atherosclerosis affect?

Answer 2

medium-sized arteries that perfuse the heart and other major organs

progressive build up of plaque in a person’s arteries

Question 3

What happens when blood flow is stopped?

Answer 3

MI

Question 4

CAD spectrum (3)

Answer 4

1) Asymptomatic

2) Stable Angina

3) Acute Coronary Syndrome

Question 5

Types of Acute Coronary Syndrome (3)

Answer 5

1) Unstable Angina

2) Myocardial Infarction

3) Sudden Coronary Death

Question 6

Ischemic occurs when arteries are about ___% occluded

Answer 6

70

Question 7

Common signs of a heart attack

Answer 7

1) midsternal chest pain

2) sweating

3) SOB

Question 8

Factors that DECREASE O2 supply (many)

Answer 8

Anemia

CAD

Hypoxia

COPD, asthma, pneumonia

Arrhythmias

CHF

Coronary spasm

Thrombosis

Valve disorders

Question 9

T or F: Someone with extreme anemia can get a heart attack.

Answer 9

TRUE

hemoglobin carries oxygen

someone with a low vs high hemoglobin - can have the same O2 sat but not indicator of how much oxygen is being delivered

Question 10

T or F: Someone with healthy arteries cannot get a heart attack.

Answer 10

FALSE

Arteries can be fine! But can still get heart attack

Question 11

Factors that INCREASE O2 demand (many)

Answer 11

Anxiety

Cocaine use

Hyperthermia

Hyperthyroidism

Physical exertion

Aortic stenosis

Arrhythmias- ↑ rates

Cardiomyopathy

Hypertension

Question 12

Stages of development in atherosclerosis (4)

Answer 12

1) Damaged endothelium & response to injury

2) Fatty streak

3) Fibrous plaque

4) Complicated lesion

Question 13

atherosclerosis progression prevention (many)

Answer 13

pharmaceuticals - statins

diet - low salt, Mediterranean

exercise

stress management

treat co-morbidities - hypertension, diabetes

Question 14

Endothelium regulates…

Answer 14

dilation and constriction of vessels

thrombosis – the formation of blood clots

transport of substances to and from the vascular space

growth and ‘apoptosis’ of vascular wall

Question 15

Endothelial dysfunction leads to… (many)

Answer 15

inadequate vasodilation

prothrombotic

altered permeability

increased secretion of growth factors (hypertrophy - decreases contraction)

increased oxidation of LDL

Question 16

Collateral Circulation

Answer 16

a protective adaptation

narrowing of arteries starts

capillaries join so there is route to go around the narrowing

so with an occlusion, there is not necessarily no oxygen

Question 17

Who has more collateral circulation
a) men
b) women

Answer 17

a) men

when women in menopause lose estrogen and cardioprotectiveness, don’t have collateral circulation developed

Question 18

Signs of CAD in women (many)

Answer 18

absence of cp/ or vague

NO radiation of pain

heaviness of arms

light-headedness

epigastric burning

N/V

diaphoresis

feeling flushed

prodromal symptoms (months before)
-sleep disturbances
-unusual fatigue
-SOB
-indigestion
-anxiety

Question 19

Signs of CAD in men (many)

Answer 19

chest pain / aching / tightness / pressure / jaw pain

SOB

pain b/w shoulder blades

shoulder/Arm/Neck pain

headache

indigestion

palpitations

cough

diaphoresis

fatigue

N/V

Question 20

T or F: The treadmill/stress test is less sensitive for women compared to men.

Answer 20

TRUE

Question 21

Challenges of care - sex differences

Answer 21

failure to recognize & difficulty interpreting symptoms

failure of HCP to recognize prodromal symptoms

ECG & stress test less sensitive

plaque tends to be distributed diffusely (women - many smaller arteries with dif levels of occlusion vs 1 big artery that is majorly occluded)

less likely to be evaluated for risk factors or treated aggressively

Question 22

Most frequent symptoms of acute MI in the elderly (3)

Answer 22

atypical presentation!

