Oxygen Needs Interference with O2 Transport. Case Study.

Oxygen NeedsOxygen NeedsInterference Interference

with with

O2 TransportO2 Transport

Case StudyCase Study

Oxygen NeedsOxygen NeedsInterference with O2 TransportInterference with O2 Transport

Coronary Artery Disease Coronary Artery Disease

ComplicationsComplicationsDysrhythmiasDysrhythmiasPulmonary EmbolismPulmonary Embolism

HypertensionHypertensionComplicationComplication

Congestive Heart FailureCongestive Heart Failure

Peripheral Vascular / Arterial DiseasePeripheral Vascular / Arterial Disease

Oxygen NeedsOxygen NeedsInterference with O2 TransportInterference with O2 Transport

Care of Patients with:Care of Patients with:

Coronary Artery DiseaseCoronary Artery DiseaseRisk FactorsRisk Factors

Myocardial InfarctionMyocardial InfarctionAlterations in:Alterations in:

Rate & Rhythm (Cardiac Conduction)Rate & Rhythm (Cardiac Conduction)Effect on Cardiac OutputEffect on Cardiac Output

Content ApproachContent Approach

Anatomy & Physiology ReviewAnatomy & Physiology Review Demographics/occurrenceDemographics/occurrence PathophysiologyPathophysiology Clinical ManifestationClinical Manifestation Medical / Surgical ManagementMedical / Surgical Management Nursing Process (APIE)Nursing Process (APIE) Assessment - Nursing Actions - Assessment - Nursing Actions -

EducationEducation

Anatomy & Physiology Anatomy & Physiology

Right HeartRight Heart Left HeartLeft Heart SystoleSystole

Valve Closure: Valve Closure: DiastoleDiastole

Valve Closure: Valve Closure:

Cardiac CirculationCardiac Circulation

Myocardium Myocardium AnteriorAnterior Posterior Posterior

Cardiac CycleCardiac Cycle

1.1. Passive Filling – Passive Filling – preloadpreload

2.2. Atrial contraction – Atrial contraction – Aortic & Pulmonic Aortic & Pulmonic semilunar valves close – S2semilunar valves close – S2

3.3. Isovolumetric ventricular contraction – allIsovolumetric ventricular contraction – all

valves closedvalves closed

4.4. Ejection – ventricular systole – Ejection – ventricular systole – Mitral & Mitral & Tricuspid valves closeTricuspid valves close – S1 - – S1 - afterloadafterload

5.5. Isovolumetric ventricular relaxation – all Isovolumetric ventricular relaxation – all valves closedvalves closed

Cardiac Cycle PhasesCardiac Cycle Phases

Heart Sounds & Stethoscope Heart Sounds & Stethoscope PlacementPlacement

Coronary Arterial SystemCoronary Arterial System

Physiology: Oxygen Supply Physiology: Oxygen Supply to the Cardiac Muscle during to the Cardiac Muscle during

the Cardiac Cyclethe Cardiac Cycle

Coronary artery oxygen deficit Coronary artery oxygen deficit during ventricular contraction & ejection during ventricular contraction & ejection

(systole)(systole) Coronary artery fillingCoronary artery filling

during ventricular filling (diastole)during ventricular filling (diastole)

What is the impact of heart rate on What is the impact of heart rate on coronary artery filling?coronary artery filling?

Oxygen Supply to the Cardiac Oxygen Supply to the Cardiac Muscle during the Cardiac Muscle during the Cardiac

CycleCycle The actual time available for diastole shortens significantly as The actual time available for diastole shortens significantly as

the heart rate increasethe heart rate increase

% of a Minute% of a Minute Heart RateHeart Rate

70%70% 60 6050% 12050% 12033% 18833% 188

Results:Results: Less time for ventricular filling & coronary artery Less time for ventricular filling & coronary artery

filling + as HR increases, increased oxygen is needed each filling + as HR increases, increased oxygen is needed each minute to eject the same volume of blood.minute to eject the same volume of blood.

Stroke volume: volume ejected in one heart beatStroke volume: volume ejected in one heart beatCardiac Output: volume ejected in one minuteCardiac Output: volume ejected in one minute

Cardiac Output = Stroke Volume x Heart RateCardiac Output = Stroke Volume x Heart Rate

Factors Factors Determining Myocardial Determining Myocardial

Oxygen NeedsOxygen Needs Decreased Oxygen SupplyDecreased Oxygen Supply::

NoncardiaNoncardiacc: Anemia, hypoxemia, pneumonia, asthma, COPD, : Anemia, hypoxemia, pneumonia, asthma, COPD, low blood volumelow blood volume

