Download Collaborative and Nursing Management

Coronary Artery Disease
and
Acute Coronary Syndrome
Chapter 34
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Leading Causes of Death
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
2
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Coronary Artery Disease (CAD)
• Atherosclerosis
 Begins as soft deposits of fat that harden
with age
 Referred to as “hardening of arteries”
 Atheromas (fatty deposits) prefer
coronary arteries
 Also known as ASHD, CVHD, IHD, CHD
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Coronary Artery Disease
Etiology and Pathophysiology
• Atherosclerosis is the major cause
of CAD
 Characterized by lipid deposits within
intima of artery
 Endothelial injury and inflammation
play a major role in development
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Stages of Atherosclerosis
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Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Coronary Artery Disease
Etiology and Pathophysiology
• C-reactive protein (CRP)
 Nonspecific marker of inflammation
 Increased in many patients with CAD
 Chronic exposure to CRP associated
with unstable plaques and oxidation
of LDL cholesterol
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Coronary Artery Disease
Etiology and Pathophysiology
• Collateral circulation
 Arterial anastomoses (or connections)
within the coronary circulation
 Increased with chronic ischemia
 May be inadequate with rapid-onset
CAD
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Vessel Occlusion With
Collateral Circulation
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Case Study
iStockphoto/Thinkstock
• M. P. is a 58-year-old white male who
visits the local health clinic for a
physical examination.
• He tells the health care provider that
he occasionally gets “indigestion”
when he mows the lawn.
• It goes away in 5-10 minutes after he
stops and rests.
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Risk Factors for CAD
• Nonmodifiable risk factors
 Age
 Gender
 Ethnicity
 Family history
 Genetic predisposition
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Risk Factors for CAD
• Modifiable risk factors
 Elevated serum lipids
• Cholesterol >200 mg/dL (5.2 mmol/L)
• Triglycerides >150 mg/dL (3.7 mmol/L)
• High-density lipoproteins (HDL)
• Low-density lipoproteins (LDL)
• Treatment according to guidelines based
on 10-year risk score
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Risk Factors for CAD
• Modifiable risk factors
 Hypertension
• >140/90 mm Hg or >130/80 mm Hg if
diabetes or CKD
• Begin lifestyle changes for
prehypertension
• Treat stage 1 or 2 hypertension with
drugs
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Risk Factors for CAD
• Modifiable risk factors
 Tobacco use
• Increased catecholamine release
• ↑ LDL, ↓ HDL, ↑oxygen radicals
• ↑ Carbon monoxide
 Second-hand smoke
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Risk Factors for CAD
• Modifiable risk factors
 Physical inactivity
 Obesity
 Diabetes
 Metabolic syndrome
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Risk Factors for CAD
• Modifiable risk factors
 Psychologic states
 Homocysteine level
 Substance abuse
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Audience Response Question
Two risk factors for coronary artery disease
that increase the workload of the heart and
increase myocardial oxygen demand are
a.
b.
c.
d.
Obesity and smokeless tobacco use.
Hypertension and cigarette smoking.
Elevated serum lipids and diabetes mellitus.
Physical inactivity and elevated
homocysteine levels.
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Audience Response Question
Which patient is most at risk for developing
coronary artery disease?
a. A hypertensive patient who smokes
cigarettes
b. An overweight patient who uses smokeless
tobacco
c. A patient who has diabetes and uses
methamphetamines
d. A sedentary patient who has elevated
homocysteine levels
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Collaborative and Nursing
Management: CAD
• Prevention and early treatment
• Identification of people at high risk
 Health history, including family
history
 Presence of cardiovascular symptoms
 Environmental patterns: diet, activity
 Psychosocial history
 Values and beliefs about health and
illness
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Collaborative and Nursing
Management: CAD
• Manage high-risk persons by
controlling modifiable risk factors
• Encourage lifestyle changes
 Education
 Clarify personal values
 Set realistic goals
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Collaborative and Nursing
Management: CAD
• Physical fitness
 FITT formula: 30 minutes most days
plus weight training 2 days a week
 Regular physical activity contributes to
• Weight reduction
• Reduction of >10% in systolic BP
• In some men more than women, increase in
HDL cholesterol
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Collaborative and Nursing
Management: CAD
• Nutritional therapy
 ↓ Saturated fats and cholesterol
 ↑ Complex carbohydrates and fiber
 ↓ Red meat, egg yolks, whole milk
 ↑Omega-3 fatty acids
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Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Audience Response Question
The nurse determines that teaching about
implementing dietary changes to decrease the risk of
CAD has been effective when the patient says,
a. “I should not eat any red meat such as beef, pork,
or lamb.”
b. “I should have some type of fish at least 3 times a
week.”
c. “Most of my fat intake should be from olive oil or
the oils in nuts.”
d. “If I reduce the fat in my diet to about 5% of my
calories, I will be much healthier.”
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Collaborative and Nursing
Management: CAD
• Lipid-lowering drug therapy


