CAD & ACS N232 LEARNING OBJECTIVES Identify Identify risk factors, signs & symptoms, and nursing care for angina and myocardial infarction. Identify Identify the Registered Nurse’s responsibilities with interacting with other health professionals Identify Identify the importance of collaboration with the multidisciplinary team Explain Explain the influence of colonization on increased incidence of cardiovascular disease among Indigenous peoples Interpret Interpret the following diagnostics: Troponin, ECG, Echocardiogram, Angiogram, Ejection Fraction and Lipid Profile Understand the following pharmacologic interventions Understand Describe • Oxygen therapy • Antianginals • Thrombolytics: alteplase (tissue plasminogen activator) • HMG-CoA Reductase Inhibitors (Statins): atorvastatin Describe the following procedures: Cardiovascular stents, coronary artery bypass graphing (CABG), valve and aortic replacements ASHD ATHEROSCLEROTIC HEART DISEASE 1. Narrows the lumen of the vessel • Reducing blood flow to the area supplied by the artery 2. Reduces elasticity • Making it less resilient in the face of volume or pressure changes. Increase the risk of vasospasm 3. Increases risk of plaque rupture & subsequent clot formation • with further occlusion & potential embolization 4. Increases risk of vasospasm http://www.khanacademy.org/science/health-and-medicine/circulatorysystem-diseases/blood-vessel-diseases/v/atherosclerosis-part-1 ATHERSOSCLEROSIS RISK FACTORS • • • Unalterable • Family history • Age • Sex • Race Medically alterable • Hypertension • Hyperlipidemia • Diabetes mellitus Alterable • Smoking • Stress • Central Obesity • Sedentary • Alcohol ACUTE CORONARY SYNDROME THINK….UNSTABLE ANGINA • STABLE ANGINA • UNSTABLE ANGINA • VARIANT (VASOSPASTIC) MI SYMPTOMS • :Neuro: Dizzy, restless, lightheaded, anxiety, pain • CV: chest pain, ↑JVD (if in HF), ↑HR or ↓ HR or irreg HR • Resp: SOB, dyspnea, crackles (if HF) • GI: Nausea, vomiting, burping, heartburn • Integ: cool, clammy, diaphoretic • Psychological: feeling of impending doom or denial that anything is wrong CV DIAGNOSTIC INTERPRETATION • Troponin • ECG • Angiogram • Echocardiogram • Ejection Fraction • Lipid Profile TROPONIN ELECTROCA RDIOGRAM (ECG) MEASURES THE ELECTRICAL ACTIVITY OF THE HEART, NOT THE MECHANICAL LOOKS AT THE RHYTHM OF THE HEART CAN GIVE INFORMATION OF AREAS OF THE HEART THAT ARE DAMAGED USED TO HELP DIAGNOSE ACUTE CORONARY SYNDROME (ACS) NONSTEMI VS STEMI ECG AND SURFACES OF THE HEART SURFACES OF THE HEART CORONARY ARTERIES CORONARY ANGIOGRAM Allows x-ray visualization of the coronary arteries following the injection of contrast medium. Is there a blockage in one or more artery? NORMAL CORONARY ANGIOGRAM ABNORMAL ANGIOGRAM CAN YOU SEE THE AREA OF RESTRICTED BLOOD FLOW? ECHOCARDIOGRAM • Sound waves create an image of the heart in motion to … • Evaluate heart wall motion • Ventricular function • Identify valvular disease • Evaluate the heart under stress • Identify & quantify pericardial fluid • Ejection fraction EJECTION FRACTION • Total cholesterol — this test measures all of the cholesterol in all the lipoprotein particles. • High-density lipoprotein cholesterol (HDL-C) — measures the cholesterol in HDL particles; often called "good cholesterol" because it removes excess cholesterol and carries it to the liver for removal. LIPID PROFILE • Low-density lipoprotein cholesterol (LDL-C) — calculates the cholesterol in LDL particles; often called "bad cholesterol" because it deposits excess cholesterol in walls of blood vessels, which can contribute to atherosclerosis. Usually, the amount of LDL-C is calculated using the results of total cholesterol, HDL-C, and triglycerides. • Triglycerides — measures all the triglycerides in all the lipoprotein particles; most is in the very low-density lipoproteins • the degree & duration of obstruction • collateral circulation THE AMOUNT OF DAMAGE DEPENDS ON… • The atherosclerotic process itself reduces blood supply >> progressively reducing blood to the myocardium • The development of a clot around a ruptured atherosclerotic plaque causes a sudden occlusion >> acutely reducing myocardial oxygen supply • Coronary artery blood flow must be reduced by at least 75% before symptoms appear O2 DEMAND > O2 SUPPLY Increased workload on the heart in the face of a fixed supply. • What would be an example of this?? 2. Reduced blood supply to the heart. • What would be an example of this?? 3. Reduced oxygen carrying capacity of coronary arteries • What would be an example of this?? O2 DEMAND > O2 SUPPLY 1. Increased workload on the heart in the face of a fixed supply • hypertension • aortic stenosis • increased metabolic demand 2. Reduced blood supply to the heart • atherosclerosis • coronary artery vasospasm • thrombus/embolus 3. Reduced oxygen carrying capacity of coronary arteries • anemia • hemodilution • acute blood loss NURSING CARE FOR ANGINA/MI WHAT IS OUR GOAL? O2 DEMAND > O2 SUPPLY Increase O2 Supply Reduce