CardiacCardiac: Arrhythmias/dysrhythmias, congestive heart failure : Arrhythmias/dysrhythmias, congestive heart failure (CHF), coronary artery spasm, coronary artery thrombosis, (CHF), coronary artery spasm, coronary artery thrombosis, valve disordersvalve disorders

Increased Oxygen Demand or ConsumptionIncreased Oxygen Demand or Consumption::

NoncardiacNoncardiac: anxiety, cocaine use, hypertension, : anxiety, cocaine use, hypertension, hyperthermia, hyperthyroidism, physical exertionhyperthermia, hyperthyroidism, physical exertion

CardiacCardiac: aortic stenosis, arrhythmias, cardiomyopathy, : aortic stenosis, arrhythmias, cardiomyopathy, hypertension, tachycardiahypertension, tachycardia

CAD - DemographicsCAD - Demographics

CAD - DemographicsCAD - Demographics

Comparison of death by CV Comparison of death by CV Disease and Breast Cancer – by Disease and Breast Cancer – by

Women’s AgeWomen’s Age

0

100

200

300

400

35-54 55-74 >=75

CardiovascularDisease

Breast Cancer

Coronary Artery Disease (CAD) Coronary Artery Disease (CAD) PathophysiologyPathophysiology

ASHD, IHD, CVHD = CADASHD, IHD, CVHD = CAD AHA AHA

1.1 mil Americans will have an MI in 20031.1 mil Americans will have an MI in 2003460,000 will die 460,000 will die

About half of those deaths occur within 1 hour of About half of those deaths occur within 1 hour of the start of symptoms and before the person the start of symptoms and before the person reaches the hospital.reaches the hospital.

Major cause: Atherosclerosis—focal Major cause: Atherosclerosis—focal deposit of cholesterol & lipidsdeposit of cholesterol & lipids

CAD – Risk FactorsCAD – Risk Factors

UnmodifiableUnmodifiable: Age, Gender, Ethnicity, Genetic predisposition/family history

Modifiable Major: Dyslipidemia--Elevated serum lipids*, hypertension*, cigarette smoking, obesity—visceral/central obesity

Modifiable Contributing: Diabetes Mellitus*, stressful lifestyle * may have genetic predisposition

CAD – Risk FactorsCAD – Risk Factors Metabolic Syndrome:Metabolic Syndrome:

– Insulin ResistanceInsulin Resistance– Hyperglycemia >110mg/dLHyperglycemia >110mg/dL– Hypertension - > 130/85Hypertension - > 130/85– Increased triglycerides >110mg/dLIncreased triglycerides >110mg/dL– Decrease HDL <40 men; < 50 womenDecrease HDL <40 men; < 50 women– Central Obesity Central Obesity

men: waist > 40” women: waist > 35”men: waist > 40” women: waist > 35”

Risk FactorsRisk Factors

One of the Major ModifiableOne of the Major Modifiable

Physical InactivityPhysical Inactivity

Types of Plasma LipoproteinsTypes of Plasma Lipoproteins HDL –HDL –

Contain more protein and less lipidContain more protein and less lipid Carry lipids away from arteries to liver for metabolismCarry lipids away from arteries to liver for metabolism

This process prevents lipid accumulation within arterial This process prevents lipid accumulation within arterial wallswalls

Higher levels are desirableHigher levels are desirable

LDL – LDL – Contain more lipids than any other lipoproteinsContain more lipids than any other lipoproteins

Affinity for arterial wallsAffinity for arterial walls Increased levels correlate closely with an increased Increased levels correlate closely with an increased incidence of atherosclerosisincidence of atherosclerosis Lower levels are desirableLower levels are desirable

VLDL VLDL Contain of triglyceridesContain of triglycerides Correlation with heart disease is uncertainCorrelation with heart disease is uncertain

Plasma LipoproteinsPlasma Lipoproteins

AtherosclerosisAtherosclerosis Elevated serum lipidsElevated serum lipids

Cholesterol Cholesterol > 200mg/dl> 200mg/dlTriglyceride Triglyceride > 200mg/dl> 200mg/dlHDL HDL

< 35 mg/dl – major risk< 35 mg/dl – major risk45-59 mg/dl – average risk45-59 mg/dl – average risk> 60 mg/dl – negative risk> 60 mg/dl – negative risk

LDL LDL < 130 – desirable< 130 – desirable130 – 159 mg/dl – borderline risk130 – 159 mg/dl – borderline risk> 160 mg/dl – high risk> 160 mg/dl – high risk

Progressive AtherosclerosisProgressive Atherosclerosis

Drug Therapy for Drug Therapy for DyslipidemiaDyslipidemia

Bile Acid SequestrantsBile Acid Sequestrants (Questran) - Binds with (Questran) - Binds with bile saltsbile salts

NiacinNiacin - Inhibits synthesis of VLDL & LDL - Inhibits synthesis of VLDL & LDL

