Lecture 2 Angina & ACS Lecture

8/17/2019 Lecture 2 Angina & ACS Lecture

1/66

Coronary Artery DiseaseCardiac PharmacologyMyocardial Infarction

Lecture 2

Joy Borrero, RN, MSN 9/10

Angina PectorisAcute Coronary yndrome


2/66

Coronary Artery Disease!tiologyRis" factors

Nonmodifia#le $s% modifia#le ris"

factorsClinical manifestations

&oals of thera'y

Medications


3/66

ATHEROSCLEROSIS

START

END


4/66

STATINS aka: (COENZYME INHIBITOR)

Mevacor, Zocor, Lipitor

BLOCS BIOSYNTHESIS O! CHOLESTEROL

• HI"H !IRST #ASS E!!ECT

$MONITOR L!T

•SIDE E!!ECTS

•N%&%D ' ABDOMINAL CRAM#S

•MYAL"IA, ARTHRAL"IA,Cataract

•HEADACHES, DIZZINESS, INSOMNIA

•Liver a* ki*e+ *+-ctio


5/66

Angina Pectoris!'isode of chest 'ain or 'ressuredue to insufficient artery flo( ofo)ygenated #lood%

Myocardial 02 demand e)ceeds 02

su''ly% CAD is the most commoncause%*ne coronary artery #ranch #ecomescom'letely occluded+ therefore, 02is not 'erfused to the myocardium,

resulting in transient ischemia andsu#se-uent retrosternal 'ain%


6/66

Angina PectorisPrecipitating Factors. /arning ign for MIClinical Signs & Symptoms. do not occur untillumen is 1 narro(ed% ternal 'ain. mild tose$ere% May #e descri#ed as hea$y, s-uee3ing,'ressing, #urning, crushing or aching% *nsetsudden or gradual% May radiate to L%shoulder and arm% Radiates less commonly toR% shoulder, nec", a(% Pt may ha$e(ea"ness5num#ness of (rist, arm, hands% 'ainusually short duration and relie$ed #yremo$al 'reci'itating factors,rest or N6&%

Can #e gradual 7CAD8 or sudden7$asos'asm8 Associated Symptoms. dys'nea, N 9 :,tachycardia, 'al'itations, fatigue,dia'horesis, 'allor, (ea"ness, synco'e,factors


7/66

6y'es of Angina Stable. 6here is a sta#le 'attern of

onset, duration andintensity of s), 'ain is triggered #y a'redicta#le degree of e)ertion or emotion%

Variant Angina 7Prin3metal;s8

Cyclical, may occur at rest%:entricular arrhythmia, #rady arrhythmiaand conduction distur#ances occur%

ynco'e associated (ith arrhythmiamay occur

oct!rnal Angina only at night% Possi#le

associated (ith R!M slee'% "nstable Angina A


8/66

Assesment =% >)

2% Physical !)am

?% !


9/66

Medications for Angina

=% Nitrates decrease myocardial 02demand $ia

'eri'heral $asodilation and re$ersecoronary artery s'asm thus increase 02su''ly to myocardial tissue%

2% Understanding ho( Nitrates /or".'eri'heral $asodilation results in.decreased 02 demanddecreased $enous return to heart

decreased $entricular filling (hichresults in decreased (all tensionand thus

decreased 02 demand


10/66

N6& Borms. L 7Nitrostat8

Lingual 'rays similar to L in use7Nitrolingual8

ustained release ca'sules5ta#lets7Nitro#id8

*intments 2 7Nitro#id8 (ear glo$es (hena''lying

6ransdermal Patch 7NitroDur8

I: 76ridil8 Bor attac"s unres'onsi$e toother t)


11/66

ide5Ad$erse !ffects

:ascular >A 7may #e se$ere8>y'otension 7may #e mar"ed86achycardia

Pal'itations


12/66

Acute Angina 6reatment

&oal. !nhance 02 su''ly to myocardium.

