Acute Coronary Syndrome?
acute myocardial ischemia caused by atherosclerotic plaque rupture and thrombus formation
Non-ST elevation CAD?
prolonged resting chest pain >20min
unstable angina: may have ST segment depression
Non-STEMI: positive CK, CK-MB, troponin or both
Pathophysiology of Non-ST elevation CAD?
partial occlusion of coronary artery
Managment of Non-STEMI MI?
- 1. close monitoring for progression
- 2. platelet aggregation inhibitors and anticoagulants: ASA, heparin, lovenox
- 3. Beta blockers\
- 4. nitrates
- 5. PCI
ST elevation MI S/S?
- 1. prolonged resting CP >20 min
- 2. ST elevation
- 3. Q waves eventually develop in some
Pathophysiology of STEMI?
complete occlusion of a coronary artery
Management of STEMI?
- 1. ASA and beta blockers
- 2. reperfusion therapy: PCI, fibrinolytics followed by ASA, heparin, lovenox
- 3. nitrates\
- 4. ACE inhibitors
homocysteine level of >14
essential sulfur-containing amino acid that is formed during the processing of dietary protein: elevted levels are toxic to the vascular endothelium and increase coagulabilty
What deficiencies may cause elevated levels of homocysteine?
folate, vitamin B12 and B6
thickening and loss of elasticity of the arterial walls
What consequences can occur as a result of atherosclerosis?
angina, MI, HF, dysrhythmias caused by ischemia, sudden death
transient chest pain associated with myocardial ischemia
Predisposing factors for angina pectoris?
Factors that decrease supply: arteriosclerosis, coronary artery spasm, aortitis, dysrhythmia, anemia, shock
Factors that increase demand: HTN, aortic valve disease, tachydysrhythmias, HF, hyperthyroidism,
What causes ischemia that results in angina pectoris?
temporary imbalance b/t myocardial oxygen supply and myocardial oxygen demand that causes ischemia
Common precipitating factors for angina pectoris:
- the 5 E's plus smoking:
- Exercise: running
- Exertion: lifting, valsalva
- Emotion: catacholamine release
- Eating: shunting of blood to gut
- Smoking: nicotine increase HR and BP
Pathophysiology of chest pain in angina pectoris?
ischemia leads to anaerobic metabolism and accumulation of lactic acid which causes chest pain
What relieves angina pectoris?
rest and nitro
What happens to cardiac markers in angina pectoris?
CK-MB and troponin are negative
What ECG change may occur with unstable angina?
ST segment depression
What medications are used to Tx variant angina?
Ca Channel blockers and nitro
Consideration when giving nitro to male patients?
do not give NTG if ED medication has been taken w/in 36 hours : can cause severe hypotension and a decreased LOC
Activity for chest pain pt?
bed rest during pain = decreased O2 demand
Use of beta blockers for angina patients?
decrease myocardial workload and myocardial O2 demand by decreasing HR and contractility
When are beta blockers contraindicated for chest pain patients?
variant angina and in pt with ischmia/infarction r/t cocaine use
blocking beta receptor leaves alpha receptors unopposed and perpetuates vascular spasm
byproduct that rises rapidly after an inflammatory response - stimulates release and expression of inflammatory mediators
How long does it take heart to heal after ischemic damage?
2to 3 months - scar does not contract or conduct electrical impulses
indicates mass loss of myocardium
Block of L main coronary artery with cause what kind of MI? ECG changes?
extensive anterior MI
L circumflex artery blockage causes what type of MI?
Lateral HIGH: I and aVL
Lateral LOW: V5 and V6
L anterior descending artery blockage cuases what kind of MI?
septal: V1 and V2
Anterior: V3 and V4
R coronary artery occlusion causes what type of MI?
inferior: II, III, aVF
Posterior: reciprocal changes in V & V2 indicative of changes in V7-V9 especially V8 & V9
R ventricle: V4R-V6R especially V4R
What population of ppl die twice as much with MI's?
women twice the mortality of men when they have MI
What patients are less likely to have pain with MI?
- older adults
- heart transplant patients (denervated)
Clues that suggest silent MI?abed
- new onset HF
- acute change in mental status
- abd pain
Tachycardia is seen most oftern with ___ MI and bradycardia is seen most often with ___ MI.