1) SOB

2) fatigue and weakness (“I just don’t feel well”)

3) abdominal or epigastric discomfort

Question 23

Common pre-existing conditions in the elderly (3)

Answer 23

1) hypertension

2) CHF

3) Previous AMI (acute myocardial infarction)

Question 24

T or F: Elderly are more likely to delay seeking treatment.

Answer 24

TRUE

transportation, financial costs/risks, think its part of aging

Question 25

Atypical presentation in the patient with diabetes - common signs and symptoms (many)

Answer 25

why: due to autonomic dysfunction 1) generalized weakness 2) generalized feeling of not being well 3) syncope 4) lightheadedness 5) change in mental status

Question 26

Non-modifiable risk factors for CAD (4)

Answer 26

1) age 2) male> female until 65 3) genetics 4) ethnicity

Question 27

Modifiable risk factors for CAD (many)

Answer 27

tobacco use abdominal obesity hypertension >140/90mm Hg hyperlipidemia physical inactivity

Question 28

Contributing factors to CAD

Answer 28

psychosocial risk factors (depression, hostility, anger, stress) elevated homocysteine levels diabetes Mellitus metabolic Syndrome

Question 29

Those with low-risk factors should be assessed every __ years and those with high-risk factors should be assessed every __

Answer 29

3 to 5 every year

Question 30

Low risk factors

Answer 30

untreated non-smokers without diabetes total cholesterol: 4.7 mmol/L BP: <120/<80

Question 31

Moderate risk factors

Answer 31

untreated non-smokers without diabetes total cholesterol: 4.8 - 5.1 mmol/L Systolic BP: 120 - 139 Diastolic BP: 80 - 89

Question 32

Elevated risk factors

Answer 32

untreated non-smokers without diabetes total cholesterol: 5.2 - 6.1 mmol/L Systolic BP: 140 - 159 Diastolic BP: 99 - 99

Question 33

Major risk factors

Answer 33

TREATED current smoker diabetes cholesterol: 6.2 mmol/L systolic BP: ≥ 160 diastolic BP: ≥100

Question 34

Who should we screen?

Answer 34

men ≥ 40 years women: ≥ 50 years of age OR post-menopausal smoker hypertension elevated cholesterol diabetic family history erectile dysfunction obesity inflammatory disease COPD HIV

Question 35

Priority assessments if heart attack is suspected (5)

Answer 35

1) baseline VS and 12-lead ECG -within 10 minutes****** 2) assessment of chest pain -OPQRST 3) associated symptoms 4) physical assessment 5) meds

Question 36

To reiterate, what should you do immediately if heart attack is suspected?

Answer 36

Baseline VS and 12-lead ECG!!! within 10 minutes

Question 37

Other things to assess, when the patient is stable (4)

Answer 37

1) personal and fam history 2) environmental factors 3) psychosocial history 4) patient's attitudes and beliefs about health and illness, level of motivation

Question 38

ECG findings

Answer 38

primary DIAGNOSTIC tool changes in QRS complex, ST segment & T wave dynamic process & evolves over time Repeat every 15-30 minute to 2-4 hours

Question 39

How often should ECGs be repeated?

Answer 39

every 15-30 minute to 2-4 hours

Question 40

What does an ST depression indicate?

Answer 40

ischemia lack of oxygenation permanent damage can be avoided if we respond appropriately

Question 41

What does an ST elevation indicate?

Answer 41

infarction more than just ischemia damage! permanent death of heart tissue

Question 42

Assessment - Diagnostic Studies

Answer 42

1) 12 lead EKG 2) cardiac monitor 3) chest X-ray [lungs] 4) coronary angiography -GOLD STANDARD other: 5) exercise stress test 6) echocardiogram

Question 43

Cardiac angiography used to assess (4)

Answer 43

1) coronary arteries 2) pressures in cardiac chambers 3) valve function 4) ventricular function

Question 44

Which arteries are used for access during cardiac angiography?

Answer 44

femoral or radial

Question 45

Stress test used to assess...