M Mor'hine for 'ain

* *)ygen 4@L as ordered

N N6& su#lingual, re'eat -1minutes )?

A As'irin to 're$ent 'lateletaggregation


13/66

Angina 6reatment

6he focus is to relie$e acute attac"s and're$ent further attac"s%

=% Acti$ity5e)ercise tolerance aregular e)ercise 'rescri'tion isesta#lished after stress testing

and5or cardiac cath%

aseline&radual increaseA$oid

AlternateADLN6& #efore e)ercise


14/66

Patient education

Lifestyle modifications forcontrolla#le ris" factors% u''ortgrou's are hel'ful, !)am'le./eight (atchers,

mo"eenders, stress (or"sho's,cardiac reha#ilitation% u''ly'atients (ith information, name ofcontact 'erson and 'hone num#ers

Identify 'reci'itating factors forAnginal 'ain

Medication com'liance


15/66

Cardiac Pharmacology


16/66

etaadrenergic loc"ers

6hera'eutic effect decrease therate and force of the cardiaccontraction 7resulting indecreased 02 demand8 anddecrease $asoconstriction inthe myocardium and $asculature%

Mechanism of Action inhi#itcirculating catecholamines fromstimulating #eta rece'torsites% 6here are t(o ty'e of#eta rece'tors 7= 9 28%


17/66


= rece'tor stimulation #y catecholamines results in increased >R 9

myocardial contractility so, #loc"ingthe = effect results in slo(ed >R 9

decreased myocardial contractility% Cardioselecti$e !)cess #loc"ade can result in

#radycardia, heart #loc", heartfailure and5or hy'otension%

atenolol 76enormin8 meto'rolol 7Lo'ressor, 6o'rol8


18/66


2 rece'tor stimulation #y catecholaminesresults in dilation of the bronc#ialtree, the coronary arteries and the'eri'heral $asculature loc"ing the 2 effect results in

#ronchoconstriction, coronary artery$asoconstriction and 'eri'heral$ascular constriction%$r!gs t#at #a%e a ' bloc(ade e))ectare !sed ca!tio!sly*contraindicated in

clients +it# COP$, Nonselecti$e eta loc"ers loc"= and 2 rece'tors

'ro'anolol 7Inderal8 car$edilol 7Coreg8


19/66

etaadrenergic loc"erside !ffects many may #e 'redicted #asedu'on understanding the mechanism ofaction%

>y'otension radycardia>eart Bailure /ea"ness5BatigueDe'ression Im'otence>y'oglycemia >allucinations

Patient 6eaching.Use (ith caution in clients 'rone tocoronary artery s'asm due to$asoconstricti$e effects%

Contraindicated in clients (ith C>B andsecond or third degree heart #loc" due tothe rate slo(ing and reduction incontractility%

Nonselecti$e #eta #loc"ers contraindicated(ith C*PD%

Do not a#ru'tly discontinue #eta #loc"ers


20/66

Calcium Channel loc"ers

Action inhi#it flo( of CaE across cellmem#rane% CaE is essential for cardiacstimulation, conduction, contractilityand rela) $ascular smooth muscle (hichresults in decreased 02 demand and

increased coronary#lood su''ly :A*DILA6I*NIndications. angina, >6N, arrhythmiaDrugs

$era'amil 7Calan, Iso'tin8

diltia3em 7Cardi3em8 nifedi'ine 7Procardia8 amlodi'ine 7Nor$asc8


21/66

Calcium Channel loc"ers

ide !ffects of Calcium Channelloc"ers

Consti'ation 7(ith :era'amil8 Di33iness Bacial Blushing >A

!dema of an"les5feet radycardia >y'otension


22/66

!'inene'herine7adrenalin8:asoconstriction Increase PAl'ha, eta = and eta 2 agonist

Decrease congestion of nasal mucosa

Catacholamine 'roduced #yFF6) of A: #loc" and cardiac arrest


23/66

AC! IN>II6*R G6heH'rils

Angiotensin Con$erting !n3ymes Inhi#itorsAction. loc"s 'roduction of Angiotensin IIin "idneys