When may elevated temp occur with MI?
48-72 hours after MI
CK normal values?
Time to rise?
Return to normal?
30-170 (men low 30 higher, women high 30 lower)
- time to rise after injury 4-6 hrs
- peak 24 hours
- return to normal 3-4 days
Time to rise?
Return to normal?
- 0% of total CK
- 6-10 hrs
- 12-24 hours
- 2-3 days
Time to rise?
Return to normal?
- 1-4 hours
- 6-12 hours
- 1-2 days
Cardiac Troponin I normal?
Time to rise?
Return to normal?
- <1.5 ng/ml
- 3-6 hours
- 24 hours
- 5-12 days
How often should ECG of chest pain pt be repeated?
every 30 minutes until pain ceases or until ECG is clearly diagnostic
Criteria for prompt reperfusion therapies?
ST segment elevation of <1mm in at least 2 contiguous leads
new L BBB
Morphine admin for MI/chest pain?
Actions of morphine for MI pt?
2to 4mg every 5 minutes until pain is relieved
decreases preload and catecholemine release via pain relief
What complication may occur r/t NTG admin?
What Tx may be used for reflex tachycardia after admin of NTG?
What may be used for intractable chest pain?
intra-aortic balloon pump - increases coronary artery perfusion pressure
Absolute contraindications for fibrinolytic therapy?
- intracranial or intraspinal surgery or trauma within 2 months
- systolic BP >200, diastolic BP > 120 or both
- prolonged or traumatic cardiopulmonary resusitation
- Hx of hemorrhagic stroke, intracranial neoplasm, AV malformation, or aneurysm
Heparin goal PTT after MI?
Heparin dose for MI patients?
- bolus 60units/kg
- drip 12units/kg/hour
Why are beta blockers given with MI?
- block effects of catecholemines: decreased
- HR, contractility, and O2 consumption
Contraindications for beta blockers?
- HR <50, SBP <100
- 2nd or 3rd degree heart block
What beta blockers are cardioselective and may
be given to pt with Hx of bronchospastic lung disease?
When may ACE inhibitors be given with MI?
with anterior or large inferior MI or with evidence of HF
*decrease water and sodium retention
Teaching for pt to prevent valsalva maneuver?
exhale when turning in bed
When should RV MI be suspected?
with acute inferior MI
Indications of RV MI?
- ECG changes in leads: V4R, V5R, and V6R
- R sided S4
Tx specific to R sided MI?
- 1. admin volume: colloids
- 2. avoid use of diuretics and venous dilators
- 3. maintain contractility: inotropes: dobutamine
Tx specific to cocaine induced MI?
- 1. Beta blockers are contraindicated
- 2. dilatizem to reduce coronary artery spasm
- 3. diazepam to reduce risk of seizures
Typical first s/s of HF?
cough, exertional dyspnea, fatigue, edema
What electrolyte imbalances typically occur with HF?
hypokalemia, hypocalcemia, and hyponatremia
LR is contraindicated in patients with ___ disease.
Replacement of ___, ____ ___, and ____ should be considered with multiple blood transfusions.
platelets, clotting factors, and calcium
Acute sodium and fluid restrictions for HF patients?
- fluid: <2000mL/24hours
- sodium: <2 to 3 g/24hours
form of BNP: brain-type natriuretic peptide: hormone released by heart in response to stretching of vessels r/t increased blood volume
reduces preload and afterload
Atrial dysrhythmias and HF?
increased volume stretches atria and causes atrial irritability and atrial dysrhythmias
Tx of HF can resolve atrial dysrhythmias
Complications of HF?
dysrhythmias: common cause of sudden death
- DVT or PE
- cardiogenic shock
Complications of therapy for HF?
fluid and electrolyte imbalance: hypokalemia, hypocalcemia, and hypomagnesemia r/t diuretics
3 types of cardiomyopathy?
Predisposing factors for cardiomyopathy?
anything that can damage heart: infection/viral, toxins, electrolyte/vitamin deficiency, pregnancy, neuromuscular disorderes, connective tissue disorders, hyperthyroidism
S/S of cardiomyopathy?