Answer 45

ischemia ST segment changes arrhythmia functional capacity efficacy of medical or surgical intervention

Question 46

Which populations can you not do a stress test with?

Answer 46

elderly patients with mobility issues

Question 47

Echocardiography used to assess...

Answer 47

myocardial structures ventricular function ejection fraction heart motion abnormalities effusions thrombus ischemia

Question 48

Assessment - labs (6)

Answer 48

1) serum cardiac markers 2) C-reactive protein -marker that indicates inflammation 3) lipid profile -won’t tell if MI occurred, but will tell if elevated cholesterol for follow-up 4) blood glucose -regardless of diabetic status 5) electrolytes -increases risk of cardiac events 6) kidney function -hopefully no damage

Question 49

Serum cardiac monitors (3)

Answer 49

1) troponin -GOLD STANDARD 2) Serum creatinine kinase (CK) – CK-MB -do MB specifically which looks at cardiac muscle -death to tissue - releases enzymes 3) myoglobin -rarely used

Question 50

T or F: Serum cardiac markers are done once, upon initial assessment

Answer 50

FALSE take a while to elevate in your system not a one time thing - trend these every 6 to 8 hours over 24 hours

Question 51

What has greater specificity? a) CK-MB b) Troponin

Answer 51

b) Troponin

Question 52

Serum creatinine kinase (CK)

Answer 52

fractionated into bands- CK-MB rises: 3 - 12 hours peaks: 24 hours returns to normal: 2-3 days

Question 53

Troponin

Answer 53

2 subsets: cTnT and cTn1 rises: 3 - 12 hours peak: 24 - 48 hours returns to normal: 5-14 days

Question 54

Main diagnoses for chest pain (3)

Answer 54

1) Stable angina 2) Unstable angina 3) MI

Question 55

Patient population most commonly with missed Dx (4)

Answer 55

1) women < 55 2) POC 3) SOB as main presenting symptom 4) normal or nondiagnostic ECG (misread)

Question 56

Characteristics of chronic stable angina (many)

Answer 56

pain usually lasts 3-5 minutes responds WELL to nitroglycerin (lessening O2 demand) subsides when the precipitating factor is relieved pain at rest is unusual ECG reveals ST segment depression chest pain occurs intermittently over a long period with the SAME PATTERN of symptoms can be controlled with medications on an outpatient basis predictable - medications can be timed

Question 57

Variants of stable angina (4)

Answer 57

1) silent ischemia 2) nocturnal angina 3) angina decubitus 4) Prinzmetal’s (variant) angina

Question 58

Silent ischemia

Answer 58

ischemia that is asymptomatic associated with diabetes mellitus

Question 59

Nocturnal angina

Answer 59

occurs only at night but not necessarily during sleep can wear nitro patches at night

Question 60

Angina decubitus

Answer 60

chest pain that occurs only while LYING DOWN relieved by standing or sitting

Question 61

Prinzmetal’s (variant) angina

Answer 61

occurs at rest usually in response to spasm of major coronary artery seen in clients with a history of migraine headaches and Raynaud’s phenomenon spasm may occur in the absence of CAD may be relieved by moderate exercise

Question 62

Characteristics of unstable angina (many)

Answer 62

chest pain that is new in onset, occurs at rest or has a worsening pattern chronic stable angina that increases in frequency, duration or severity unpredictable NOT relieved by rest pain refractory to nitroglycerin associated with deterioration of once stable atherosclerotic plaque unstable lesion can progress to MI or return to stable lesion

Question 63

Symptoms of unstable angina (4)

Answer 63

1) fatigue 2) SOB 3) indigestion 4) anxiety

Question 64

Myocardial Infarction

Answer 64

severe, prolonged ↓ O2 supply (ischemia) resulting in necrosis 90% associated with acute coronary thrombosis presence of Q wave- area of necrosis, permanent transmural (full thickness) versus subendocardial (partial)

Question 65

Should you give nitro before or after an ECG?

Answer 65

AFTER give info on what heart look like without intervention

Question 66

How to differentiate between non-ST elevation STEMI and unstable angina?