Fibric Acid DerivativesFibric Acid Derivatives (Atromid)– Decrease VLDL (Atromid)– Decrease VLDL

HMG CoA Reductase InhibitorsHMG CoA Reductase Inhibitors (Statins - Lipitor, (Statins - Lipitor, Pravachol, Zocor) – Block synthesis of cholesterolPravachol, Zocor) – Block synthesis of cholesterol

Cholesterol Absorption InhibitorCholesterol Absorption Inhibitor (Zetia)– Inhibits (Zetia)– Inhibits intestinal absorption of cholesterolintestinal absorption of cholesterol

Natural Lipid Lowering Natural Lipid Lowering AgentsAgents

NiacinNiacin - < LDL levels - < LDL levels Omega-3 fatty acidsOmega-3 fatty acids – fish/flaxseed oil - – fish/flaxseed oil -

<Triglycerides & > HDL levels<Triglycerides & > HDL levels Milk thistleMilk thistle – Silymarin - > HDL levels – Silymarin - > HDL levels FiberFiber - < Cholesterol - < Cholesterol PhytosterolsPhytosterols - < Cholesterol - < Cholesterol SoySoy - < Cholesterol absorption from GI tract - < Cholesterol absorption from GI tract CoEnzyme Q10CoEnzyme Q10 – HMG CoA reductase – HMG CoA reductase

inhibitors – natural statinsinhibitors – natural statins

Coronary ThrombogenesisCoronary Thrombogenesis

During an Acute Coronary During an Acute Coronary SyndromeSyndrome

AnginaAngina

Clinical ManifestationsClinical ManifestationsAngina – Chest PainAngina – Chest Pain

Stable Angina PectorisStable Angina Pectoris – intermittent, same pattern of – intermittent, same pattern of onset, duration, intensity of symptoms - 3-5 mins.onset, duration, intensity of symptoms - 3-5 mins.

Silent IschemiaSilent Ischemia – 80% of patients with ischemia are – 80% of patients with ischemia are asymptomaticasymptomatic

Prinzmetal’s AnginaPrinzmetal’s Angina – variant – not precipitated by physical – variant – not precipitated by physical activity – may be due to spasmactivity – may be due to spasm

Nocturnal Angina Nocturnal Angina – occurs at night but not necessarily – occurs at night but not necessarily during sleep or in recumbent positionduring sleep or in recumbent position

Angina DecubitisAngina Decubitis – recumbent position – relieved by – recumbent position – relieved by standingstanding

Unstable AnginaUnstable Angina – Unpredictable or may evolve from stable – Unpredictable or may evolve from stable angina – increasing frequency, duration, intensityangina – increasing frequency, duration, intensity

CAD CAD Clinical Manifestation – Clinical Manifestation –

DiagnosticsDiagnostics History & Physical ExaminationHistory & Physical Examination

EKGEKG / / EchocardiogramEchocardiogram / / Stress EchocardiogramStress Echocardiogram

Thallium Stress TestThallium Stress Test (perfusion scanning) cold spots where (perfusion scanning) cold spots where tissue is inadequately perfused cardiac tissuetissue is inadequately perfused cardiac tissue

CAT scan- calcium scoreCAT scan- calcium score/CT coronary angiogram/CT coronary angiogram

MUGA MUGA (Multiple gated radioisotope scan) – left ventricular (Multiple gated radioisotope scan) – left ventricular function function

MRI of the heartMRI of the heart

PETPET (Positron emission computed tomography) – evaluate (Positron emission computed tomography) – evaluate coronary artery patencycoronary artery patency

Normal Thallium Stress TestNormal Thallium Stress Test

Abnormal Thallium-Stress TestAbnormal Thallium-Stress Test

CAD - Clinical ManifestationCAD - Clinical ManifestationInvasive DiagnosticsInvasive Diagnostics

Cardiac CatheterizationCardiac Catheterization

Right sided: Right sided: Catheter through the femoral vein through the vena Catheter through the femoral vein through the vena

cava into right atrium and right ventricle – pulmonary cava into right atrium and right ventricle – pulmonary artery – wedge pressureartery – wedge pressure

Left sided:Left sided: Catheter through the femoral artery through the aorta Catheter through the femoral artery through the aorta

into the left atrium and left ventricle / openings of the into the left atrium and left ventricle / openings of the coronary arteries coronary arteries

Coronary arteriography: Injected dye with video & x-raysCoronary arteriography: Injected dye with video & x-rays

CAD - Clinical ManifestationCAD - Clinical ManifestationInvasive DiagnosticsInvasive Diagnostics

Cardiac CatheterizationCardiac CatheterizationPotential ComplicationsPotential Complications

Catheter looping/breaking, dysrhythmias, Catheter looping/breaking, dysrhythmias, allergic reaction to contrast medium, arterial allergic reaction to contrast medium, arterial thrombosis, myocardial infarction, thrombosis, myocardial infarction, hemorrhage, infection.hemorrhage, infection.