- syncope, weakness, fatigue, ortho hypotension
- cp and palpitations
- s/s of HF: dyspnea, edema
- murmurs, valve regurg
- s/s of LVF and RVF: S3, crackles, JVD, peripheral edema, hepatomegally
CXR with cardiomyopathy?
- cardiomegaly\pulmonary congestion
- pleural effusion
Tx of cardiomyopathy?
- mitral valve replacement or cardiac transplantation
- hypertrophic: prevent obstruction of LV outflow with beta blockers or Ca channel blockers and avoid inotropic agents (increase outflow obstruction)
- Restrictive: Tx cause, may use steroids
Major complication of pericarditis?
How much fluid can cause cardiac tamponade?
50-100mL if fluid accumulation is acute and rapid
Patho of constrictive percarditis and cardiac tamponade?
decreases diastolic filling: systemic or pulmonary congestion, decreased CO
may lead to shock
S/S of pericarditis?
- hoarseness, dysphagia, dyspnea
- cough, hemoptysis
- tachypnea, tachycardia
- fever, malaise
- heart sound changes: *friction rub, muffled heart sounds
What is CP like with pericarditis?
What makes it better/worse?
- precordial or L pleuritic CP that radiates to L shoulder, neck, arms, or abd
- aggravated by inspiration, cough, and supine position
- alleviated by sitting up or leaning forward
What is the hallmark sign of percarditis?
ECG of pericarditis?
diffuse concave ST elevation in all leads except aVL aVR V1, upright T waves flattened, no Q waves
What should pulse ox goal be for pt with COPD?
O2 admin to get SpO2 to 90%
Complications of pericarditis?
- constrictive pericarditis, cardiac tamponade
Patho of myocarditis?
viral infections causes immune response that becomes autoimmune process that leads to inflammation of myocardium
What occurs in diffuse and focal damage to myocardium?
diffuse injury may cause HF
focal injury may damage conduction system and cause conduction blocks
S/S of myocarditis?
- CP: soreness, burning, pressure
- easily fatigued, syncope
- URI or GI viral infection
- sudden unexplained dyspnea, orthopnea or PND
- heart sound changes: S3, S4, distant heart sounds, murmur of mitral regurg, pericardial friction rub
What dysrhythmias and blocks may occur with myocarditis?
SVT, ventricular dysrythmias, AV or bundle branch blocks
Medication for fungal infections with myocarditis?
When may steriods be used for myocarditis?
When are they contraindicated?
for connective tissue diseases
contraindicated in early infectious viral myocarditis
Complications of myocarditis?
- dilated cardiomyopathy
- pericarditis: monitor for cardiac tamponade
- systemic emboli: may receive anticoagulants
What may be required with myocarditis r/t complication of blocks?
temporary or permanent pacemaker
usually occurs in heart valves and my involve prostheses
Predisposing factors for endocarditis?
- valvular heart disease: septal defects, rheumatic heart disease, Hx of endocarditis
- cardiac Sx: esp valve repair or replacement
- invasive tests/monitoring
- skin, bone, or pulmonary infections
- poor oral hygiene and dental procedures
- long-term venous access devices
- body piercing
- immunosuppressed state
What valves of heart are most often affected with endocarditis in IV drug users?
R sided heart valves
L side usually affected with other types of endocarditis
What happens to valve affected by endocarditis?
becomes incompetent and may later scar to become stenotic
S/S of endocarditis?
- infectious s/s: fever, malaise, body aches, etc
- pleuritic cp, abd pain, back pain
- s/s of HF: dyspnea, orthopnea, PND
- cough, hemoptysis
- new or changed murmur
- s/s of embolic or allergic vasculitis
- may have s/s of HF
S/S of embolic or allergic vasculitis that may occur with endocarditis?
- splinter hemorrhages of nail beds
- roth spots: round white lesions on the retina
- janeway lesions: flat, painless eerythematous lesions on the palms, soles of feet, and extremities
- osler nodes: painful nodules on fingers and toes
round white lesions on retina
flat, painless erythematous leasions on the palms, the soles of feet and extremities
painful nodules on fingers and toes
How long is ABX therapy usually for endocarditis?
4 to 8 weeks
Complications of endocarditis?
