1. Elsevier items and derived items © 2006 by Elsevier Inc. Coronary Artery Disease Includes stable angina pectoris and acute coronary syndromes Ischemia: oxygen supply insufficient to meet requirements of the myocardium Infarction: necrosis or cell death that occurs when severe ischemia is prolonged and irreversible damage to tissue results Includes stable angina pectoris and acute coronary syndromes Ischemia: oxygen supply insufficient to meet requirements of the myocardium Infarction: necrosis or cell death that occurs when severe ischemia is prolonged and irreversible damage to tissue results

2. Elsevier items and derived items © 2006 by Elsevier Inc. Stable Angina Pectoris A feeling of “strangling of the chest” Temporary imbalance between the coronary artery’s ability to supply oxygen and the cardiac muscle’s demand for oxygen Ischemia limited in duration and does not cause permanent damage to myocardial tissue Stable and unstable angina A feeling of “strangling of the chest” Temporary imbalance between the coronary artery’s ability to supply oxygen and the cardiac muscle’s demand for oxygen Ischemia limited in duration and does not cause permanent damage to myocardial tissue Stable and unstable angina

3. Elsevier items and derived items © 2006 by Elsevier Inc. Acute Coronary Syndrome Atherosclerotic plaque in the coronary artery ruptures, resulting in platelet aggregation, thrombus formation, and vasoconstriction. Between 10% and 30% of clients with unstable angina progress to having MI within 1 year. 29% die from MI within 5 years. Atherosclerotic plaque in the coronary artery ruptures, resulting in platelet aggregation, thrombus formation, and vasoconstriction. Between 10% and 30% of clients with unstable angina progress to having MI within 1 year. 29% die from MI within 5 years.

4. 4 Hospitalizations in the U.S. Due to Acute Coronary Syndromes (ACS) Acute Coronary Syndromes* 1.57 Million Hospital Admissions - ACS UA/NSTEMI † STEMI 1.24 million Admissions per year.33 million Admissions per year Heart Disease and Stroke Statistics – 2007 Update. Circulation 2007; 115:69-171. *Primary and secondary diagnoses. †About 0.57 million NSTEMI and 0.67 million UA.

5. 5 Class I Benefit >>> Risk Procedure/ Treatment SHOULD be performed/ administered Class IIa Benefit >> Risk Additional studies with focused objectives needed IT IS REASONABLE to perform procedure/administer treatment Class IIb Benefit ≥ Risk Additional studies with broad objectives needed; Additional registry data would be helpful Procedure/Treatment MAY BE CONSIDERED Class III Risk ≥ Benefit No additional studies needed Procedure/Treatment should NOT be performed/administered SINCE IT IS NOT HELPFUL AND MAY BE HARMFUL should is recommended is indicated is useful/effective/ beneficial is reasonable can be useful/effective/ beneficial is probably recommended or indicated may/might be considered may/might be reasonable usefulness/effectiveness is unknown /unclear/uncertain or not well established is not recommended is not indicated should not is not useful/effective/beneficial may be harmful Applying Classification of Recommendations and Level of Evidence

6. Elsevier items and derived items © 2006 by Elsevier Inc. Myocardial Infarction Most serious acute coronary syndrome Occurs when myocardial tissue is abruptly and severely deprived of oxygen Dynamic process that does not occur instantly but evolves over several hours Most serious acute coronary syndrome Occurs when myocardial tissue is abruptly and severely deprived of oxygen Dynamic process that does not occur instantly but evolves over several hours

7. Elsevier items and derived items © 2006 by Elsevier Inc. Nonmodifiable Risk Factors Age Gender Family history Ethnic background Age Gender Family history Ethnic background

8. Elsevier items and derived items © 2006 by Elsevier Inc. Modifiable Risk Factors Elevated serum cholesterol Cigarette smoking Hypertension Impaired glucose tolerance Obesity Physical inactivity Stress Elevated serum cholesterol Cigarette smoking Hypertension Impaired glucose tolerance Obesity Physical inactivity Stress

9. Elsevier items and derived items © 2006 by Elsevier Inc. Pain Assessment Discomfort in the chest, epigastric area, jaw, back, or arm is noted. (Rate discomfort on scale of 0 to 10.) Discomfort is often described as tightness, burning, pressure, or indigestion. Anginal pain improves with rest and nitroglycerine; MI does not. (Continued) Discomfort in the chest, epigastric area, jaw, back, or arm is noted. (Rate discomfort on scale of 0 to 10.) Discomfort is often described as tightness, burning, pressure, or indigestion. Anginal pain improves with rest and nitroglycerine; MI does not. (Continued)

10. Elsevier items and derived items © 2006 by Elsevier Inc. Pain Assessment (Continued) Other manifestations include nausea and vomiting, diaphoresis, dizziness, weakness, palpitations, and shortness of breath. What group of patients will not show classic symptoms and why? Other manifestations include nausea and vomiting, diaphoresis, dizziness, weakness, palpitations, and shortness of breath. What group of patients will not show classic symptoms and why?

11. What else will you assess? Elsevier items and derived items © 2006 by Elsevier Inc.

12. Diagnostic Assessment Electrocardiogram Stress test Myocardial perfusion imaging Magnetic response imaging Cardiac catheterization Electrocardiogram Stress test Myocardial perfusion imaging Magnetic response imaging Cardiac catheterization

13. Lab Test CK CK-MB Tropopnin CBC Chem 7 CK CK-MB Tropopnin CBC Chem 7 Elsevier items and derived items © 2006 by Elsevier Inc.