Indications. >B, >6N, MI, DM neuro'athy

Causes. :asodilation 7mostly arteriole8 Decreased P

!)cretion of Na and >2* 7#utnot


24/66

Angiotensin Rece'torloc"ers ARs

Action loc" the #inding ofAngiotensin II

to itJs rece'tor in the $ascular andadrenal tissues

!)am'les. candesartan 7Atacand8

losartan 7Co3aar8


25/66

Cardiac &lycosidedigo)in

7Lano)in8Action .EInotropic e))ect Increases force of myocardialcontraction

- C#ronotropic e))ect

decreases >R6). heart failure, afi#Nsg. A'ical Pulse for = full minute, hold forK@0, same time daily

Monitor Dig le$els 0%10% ng5ml Monitor < le$els Monitor for Dig to)icity. anore)ia,fatigue, (ea"ness, $ision changes 7halos8


26/66

Myocardial InfarctionLeading cause of death in U6hrom#osis in atherosclerotic arterycauses 0 of MIs%

A region of the myocardium isa#ru'tly de'ri$ed of #lood su''lydue to restricted coronary #loodflo(

Ischemia results and may lead tonecrosis (ithin @ hours

CA>* Core Measures for AMI 745=08


27/66

&ender Differences in MI

Bemales, (hen com'ared to males.'resent (ith MI later in life

ha$e 'oorer 'rognosis and highmor#idity

are 2) as li"ely to die in the first(ee"s

are more li"ely to die from the first

MIha$e higher rates of unrecogni3ed MI

N6!MI MI $s 6!MI


28/66

!


29/66

Location of MI

De'ends on (hich artery is affectedL: recei$es most of the CA su''ly andso it is the most affected

Left Anterior Descending 7LAD8

Left Circumfle) artery 7LCA8

Right Coronary Artery 7RCA8


30/66

&eneral 6y'es of MI6ransmuralin$ades full thic"ness ofmyocardium

u#enedocardialin$ades 'artialthic"ness


31/66

Collateral Circulation

A net(or" of #lood $essels 'resentat #irth that can dilate and #ecomefunctional a5r5o coronary arteryocclusion and ischemia% Hcollateral

circulationNatural H#y'ass mechanism hel'sdecrease the si3e of the MI


32/66

Ris" Bactors and!tiologyCAD and its ris" factorsAny situation re-uiring increased *2in the 'resence of decreased *2su''ly%

Non atherosclerotic coronary arteryocclusions


33/66

!ffects of MICell deathContractility in the affected areasreduced or a#sent

!lectrical insta#ility


34/66

Dysrhythmias occur in 0 of 'atientsP:Cs: tach

: fi#

radycardia


35/66

Com'lications of MI

C>BMitral :al$e Insufficiency

Dysrhythmias

PericarditisPost Infarction MI

6hrom#oem#olic Com'lications

Ru'ture of :entricular /all


36/66

MI Preci'itating Bactors

None in most casese$ere e)ertion and stress

1 occur at rest or (hile aslee'


37/66

Clinical Manifestations

AnginaChest Pain:ital igns

>eart and Lung

Associated 9


38/66

/hatJs the differenceO

Angina.yocardialIn)arction


39/66

Diagnosis of MI

ased on 2 out of ? criteria=% Chest 'ain indicati$e of ischemic

heart disease

2% Characteristic !


40/66

Diagnostic studies

!


41/66

&oals

Limit si3e of infarct5're$entfurther damage

Increase *2 su''ly and decrease *2demand

Pre$ent and 5or recogni3ecom'lications early

Reduce 'ain


42/66

Nursing Diagnosis


43/66

Nursing Inter$entionsRemem#er. M*NA and *h

atman*#tain !


