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Whats going on with Angina
- not enough
- usually associated with
- precipitating factors
- - myocardal supply
- - atherosclerosis,arteriosclerosis, vasospasm, myocardialhypertrophy, severe anemia, respiratory disease,tachycardia, hyperthyroidism, increased forceof contraction as seen with HTN
- - Running, going upstairs, getting angry, respiratoryinfection with fever, exposure to cold weather,eating large meals
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what do we see (with angina)
- recurrent, intermittent
- usually triggered by
- pain described as
- may have
- vary in...and lasts
- - brief episodes of substernal chest pain
- - physical or emotional stress
- - “tightness or pressure in the chest, may radiate to neck or left arm.
- - pallor, diaphoresis, nausea
- - severity and lasts a few seconds to minutes
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Treatment for Angina
- have pt
- sit in
- admin
- check
- if no hx, call 911 after
- if hx give...if no relief...
- - patient rest, stop activity
- - upright position
- - NTG (sublingual); oxygen if needed pulse oximetry <95%
- - pulse/respirations
- - should call 911 after 2minutes if pain not relieved on its own
- - NTG X 3, 5 minutes apart if needed, if norelief treat as AMI, Call 911
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NTG
- for angina use waht form
- pill under toungue should
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Acute Coronary Syndrome
- S/S of
- unstable
- NSTEMI
- STEMI
- sudden reduction of
- - myocardial ischemia:
- - angina
- - non ST segment elevation MI
- - ST segment elevation MI
- - blood flow to the heart
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Unstable Angina
- causes
- S&S
- Dx
- Tx
- - Partial thrombus or intermittent occlusion of coronary artery
- - Pain with or without radiation to arm, neck or epigastric region •SOB, Diaphoresis,lightheadedness,tachycardia, decreased arterial oxygen saturation and rhythm abnormalities
- - ST depression or T wave inversion on ECG •Cardiac Biomarkers not elevated
- -
Oxygen to maintained >90%•NTG or Morphine to control pain•Beta blockers, ace Inhibitors, Statins on admit and DC clopiodogrel (plavix) unfractionated heparin or low molecular weight heparin, and glycopaclin Ib and IIb inhibitor
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NSTEMI
- causes
- S&S
- Dx
- Tx
- - Thrombus partially or intermittently occludes coronary artery
- - Same as unstable angina Pain is longer in duration and more severe than unstable angina
- - Same Changes on ECG* Cardiac biomarkers are elevated
- -
Same as unstable angina* Cardiac Catherization and possible PCI with STENTS for patient with ongoing pain, unstable,increased risk of worsening of clinical outcomes
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STEMI
- causes
- S&S
- Dx
- Tx
- - Thrombus fully occludes coronary artery
- - Same as NSTEMI but also have irreversible tissue damage (infarction)occurs if perfusion not restored
- - ST elevation or new LBBB on ECG•* Cardiac biomarkers are elevated
- -
Same as NSTEMI Percutaneous Coronary Intervention, within 90minutes MD evaluation Fibrolytic therapy within 30 minutes of arrival
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Who is at risk for AMI, unstable angina
- non modifiable
- modifiable
- - (age, sex, family history, ethnicity or race): Men > women, men over 45; women over 55; Anyone with first degree male or female relative who developed heart disease before age of 55 or 65
- - Increased serum cholesterol, LDL’s, Triglycerides; Decreased level of HDL; DM II, Smokers, Obesity, HTN, Stress, Sexual activity, Sedentary life style, Hyperthyroidism, Methamphetamine or cocaine use
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S&S of ACS
- degree to which coronary artery is occluded typicallycorrelates
- recognizable classicsymptom of ACS
- frequency and intensity can increase if not resolved with
- may last longer than....and may not
- along with CP may have...
- - presenting symptoms and with change incardiac markers, ECG changes
- - Angina or Chest Pain
- - rest, NTG, orboth
- - 15 min; radiate
- - SOB, Diaphoresis, Nausea, Lightheadedness, change in V/S, Tachycardia, tachypnea,HTN, Hypotension, decreased sao2, Cardiac rhythm abnormalities
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Atypical ACS symptoms
- women
- frequently present with
- tend to experience
- report as
- - SOB, fatigue, lethargy,indigestion, anxiety prior to AMI
- - palpitations, pain in the back rather than substernal or in the left side
- - numb, tingling, burning, stabbing pain
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Atypical ACS symptoms
- silent ischemia
- occurs w/out
- 50% dx with AMI did not have or exhibit classic sx of...
- - s/s
- - Chest Pain, especially diabetics,women, older adults with history of heart failure
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Dx with ACS
- h/p
- cardiac troponin T & I most specific for cardiac muscle damage; may predict
- if cant do troponin at facility then do....which is...
- myoglobin, heme protein not cardiac specific. But 1st to increase after; increases withn
- ECG
- Unstable Angina and NSTEMI will have ST
- ST elevation in 2 contiguous leads is dx
- Abnormal Q wave appears in presence
- once have Q wave
- - present symptoms, biomarker levels and ECG
- - degree of thrombus formation and micro vascular embolism
- - get CK-MB; less accurate, with more false +
- - damage to myocardium; 3 hours and the Troponin willnot be increased yet
- - 12 lead within 10 minutes arrival to ED, can tell ischemia, injury or infarction locate affected area, assess related conduction abnormalities
- - segment depression, invertedT wave, ST depression resolves when ischemia or pain resolves but mayhave a persistent T wave inversion
- - of STEMI; may also have T waveinversion, normally subsides within hrs of the AMI
- - MI due to alterations inelectrical conductivity of Myocardial cells,
- - will alwayshave a Q wave so not signal AMI but can indicate an old MI
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Initial meds used with Angina
- MONA (not in that order!)