If diet and exercise ineffective
Statins
• Inhibit cholesterol synthesis, decrease LDL,
increase HDL
• Monitor for liver damage and myopathy

Niacin
• Lowers LDL and triglyceride by inhibiting
synthesis
• Increases HDL
• Flushing, pruritus, GI side effects, orthostatic
hypotension
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Collaborative and Nursing
Management: CAD
• Lipid-lowering drug therapy

Fibric acid derivatives (Lopid)
• Decrease triglycerides and increase HDL
• GI side effects

Bile acid sequestrants
• Increase conversion of cholesterol to bile acids
• GI side effects; bind with other drugs

Ezetimibe (Zetia)
• Decrease absorption of dietary and biliary
cholesterol
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Collaborative and Nursing
Management: CAD
• Antiplatelet therapy
 ASA
 Clopidogrel (Plavix)
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Gerontologic Considerations
CAD
• Increased incidence and mortality
associated with CAD in older adults
• Strategies to reduce risk and treat
CAD are effective
• Treat hypertension, ↑lipids
• Smoking cessation
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Gerontologic Considerations
CAD
• Necessary to modify guidelines for
physical activity
 Longer warm-up
 Longer periods of low-level activity
 Longer rest periods
 Avoid extremes of temperature
 30 minutes most days minimum
• Most likely to change when
hospitalized or symptomatic
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Case Study
M.P.’s health history and physical
examination reveals the following risk
factors for CAD:
Family history of CAD
 Smokes 1 pack of cigarettes a day
 Sedentary lifestyle
 High fat diet
 BP 152/94
 BMI 30.2 kg/m2

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Case Study
iStockphoto/Thinkstock
• Based on the presence of these risk
factors and M.P.’s complaints of
“indigestion” associated with
activity, what type of angina is M.P.
likely experiencing?
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Clinical Manifestations of CAD
Angina
• Progressive disease
• O2 demand > O2 supply →
myocardial ischemia
• Angina = reversible ischemia
• Occurs when arteries are blocked
75% or more
• Hypoxic within 10 seconds of
occlusion
• Viable for 20 minutes
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Clinical Manifestations of CAD
Angina
• Lack of oxygen and glucose leads
to anaerobic metabolism
• Lactic acid irritates nerve fibers →
pain in cardiac nerves
• Referred pain from transmission to
the upper thoracic posterior nerve
roots
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Clinical Manifestations of CAD
Angina Pain
• Pressure/ache
• Squeezing, heavy, choking, or
suffocating sensation
• Rarely sharp or stabbing
• Indigestion or burning
• Various locations
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Clinical Manifestations of CAD
Chronic Stable Angina
• Intermittent chest pain that occurs
over a long period with the same
pattern of onset, duration, and
intensity of symptoms
• 5 to 15 minute duration
• ST segment depression and/or Twave inversion
• Control with drugs
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Chronic Stable Angina
Types of Angina
• Silent ischemia
 Ischemia that occurs in the absence of
any subjective symptoms
 Associated with diabetic neuropathy
 Confirmed by ECG changes
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Chronic Stable Angina
Types of Angina
• Nocturnal angina
 Occurs only at night but not
necessarily during sleep
• Angina decubitus
 Chest pain that occurs only while
lying down
 Relieved by standing or sitting
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Chronic Stable Angina
Types of Angina
• Prinzmetal’s (variant) angina
 Occurs at rest usually in response to
spasm of major coronary artery
 Seen in patients with a history of
migraine headaches and Raynaud’s
phenomenon
 Spasm may occur in the absence of
CAD
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Chronic Stable Angina
Types of Angina
• Prinzmetal’s (variant) angina
 Occurs at rest due to spasm of a
major coronary artery
 May occur with or without CAD
 Not precipitated by increased
demand
 Chest pain with marked, transient STsegment elevation
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Chronic Stable Angina
Types of Angina
• Microvascular angina
 Chest pain occurs in the absence of
significant coronary atherosclerosis
or coronary spasm
 Myocardial ischemia associated with
abnormalities of the coronary
microcirculation
• Coronary microvascular disease (MVD)
affects small, distal coronary arteries
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Case Study
iStockphoto/Thinkstock
• While awaiting diagnostic testing
for M.P., what drug would you
expect the health care provider to
prescribe for M.P. to use if he
develops the “indigestion” pain the
next time he mows the lawn?
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Chronic Stable Angina
Collaborative Care
• Goal: ↓ O2 demand and/or ↑ O2 supply
• Short-acting nitrates
Dilate peripheral and coronary blood
vessels
 Give sublingually (tablet) or by spray
 If no relief in 5 minutes, call EMS; if some
relief ,repeat every 5 minutes for maximum
3 doses
 Patient teaching
 Can use prophylactically