Patient PreparationPatient PreparationInformed consent; allergies – shellfish/iodine; Informed consent; allergies – shellfish/iodine;

NPO x 6 hrs; explanation “flushed/tingling”; NPO x 6 hrs; explanation “flushed/tingling”; supine – absolutely stillsupine – absolutely still

Postprocedure Care Postprocedure Care

Right Heart CatherizationRight Heart Catherization

Left Heart CatheterizationLeft Heart Catheterization

Coronary AngiographyCoronary AngiographyCoronary Blockage - LADCoronary Blockage - LAD

Cardiac CatheterizationCardiac CatheterizationPost Procedure Care Post Procedure Care

Assess:Assess:

VS q15 mins. x 2 hrs; q30 min x 2 hrsVS q15 mins. x 2 hrs; q30 min x 2 hrs Monitor cardiac rate and rhythmMonitor cardiac rate and rhythm Check site for bleedingCheck site for bleeding Extremity: Peripheral pulse check, temperature, color, sensation, Extremity: Peripheral pulse check, temperature, color, sensation,

mobilitymobility Assess for chest pain, dizziness, dyspneaAssess for chest pain, dizziness, dyspnea

Nursing Action:Nursing Action:

Straight at groin x 24 hours; pressure at site x 30 mins.Straight at groin x 24 hours; pressure at site x 30 mins. Maintain IV KVO for 2 hrs; IV capped x 2 hrs; then d/cMaintain IV KVO for 2 hrs; IV capped x 2 hrs; then d/c Encourage oral fluidsEncourage oral fluids

Patient/Family Education:Patient/Family Education:

Rationale for all nursing actionsRationale for all nursing actions No squatting, sitting, lifting for 24 – 48 hours++No squatting, sitting, lifting for 24 – 48 hours++ Report bleeding, swelling, discoloration, drainageReport bleeding, swelling, discoloration, drainage Change dressing after 24 hours – small dressing to bandaidChange dressing after 24 hours – small dressing to bandaid

Clinical Manifestation Clinical Manifestation Myocardial Infarction Myocardial Infarction

Lab DiagnosticsLab Diagnostics Cardiac Protein – Cardiac Protein – Troponin TTroponin T

More sensitive than CK More sensitive than CK Elevates 3 hr – peak 24-48 hrs; normal 5-14 daysElevates 3 hr – peak 24-48 hrs; normal 5-14 days

Cardiac Enzyme – Cardiac Enzyme – Creatine kinase (CK-MB)Creatine kinase (CK-MB)Released when cardiac cells dieReleased when cardiac cells dieElevates 3 hrs – peak 12-24 hrs; normal 2-3 daysElevates 3 hrs – peak 12-24 hrs; normal 2-3 days

Cardiac Marker - Cardiac Marker - MyoglobinMyoglobin First to elevateFirst to elevateLacks cardiac specificityLacks cardiac specificityNormal range within 24 hoursNormal range within 24 hours

Serum Cardiac Markers after Serum Cardiac Markers after MIMI

CAD – Angina RelationshipCAD – Angina Relationship

Coronary Artery DiseaseCoronary Artery Disease

// \\

Stable AnginaStable Angina Acute coronary Acute coronary syndromesyndrome

// // \ \

Unstable Angina >Unstable Angina > Myocardial InfarctionMyocardial Infarction ST-elevated MI ST-elevated MI

Non-ST-elevated MINon-ST-elevated MI

CAD & Acute Coronary CAD & Acute Coronary SyndromeSyndrome

Heart With Muscle Damage and a Heart With Muscle Damage and a Blocked ArteryBlocked Artery

Myocardial InfarctionMyocardial Infarction

Myocardial Infarction Myocardial Infarction Acute Coronary SyndromeAcute Coronary Syndrome

Location correlates with coronary Location correlates with coronary circulation involvedcirculation involvedInferior Wall – Right coronary arteryInferior Wall – Right coronary arteryAnterior Wall – Left anterior descendingAnterior Wall – Left anterior descendingLateral, posterior or inferior – left circumflex Lateral, posterior or inferior – left circumflex

Healing ProcessHealing Process Within 24 hours – leukocytes & enzymesWithin 24 hours – leukocytes & enzymesThird day – collateral circulation developingThird day – collateral circulation developing10-14 days – scar tissue is still weak 10-14 days – scar tissue is still weak

Vulnerable time – unstable state of healing + Vulnerable time – unstable state of healing + increased activityincreased activity

