Stable Angina and ACS
Collateral Circulation definition
A natural bypass or narrow blood vessels that develop over time as we age, the development of new or enlarged blood vessels that provide an alternative pathway when a main artery is blocked or narrowed
NSTEMI patho and diagnostic values
Patho: same as unstable except the partial occulsion causes injury and infarction to the heart tissue
Troponin: positive
ECG: ST depression or inverted T wave
What order do you give MONA in for either:
-shortness of breath, low SpO2, or difficulty breathing
-OR no respiratory issues
OANM
ANMO
Manifestations of Left Sided versus Right Sided heart failure
Left: blood backs into lungs- pulm congestion, orthopnea, crackles, shortness of breath, paroxysmal nocturnal dyspnea, increased cap refill, cold intolerance, altered mental status
Right: blood backs into body- JVD, hepatomegaly, renal failure, ascites
ADHF definition and clinical manifestations (early, later, late)
Definition: exacerbations related to increased shortness of breath, goal is to minimize the number of exacerbations
Early: mild increased RR and decrease in O2 sat
Later: use of accessory muscles, severe tachypnea, JVD, cough (goes from dry to wet foamy blood tinged sputum)
Late: flash pulmonary edema
Risk Factors for stable angina; metabolic syndrome
CAD, damage to the blood vessel, building blocks of atherosclerotic plaque
metabolic syndrome: increased triglycerides (≥150), decreased HLD (<40 in MAB, <50 m in FAB), increased BP, diabetes, increased waist circumference (≥40 in MAB, ≥35 in FAB)
Diagnostic Studies for STEMI and considerations
Serial Troponins: positive and elevates, can take 4-6 hours to become elevated after NSTEMI or STEMI occurs, troponin stays elevated for around 10 days after MI occurs
Serial ECGs: can take 1-2 hours to develop
ECG: ST elevation
Patient Discharge instructions for SL Nitro
take sitting or lying, don't swallow or crush, can take up to 3 doses 5 min apart, if no relief after 1st dose call 911, flushing and headaches are common, bathroom is not a good storage space, needs to be stored away from light and heat, replace every 6 months
Diagnostic tests of HF and results: 12 lead, chest x ray, echo, right heart cath, endomyocardial biopsy, BNP
12 lead: can show pathological Q waves (sign of previous MI) and arrythmias that may develop as a complication of HF
Chest X-ray: can show fluid accumulation in the lungs and indicate if the heart is enlarged
Echo- size of chambers, ejection fraction, valvular function and abnormalities
Right heart cath: SWAN Ganz catheter
Endomyocardial biopsy: useful if unsure of the cause
BNP: will be >100
Monitoring and Assessment management of decompensated HF for Nurses
Goal- bring patient back to baseline
strict I/O, monitor daily weights, auscultate lungs for crackles, assess edema, daily chest X ray, raise HOB
monitor for hypoperfusion (cap refill, pulses, temp, mental status, urine output, hypotension with tachycardia)
Diagnostic Studies of Stable Angina
ECG Changes= transient, will return to NSR once episode of chest pain or stress has ended
Cardiac Catheterization uses and treatment
Angiogram: visualization of the coronary arteries and any blockages
Determine: coronary arteries affected, exact location of blockages, % of occlusion
Treatment: followed by percutaneous coronary intervention (balloon angioplasty, stenting)
Nursing role before and after PCI
keep patient on bed rest if femoral approach for 4-6 hours with no hip flexion, evaluate kidney function, monitor for bleeding at the puncture site, monitor ECG for reperfusion ectopy (PVCs and short runs of unsustained VT are expected but increased frequency can indicate a complication, administer dual antiplatelets, monitor for stent re-occlusion (patient should be on tele and ST elevation should be monitored)
Pharmacological therapy for HF: reduce afterload, reduce preload, positive inotropes
Reduce afterload, decreases the workload of the heart (BP): ACE inhibitors, beta blockers
Reduce preload (fluid volume): loop diuretics, aldosterone antagonists
Positive inotropes: Oral Digoxin (cardiac glycoside that stregthens heart contractions while decreasing HR), IV Milrinone (patient can be discharged on this, they just need a PICC line)
Home oxygen
Interventions for worsening pulmonary edema and cardiogenic shock/decreased CO in DHF
Pulomonary: furosemide, supplemental oxygen continutous positive airway pressure, intubation or mechanical ventilation, low sodium diet, 1-2 L fluid restriction
Cardiac:
positive inotropes (IV milrinone, dobutamine, dopamine)
pressors: norepinepthine, phenylephrine, vasopressin
Clinical Manifestations of all ACS (unstable angina, NSTEMI, STEMI)
pain is new in onset, occurs at rest, occurs with increasing frequency, or lasts more than 10 min
pain does not go away with rest or nitrate
not predictable and more severe pain
Management and Treatment of Unstable Angina and NSTEMI
MONA, antiplatelets, BB, ACE inhibitor, statin
Cath lab within 12-72 hours for PCI or CABG
Thromobolytic therapy: when, how, contraindications, monitor
When: within 30 min for STEMI if there is no option for PCI, perform all other invasive procedures prior to admin due to bleeding risk
How: IV
Contra: active bleed, history of bleeding
Monitor: internal bleeding through BP and HR
Nutritional therapy and fluid considerations for HF
Low sodium diets <2 grams per day
fluid restriction in later stages, patient should notify their HCP if they gain 2-3 pounds in one day or 5 pounds in a week
Complications of HF and interventions
Pleural effusion
A-fib: check BP, determine if asymptomatic or symptomatic
VT: check for pulse, pulse do Valsalva or cardioversion
V-fib: code, CPR, epi, defib
Cardiorenal syndrome: check for decreased GFR, increased creatinine, decreased urinary output
Unstable angina patho and diagnostic results
Patho: plaque ruptures, clot forms around rupture, causes partial occlusion of vessel, no infarction (necrosis), just supply ischemia
Tests: troponin is negative, ECG has ST depression OR inverted T wave
Management and Treatment of STEMI
Cath lab within 90 min for PCI or thrombolytic therapy within 30 min or CABG
Complications of MI
Dysrythmias, Bradiycardia, V fib, cardiogenic shock, HF, Dressler Syndrome (peri friction rub and fever)
Bioprosthetic valve versus Mechanical valve requirements and considerations
Bioprosthetic: made of animal tissue so less clot risk, patient only needs to be anticoagulants for one month, lasts 10-15 years
Mechanical: made of metal so clot risk, patient on anticoagulation for the rest of their lives, lasts 20-30+ years
Indications and Contraindications for a heart transplant
Indications: end stage HF resistant to treatment, severe decompensated or inoperable valvular disease, recurrent life threatening dysrtyhmias resistant to treatment
Contraindications: over age 70, untreatable cancer with life expectancy <5 years, advanced valvular disease not amenable to treatment, active infection, irreversible HTN, active substance use (patient eligble if they are over 6 months sober), lack of social support, history of medical inadherence