1. Acute Coronary Syndromes Chapter 12 Cardiovascular Disorders Medical Surgical Nursing II

2. Acute Coronary Syndromes Term describes array of clinical presentations Range from unstable angina to acute myocardial infarction (MI)

3. Angina Chest pain that occurs in response to myocardial ischemia Causes spasm/blockage Symptoms in women often present differently as we discussed

4. Anginal pain presentations FIGURE 12-1 Common Sites for Anginal Pain. A, Upper part of chest. B, Beneath sternum, radiating to neck and jaw. C, Beneath sternum, radiating down left arm. D, Epigastric. E, Epigastric, radiating to neck, jaw, and arms. F, Neck and jaw. G, Left shoulder. H, Intrascapular.

5. Types of Angina Stable Predictable Patient knows what causes the pain and can tell a provider if it is their usual chest pain. Relieved with nitrates prescribed, rest, relaxation, or sometimes even activity Unstable Unstable is a change in a known pattern of chest pain Pain is more intense or has added cardiac equivalents not normally experienced Usually not relieved with the usual amount of nitrates

6. Care of the Patient with Stable Angina Eliminate chest pain A- Aspirin/Antianginal medications B. Beta-blockers/blood pressure – ACEI’s goal bp <140/90 if no other CAD factors <130/80 if diabetes or chronic kidney disease is present Eliminate Chest pain Cholesterol/Cigarettes Monitor lipid profiles fasting Lower LDL<100 Increase HDL>40 in men Increase HDL>50 in women Increase fiber Smoking cessation

7. Care of the Patient with Stable Angina D – Diet and Diabetes Low fat Low calorie Keep fasting glucose 70 to 100 mg/dl HbA1C <7% Education and Exercise Assess risk factors and develop an individualized teaching plan Exercise 30 to 60 minutes per day Treat metabolic syndrome BMI within Height and weight Treat Depression Flu Shot yearly

8. Care of the patient with stable angina Summarize the differences between stable and unstable angina based on symptoms? If a nurse caring for a patient say on the medical floor has relief of chest pain/pressure with the usual dose of nitrates or usual method of pain reduction nursing action indicated would be?

9. Unstable Angina Stable to unstable – Medical Emergency – Unstable angina is an indication of atherosclerotic plaque instability. – It is often a warning sign that precedes an acute heart attack – A patient with unstable angina needs to be treated with interventional cardiac methods the sooner the better

10. Other medications that are commonly administered for Unstable Angina Aspirin Nitroglycerin LMWH – Lovenox Heparin Drip Intravenous antiplatlet agents

11. Nursing Diagnosis Priority Acute pain r/t transmission and perception ischemic impulses amb patients individualized complaints. – Myocardial Ischemia is the one diagnosis in which relief of pain equals patient improvement from the cellular level all the way to the psychological level.

12. Recognition of Myocardial Ischemia Subjective Rate the discomfort – 0 to 10 scale Individualize the pain scale to the person’s abilities Avoid the use of the word pain as patients with myocardial ischemia do not feel like it is pain Other descriptors are:

13. Objective Assessment of Myocardial Ischemia Vitals Place the patient on a cardiac monitor Oxygen saturation Note skin color, temperature Peripheral pulse strength Mentation Overall tissue perfusion

14. 12 Lead EKG From initial complaint to EKG should be less than 10 minutes

15. Why the 12 lead ECG

16. Zones of Ischemia, Injury, and Infarction FIGURE 12-3 Zone of ischemia, zone of injury, and zone of infarction are shown through ECG waveforms and reciprocal waveforms corresponding to each zone.

17. ECG Changes FIGURE 12-4 ECG Changes Indicative of Ischemia, Injury, and Infarction (Necrosis) of the Myocardium. A, Normal ECG. B, Ischemia indicated by inversion of the T wave. C, Ischemia and current of injury indicated by T-wave inversion and ST-segment elevation. The ST segment may be elevated above or depressed below the baseline, depending on whether the tracing is from a lead facing toward or away from the infarcted area and depending on whether epicardial or endocardial injury occurs. Epicardial injury causes STsegment elevation in leads facing the epicardium. D, Ischemia, injury, and myocardial necrosis. The Q wave indicates necrosis of the myocardium.

18. Surface of Left Ventricle Electrocardiographic Leads Coronary Artery Usually Involved Inferior II, III, aV F Right coronary artery Lateral V 5 -V 6, I, aV L Left circumflex Anterior V 2 -V 4 Left anterior descending Anterior lateral V 1 -V 6, I, aV L Left main coronary artery Septal V 1 -V 2 Left anterior descending Posterior V 1 -V 2 Left circumflex or right coronary artery (reciprocal changes) Correlations among Ventricular Surfaces, Electrocardiographic Leads, and Coronary Arteries

19. FIGURE 12-6 Changes Seen on a 12-Lead ECG with An Anterior Wall MI. A, Infarction location on the cardiac wall. B, ECG leads with expected ST-segment elevation. C, A 12-lead ECG from a patient experiencing left anterior wall MI. LAD, left anterior descending artery.

20. FIGURE 12-6 Changes Seen on a 12-Lead ECG with An Lateral Wall MI. A, Infarction location on the cardiac wall. B, ECG leads with expected ST-segment elevation. C, A 12-lead ECG from a patient experiencing lateral STEMI

21. FIGURE 12-8 Changes Seen on a 12-Lead ECG with an Inferior Wall MI. A, Infarction location on cardiac wall. B, ECG leads with expected ST-segment elevation. C, A 12-lead ECG from a patient experiencing inferior wall MI.