Asprin, oxygen, ngt, morphine sulfate
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with angina give what first
asprin
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Asprin for CP (agina)
- dose
- when
- contraindicated in
- s/s for asprin toxicity
- works by
- - 165-325 mg orally, chew, crush, can place under the tongue then 81-325 mg daily
- - ASAP after onset of symptoms; unless contraindicated
- - GI bleed active ulcer disease bleeding disorder allergy to aspiriGI bleed, disease, disorder, aspirin
- - tennitus, ringing in ears
- - inhibiting platelet aggregation and vasoconstriction by preventing production of thromboxane
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oxygen admin in angina
- dose
- be alert for
- works to...
- - 2-4 L/min via nasal cannule keep SaO2 > 90%
- - S/S of hypoxia
- - increase the amount of oxygen that goes to myocardium thus decreases pain associated with myocardial ischemia
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Asprin admin
- inhibits
- contraindications
- SE
- - platelet aggregation
- - Don’t give to children (Reyes), allergy,bleeding disorders, GI ulcers
- - used for platelet aggregations; bleeding, epigastricdistress
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Nursing implications for asprin admin
- potential for toxicity higher in
- give with
- do not take when
- - older adults and children
- - mild or full glass of water to decrease GI irritation
- - one week prior to invasive procedure, notify MD
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Morphine Sulfate
- action
- use for
- contraindication
- SE
- toxicity
- - dilates coronary artery; interacts at specific receptor binding sites
- - pain; decreases anxiety, therefore decreases myocardial oxygendemands with pain from ACS
- - hypersensitivity, head injury, hepatic renal dysfunction
- - most serious respiratory depression, most common confusion,orthostatic hypotension, constipation, tolerance with long term use
- - coma, respiratory depression, pinpoint pupils
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Nursing Implications with Morphine admin
- assess
- document using
- reversal agent
- - pain, v/s prior to dose
- - strict inventory assessment of narcotics
- - naloxone (narcan)
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with acs give morphine until
pain is gone (2-4mg IVP every 5 to 15 min)
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Clopidogrel (plavix)
- indicated for
- non ST segment elevation ACS
- give
- ST segment MI
- give
- SE
- teaching
- - single 300 mg oral loading dose then 75 mg/Q day and start ASA 75-325 mgdaily
- - 75 mg daily with ASA 75-325 mg/day with or without thrombolytic may be startedwith or without the loading dose
- - Most common bleeding; Most severe TTP(Occurs within or < 2 weeks)
- - take as ordered, monitor platelet count, hold 3-7 days before invasive procedure
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when pushing fluids after dye is given make sure they are...
peeing the fluid out as not to OVERLOAD them
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reperfusion therapy
- recommended for
- includes
- goal
- - pt with STEMI
- - PCI, fibrinolytic drug therapy
- - restore blood flow to myocardium (PTCA, STENT, arthrectomy)
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reperfusion therapy
- PCI indicated if
- PCI in how long
- post care
- - onset symptoms occurred within 3 hours,fibrolytic therapy contraindicated for some reason, patient ishigh risk HF, STEMI diagnosis not absolute
- - 90 minutes from medical evaluation
- - frequent monitoring, v/s, rhythm, pulse, pain,insertions site, i/o
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Glycoprotein IIb/IIIa inhibitors
- examples
- indicated for
- work by
- dose (load, infusion)
- reopro
- integrilin
- angioplasty
- aggrastat
- - Eptifibatide (Integrilin), Tirofiban (Aggrastat), Abciximab (ReoPro)
- - AMI, Unstable Angina, Angioplasty
- - inhibiting platelet aggregation
- - load – 0.25 mg/kg IVP; Infustion 0.125 ug/kg/min up to 10 ug/min IV X 12 hours
- - load 189 ug/kg; Infusion 2 ug/kg/min IV X 72 hours;
- - Angioplasty-load 135 ug/kg IV prior to procedure; Infuse 0.5 ug/kg/min IV X 24 hours
- -Load 0.4 ug/kg/min for 30 minutes; Infusion (AMI 48-108 hours; Angioplasty 12-24 hours)
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Fibrolytics
- do what
- examples
- give within
- initiate within
- contraindication
- complication
- - administer clot bustingdrugs dissolve existing thrombus
- - alteplase (activase); reteplase (retavase) tenecteplase (TNKace)
- - 3 hours of symptoms although can give up to 12 hours but giving after 24 hoursCan be harmful.
- - 30 minutes of medical evaluation
- - bleeding disorder; recent ischemic stroke; CVA disease; uncontrolled HTN, brain tumor
- - Bleeding, hemorrhage
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Alteplase (activase)
- weight dependent
- half life
- dosing
- - yes
- - 4-8 min
- - IV bolus, 90 min continuous infusino
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Reteplase (retavase)
- weight dependent
- half life
- dosing
- - no
- - 13-16 min
- - 2 rapid bolus of 10 units each 30 min apart
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Tenecteplase (TNKace)
- weight dep
- half life
- dosing
- - yes
- - 20-24 min
- - single IV bolus
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Nursing Assessment with Reperfusion therapy
- monitor
- ECG
- have IV
- SaO2
-I/V
- - s/s (asymptomatic, CP, Dyspnea); v/s q 15 min till stable then Q 4hrs
- - serial; monitor bedside or telemetry
- - access
- - continuous, keep >90
- - hourly or >30ml/hr
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