6 weeks – scar tissue replaces necrotic tissue6 weeks – scar tissue replaces necrotic tissueNormal myocardial tissue may compensate – Normal myocardial tissue may compensate –

ventricular remodeling – can cause late ventricular remodeling – can cause late congestive heart failurecongestive heart failure

Coronary Artery Coronary Artery Collateral CirculationCollateral Circulation

AnginaAngina Medical Management Medical Management

AA Aspirin / Antianginal therapy / ACE Aspirin / Antianginal therapy / ACE InhibitorInhibitor

B b-Adrenergic blocker / blood pressureB b-Adrenergic blocker / blood pressure

CC Cigarette smoking / CholesterolCigarette smoking / Cholesterol

DD Diet / DiabetesDiet / Diabetes

E Education / ExerciseE Education / Exercise

Angina- MI Angina- MI Medical Management Medical Management

B-Adrenergic BlockersB-Adrenergic Blockers – decreases rate, contractility, – decreases rate, contractility, afterloadafterload

NitratesNitrates – peripheral vasodilation decreasing preload – peripheral vasodilation decreasing preload and afterload / coronary artery vasodilationand afterload / coronary artery vasodilation

Calcium Channel BlockersCalcium Channel Blockers – Coronary & peripheral – Coronary & peripheral vasodilation, decreases AV conduction and vasodilation, decreases AV conduction and myocardial contractilitymyocardial contractility

MorphineMorphine – analgesic – reduces preload & myocardial – analgesic – reduces preload & myocardial oxygen consumptionoxygen consumption

Angiotensin-Converting Enzyme InhibitorsAngiotensin-Converting Enzyme Inhibitors – Vasotec / – Vasotec / Capoten - prevents Angiotensin I conversion to Capoten - prevents Angiotensin I conversion to Angiotensin II – HTN, CHF Angiotensin II – HTN, CHF

Antiplatelet and Anticoagulant Agents Antiplatelet and Anticoagulant Agents in unstable angina and NSTEMIin unstable angina and NSTEMI

Oral anti-platelet agentOral anti-platelet agent AspirinAspirin Initially 300 mg p.o. then 75 - 150 mg daily Initially 300 mg p.o. then 75 - 150 mg daily

Clopidogrel (Plavix) Clopidogrel (Plavix) Initial loading dose of 300 mg then 75 mg daily Initial loading dose of 300 mg then 75 mg daily

• • Increased bleeding riskIncreased bleeding risk

HeparinsHeparins

Heparin Sodium: Bolus: Heparin Sodium: Bolus: 60 U/kg IV bolus to a maximum of 4,000 60 U/kg IV bolus to a maximum of 4,000 units units

Drip:Drip: 12 units/kg/h infusion to a maximum of 1 000 12 units/kg/h infusion to a maximum of 1 000 units/hunits/h

• • Monitor PTT: keep at 50 - 70 secondsMonitor PTT: keep at 50 - 70 seconds

Low-molecular-weight heparin - Low-molecular-weight heparin - Enoxaparin Enoxaparin 1 mg/kg subcut q12 hr 1 mg/kg subcut q12 hr

Precautions: Precautions: • Peptic ulceration • Aspirin allergy • GI bleeding • Peptic ulceration • Aspirin allergy • GI bleeding

Antiplatelet DrugsAntiplatelet Drugsused in unstable angina and used in unstable angina and

NSTEMINSTEMI

IntravenousIntravenous– tirofiban (Aggrastat), eptifibatide (Integrilin) tirofiban (Aggrastat), eptifibatide (Integrilin)

New class, GP IIb/IIIa inhibitorsNew class, GP IIb/IIIa inhibitors

– Abciximab (ReoProAbciximab (ReoPro) 0.25 mg/kg IV bolus 10 - 60 min ) 0.25 mg/kg IV bolus 10 - 60 min before PCI, than 10 before PCI, than 10 μμg/min IV - Infusion for 12 hg/min IV - Infusion for 12 h

Precautions: Precautions:

• • Thrombocytopenia • Bleeding disorder • Surgery < 6 weeks Thrombocytopenia • Bleeding disorder • Surgery < 6 weeks

• • Abnormal bleed < 30 d • Active GI ulcerationAbnormal bleed < 30 d • Active GI ulceration

• • Puncture of a non-compressible • Prior stroke, organic CNS pathologyPuncture of a non-compressible • Prior stroke, organic CNS pathology

• • Any systolic BP > 180 mmHg during the acute eventAny systolic BP > 180 mmHg during the acute event

Thrombolytic DrugsThrombolytic DrugsDrugs that break down, or lyse, preformed Drugs that break down, or lyse, preformed

clotsclots

Tissue plasminogen activatorTissue plasminogen activator– plasminogen-streptokinase activator plasminogen-streptokinase activator

complex (APSAC)complex (APSAC) – streptokinase (Streptase)streptokinase (Streptase)– alteplase (t-PA, Activase)alteplase (t-PA, Activase)– reteplase (Retavase)reteplase (Retavase)