44/66

*> A6MANQ

*>

A6

M

A

N


45/66

Nursing Inter$entions

Acti$ityafety

Reduce an)iety

Patient !ducationNutrition


46/66

Pharmacology 6hera'y for MI

6hrom#olytic Agents a5"5aPlasminogen Acti$ators7tre'to"inase, 6PA,Reta$ase8

decrease infarct si3e

im'ro$ed $entricular function

increased sur$i$al rates

&lyco'rotein II and IIIA


47/66

Pharmacology 6hera'y

AANitrates

Mor'hine ulfate

eta #loc"ersCalcium channel #loc"ers

AC!s and ARs


48/66

Antiarrhythmics

Class IA Na channel #loc"ersClass I Na channel #loc"ers

Class II eta #loc"ers

Class III AmiodaroneClass I: Ca Channel #loc"ers


49/66

Anticoagulants

>e'arinLM/> Lo$eno), Bragmin


50/66

Post MI Cardiac reha#

egins in acute 'hase and continuesindefinitely as out'atient

Includes.

education

acti$ity 'rogression

counseling

medical management


51/66

on-P#armacologic T#erapy

Percutaneous transluminal coronaryangio'lasty 7P6CA8Dilates coronary arteries o#structed#y 'lague% ?0 restenosis rate (ithinfirst @ months%

Patient CriteriaNoncalcified lesions less than 2 cm%6he ideal candidate (ould ha$e lessthan a one year history of angina and#e a#le to undergo coronary artery #y

'ass grafting if necessary% Patients(ith calcified lesions or lesions in#ranch $essels are not considered goodcandidates


52/66

on-P#armacologic T#erapy

Cardiac Catheteri3ation5 alloonAngio'lasty

Performed in the cardiac cath la#% Acatheter (ith a #alloon ti' is 'assed

into the o#structed artery and isalternately inflated and deflated toincrease arterial diameter and'erfusion%

Com'licationsArterial ru'ture, s'asm, em#oli, MI

Post'rocedure care


53/66

*ther Procedures

Coronary Artery tentstainless steel mesh stent is 'laced inlumen to 're$ent restenosis afterangio'lasty% Re-uires anticoagulationand anti'latelet t) to 're$ent local

throm#osis%Coronary Laser urgery

Laser can destroy atherosclerotic 'la-ue%Research is #eing conducted in

transluminal laser angio'lasty tocoronary arteries%

Atherectomy surgical remo$al ofatheroma%

C A t P


54/66

Coronary Artery yPass&rafting 7CA&8

Procedure urgicalre$asculari3ation to increasecoronary #lood flo(%

Patients (ith se$ere disease may not#e candidates% Longe$ity aftersurgery still #eing de#ated%urgery does not cureatherosclerosis and 'atients muststill control ris" factors


55/66

Posto' CA&

Post*'erati$e Nursing Assessments 9Care

Cardio$ascular functionRes'iratory function 't may #e on

mechanical $entilator for short time%Renal BunctionNeurologic BunctionPeri'heral :ascular BunctionBluid 9 !lectrolyte alance

Pain managementPsychological tatusafety Pt may #e restrained to'resent self e)tu#ation


56/66

Cardiac 6am'onade of CA&

!tiology heart is com'ressed #y fluid(ithin the 'ericardial sac% :entricularfilling is thus im'aired resulting indecreased cardiac out'ut and circulatorycolla'se%

Clinical igns Pulsus Parado)us loodPressure

Nec" :eins >eart ounds

Res'irations Mental tatus Pain6reatment 6horacotomy Pericardiocentesis


57/66

NCL! 6IM!

Modifia#le ris" factors associated(ith CAD include.

A% age, (eight, cholesterol le$el

% mo"ing, diet, P

C% Bamily h), (eight, P

D% lood glucose, acti$ity le$el,family h)


58/66

NCL! 6IM!

A 'atient has ust returned fromcardiac cath% /hich nursinginter$ention is most a''ro'riateO

A% Assist 't to am#ulate to the R

% Restrict fluids

C% Monitor 'eri'heral 'ulses

D% Insert an ind(elling catheter


59/66

NCL! 6IM!

