NCM 118 Cardiology Lecture - Life-Threatening Emergencies - 2021

Cardiovascular System M.V. IMMACULATA, MAN, RN MANUEL V. IMMACULATA, MAN, RN Anatomy, Blood Flow Source: Medicine.net MANUEL V. IMMACULATA, MAN, RN Acute Coronary Syndrome (ACS)  Acute Coronary Syndrome The term is applied to the cascade of...

Cardiovascular System M.V. IMMACULATA, MAN, RN MANUEL V. IMMACULATA, MAN, RN Anatomy, Blood Flow Source: Medicine.net MANUEL V. IMMACULATA, MAN, RN Acute Coronary Syndrome (ACS)  Acute Coronary Syndrome The term is applied to the cascade of symptoms associated with acute myocardial ischemia with or without infarction. ❑ Inclusion of all the pathologic processes that impede oxygen transport to the myocardium: angina, non-ST elevation myocardial infarction Omisconline.org (NSTEMI), and ST segment elevation myocardial infarction (Q wave). MANUEL V. IMMACULATA, MAN, RN ACUTE CORONARY SYNDROME ▪ ACS is applied to patients in whom there is a suspicion or confirmation of myocardial ischemia. ▪ 3 types of ACS: STEMI, NSTEMI, and UA. The first two are characterized by a typical rise and/or fall in troponin with at least one value > 99th percent upper reference limit. ▪ UA is considered to be present in patients with ischemic symptoms suggestive of an ACS without elevation in biomarkers with or without ECG changes indicative of ischemia. ▪ Symptoms which occur due to a partial or total blockage of a coronary artery causing myocardial ischemia (cells starving of oxygen) OR infarction (cell death). (AHA 2014) MANUEL V. IMMACULATA, MAN, RN Acute Coronary Syndrome ▪ Caused by a decrease in the oxygen available to the myocardium due to: ▪ Unstable or ruptured atherosclerotic plaque ▪ Coronary vasospasm ▪ Atherosclerotic obstruction without clot or vasospasm ▪ Inflammation or infection ▪ Unstable angina due to a noncardiac cause ▪ Thrombus formation with subsequent coronary artery occlusion. MANUEL V. IMMACULATA, MAN, RN  Variance in Symptoms Symptoms are Confusing Abdominal or Chest Pain, Profuse sweating Pressure Indigestion Any Discomfort above the Shortness of breath Navel Unexplained Jaw Pain excessive fatigue Tooth Ache Source: AHA 2014 Unexplained Arm Pain Alterations in Mental status, confusion, dizziness MANUEL V. IMMACULATA, MAN, RN  Acute Coronary Syndrome The classic symptoms defining this diagnosis include: o Substernal (retrosternal) o Chest discomfort, which may or not radiate to the shoulders, arms, neck, jaw, and back, and is described as pressure, heaviness, or crushing o Shortness of breath (dyspnea) o Nausea o Diaphoresis o and dizziness. MANUEL V. IMMACULATA, MAN, RN  Angina (Angina Pectoris)  Angina Pectoris ▪ A clinical syndrome usually characterized by episodes or paroxysms of pain or pressure in the anterior chest. ▪ Cause is usually insufficient coronary blood flow. ▪ Insufficient flow results in a decreased oxygen supply to meet an increased myocardial demand for oxygen in response to physical exertion or emotional stress. Severity of angina is based on the precipitating activity and its effect on the activities of daily living. ▪ This usually happens because one or more of the heart's arteries is narrowed or blocked, also called ischemia. MANUEL V. IMMACULATA, MAN, RN  Angina Pectoris ▪ Because myocardial oxygen demand is determined mainly by heart rate, systolic wall tension, and contractility, narrowing of a coronary artery typically results in angina that occurs during exertion and is relieved by rest. Source: Medline Fairview.org MANUEL V. IMMACULATA, MAN, RN  Angina Pectoris ▪ Angina is not a disease. It is a symptom of an underlying heart problem, usually coronary heart disease (CHD). ▪ Caused by inadequate blood flow to the myocardium,is the most common manifestation of CAD. ▪ The ability of the coronary artery to deliver blood to the myocardium is impaired because of obstruction by a significant coronary lesion (>70% narrowing of the