Angina - MIAngina - MI Invasive Medical Management Invasive Medical Management

Percutaneous Coronary InterventionPercutaneous Coronary Intervention – – PCTAPCTA – Percutaneous transluminal – Percutaneous transluminal coronary angioplastycoronary angioplasty

Balloon-tipped catheter passed through just Balloon-tipped catheter passed through just beyond the lesion – balloon inflated – beyond the lesion – balloon inflated – atherosclerotic plaque is compressed atherosclerotic plaque is compressed

Reduction in lesion size by >50% in 90% of Reduction in lesion size by >50% in 90% of patientspatients

Used in conjunction with thrombin inhibitorsUsed in conjunction with thrombin inhibitors

Angina- MIAngina- MI Invasive Medical Management Invasive Medical Management

Stent PlacementStent Placement – may be placed during – may be placed during PCTA – expandable meshlike structures to PCTA – expandable meshlike structures to maintain vessel patency – placed over the maintain vessel patency – placed over the angioplasty site to hold the vessel openangioplasty site to hold the vessel open* Stents are thrombogenic – * Stents are thrombogenic –

IV antiplatelet agentsIV antiplatelet agentsASA/PlavixASA/Plavix

AtherectomyAtherectomy – plaque is shaved away – plaque is shaved away from the coronary artery wall from the coronary artery wall

Limited to use in larger portions of vesselsLimited to use in larger portions of vessels

Laser AngioplastyLaser Angioplasty – “cool” laser – no heat – “cool” laser – no heat

Coronary Artery Stent Coronary Artery Stent PlacementPlacement

Coronary AtherectomyCoronary Atherectomy

Angina - MIAngina - MIInvasive Medical ManagementInvasive Medical Management

ComplicationsComplicationsAbrupt closure of angioplasty site Abrupt closure of angioplasty site Stent thrombosis / embolizationStent thrombosis / embolizationHemorrhage / vascular damageHemorrhage / vascular damageCoronary spasm, Acute MICoronary spasm, Acute MINeed for emergent coronary artery Need for emergent coronary artery

bypass graft (CABG)bypass graft (CABG)

Fibrinolytic Fibrinolytic ContraindicationsContraindications

Absolute ContraindicationsAbsolute ContraindicationsActive internal bleeding, active inflammatory Active internal bleeding, active inflammatory

bowel disease, active peptic ulcer disease, acute bowel disease, active peptic ulcer disease, acute pericarditis, GI/GU bleeding within 6 months, Hx pericarditis, GI/GU bleeding within 6 months, Hx of hemorrhage CVA, Neurosurgical procedure of hemorrhage CVA, Neurosurgical procedure within 2 months, Pregnancy, Suspected aortic within 2 months, Pregnancy, Suspected aortic dissection, Uncontrolled HTN, >180/110dissection, Uncontrolled HTN, >180/110

Relative ContraindicationsRelative ContraindicationsBacterial endocarditis, chronic Coumadin Bacterial endocarditis, chronic Coumadin

Therapy, Diabetic hemorrhagic retinopathy, Therapy, Diabetic hemorrhagic retinopathy, Poorly controlled HTNPoorly controlled HTN

Angina - MI Angina - MI Surgical Management Surgical Management

Coronary Artery Bypass Graft Coronary Artery Bypass Graft (CABG)(CABG)

construction of new vessels between the construction of new vessels between the aorta to beyond the obstructed coronary aorta to beyond the obstructed coronary

artery artery (or arteries)(or arteries)

Saphenous vein or internal mammary arterySaphenous vein or internal mammary arteryPalliative treatment for CAD – Palliative treatment for CAD – not a curenot a curePostoperative care: Care of cardiac patient Postoperative care: Care of cardiac patient

with chest tubes / sternotomy; pain with chest tubes / sternotomy; pain management; short ventilator support; early management; short ventilator support; early ambulation; 4-5 day hospital stayambulation; 4-5 day hospital stay

Coronary Artery BypassCoronary Artery Bypass

Coronary Artery BypassCoronary Artery Bypass

Complications of MIComplications of MI Arrhythmias Arrhythmias – lethal PVC’s within 4 hours of – lethal PVC’s within 4 hours of

onset of chest painonset of chest pain Congestive Heart FailureCongestive Heart Failure Cardiogenic ShockCardiogenic Shock – severe left ventricular – severe left ventricular

failure – intra-aortic balloon pump & vasoactive failure – intra-aortic balloon pump & vasoactive medicationsmedications