A @? man is resuscitated successfullyafter cardiac arrest% lood studiessho( that he is acidotic% /hyO

A% Decreased tissue 'erfusion causes

lactic acid 'roduction% 6he 't ty'ically has an irregularheart #eat

C% 6he 't (as treated ina''ro'riately(ith Na icar#

D% Bat forming "etoacids are #rea"ingdo(n


60/66

NCL! 6IM!

Rosie is 're'aring her client fordischarge follo(ing his in'atient stay(ith angina, (hich is no( sta#le%Rosie is re$ie(ing #oth modifia#le andnonmodifia#le ris" factors% elect allfactors #elo( that are nonmodifia#le%

A,Age

,&ender

C,*#esity

$,Bamily history

E,>y'ertension


61/66

NCL! 6IM!

Bollo(ing her inferior (all MI, Mrs%&reen is -uiet, reser$ed, and a$oidingcontact (ith her family% Understandingthe 'sychosocial as'ects of AC, (hichinter$ention (ould #e #est for thenurse to do firstO

A,>a$e the clientJs cardiologist (ritefor a 'sychiatric referral%

,Pro$ide an atmos'here of acce'tance%

C,Boster mechanisms to su''ress angerand hostility%$,Pro$ide factual information to theclientJs family alone%


62/66

NCL! 6IM!

/hen Rosie is assessing her client (ithchest 'ain, she is e$aluating (hetheror not the client is suffering fromangina or MI% /hich sym'tom (ould #eindicati$e of an MIO

A,u#sternal chest discomfort,Chest 'ain #rought on #y e)ertion orstress

C,u#sternal chest discomfort relie$ed

#y nitroglycerin or rest$,u#sternal chest 'ressure relie$edonly #y o'ioids


63/66

NCL! 6IM!

All of the follo(ing clients are #eing cared foron the coronary care Hste'do(n unit% /henma"ing client assignments, (hich client (ill#e #est for the charge nurse to assign to ane( graduate RN (ho has com'leted @ months oforientation to the unitO

A,A client (ho has a ne( diagnosis of heartfailure and needs discharge teaching a#outmedications

,A client (ho has ust returned to the unitafter ha$ing a coronary arteriogram and hasorders for $ital signs e$ery =1 minutes

C,A client (ith a history of angina (ho isre-uesting nitroglycerin for left anteriorchest 'ain

$,A client (ho has many -uestions a#out theelectro'hysiology studies that are scheduled


64/66

NCL! 6IM!

/,An RN and an LPN (ho #oth ha$e se$eral years ofe)'erience in the intensi$e care unit are caringfor a grou' of clients% /hich tas" (ill #e mosta''ro'riate for the RN to delegate to the LPNO

A,*#taining 'ulmonary artery (edge 'ressures e$eryhour for a client admitted (ith 'ulmonary edema

,Monitoring $ital signs and assessing thecatheter insertion site for a client (horeturned from a coronary arteriogram an hour ago

C,6eaching the family mem#ers of a client (ho isscheduled for myocardial nuclear 'erfusionimaging a#out the 'rocedure

$,Com'leting the admission assessment for a clientadmitted to the unit (ith acute coronarysyndrome


65/66


66/66

Cardiac Case tudy

A 1yo male is admitted to your unit c5odull 'ain in the left side of his chestand radiating to his nec"% 6hereJs nodia'horesis or *% Ris" factorsinclude hy'ercholesteremia and a 0

'ac" year h) of smo"ing%P! re$eals P =405@, >R ==0, normalheart sounds and clear lungs #ilat%Cardiac mar"ers dra(n hour after theonset of 'ain sho( Myoglo#in 41mcg%6ro'onin I at 0%0=ng5mL and CP

Lecture 2 Angina & ACS Lecture

Documents

Transcript of Lecture 2 Angina & ACS Lecture