O2 demand • oxygen Rest • Aspirin 160-325 mg chewed • Thrombolytic: Tissue Plasminogen Activase Nitrates • PCI (Percutaneous Coronary Interventions) • Coronary Artery Bypass • Heparins Morphine Beta blockers • • Antiplatelets • Ca channel blockers ACE Inhibitors/ARB Unfractionated Heparin, LMWH Thienopyridines • • • Clopidogrel/Prasugrel Glycoprotein llb/llla Inhibitors HMG Coenzyme A Reductase Inhibitors (Statins) • CA Channel Blockers MANAGEMENT OF ISCHEMIA Decrease activity Oxygen – When indicated Nitrates Aspirin Not necessarily in this order!! (also give a beta-blocker ) • What do these drugs do? • relax vascular smooth muscle ie arteries (including coronary arteries) but particularly veins…reducing preload and consequently reducing cardiac workload. NITRATES • What is the worst thing that can happen if someone takes this drug? How would you know? What would you do? • Vessels dilate too much and blood pools in periphery >> reducing CO • Headache, orthostatic hypotension, reflex tachycardia (tolerance can develop) • Examples • Nitroglycerine (sl tabs, spray, transdermal patches, IV) ASPIRIN What does this drug do? •Anti-inflammatory •Anti-platelet •Reduces mortality by up to 23% What is the worst thing that can happen if someone takes this drug? How would you know? What would you do? • Allergic reaction >> antihistamine/epinephrine • Bleeding risk Examples : • non-enteric coated ASA 160-325 mg chewed asap. BETA BLOCKERS What do these drugs do? • reduction in cardiac output (stroke volume) by blocking beta receptors (beta 1) What is the worst thing that can happen if someone takes this drug? How would you know? What would you do? • bradycardia • inadequate cardiac output (through reduction in contractility) • bronchospasm (non-selective) Examples: • Atenolol, Metoprolol, Propranolol, Doxazosin, Terazosin • CALCIUM CHANNEL BLOCKERS What do these drugs do? • relaxation of vessel walls through blocking of calcium ion channels (primarily in arterioles) • >>> reduce afterload & consequently cardiac workload What is the worst thing that can happen if someone takes this drug? How would you know? What would you do? • Hypotension • Reflex tachycardia • use cautiously in heart failure • *No grapefruit juice • Examples: • • Norvasc, Renidil, Diltiazem, Verapamil, Amlodipine • • What do these drugs do? • Inhibition of the conversion of angiotensin 1 to angiotensin ll • >>> reduces afterload and consequently cardiac workload What is the worst thing that can happen if someone takes this • drug? How would you know? What would you do? • inadequate cardiac output • cough (angioedema) from action on vasodilator bradykinins • Examples: • ACE INHIBITORS • Enalapril (Vasotec), Captopril, Ramipril (Altace), • Quinapril (Accupril) For STEMI if it is within 6 hours of first symptoms and PCI is not available within 90 minutes of first medical contact FIBRINOLYTICS 47-75% reduction in mortality if delivered within 1st hour of onset of symptoms Dissolves body’s fresh fibrin clots…all of them >>> the diagnosis has to be right! Delivered in critical care areas PERCUTANEOUS CORONARY INTERVENTION • https://www.youtube.com/watch?v=I 45kJJoCa6s HEPARIN • lengthen clotting time, prevents thrombus formation/growth, inhibits certain clotting factors • IV onset is immediate. SC may take up to 1 hour. Half life is 1.5hours. LOW MOLECULAR WEIGHT HEPARIN • LMWH’s are heparin molecules that have been modified and shortened • LMWH’s work similarily to Heparin but, their inhibition is specific to active factor X • Less likely to cause thrombocytopenia • Duration of action is 2- 4x’s longer than regular Heparin od vs. bid • LMWH’s produce a more stable response than heparin • Hence, less follow-up lab tests are needed ANTIPLATELETS What do these drugs do? • reduce platelet aggregation Salicylates: Example: ASA Thienopyridines Examples : Clopidogrel/Prasugrel, Glycoprotein llb/llla Inhibitors Examples : Abciximab MAINTENANCE – STATINS HMG COENZYME A REDUCTASE INHIBITORS (LIPID-LOWERING AGENTS) What do these drugs do? • inhibit cholesterol production • 20-40% reduction in LDL, raise HDL levels, and lower triglycerides What is the worst thing that can happen if someone takes this drug? • liver dysfunction can occur – LFT tests need to be done prior/3months post • Muscle pain, tenderness and weakness – check CPK – Creatinine phosphokinase – may d/c drug • n/v, heartburn, abdominal cramping and diarrhea – give with meal in evening. Example : Atorvastatin (Lipitor) CORONARY ARTERY BYPASS GRAFT (CABG) EXPLAIN THE INFLUENCE OF COLONIZATI ON ON INCREASED INCIDENCE OF CARDIOVASC ULAR DISEASE AMONG INDIGENOUS PEOPLES YOUTUBE -Social Determinants of Health- CLICK HERE ARTICLE: Explaining the variability in cardiovascular risk factors among First Nations communities in Canada: a population-based study THE END WHAT ELSE ?? • What other data / information would you like to know? • What would you like to do? • What’s the problem? • What should happen next?