Papillary Muscle DysfunctionPapillary Muscle Dysfunction – Mitral valve – Mitral valve regurgitation – treat dyspnea, pulmonary edema regurgitation – treat dyspnea, pulmonary edema & decreased CO& decreased CO

Ventricular AneurysmVentricular Aneurysm Pericarditis – 1-3 days Pericarditis – 1-3 days post MI; pleural friction rub & feverpost MI; pleural friction rub & fever

Dressler SyndromeDressler Syndrome – pericarditis with effusion – pericarditis with effusion & fever 1- 4 wks post MI; elevated WBC & Sed & fever 1- 4 wks post MI; elevated WBC & Sed Rate. Tx-Steroids Rate. Tx-Steroids

Pulmonary EmbolismPulmonary Embolism

Acute Coronary SyndromeAcute Coronary SyndromePair SharePair Share

Discomfort or a heavy feeling in the chest can signal a heart attack. Discomfort or a heavy feeling in the chest can signal a heart attack. A. True A. True B. False B. False

Women do not frequently experience heart attacks. Women do not frequently experience heart attacks. A. True A. True B. False B. False

African-American women die of heart attacks at the same rate as white African-American women die of heart attacks at the same rate as white women. women. A. True A. True B. False B. False

Some people who are experiencing the symptoms of a heart attack may Some people who are experiencing the symptoms of a heart attack may wait hours or even days before seeking needed medical care. wait hours or even days before seeking needed medical care. A. True A. True B. False B. False

Being treated within about an hour of the first symptoms can make a Being treated within about an hour of the first symptoms can make a significant difference. significant difference. A. True A. True B. False B. False

Acute Coronary Syndrome Acute Coronary Syndrome Pair SharePair Share

Many heart attack victims say their heart attack wasn’t what they’d expected. Many heart attack victims say their heart attack wasn’t what they’d expected. A. True A. True B. False B. False

A family member, such as a spouse, can persuade a loved one having a heart A family member, such as a spouse, can persuade a loved one having a heart attack to seek help immediately. attack to seek help immediately. A. True A. True B. False B. False

Calling 9-1-1 for chest pain alone would probably turn out to be a waste of the Calling 9-1-1 for chest pain alone would probably turn out to be a waste of the emergency medical personnel’s time. emergency medical personnel’s time. A. True A. True B. False B. False

Most heart attacks occur in people over 65. Most heart attacks occur in people over 65. A. True A. True B. False B. False The major issue in delay is how long it takes for emergency medical personnel The major issue in delay is how long it takes for emergency medical personnel to find the address and deliver the patient to the hospital. to find the address and deliver the patient to the hospital. A. True A. True B. False B. False

Nursing DiagnosesNursing Diagnoses

TOP 4TOP 4

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Nursing ProcessNursing ProcessNsg Dx: Acute Pain related to Nsg Dx: Acute Pain related to

Cardiac IschemiaCardiac Ischemia AssessAssess: Chest pain—intensity, location, : Chest pain—intensity, location,

duration, precipitating, alleviating factors; duration, precipitating, alleviating factors; Monitor cardiac rate & rhythm; effect of Monitor cardiac rate & rhythm; effect of pain medication; peripheral pulses; VS; pain medication; peripheral pulses; VS; Pulse OximetryPulse Oximetry

Nsg ActionNsg Action: Administer O2 NC; IV access; : Administer O2 NC; IV access; position of comfortposition of comfort

Patient EducationPatient Education: Rationale for all : Rationale for all procedures; pain scale; instruct to report procedures; pain scale; instruct to report painpain

Nsg Dx: Ineffective Tissue Nsg Dx: Ineffective Tissue Perfusion related to Myocardial Perfusion related to Myocardial

InjuryInjury AssessAssess: VS & Pulse Oximetry qh; continuous : VS & Pulse Oximetry qh; continuous

cardiac monitoring; respiratory status if cardiac monitoring; respiratory status if Morphine IV is used; fluid balance – strict I&O Morphine IV is used; fluid balance – strict I&O peripheral edema; heart & breath soundsperipheral edema; heart & breath sounds

Nsg ActionNsg Action: Rest periods; Administer meds : Rest periods; Administer meds & oxygen as ordered& oxygen as ordered

Patient EducationPatient Education: Rationale for rest; : Rationale for rest; energy conservationenergy conservation

Nsg Dx: Anxiety related to Nsg Dx: Anxiety related to perceived or actual threat of perceived or actual threat of

deathdeathAssessAssess: verbal & nonverbal queues: verbal & nonverbal queues

Nsg ActionNsg Action: Calm, reassuring approach; : Calm, reassuring approach; encourage verbalization of feelings, encourage verbalization of feelings, fears, perceptions; family involvement; fears, perceptions; family involvement;