Answer 66

troponin!! eventually their troponin will rise - someone with unstable angina will not

Question 67

What is worse - an occlusion higher up on the artery or lower?

Answer 67

higher up feeds more muscle

Question 68

Zones (3)

Answer 68

1) zone of infarction 2) zone of injury 3) zone of ischemia

Question 69

Zone of infarction

Answer 69

necrosis and damage want to prevent this zone from spreading

Question 70

Zone of injury

Answer 70

compromise of oxygen delivery still salvageable

Question 71

Zone of ischemia

Answer 71

deprived of oxygen also salvageable

Question 72

Characteristics of an MI (many)

Answer 72

severe, immobilizing chest pain not relieved by rest, position change, or nitrate administration epigastric pain – indigestion SOB, diaphoresis, N&V, dizziness SNS stimulation: -elevated glucose -vasoconstriction (skin ashen, cool or clammy) -increased BP & HR (initially) if CO falls: -decreassed BP -crackles -JVD -peripheral edema -hepatic engorgement pulmonary edema (crackles on lung auscultation) extra heart sounds (S3 & S4)- ventricular dysfunction fever (inflammatory process)

Question 73

T or F: Diabetic patients may not experience any pain with an MI

Answer 73

TRUE

Question 74

Diagnostic criteria for MI (3)

Answer 74

2 out of 3 1) Chest pain > 30 minutes 2) ECG – Q waves / ST segment elevation / T wave inversion 3) Serum cardiac markers: Troponin T Creatine kinase (CK)

Question 75

Goal for patient with ACS

Answer 75

relief of ischemic pain preservation of the myocardium (decrease O2 demand or increase O2 supply) immediate and appropriate treatment of ischemia -drug therapy -interventions effective coping with illness-associated anxiety participation in a rehabilitation plan reduction of RF

Question 76

Acute interventions for ACS

Answer 76

prompt recognition of S&S -assessment of CAB -hemodynamic stability preliminary history 12 lead and continuous ECG monitoring bloodwork (Routine, Trop, CK-MB) oxygenation +/- (to keep O2>90%) IV access initial medications immediate reperfusion therapy -PCI or fibrinolytic therapy

Question 77

Initial meds (4)

Answer 77

1) ASA (160-325mg, chewed) and Plavix (600mg)/Ticagrelor (180mg) -prevent additional platelet activation and interferes with platelet adhesion 2) Oxygen -given to hypoxic patients, respiratory distress -SaO2<90% -can worsen size of infarct with high flow rates 8L/min -titrate to SaO2 3) Nitro -S/L (x3 if needed) followed by IV for persistent pain, hypertension or heart failure 4) Morphine -when nitro ineffective -decreases myocardial O2 consumption, BP & HR, contractility

Question 78

Other meds (7)

Answer 78

1) beta-blockers -initiated within 24 hours/no contraindications (super bradycardic or hypotensive) 2) LMWH or IV heparin -minimally 48 hours after MI -to prevent re-thrombosis or acute stent thrombosis 3) ACE inhibitors -lowers BP -reduce vasoconstriction and fluid retention 4) P2Y12 inhibitors (Ticagrelor, Plavix) 5) Antidysrhythmic medications (ami) 6) Cholesterol lowering medications (statin) 7) Stool softeners -from narcotics

Question 79

Reperfusion therapy types (2)

Answer 79

trying to salvage as much of the heart as you can 1) Mechanical Reperfusion 2) Pharmacologic Reperfusion

Question 80

Mechanical Reperfusion

Answer 80

Primary Percutaneous Coronary Intervention (Primary PCI) angiogram then insert stent to reestablish perfusion distal to where occlusion is - localized stable angina, unstable angina, MI 1 or 2 vessel disease