vessel). MANUEL V. IMMACULATA, MAN, RN  Angina Pectoris ▪ Usually precipitated by physical exertion or emotional stress, which puts an increased demand on the heart to circulate more blood and oxygen. ▪ Can also occur in other cardiac problems, such as arterial spasm, aortic stenosis, cardiomyopathy, or uncontrolled hypertension. ▪ Noncardiac causes include anemia, fever, thyrotoxicosis, and anxiety/panic attacks. MANUEL V. IMMACULATA, MAN, RN Risk factors Three broad categories: 1. Major risk factors – Research has shown that these factors significantly increase the risk of heart and blood vessel (cardiovascular) disease. 2. Modifiable risk factors – Some major risk factors can be modified, treated or controlled through medications or lifestyle change. 3. Contributing risk factors – These factors are associated with increased risk of cardiovascular disease, but their significance and prevalence haven’t yet been determined. Source: AHA MANUEL V. IMMACULATA, MAN, RN  Risk Factors – Major ▪ Increasing Age – Mortality due to CHD are 65 or older. Heart attacks in both people in old age. Women at a greater risk of dying (within a few weeks). ▪ Male gender – Men have a greater risk. Men have attacks earlier in life. ▪ Heredity (including race) – Children of parents with heart disease are more likely to develop heart disease themselves. African-American > sever high BP than Caucasians. Heart disease risk is higher among Mexican-Americans, American Indians, native Hawaiians and some Asian-Americans. This is partly due to higher rates of obesity and diabetes. Source: AHA MANUEL V. IMMACULATA, MAN, RN  Risk Factors – Modifiable ▪ Tobacco smoke ▪ High blood cholesterol ▪ High blood pressure ▪ Physical inactivity ▪ Obesity and being overweight ▪ Diabetes Source: AHA MANUEL V. IMMACULATA, MAN, RN  Risk Factors – Other Factors ▪Stress ▪Alcohol ▪Diet and Nutrition Source: AHA MANUEL V. IMMACULATA, MAN, RN  Pathophysiology - Angina Obstruction of Oxygen Inadequate Demand coronary blood blood supply flow Atherosclerotic disease Increased Afterload Myocardial and Preload Ischemia Increased Myocardial contractile strength Decreased blood wall thickness supply of Increased HR myocardial cells Functional impairment Metabolic Aerobic Anaerobic Mechanical respiration respiration Electrical MANUEL V. IMMACULATA, MAN, RN  Clinical Manifestations o Pain felt deep in the chest behind the upper or middle third of the sternum (retrosternal area) may radiate to the neck, jaw, shoulders, and inner aspects of the upper arms, usually the left arm. o Weakness or numbness in the arms, wrists, and hands may accompany the pain. o Shortness of breath, pallor, diaphoresis, dizziness or lightheadedness, and nausea and vomiting. o Anxiety may accompany angina. ▪ An important characteristic of angina is that it abates or subsides with rest or nitroglycerin. MANUEL V. IMMACULATA, MAN, RN  Types of Angina 1. Stable angina: predictable and consistent pain that occurs on exertion and is relieved by rest 2. Unstable angina (also called preinfarction angina or crescendo angina): symptoms occur more frequently and last longer than stable angina. The threshold for pain is lower, and pain may occur at rest. 3. Intractable or refractory angina: severe incapacitating chest pain 4. Variant angina (also called Prinzmetal’s angina): pain at rest with reversible ST-segment elevation; thought to be caused by coronary artery vasospasm 5. Silent ischemia: objective evidence of ischemia (such as electrocardiographic changes with a stress test), but patient reports no symptoms (Source: Brunner) MANUEL V. IMMACULATA, MAN, RN Canadian Cardiovascular Society Angina Classification MANUEL V. IMMACULATA, MAN, RN  Source: Brunner MANUEL V. IMMACULATA, MAN, RN Clinical Syndromes Three Common Types of ANGINA 1. STABLE ANGINA ▪ The typical angina that occurs during exertion, like walking up a hill or climbing stairs—the heart works harder