Patient EducationPatient Education: Relaxation : Relaxation techniques; simple instructionstechniques; simple instructions

Nsg Dx: Ineffective Nsg Dx: Ineffective therapeutic regimen therapeutic regimen

management related to lack of management related to lack of knowledge knowledge

AssessAssess: Current knowledge level & : Current knowledge level & readiness to learn; family dynamicsreadiness to learn; family dynamics

Nsg ActionNsg Action: Assist pt in identifying small : Assist pt in identifying small successes; Assist pt is identifying lifestyle successes; Assist pt is identifying lifestyle that needs to be changed; Community that needs to be changed; Community referrals—smoking cessation, cardiac referrals—smoking cessation, cardiac rehab, support groups, rehab, support groups,

Patient EducationPatient Education: Lifestyle changes, : Lifestyle changes, Medications—desired effect/side effects; Medications—desired effect/side effects; comprehensive discharge plan—continuity comprehensive discharge plan—continuity with community cardiac rehabilitationwith community cardiac rehabilitation

Nsg Dx: Activity Intolerance Nsg Dx: Activity Intolerance related to fatigue & chest painrelated to fatigue & chest pain

AssessAssess: Monitor patient’s response to : Monitor patient’s response to medications, activity tolerance as increased; medications, activity tolerance as increased; Cardiac rate, rhythm, respiratory effortCardiac rate, rhythm, respiratory effort

Nsg ActionNsg Action: Include family; advance : Include family; advance activity as tolerated; supplement oxygen as activity as tolerated; supplement oxygen as neededneeded

Patient EducationPatient Education: Teach patient energy : Teach patient energy conservation – activity/rest – activities that conservation – activity/rest – activities that will promote independence and decrease will promote independence and decrease oxygen consumption; Cardiac Rehab: oxygen consumption; Cardiac Rehab: exercise & sexual activity exercise & sexual activity

Patient Education: Exercise Patient Education: Exercise Guidelines post MIGuidelines post MI

Type of ExerciseType of Exercise – regular, rhythmic & – regular, rhythmic & repetitive – using large muscle groupsrepetitive – using large muscle groups

IntensityIntensity – determined by patient’s HR – should – determined by patient’s HR – should not exceed 20 beats per min > resting HRnot exceed 20 beats per min > resting HR

DurationDuration – Build to 20 -30 mins – Build to 20 -30 mins

Frequency Frequency -- 3-4x/week -- 3-4x/week

Warm-up/Cool-downWarm-up/Cool-down – 5 mins before and after – 5 mins before and after aerobic exercise. Exercise should not be stopped aerobic exercise. Exercise should not be stopped abruptlyabruptly

Cardiac Rehab – Metabolic Cardiac Rehab – Metabolic Equivalents of Energy Equivalents of Energy

ExpenditureExpenditure

Patient Education: Patient Education: Sexual Activity post MISexual Activity post MI

Plan of resumption of sexual activity should correspond to activity Plan of resumption of sexual activity should correspond to activity prior to MIprior to MI

Physical training improves physical response to coitusPhysical training improves physical response to coitus

Food & alcohol < prior to sexual activityFood & alcohol < prior to sexual activity

Familiar & relaxed surroundings; positions of comfort Familiar & relaxed surroundings; positions of comfort

Avoid hot or cold showersAvoid hot or cold showers

Foreplay is desirable – gradual increase in heart rate prior to orgasmForeplay is desirable – gradual increase in heart rate prior to orgasm

Prophylactic use of nitrates decreases anginaProphylactic use of nitrates decreases angina

Orogenital sex places no undue strain on the heartOrogenital sex places no undue strain on the heart

Anal intercourse may cause undue cardiac stress – vasovagal Anal intercourse may cause undue cardiac stress – vasovagal responseresponse

Emotional & Behavioral Emotional & Behavioral Response to Acute MIResponse to Acute MI

DenialDenial – Ignores symptoms; minimizes severity; ignores – Ignores symptoms; minimizes severity; ignores activity restrictionsactivity restrictions

Anger Anger – “Why did this happen to me?”– “Why did this happen to me?”

Anxiety & FearAnxiety & Fear – Fear of death & disability –apprehension, – Fear of death & disability –apprehension, tachycardia, restlessness, hypochondria, projection of tachycardia, restlessness, hypochondria, projection of feelingsfeelings

DependencyDependency – reliant on staff; hesitant to leave ICU or – reliant on staff; hesitant to leave ICU or hospitalhospital

DepressionDepression – Mourning period; realizes seriousness of – Mourning period; realizes seriousness of situationsituation

Realistic AcceptanceRealistic Acceptance – Focuses on optimum – Focuses on optimum rehabilitation; plans changes compatible with cardiac rehabilitation; plans changes compatible with cardiac functionfunction