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Chronic Stable Angina
Collaborative Care
• Long-acting nitrates
 To reduce angina incidence
 Main side effects: headache,
orthostatic hypotension
 Methods of administration
• Oral
• Nitroglycerin (NTG) ointment
• Transdermal controlled-release NTG
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Chronic Stable Angina
Collaborative Care
• Angiotensin-converting enzyme
inhibitors
• β-adrenergic blockers
• Calcium channel blockers
• Sodium current inhibitor
 Ranolazine (Ranexa)
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Chronic Stable Angina
Collaborative Care
• Diagnostic studies
 Chest x-ray
 Laboratory studies
 12-lead ECG
 Calcium-score screening heart scan
 Echocardiogram
 Exercise stress test
 Pharmacologic nuclear imaging
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Case Study
iStockphoto/Thinkstock
•
M.P.’s chest x-ray and ECG results
are all within normal limits.
•
His cholesterol and triglyceride
levels are also elevated.
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Case Study
iStockphoto/Thinkstock
•
He develops chest pain and STsegment depression during an
exercise stress test.
•
What additional testing would you
expect M.P. to undergo at this
point?
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Chronic Stable Angina
Nursing/Collaborative Management
• Cardiac catheterization/coronary
angiography
 Visualize blockages (diagnostic)
 Open blockages (interventional)
• Percutaneous coronary intervention (PCI)
• Balloon angioplasty
• Stent
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Placement of a Coronary
Artery Stent
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Pre-PCI and Post-PCI With Stent
Placement
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Case Study
• M.P. undergoes a cardiac
catheterization.
• A 90% occlusion of his right
coronary artery (RCA) is
discovered.
• He has a balloon angioplasty and
stent placement.
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Case Study
iStockphoto/Thinkstock
• Discharge teaching related to CAD
and necessary lifestyle changes
(diet and exercise) is provided.
• He is scheduled for a follow-up with
his health care provider.
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Case Study
iStockphoto/Thinkstock
• Six months later, MP arrives in the
emergency department (ED)
complaining of severe,
immobilizing chest pain radiating
down his left arm.
• He admits to not following his
health care provider’s advice
related to diet and exercise.
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Case Study
iStockphoto/Thinkstock
• He states that he thought the stent
opened up his arteries and cured
his CAD.
• The ED physician suspects ACS.
Explain this diagnosis.
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Acute Coronary Syndrome
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Acute Coronary Syndrome
Etiology and Pathophysiology
Deterioration
of once stable
plague
Rupture
Platelet
aggregation
Thrombus
• Result
 Partial occlusion of coronary artery:
UA or NSTEMI
 Total occlusion of coronary artery:
STEMI
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Clinical Manifestations of ACS
Unstable Angina
• New in onset
• Occurs at rest
• Worsening pattern
• Increase in frequency
• Unpredictable
• Medical emergency
• Symptoms in women may be more
vague
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Clinical Manifestations of ACS
Myocardial Infarction (MI)
• Result of sustained ischemia
(>20 minutes), causing irreversible
myocardial cell death (necrosis)
• 80%-90% secondary to thrombus
• Ischemia starts in subendocardium
• Necrosis of entire thickness of
myocardium takes 4 to 6 hours
• Loss of contractile function
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Myocardial Infarction From
Occlusion
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Acute Myocardial Infarction
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Clinical Manifestations of ACS
Myocardial Infarction
• Pain
Severe, immobilizing chest pain not
relieved by rest, position change, or
nitrate administration
 Heaviness, pressure, tightness, burning,
constriction, crushing
 Substernal, retrosternal, epigastric
 More common in AM
 Atypical in women, elderly
 No pain if cardiac neuropathy (diabetes)