- HF, cardiogenic shock, and pulmonary edema
- extension of infection: abscess, fistula
- systemic emboli and stroke
- neurologic complications: stroke-like s/s
- bacterial or myocotic aneurysm: localized abnormal expansion of a vesseel as a result of destruction of part of all ov the vessel wall from growth of bacteria or fungi
- dysrhythmias or blocks
- septic shock
Consideration for ppl with valvular heart disease having a procedure?
should receive prophylactic ABX before intrusive procedures: dental procedures, cardiac cath
- rapid rise in BP and is severe enough to cause threat of vascular necrosis and end-organ damage
- BP usually >240/140
- associated with organ damage to kidneys, brain, heart, eyes, or vascular system
Predisposing factors for HTN crisis?
- untreated essential HTN: noncompliance is frequently cause
- renal disease
- CNS injuries
- drug side effects: oral contraceptives, steroids, cocaine, amphetamines, meth, and decongestions
Organs most likely to be damaged by HTN?
heart, brain, kidneys, retina
S/S of hypertensive crisis?
- Hx HTN
- significant elevated BP above normal
- epistaxis may occur
- cardiovascular: cp, s/s of LV hypertrophy, s/s LVF, carotid/abd bruits
- renal involvement: nocturia, pressure-related diuresis, hematuria, elvated bun/creatinine
- retinal involvement: visual disturbances, funduscopic changes
- neurologic involvement: occipital or anterior HA esp in am, NV, seizures, focal neurologic s/s
What is widening of the mediastinum on CXR indicative of?
dissecting thoracic aortic aneurysm
BP checks with hypertensive crisis?
every 5 minutes until stable
Sodium restriction for HTN crisis?
Reduction of MAP in hypertensive crisis by no more than __ to ___ % during first 2 hours.
may cause neurologic damge by significantly decreasing cerebral perfusion pressure if decreased too quickly
What drug is usually the first-line agent for HTN crisis?
rapid onset and short duration of effect
What is the medication of choice for hypertensive crisis r/t eclampsia?
What drug use for HTN crisis is contraindicated in HF patients?
What type of drug is phentolamine/regitine?
What type of hypertensive crisis contraindicates beta blockers?
What may be used instead?
autonomic dysreflexia because of bradycardia that occurs
alpha blockers used instead: phentolamine
Why may beta blockers be used in HTN crisis?
block the reflex tachycardia associated with vasodilators
Alpha and beta blockers selective and nonselective?
What type of drug is phentolamine?
What it may used for?
HTN crisis r/t autonomic dysreflexia because of bradycardia - cannot use beta blocker
In what type of HTN crisis is a beta blocker contraindicated?
autonomic dysreflexia r/t bradycardia
Why may a beta blocker be used for htn crisis?
blocks reflex tachycardia caused by vasodilators
What type of beta blocker is esmolol?
When is it contraindicated?
cardioselective beta blocker: does not effect airway
HF, heart block, and htn caused by stimulants
Which beta blocker is preferred for htn in patients with aortic dissection: propranolol or esmolol?
What type of drug is labetalol?
When is it contraindicated?
alpha and noncardioselective beta blocker
contraindicated with HF, asthma, and heart block
When are ACE inhibitors particularly helpful in HTN crisis?
Only IV ACE inhibitor?
Complications of htn crisis?
- cerebral infarction
- HF or pulmonary edema
- dissection of aorta
- renal failure
Predisposing factors for arterial occlusion?
arterial embolization: Afib, valvular heart disease, HF, ventricular aneurysm, bacterial endocarditis
- injury to arterial wall: vascular trauma, arterial pnuctures, postcardiac catheterization, PCI, and vascular surgery
- compression of artery with swelling: fracture, circumferential burn
- comparison of ankle and brachial systolic BP
- obtained with a doppler stethoscope0
What ankle-brachial index is not compatible with limb viability?
Diagnostic study for arterial occlusion?
antiography indicates arterial occlusion
Procedures to reestablish the patency of an artery?
- intra-arterial fibrinolytics/tpa
- percutaneous endovascular
Predisposing factors for acute aortic aneurysm?