and needs more oxygen. ▪ Relieved by rest and drugs and the severity does not change. MANUEL V. IMMACULATA, MAN, RN Clinical Syndromes 2. UNSTABLE ANGINA ▪Occurs unpredictably during exertion and emotion, severity increases with time and pain may not be relieved by rest and drug MANUEL V. IMMACULATA, MAN, RN Clinical Syndromes 3. VARIANT ANGINA ▪Prinzmetal angina, results from coronary artery VASOSPASMS, may occur at rest MANUEL V. IMMACULATA, MAN, RN  ASSESSMENT and FINDINGS 1. Chest pain- ANGINA ▪The most characteristic symptom ▪PAIN is described as mild to severe retrosternal pain, squeezing, tightness or burning sensation ▪Radiates to the jaw and left arm MANUEL V. IMMACULATA, MAN, RN  Source: Brunner MANUEL V. IMMACULATA, MAN, RN  ASSESSMENT and FINDINGS ▪Precipitated by Exercise, Eating heavy meals, Emotions like excitement and anxiety and Extremes of temperature ▪Relieved by REST and Nitroglycerin MANUEL V. IMMACULATA, MAN, RN  ASSESSMENT and FINDINGS 2. Diaphoresis 3. Nausea and vomiting 4. Cold clammy skin 5. Sense of apprehension and doom 6. Dizziness and syncope MANUEL V. IMMACULATA, MAN, RN  DIAGNOSTICS and LABORATORY FINDINGS 1. ECG may show normal tracing if patient is pain-free. Ischemic changes may show ST depression and T wave inversion 2. Cardiac catheterization ▪ Provides the MOST DEFINITIVE Source: Nataliescasebook.com source of diagnosis by showing the presence of the atherosclerotic lesions Source: BMC Cardiovascular Disorders Healthxchange.sg MANUEL V. IMMACULATA, MAN, RN  MEDICAL MANAGEMENT The objectives of the medical management of angina are to decrease the oxygen demand of the myocardium and to increase the oxygen supply. Revascularization procedures to restore the blood supply to the myocardium include: ▪ Percutaneous coronary interventional (PCI) procedures (eg, percutaneous transluminal coronary angioplasty [PTCA], intracoronary stents, and atherectomy), CABG, and percutaneous transluminal myocardial revascularization (PTMR). MANUEL V. IMMACULATA, MAN, RN  MEDICAL MANAGEMENT PHARMACOLOGIC THERAPY Among medications used to control angina are: ▪ Nitroglycerin - A vasoactive agent, nitroglycerin (Nitrostat, Nitrol, Nitrobid IV) ▪ Beta-adrenergic blocking agents - Beta-blockers such as propranolol (Inderal), metoprolol (Lopressor, Toprol), and atenolol (Tenormin) appear to reduce myocardial oxygen consumption by blocking the beta-adrenergic sympathetic stimulation to the heart. ▪ Calcium channel blockers, and antiplatelet agents - The calcium channel blockers most commonly used are amlodipine (Norvasc), verapamil (Calan, Isoptin, Verelan), and diltiazem (Cardizem, Dilacor, Tiazac). - decrease sinoatrial node automaticity and atrioventricular node conduction, resulting in a slower heart rate and a decrease in the strength of the heart muscle contraction (negative inotropic effect). - relax the blood vessels, causing a decrease in blood pressure and an increase in coronary artery perfusion. Calcium channel blockers increase myocardial oxygen supply by dilating the smooth muscle wall of the coronary arterioles; - decrease myocardial oxygen demand by reducing systemic arterial pressure and the workload of the left ventricle. MANUEL V. IMMACULATA, MAN, RN  NURSING MANAGEMENT 1. Administer prescribed medications ▪ Nitrates- to dilate the coronary arteries ▪ Aspirin- to prevent thrombus formation ▪ Beta-blockers- to reduce BP and HR ▪ Calcium-channel blockers- to dilate coronary artery and reduce vasospasm MANUEL V. IMMACULATA, MAN, RN  NURSING MANAGEMENT 2. Teach the patient about management of anginal attacks ▪ Advise patient to stop all activities ▪ Put one nitroglycerin tablet under the tongue (SL) ▪ Wait for 5 minutes ▪ If not relieved, take another tablet and wait for 5 minutes ▪ Another tablet can be taken (third tablet) ▪ If unrelieved after THREE tablets→ seek medical attention MANUEL V. IMMACULATA, MAN, RN NURSING MANAGEMENT 3. Obtain