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Clinical Manifestations of ACS
Myocardial Infarction
• Pain
 Described as heaviness, constriction,
tightness, burning, pressure, or
crushing
 Common locations: substernal,
retrosternal, or epigastric areas; pain
may radiate to neck, jaw, arms
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Clinical Manifestations of ACS
Myocardial Infarction
• Catecholamine release –
stimulation of SNS
 Release of glycogen
 Diaphoresis
 Vasoconstriction of peripheral blood
vessels
 Skin: ashen, clammy, and/or cool to
touch
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Clinical Manifestations of ACS
Myocardial Infarction
• Cardiovascular
 Initially, ↑ HR and BP, then ↓ BP
(secondary to ↓ in CO)
 Crackles
 Jugular venous distention
 Abnormal heart sounds
• S3 or S4
• New murmur
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Clinical Manifestations of ACS
Myocardial Infarction
• Nausea and vomiting
 Reflex stimulation of the vomiting
center by severe pain
 Vasovagal reflex
• Fever
 Up to 100.4° F (38° C) in first 24 hours
 Systemic inflammatory process
caused by myocardial cell death
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Myocardial Infarction
Healing Process
• Within 24 hours, leukocytes
infiltrate the area of cell death
• Proteolytic enzymes of neutrophils
and macrophages begin to remove
necrotic tissue by fourth day →
thin wall
• Necrotic zone identifiable by ECG
changes and nuclear scanning
• Collagen matrix laid down
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Myocardial Infarction
Healing Process
• 10 to 14 days after MI, scar tissue is
still weak
• Myocardium vulnerable to stress
• Monitor patient carefully as activity
level increases
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Myocardial Infarction
Healing Process
• By 6 weeks after MI, scar tissue has
replaced necrotic tissue
 Area is said to be healed, but less
compliant
• Ventricular remodeling
 Normal myocardium will hypertrophy
and dilate in an attempt to
compensate for the infarcted muscle
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Complications of Myocardial
Infarction
• Dysrhythmias
 Most common complication
 Present in 80% of MI patients
 Can be caused by ischemia,
electrolyte imbalances, or SNS
stimulation
 Life-threatening dysrhythmias seen
most often with anterior MI, heart
failure, or shock
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Complications of Myocardial
Infarction
• Heart failure
 Occurs when the pumping power of
the heart has diminished
 Can be subtle or severe
• Cardiogenic shock
 Occurs because of severe LV failure
 Requires aggressive management
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Complications of Myocardial
Infarction
• Papillary muscle dysfunction
 Causes mitral valve regurgitation
 Aggravates an already compromised
LV → rapid clinical deterioration
• Ventricular aneurysm
 Myocardial wall becomes thinned and
bulges out during contraction
 Leads to HF, dysrhythmias, and
angina
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Complications of Myocardial
Infarction
• Acute pericarditis
An inflammation of visceral and/or
parietal pericardium
 May result in cardiac tamponade, ↓ LV
filling and emptying, heart failure
 Chest pain
 Pericardial friction rub
 ECG changes
 Treated with antiinflammatory agents

