Week 3B: Initial Assessment of CAD

Question 1

WWYD: a pt presents with what you expect is a heart attack. What would you focus on in your initial assessment? (5)

Answer 1

-Baseline VS + 12-lead ECG in 10’
-Assessment of chest pain
-Associated symptoms
-Physical assessment
-Medications

Question 2

What are some other steps in an initial assessment of a pt with a suspected heart attack (following the initial 5)? (4)

Answer 2

Personal and family Hx, environmental factors, psychosocial Hx, pt attitudes and believes about health and illness (do not get these while they are unstable, this is not top of priority list)

Question 3

How many minutes must you do you ECG within once the patient presents to the ER?

Answer 3

10

Question 4

How frequently do you take a patients EKG?

Answer 4

15-30’ over 2-4hr

Question 5

What is an ST depression?

Answer 5

Lack of oxygenation, permanent damage can be avoided if we respond appropriately!

Lack of “motivation” because you’re depressed

Question 6

What is an ST elevation?

Answer 6

More than just schema, this is indicative of infra and permenant death of heart tissue. We would proceed with an echo

Question 7

What are the stages of an assessment and the diagnostic studies we perform?

Answer 7

12-lead ECG (in 10’ q15-30/2-4h)
Cardiac monitor
Chest Xray
Coronary angiography
Exercise stress test
Echocardiogram

Question 8

Explain a cardiac angiography

Answer 8

Assess: Coronary arteries
Looks at: Pressure in cardiac chambers, valve function, ventricular function

Use a dye to take photos via radial or femoral access threaded up to the aorta.

Question 9

What does a stress test tell us?

Answer 9

Ischemia, ST segment changes, arrhythmia, functional capacity, efficacy of surgical intervention

Question 10

Who cannot receive a stress test?

Answer 10

Elderly, with mobility issues

Question 11

What does an echo assess?

Answer 11

Myocardial structures, ventricular function, effusions, thrombus, ischemia

Question 12

What are the lab values we’re assessing in our cardio work-up?

Answer 12

Serum cardiac markers, C-reactive protein, lipid profile, blood glucose, electrolytes, kidney function

Question 13

What are the serum cardiac markers?

Answer 13

Troponin, serum creatinine kinase, myoglobin

Question 14

Do serum cardiac markers rapidly change in your system?

Answer 14

No. They take time to elevate and they’re examined in a “trending” manner

Question 14

Troponin

Answer 14

Two subsets: cTnT, cTn1

Greater specificity than CK-MB

Levels rise 3-12hr
Peak 1-2days
Return to normal over 5-10 days

Question 15

Serum Creatinine Kinase

Answer 15

Fractionated into bands

Rises 3-12hrs, peaks in 24

Return to normal after 2-3 days

Question 16

Pt presents with chest pain, what could be the diagnosis

Answer 16

Stable or unstable angina, myocardial infarction

Question 17

A patient presents with pain that lasts 3-5 minutes and responds well to nitro. There is usually no pain at rest and there is a ST segment depression on the ECG.

Answer 17

Chronic stable angina: Episodes are predictable and Brought on by precipitating factors, so we can time medications well. A disease grounded in supply and demand. Decrease load.

Question 18

What are the variants of stable angina?

Answer 18

Silent ischemia, nocturnal angina, angina decubitus, and variant

Question 19

Silent ischemia

Answer 19

Asymptomatic, diabetes mellitus

Question 20

Nocturnal Angina

Answer 20

At night, not always while sleeping. Wear nitro patches at night

Question 21

Angina decubitus

Answer 21

Chest pain while lying down. Relieved by standing or sitting

Question 22

Variant angina

Answer 22

At rest or in response to spasm of major artery. Seen in clients w. Hx migraine, raynaids, not necessarily CAD, relieved by moderate exercise

Question 23

A pt presents with chest pain that is new, occurs at rest and is also becoming worse. It is not relieved by rest and nitro does not work. This patient also has anxiety and indigestion.

Answer 23

Unstable angina. Associated with deterioration of plaque, can lead to MI or return to a stable lesion. Increases in frequency, duration, or severity.

Question 24

What causes a myocardial infarction?

Answer 24

Severe and prolonged decrease in oxygen supply. This leads to necrosis. Usually associated with acute coronary thrombosis.

Question 25

Is it more severe the lower on an artery the area of necrosis is?

Answer 25

No. The higher up on the artery it is, the more muscle it feeds and the worse the situation.

Question 26

Zone of injury vs. zone of ischemia

Answer 26

Ischemia is the area deprived of oxygen but it is salvageable. The zone of injury is an area with compromised oxygen delivery but this is still salvageable.

Question 27

A Pt presents with severe and immobilizing chest pain, position change and NO does not relieve their discomfort. They are not diabetic. There is initially an increase in glucose, BP and HR, and then there is a decline. There is pulmonary edema as you can hear crackles in their lungs. There are S3 and S4 lung sounds as well. They also have a fever.

Answer 27

MI

Question 28

If a diabetic patient is having an MI, they will experience more pain than a non-diabetic patient (T/F)

Answer 28

False. A diabetic patient might not experience any pain at all!

Question 29

What is the diagnostic criteria for a patient with an MI?

Answer 29

2/3 needed -Chest pain more than 30' -ECG-Q waves/ST elevation/Twave inversion -Serum cardiac markers (troponin T, Creatinine kinase)

Question 30

Which has an ST elevation: STEMI or NSTEMI?

Answer 30

STEMI (duh)

Question 31

Which has elevated serum markers, STEMI or NSTEMI?

Answer 31

Both

Question 32

Which leads to an elevation in serum markers, NSTEMI or unstable angina?

Answer 32

NSTEMI (eventually) and in NSTEMI there is an ST depression or T-wave inversion