a 12-lead ECG 4. Promote myocardial perfusion ▪ Instruct patient to maintain bed rest ▪ Administer O2 @ 3 Lpm (ordered) ▪ Advise to avoid valsalva maneuvers ▪ Provide laxatives or high fiber diet to lessen constipation ▪ Encourage to avoid increased physical activities MANUEL V. IMMACULATA, MAN, RN  NURSING MANAGEMENT 5. Assist in possible treatment modalities ▪PTCA- percutaneous transluminal coronary angioplasty ▪To compress the plaque against the vessel wall, increasing the arterial lumen ▪CABG- coronary artery bypass graft ▪To improve the blood flow to the myocardial tissue MANUEL V. IMMACULATA, MAN, RN  NURSING MANAGEMENT 6. Provide information to family members to minimize anxiety and promote family cooperation 7. Assist client to identify risk factors that can be modified 8. Refer patient to proper agencies MANUEL V. IMMACULATA, MAN, RN  NURSING DIAGNOSES - Angina Based on the assessment data, major nursing diagnoses for the patient may include: ▪ Ineffective myocardial tissue perfusion secondary to CAD, as evidenced by chest pain or equivalent symptoms ▪ Anxiety related to fear of death ▪ Deficient knowledge about the underlying disease and methods for avoiding complications ▪ Noncompliance, ineffective management of therapeutic regimen related to failure to accept necessary lifestyle changes MANUEL V. IMMACULATA, MAN, RN Myocardial Infarction (MI) Myocardial infarction ▪Death of myocardial tissue in regions of the heart with abrupt interruption of coronary blood supply Source: Cor Medical Group MANUEL V. IMMACULATA, MAN, RN ETIOLOGY 1. CAD 2. Coronary vasospasm 3. Coronary artery occlusion by embolus and thrombus 4. Conditions that decrease perfusion- hemorrhage, shock MANUEL V. IMMACULATA, MAN, RN Risk factors 1. Hypercholesterolemia 2. Smoking 3. Hypertension 4. Obesity 5. Stress 6. Sedentary lifestyle MANUEL V. IMMACULATA, MAN, RN  PATHOPHYSIOLOGY Interrupted coronary blood flow → myocardial ischemia →anaerobic myocardial metabolism for several hours → myocardial death → depressed cardiac function → triggers autonomic nervous system response → further imbalance of myocardial O2 demand and supply MANUEL V. IMMACULATA, MAN, RN ASSESSMENT and findings 1.CHEST PAIN ▪Chest pain is described as severe, persistent, crushing substernal discomfort ▪Radiates to the neck, arm, jaw and back ▪Occurs without cause primarily early in the morning ▪Not relieved by rest or Nitroglycerin ▪Last 30 mins or longer MANUEL V. IMMACULATA, MAN, RN ASSESSMENT and findings 2. Dyspnea 3. Diaphoresis 4. cold clammy skin 5. Nausea and vomiting 6. restlessness, sense of doom 7. tachycardia or bradycardia 8. hypotension 9. S3 and dysrhythmias MANUEL V. IMMACULATA, MAN, RN  COMPLICATIONS of Acute MI ❑ Acute MI can result in an array of cardiac functional impairments that can range from mild to moderate. ❑ Physiological changes can include reduced contractility with abnormal wall motion, decreased SV, altered left ventricular compliance, decreased ejection fraction, increased left ventricular end-diastolic pressure, and SA node malfunction. These impairments can lead to a variety of clinical complications such as: o Arrhythmias (affect 90 % of patients) : First-degree AV block, Second-degree AV block, Third-degree AV block, Atrial fibrillation, Ventricular fibrillation, Ventricular tachycardia, Ventricular fibrillation. o Pericarditis, Cardiac tamponade, Papillary muscle rupture, Chordae tendineae cordis rupture, Pulmonary embolus, CVA, HF, Pulmonary edema, Cardiogenic shock, Cardiac arrest, Death. MANUEL V. IMMACULATA, MAN, RN NORMAL ECG MANUEL V. IMMACULATA, MAN, RN  Laboratory findings 1. ECG- the ST segment is ELEVATED. T wave inversion, presence of Q wave 2. Myocardial enzymes- elevated CK-MB, LDH and Troponin I, TroponinT levels Assays for cTn, namely cTnI and cardiac troponin T (cTnT), are the preferred diagnostic tests for ACS, in particular non–ST- segment–elevation myocardial infarction, because of the tissue- specific expression of cTnI and cTnT in the myocardium. 