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Complications of Myocardial
Infarction
• Dressler syndrome
 Pericarditis with effusion and fever
that develops 4 to 6 weeks after MI
 Pericardial (chest) pain
 Pericardial friction rub
 Pericardial effusion
 Arthralgia
 Treated with short-term
corticosteroids
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Unstable Angina and MI
Diagnostic Studies
• Detailed health history
• 12-lead ECG
 Changes in QRS complex, ST
segment, and T wave
 Distinguish between STEMI and
NSTEMI
 Pathologic Q wave
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Serum Cardiac Markers After MI
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Unstable Angina and MI
Diagnostic Studies
• Coronary angiography
• Exercise or pharmacologic stress
testing
• Echocardiogram
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Case Study
• Identify priority interventions for
M.P. on his arrival at the ED.
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Collaborative Care
Acute Coronary Syndrome
• Initial interventions
 12-lead ECG
 Semi-fowler’s position
 Oxygen
 IV access
 Nitroglycerin (SL) and ASA (chewable)
 Morphine
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Case Study
iStockphoto/Thinkstock
•
M.P.’s ECG demonstrates
significant ST elevation.
•
What evidence-based
intervention would you expect to
prepare M.P. to undergo within
90 minutes of arrival to the ED?
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Collaborative Care
Acute Coronary Syndrome
• Ongoing monitoring
Treat dysrhythmias
 Frequent vital sign monitoring
 Bed rest/limited activity for 12–24 hours

• UA or NSTEMI
Aspirin, heparin, and glycoprotein
inhibitor
 Coronary angiography with PCI once
stable

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Collaborative Care
Acute Coronary Syndrome
• STEMI or NSTEMI with + cardiac
markers → reperfusion therapy
• Emergent PCI
 Treatment of choice for confirmed MI
 Goal: 90 minutes from door to
catheter laboratory
 Balloon angioplasty + drug-eluting
stent(s)
 Many advantages over CABG
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Collaborative Care
Acute Coronary Syndrome
• Thrombolytic therapy
 When PCI not available
 Stops infarction process by dissolving
thrombus
 Within 6 hours of onset of symptoms
 Ideally within first hour
 Given IV
 Patient selection critical
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Collaborative Care
Acute Coronary Syndrome
• Thrombolytic therapy
 Draw blood and start 2–3 IV sites
 Complete invasive procedures prior
 Administer according to protocol
 Monitor closely for signs of bleeding
 Assess for signs of reperfusion
• Return of ST segment to baseline best
marker
• IV heparin to prevent reocclusion
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Collaborative Care
Acute Coronary Syndrome
• Coronary surgical revascularization
Failed medical management
 Presence of left main coronary artery or
three-vessel disease
 Not a candidate for PCI (e.g., lesions are
long or difficult to access)
 Failed PCI with ongoing chest pain
 History of diabetes mellitus
 When long-term benefits of CABG are
superior to those of PCI

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Collaborative Care
Acute Coronary Syndrome
• Coronary surgical revascularization
 Coronary artery bypass graft (CABG)
surgery
• Requires sternotomy and
cardiopulmonary bypass (CPB)
• Uses arteries and veins for grafts
 Minimally invasive direct coronary
artery bypass (MIDCAB)
• Alternative to traditional CABG
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Cardiopulmonary Bypass
From: Frank W. Sellke et al, Sabiston & Spencer
Surgery of the Chest, ed 8, 2010, Saunders.
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Internal Mammary Artery and
Saphenous Vein Grafts
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Radial Artery Graft
• The radial artery is another conduit that
can be used.
• It is a thick muscular artery that is prone
to spasm.
• Perioperative calcium channel blockers
and long-acting nitrates can control the
spasms.
• Patency rates at 5 years are as high as
84%. There have been no reports of
extremity complications (e.g., hand
ischemia, wound infection) following the
removal of this artery.
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Collaborative Care
Acute Coronary Syndrome
• Coronary surgical revascularization
 Off-pump coronary artery bypass
• Sternotomy but no CPB
 Robot-assisted surgery
 Transmyocardial laser revascularization
• Indirect revascularization
• High-energy laser creates channels in heart
to allow blood flow
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Collaborative Care
Acute Coronary Syndrome
• Drug therapy
 IV nitroglycerin
 Morphine sulfate
 β-adrenergic blockers
 Angiotensin-converting enzyme
inhibitors
 Antidysrhythmia drugs
 Cholesterol-lowering drugs
 Stool softeners
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Audience Response Question
A patient is admitted to the coronary care unit following a
cardiac arrest and successful cardiopulmonary resuscitation.
When reviewing the health care provider’s admission orders,
which order should the nurse question?
a. Oxygen at 4 L/min per nasal cannula
b. Morphine sulfate 2 mg IV every 10 minutes until the pain is
relieved
c. Tissue plasminogen activator (t-PA) 100 mg IV infused
over 3 hours
d. IV nitroglycerin at 5 mcg/minute and increase 5
mcg/minute every 3 to 5 minutes
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Collaborative Care
Acute Coronary Syndrome
• Nutritional therapy
 Initially NPO
 Progress to
• Low salt
• Low saturated fat
• Low cholesterol
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Types of Fat in Food
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Nursing Management
Chronic Stable Angina and ACS
• Nursing assessment: subjective data