- degenerative changes of aging
- congenital weakness of aorta
- pregnancy esp in 3rd trimester
- coarctation of aorta
- severe systemic infection
- marfan syndrome
- trauma esp accel/decel injury
What s/s occurs as an aortic aneurysm as dissection extends?
pain moves from site of origin to other sites
S/S of acute aortic aneurysm?
usually asymptomatic until dissection or rupture
- sharp, knife-like, tearing/ripping pain
- normal to high BP - hypotension suggests cardiac tamponade or aortic rupture
- pulsatile mass
- increased aortic ciameter on palpation
- bruit over the aorta
CXR with aortic aneurysm?
- mediastinal widening
- widening of aortic silhouette
- aortic calcification
- L pleural effusion
What test will show presence, size, shape, and location of aortic aneurysm?
BP management of aortic aneurysm if dissection occurs or if patient is hypertensive?
maintain MAP at approx 70mmHG
- nitroprusside with propranolol
Blunt cardiac injury/myocardial contusion?
transient or permanent myocardial dysfunction caused by blunt trauma to the heart - may include myocardial necrosis without CAD
What is the most common cause of blunt cardiac trauma/myocardial contusion?
ace/decel injury in MVA
What type of blunt cardiac injury can cause sudden cardiac death?
blunt, nonpenetrating blow to the precordium
S/S of blunt cardiac trauma/myocardial contusion?
- precordial cp: usually increased with inspiration, cough, and mvmt - unresponsive to nitro - decreased with O2, antiinflammatories, and narcotics
- tachycardia, tachypnea
- chest wall tenderness with palpation
- cardiac arrest r/t vent arrhythmias
What part of the heart is usually affected by blunt cardiac trauma/cardiac contusion?
atria and R ventricle r/t anterior positioning
Why are inotropes used with cardiac contusion and blunt cardiac trauma?
improve RV contractility
What type of drug is dobutamine?
Treatment of atrial arrhythmia r/t cardiac blunt trauma?
Tx of ventricular arrhythmias r/t cardiac blunt trauma?
Tx of blocks r/t blunt cardiac trauma?
temporary or permenant pacemaker
Complications of penetrating cardiac trauma?
- hemorrhagic shock
- cardiac tamponade
S/S of great vessel injury?
- Hx of events/MOI
- pain that radiates to back
- sensory or motor changes in the lower ext
- htn, hypotension
- difference b/t L and R arms or upper and lower ext
- tracheal shift
BP control for great vessel injury?
antihypertenisives to keep MAP below 90
Complications of great vessel injury
- hemorrhagic shock
- cardiac tamponade
- false aneurysm
Predisposing factors for cardiac tamponade?
- heart injury
- post MI
- pericarditis esp in anticoagulated pt
- iatrogenic: pacemaker wire injury, invasive catheters, intracardiac injection, cardiac needle biopsy
- transmyocardial revascularization
- after cpr or cardioversion
- fibrinolytic or anticoagulant therapy
- connective tissue disease: rheumatoid arthritis, SLE, scleroderma
- metabolic disease: renal failure, hepatic, failure, or myxedema
- inflammation: pericarditis
How much fluid is usually contained in the percardial space?
S/S of cardiac tamponade?
- precordial fullness/pain
- dyspnea - improved with sitting up
- anxiety, impending doom
- tachycardia - early sign
- hypotension and narrowed pulse pressure
- absent PMI
- dullness to percussion below L scapula
- pulsus paradoxus: SBP decrease of <10 with inspiration
- Beck triad: hypotension, distended neck veins, and muffled heart sounds
- hypotension, distended neck veins, and muffled heart sounds
- s/s of cardiac tamponade
CXR with cardiac tamponade?
widened mediastinum, enlarged heart
|"water bottle silhouette"
ECG with cardiac tamponade?
decrease amplitude of ZRS or electrical alternans (alternating tall/small QRS)
bradycardia (may indicate impending PEA)
What is usually an early sign of cardiac tamponade?
What may bradycardia indicate with cardiac tamponade?
Tx of bradycardia in cardiac tamponade?
atropine or trascutaneous pacing
Tx of emergency cardiac tamponade?
Pt position during pericardiocentesis?
Complications of cardiac tamponade?
- laceration of coronary artery or conduction system
- myocardial perforation