3. CBC- may show elevated WBC count 4. Test after the acute stage- Exercise tolerance test, thallium scans, cardiac catheterization MANUEL V. IMMACULATA, MAN, RN ST ELEVATION MYOCARDIAL INFARCTION (STEMI) A complete blockage of a coronary artery means you suffered a “STEMI” heart attack or ST-elevation myocardial infarction. MANUEL V. IMMACULATA, MAN, RN NON ST ELEVATION MYOCARDIAL INFARCTION (NON STEMI) A partial blockage is an “NSTEMI” heart attack or a non-ST-elevation myocardial infarction MANUEL V. IMMACULATA, MAN, RN  Source: Brunner MANUEL V. IMMACULATA, MAN, RN  Source: AHA MANUEL V. IMMACULATA, MAN, RN  Source: AHA MANUEL V. IMMACULATA, MAN, RN  Source: AHA Figure 3. Troponin kinetics in the index cases. Plasma cardiac troponin I (cTnI) values in the 3 index cases. The cutoff for the TnI assay (0.04 ng/mL) is indicated with a dashed horizontal line. MANUEL V. IMMACULATA, MAN, RN Medical Management 1. ANALGESIC - The choice is MORPHINE ▪ It reduces pain and anxiety ▪ Relaxes bronchioles to enhance oxygenation 2.ACE Inhibitors - Prevents the formation of Angiotensin II - Limits the area of infarction - Expands blood vessels and decreases resistance by lowering levels of angiotensin II. Allows blood to flow more easily and makes the heart’s work easier or more efficient. MANUEL V. IMMACULATA, MAN, RN Medical Management 3. Thrombolytics ▪Streptokinase, Alteplase ▪Dissolve clots in the coronary artery allowing blood to flow 4. Oxygen Therapy MANUEL V. IMMACULATA, MAN, RN  Nursing Interventions 1. Provide Oxygen at 2 Lpm (ordered), Semi-fowler’s position 2. Administer medications ▪ Morphine to relieve pain ▪ Nitrates, thrombolytics, aspirin and anticoagulants ▪ Stool softener and hypolipidemics 3. Minimize patient anxiety ▪ Provide information as to procedures and drug therapy MANUEL V. IMMACULATA, MAN, RN Nursing Interventions 4. Provide adequate rest periods 5. Minimize metabolic demands ▪Provide soft diet ▪Provide a low-sodium, low cholesterol and low fat diet 6. Minimize anxiety ▪Reassure client and provide information as needed MANUEL V. IMMACULATA, MAN, RN Nursing Interventions 7. Assist in treatment modalities such as PTCA and CABG 8. Monitor for complications of MI- especially dysrhythmias, since ventricular tachycardia can happen in the first few hours after MI 9. Provide client teaching MANUEL V. IMMACULATA, MAN, RN NURSING INTERVENTIONS AFTER ACUTE EPISODE 1. Maintain bed rest for the first 3 days 2. Provide passive ROM exercises 3. Progress with dangling of the feet at side of bed 4. Proceed with sitting out of bed, on the chair for 30 minutes TID 5. Proceed with ambulation in the room, toilet, hallway 6. Check patient’s condition before, during, and after the activity MANUEL V. IMMACULATA, MAN, RN Cardiac rehabilitation ❑To extend and improve quality of life ▪Physical conditioning ▪Patients who are able to walk 3-4 mph are usually ready to resume sexual activities MANUEL V. IMMACULATA, MAN, RN NURSING DIAGNOSES - MI Based on the clinical manifestations, history, and diagnostic assessment data, the patient’s major nursing diagnoses may include: ▪ Ineffective cardiopulmonary tissue perfusion related to reduced coronary blood flow from coronary thrombus and atherosclerotic plaque ▪ Potential impaired gas exchange related to fluid overload from left ventricular dysfunction ▪ Potential altered peripheral tissue perfusion related to decreased cardiac output from left ventricular dysfunction ▪ Anxiety related to fear of death ▪ Deficient knowledge about post-MI self-care MANUEL V. IMMACULATA, MAN, RN References ▪ Critical Care and Emergency Nursing (Schumacher, Chernecky) ▪ Brunner and Suddarth’s Textbook of Medical and Surgical Nursing ▪ American Heart Association ▪ New York Heart Association MANUEL V. IMMACULATA, MAN, RN Thank you MANUEL V. IMMACULATA, MAN, RN