14. Acute Pain Interventions include: –Provide pain relief modalities. –Decrease myocardial oxygen demand. –Increase myocardial oxygen supply. Interventions include: –Provide pain relief modalities. –Decrease myocardial oxygen demand. –Increase myocardial oxygen supply.

15. Elsevier items and derived items © 2006 by Elsevier Inc. Pain Management MONA Morphine sulfate Nitroglycerine Oxygen ASA Position of comfort; semi-Fowler’s position Quiet and calm environment Deep breaths to increase oxygenation GET PATIENT TO CATH LAB ASAP Morphine sulfate Nitroglycerine Oxygen ASA Position of comfort; semi-Fowler’s position Quiet and calm environment Deep breaths to increase oxygenation GET PATIENT TO CATH LAB ASAP

16. Elsevier items and derived items © 2006 by Elsevier Inc. Ineffective Tissue Perfusion (Cardiopulmonary) Interventions include: –Restoration of perfusion to the injured area often limits the amount of extension and improves left ventricular function. –Complete sustained reperfusion of coronary arteries in the first few hours after an MI has decreased mortality. GET PATIENT TO CATH LAB ASAP Interventions include: –Restoration of perfusion to the injured area often limits the amount of extension and improves left ventricular function. –Complete sustained reperfusion of coronary arteries in the first few hours after an MI has decreased mortality. GET PATIENT TO CATH LAB ASAP

17. Elsevier items and derived items © 2006 by Elsevier Inc. Identification of Coronary Artery Reperfusion Abrupt cessation of pain or discomfort Sudden onset of ventricular dysrhythmias A peak at 12 hours of markers of myocardial damage Abrupt cessation of pain or discomfort Sudden onset of ventricular dysrhythmias A peak at 12 hours of markers of myocardial damage

18. Elsevier items and derived items © 2006 by Elsevier Inc. Oral Drug Therapy Aspirin Beta-adrenergic blocking agents ACE inhibitors Calcium channel blockers The study called “Clopidogrel in Unstable Angina to Prevent Recurrent Ischemic Events (CURE)” (Palatnik, 2001) Aspirin Beta-adrenergic blocking agents ACE inhibitors Calcium channel blockers The study called “Clopidogrel in Unstable Angina to Prevent Recurrent Ischemic Events (CURE)” (Palatnik, 2001)

19. Elsevier items and derived items © 2006 by Elsevier Inc. Ineffective Coping Interventions Assess the client’s level of anxiety but allow expression of any anxiety and attempt to define its origin. Give simple explanations of therapies, expectations, and surroundings, and explanations of progress to help relieve anxiety. Provide coping enhancement. Assess the client’s level of anxiety but allow expression of any anxiety and attempt to define its origin. Give simple explanations of therapies, expectations, and surroundings, and explanations of progress to help relieve anxiety. Provide coping enhancement.

20. Elsevier items and derived items © 2006 by Elsevier Inc. Potential for Dysrhythmias Dysrhythmias are the leading cause of death in most clients with MI who die before they can be hospitalized. Interventions include: –Identify the dysrhythmias. –Assess hemodynamic status. –Evaluate for discomfort. Dysrhythmias are the leading cause of death in most clients with MI who die before they can be hospitalized. Interventions include: –Identify the dysrhythmias. –Assess hemodynamic status. –Evaluate for discomfort.

21. Elsevier items and derived items © 2006 by Elsevier Inc. Potential for Heart Failure Interventions Assessment Monitoring for signs of poor organ perfusion Hemodynamic monitoring Assessment Monitoring for signs of poor organ perfusion Hemodynamic monitoring

22. Elsevier items and derived items © 2006 by Elsevier Inc. Care of the patient going for PTCA/Stent Percutaneous transluminal coronary angioplasty (PTCA) Assessment Plan Goals Interventions Evaluations Percutaneous transluminal coronary angioplasty (PTCA) Assessment Plan Goals Interventions Evaluations

23. Elsevier items and derived items © 2006 by Elsevier Inc. Care of the patient Post PTCA/Stent Percutaneous transluminal coronary angioplasty (PTCA) Assessment Plan Goals Interventions Evaluations Percutaneous transluminal coronary angioplasty (PTCA) Assessment Plan Goals Interventions Evaluations

24. Elsevier items and derived items © 2006 by Elsevier Inc. Percutaneous Transluminal Coronary Angioplasty Monitoring for acute closure of the vessel, bleeding from the insertion site, reaction to dye, hypotension, hypokalemia, and dysrhythmias Long-term nitrate, calcium channel blocker, and aspirin therapy Beta blocker and ACE inhibitor if MI Infusions of GPIIa/IIIb inhibitors Monitoring for acute closure of the vessel, bleeding from the insertion site, reaction to dye, hypotension, hypokalemia, and dysrhythmias Long-term nitrate, calcium channel blocker, and aspirin therapy Beta blocker and ACE inhibitor if MI Infusions of GPIIa/IIIb inhibitors

25. Elsevier items and derived items © 2006 by Elsevier Inc. Health Teaching Smoking cessation Diet control Complementary and alternative therapies Physical activity Sexual activity (Continued) Smoking cessation Diet control Complementary and alternative therapies Physical activity Sexual activity (Continued)

26. Elsevier items and derived items © 2006 by Elsevier Inc. Health Teaching (Continued) Blood pressure, blood glucose control Cardiac medications Self-monitoring; seeking medical assistance if needed Blood pressure, blood glucose control Cardiac medications Self-monitoring; seeking medical assistance if needed