Question 81

PCI should be performed within _____ minutes of first medical contact

Answer 81

120 minutes ideally 90 minutes not great if you live in a rural area :/

Question 82

Goal of PCI

Answer 82

trying to perfuse to stop pain***

Question 83

PCI Nursing Management

Answer 83

Angina -ay be caused by transient coronary vasospasm, or it may signal a more serious complication Vascular site care -assessing for bleeding and swelling at sheath site Peripheral Ischemia -secondary to cannulation of vessel, assess for adequate circulation Renal protection -hydration -fluids -D/C of some meds - dye and Metformin hard on the kidneys

Question 84

Pharmacologic Reperfusion

Answer 84

fibrinolytic therapy -streptokinase, Alteplase (tPA), Reteplase (rPA), Tenecteplase (TNK-tPA)) STEMI only**** systemic, risk for bleeding, risk for stroke

Question 85

Fibrinolytic therapy target (time)

Answer 85

first 30 minutes! ideally within 1st hour after onset of symptoms less than 6 hrs improved results after 6 hours - risk for bleeding

Question 86

Major complication of fibrinolytic therapy

Answer 86

BLEEDING differentiate between surface and internal bleeding surface bleeding e.g. IV site --> continue internal bleeding e.g. stroke --> STOP

Question 87

Eligibility criteria for fibrinolytic therapy

Answer 87

patients with recent onset (less than 12 hours) of chest pain and persistent ST elevation patients who present with bundle branch blocks (BBBs) that may obscure ST segment analysis and a history suggesting an acute MI chest pain unresponsive to S/L nitro no conditions that might cause a predisposition to hemorrhage

Question 88

Absolute contraindications for fibrinolytic therapy (many)

Answer 88

active internal bleeding or bleeding diathesis (except for menstruation) known history of brain aneurysm known brain cancer previous cerebral hemorrhage oschemic stroke within past 3 mo significant closed head or facial trauma within past 3 mo suspected aortic dissection

Question 89

Relative contraindications for fibrinolytic therapy

Answer 89

active peptic ulcer disease current use of anticoagulants pregnancy prior ischemic stroke not within past 3 mo; dementia; or known intracranial disease not covered under absolute contraindications surgery (including laser eye surgery) or puncture of noncompressible vessel within past 3 wk internal bleeding within past 2–4 wk serious systemic disease (e.g., advanced or terminal cancer, severe liver or kidney disease) severe uncontrolled hypertension (BP >180/110 mm Hg) traumatic or prolonged (>10 min) cardiopulmonary resuscitation

Question 90

Coronary Artery Bypass Graft

Answer 90

when you have blockages but stent isn’t appropriate not usually an emergency surgery take from breast or leg put into heart to bypass area where there is an occlusion reestablish perfusion distal

Question 91

Who is considered for Coronary Artery Bypass Graft Surgery (CABG)?

Answer 91

left main disease multivessel disease satisfactory improvement is not reached with medical management patient is not a candidate for PCI (e.g., lesions are long or difficult to access) lifestyle limiting angina unresponsive to medical therapy or PCI

Question 92

Post MI
Ongoing Assessment and Care (many)

Answer 92

ARE THEY STILL HAVING PROBLEMS pain site care PCI - assessment of extremities monitoring -cardiac -respiratory -VS, O2 ultrasound -left ventricular function rest and sleep - activity gradually increased anxiety - give info** driving - 1 week effectiveness of interventions patient teaching emotional and behavioural reactions

Question 93

Long-term drug therapy (6)

Answer 93

1) Antiplatelet therapy -aspirin -Clopidogrel (Plavix) -ASA plus Ticagrelor or Plavix 2) Statins -atorvastatin 80 mg daily or Rosuvastatin 20 or 40 mg daily 3) Beta-blockers 4) ACE inhibitors or ARB’s ("pril" 5) Nitrates 6) Ca+ channel blockers (e.g. Diltiazem, Verapamil, Nifedipine)

Question 94

Complications post MI (many)

Answer 94

arrhythmias -ventricular Tachycardia/Fibrillation -atrial Fibrillation -bradycardia and heart blocks congestive heart failure cardiogenic shock -not pumping effectively, not enough perfusion leading to cariogenic shock papillary muscle dysfunction ventricular aneurysm pericarditis pulmonary embolism