Care of Patients with Acute Coronary Syndromes ~ Every 25 seconds a person in the United States has a major coronary event ~ Every minute someone will die due to a coronary event

 Includes stable angina and acute coronary syndromes  Ischemia—insufficient oxygen supply to meet the requirements of the myocardium  Infarction—necrosis or cell death that occurs when severe ischemia is prolonged and decreased perfusion causes irreversible damage to tissue

 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  Chronic stable angina- progresses to: Unstable angina

 Patients who present with either unstable angina or an acute myocardial infarction  ST elevation MI (STEMI) traditional manifestation  Non–ST elevation MI (non-STEMI) common in women

 New-onset angina - First symptoms, usually after exertion  Variant (Prinzmetal’s) angina - usually a coronary spasm, occurs at rest  Pre-infarction angina - Chest pain occurring prior to MI Causes severe activity limitation

MI is the most serious acute coronary syndrome  Occurs when myocardial tissue is abruptly and severely deprived of oxygen  Occlusion of blood flow  Necrosis  Hypoxia  Locations: i.e. inferior, anterior, lateral, posterior, septal  Ventricular remodeling

EKG changes seen with Myocardial Infarction

 Age  Gender (women develop CAD 10 years later than men and have higher incidence of death during hospitalization)  Family history = high risk  Ethnic background

 Elevated serum cholesterol  Cigarette smoking  Hypertension  Impaired glucose tolerance  Obesity  Physical inactivity  Stress

 Delay interview data collection until interventions for symptom relief, vital instability, and dysrhythmias are resolved  Rapid assessment is crucial to determine characteristics of the discomfort. Interview: 1. onset 2. location 3. radiation 4. intensity 5. duration 6. precipitating and relieving factors

 Nausea/vomiting  Diaphoresis  Dizziness  Weakness  Palpitations  Shortness of air  Skin color ashen  Sense of impending doom  Decreased distal peripheral pulses  Auscultate for extra heart sounds  Watch for denial, fear, anxiety, and anger

 Troponin T and troponin I  Creatine kinase-MB (CK-MB)  Myoglobin  Imaging assessment (exercise stress test, echocardiogram)  12-lead electrocardiograms  Cardiac catheterization

EKG changes seen with Myocardial Infarction

 Interventions include:  Provide pain-relief modalities, drug therapy  Decrease myocardial oxygen demand  Increase myocardial oxygen supply

 Nitroglycerine  Morphine sulfate  Oxygen  Position of comfort; semi-Fowler’s position  Quiet and calm environment  Deep breaths to increase oxygenation

Correct order: 1. Oxygen 2. Nitro 3. Aspirin 4. Morphine

 Interventions include:  Drug therapy (aspirin, thrombolytic agents)  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

 Glycoprotein (GP) IIB/IIIa inhibitors (Integrillin) decrease thrombus formation  Once-a-day beta-adrenergic blocking agents – (Coreg) (decrease size of infarct and decrease mortality)  Angiotensin-converting enzyme inhibitors (ACE) or angiotensin receptor blockers (prevent ventricular remodeling, and increase survival rate)  Calcium channel blockers (vasodilatory for angina)  Ranolazine (anti anginal for CSA)

 Fibrinolytics dissolve thrombi in the coronary arteries and restore myocardial blood flow  Tissue plasminogen activator (TPA)  Reteplase  Tenecteplase (TNK) 5 sec IVP Note: Heparin gtt follows therapy to prevent clots

 Cardiac Rehabilitation  Phase 1- acute illness through discharge  Phase 2- discharge through home convalescence  Phase 3- long term conditioning

 Assess the patient’s level of anxiety, and 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 - LISTEN

Dysrhythmias are the leading cause of death in most patients with MI, who die before they can be hospitalized  Interventions include:  Identify the dysrhythmias  Assess hemodynamic status  Evaluate for discomfort

 Necrosis of more than 40% of the left ventricle  Tachycardia  Hypotension  Blood pressure <90 mm Hg or 30 mm Hg less than patient’s baseline  Urine output <30 mL/hr (sign of inadequate organ perfusion)

 Cold, clammy skin  Poor peripheral pulses  Agitation, restlessness, confusion  Pulmonary congestion  Tachypnea  Continuing chest discomfort Early detection is essential as diagnosed cardiogenic shock has a high mortality rate

 Pain relief with Morphine, and decreased myocardial oxygen requirements through preload and afterload reduction (swan ganz catheter insertion for measurements to guide fluid and vasoactive drug administration  Drug therapy- nitrates, diuretics, beta blockers, positive inotropes, i.e: Dobutamine  Intra-aortic balloon pump to improve perfusion when drug therapy ineffective  Immediate reperfusion – pt taken to cath lab for PTCA

 Clopidogrel (Plavix) before the procedure  IV heparin after the procedure  IV or intracoronary nitroglycerine or diltiazem  Possible IV GP IIb/IIIa inhibitors (Integrillin)  Long-term therapy: antiplatelet therapy, beta blocker, ACE inhibitor or ARB

Candidates: Angina with >50% occlusion LMA Unstable angina with severe vessel disease Acute MI with cardiogenic shock Coronary vessels are unsuitable for PTCA

 Operative care: Pt has sternal incision, large leg incision (usually), 2 or 3 chest tubes, mediastinal tubes, foley cather, pacemaker wires and swan ganz, and will be on a ventilator  Post operative care: Pt is 1:1 care in ICU on vent approx 6 hrs. Manage fluid and electrolyte balance and cardiac rhythm closely  Management of other complications: a. hypotension b. hypothermia c. hypertension d. bleeding e. cardiac tamponade f. change in level of consciousness