Health history
• CAD/chest pain/angina/ MI
• Valve disease
• Heart failure/cardiomyopathy,
• Hypertension, diabetes, anemia, lung
disease, hyperlipidemia
Drugs
 History of present illness

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Nursing Management
Chronic Stable Angina and ACS
• Nursing assessment: subjective data
Family history
 Indigestion/heartburn; nausea/vomiting
 Urinary urgency or frequency
 Straining at stool
 Palpitations, dyspnea, dizziness,
weakness
 Chest pain
 Stress, depression, anger, anxiety

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Nursing Management
Chronic Stable Angina and ACS
• Nursing assessment: objective data
 Anxious, fearful, restless, distressed
 Cool, clammy, pale skin
 Tachycardia or bradycardia
 Pulsus alternans
 Pulse deficit
 Dysrhythmias
 S3, S4, ↑ or ↓ BP, murmur
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Case Study
•
•
•
iStockphoto/Thinkstock
M.P. undergoes emergent PCI
with additional stent placement,
this time to his circumflex artery.
He is admitted to the coronary
critical care unit.
Identify appropriate nursing
diagnoses for M.P.
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Nursing Management
Chronic Stable Angina and ACS
• Nursing diagnoses
 Decreased cardiac output
 Acute pain
 Anxiety
 Activity intolerance
 Ineffective self-health management
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Nursing Management
Chronic Stable Angina and ACS
• Planning: overall goals
 Relief of pain
 Preservation of myocardium
 Immediate and appropriate
treatment
 Effective coping with illnessassociated anxiety
 Participation in a rehabilitation plan
 Reduction of risk factors
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Nursing Management
Chronic Stable Angina
• Acute intervention
 Semi-Fowler’s position
 Supplemental oxygen
 Assess vital signs
 12-lead ECG
 Administer a nitrate followed by an
opioid analgesic, if needed
 Auscultate heart and breath sounds
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Nursing Management
Chronic Stable Angina
• Ambulatory and home care
 Provide reassurance
 Patient teaching
• CAD and angina
• Precipitating factors for angina
• Risk factor reduction
• Drugs
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Nursing Management
Acute Coronary Syndrome
• Acute intervention
• Pain: nitroglycerin, morphine, oxygen
• Continuous monitoring
• ECG
• ST segment
• Heart and breath sounds
• VS, pulse oximetry, I&O
• Rest and comfort
• Balance rest and activity
• Begin cardiac rehabilitation
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Nursing Management
Acute Coronary Syndrome
• Acute intervention
 Anxiety reduction
• Identify source and alleviate
• Patient teaching important
 Emotional and behavioral reaction
• Maximize patient’s social support
systems
• Consider open visitation
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Case Study
•
Describe appropriate nursing
care of M.P. following his PCI.
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
iStockphoto/Thinkstock
Nursing Management
Acute Coronary Syndrome
• Coronary revascularization: PCI
 Monitor for recurrent angina
 Frequent VS, including cardiac
rhythm
 Monitor catheter insertion site for
bleeding
 Neurovascular assessment
 Bed rest per institutional policy
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Nursing Management
Acute Coronary Syndrome
• Coronary revascularization: CABG
ICU for first 24–36 hours
Pulmonary artery catheter
Intraarterial line
Pleural/mediastinal chest tubes
 Continuous ECG
 ET tube with mechanical ventilation
 Epicardial pacing wires
 Urinary catheter
 NG tube




Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Nursing Management
Acute Coronary Syndrome
• Complications related to CPB
 Bleeding and anemia from damage to
RBCs and platelets
 Fluid and electrolyte imbalances
 Hypothermia as blood is cooled as it
passes through the bypass machine
 Infections
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Nursing Management
Acute Coronary Syndrome
• CABG: postoperative nursing care
 Assess patient for bleeding
 Monitor hemodynamic status
 Assess fluid status
 Replace electrolytes PRN
 Restore temperature
 Monitor for atrial fibrillation (which is
common)
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Nursing Management
Acute Coronary Syndrome
• CABG: postoperative nursing care
 Surgical site care
• Radial artery harvest site
• Leg incisions
• Chest incision
 Pain management
 DVT prevention
 Pulmonary hygiene
 Cognitive dysfunction
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Nursing Management
Acute Coronary Syndrome
• Ambulatory and home care
 Cardiac rehabilitation
 Patient and caregiver teaching
 Physical activity
• METs or Borg Scale
• Monitor heart rate
• Low-level stress test before discharge
• Isometric versus isotonic activities
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Case Study
iStockphoto/Thinkstock
• When discussing activity
restrictions and expectations after
discharge with M.P., he assumes
his sex life is now over as he does
not want to die having sex with his
wife.
• How will you respond?
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Nursing Management
Acute Coronary Syndrome
• Ambulatory and home care
 Resumption of sexual activity
• Teach when discuss other physical activity
• Erectile dysfunction drugs contraindicated
with nitrates
• Prophylactic nitrates before sexual activity
• When to avoid sex
• Typically 7–10 days post MI or when patient
can climb two flights of stairs
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Nursing Management
Acute Coronary Syndrome
• Evaluation
 Stable vital signs
 Relief of pain
 Decreased anxiety
 Realistic program of activity
 Effective management of therapeutic
regimen
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Sudden Cardiac Death (SCD)
• Unexpected death from cardiac
causes
• Abrupt disruption in cardiac
function, resulting in loss of CO and
cerebral blood flow
• Most commonly caused by
ventricular dysrhythmias
• Structural heart disease
• Conduction disturbances
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Sudden Cardiac Death (SCD)
• No warning signs or symptoms if
no MI
• Prodromal symptoms if associated
with MI
 Chest pain, palpitations, dyspnea
 Death usually within 1 hour of onset
of acute symptoms
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Sudden Cardiac Death
Nursing/Collaborative Management
• Diagnostic workup to rule out or
confirm MI
 Cardiac markers
 ECGs
 Treat accordingly
• Cardiac catheterization
• PCI or CABG
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Sudden Cardiac Death
Nursing/Collaborative Management
• 24-hour Holter monitoring
• Exercise stress testing
• Signal-averaged ECG
• Electrophysiologic study (EPS)
• Implantable cardioverterdefibrillator (ICD)
• Antidysrhythmic drugs
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Sudden Cardiac Death
Nursing/Collaborative Management
• Patient teaching
• Psychosocial adaptation
 “Brush with death”
 “Time bomb” mentality
 Additional issues
• Driving restrictions
• Role reversal
• Change in occupation
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Audience Response Question
The most significant factor in long-term survival of a
patient with sudden cardiac death is
a. Absence of underlying heart disease.
b. Rapid institution of emergency services and
procedures.
c. Performance of perfect technique in resuscitation
procedures.
d. Maintenance of 50% of normal cardiac output
during resuscitation efforts.
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Audience Response Question
The nurse is caring for a patient who survived a
sudden cardiac death. What should the nurse include
in the discharge instructions?
a. “Because you responded well to CPR, you will not
need an implanted defibrillator.”
b. “Your family members should learn how to
perform CPR and practice these skills regularly.”
c. “The most common way to prevent another arrest
is to take your prescribed drugs.”
d. “Since there was no evidence of a heart attack,
you do not need to worry about another episode.”
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Case Study
iStockphoto/Thinkstock
• What diagnostic testing would you
expect the health care provider to
order for M.P. ?
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.