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1 Angina and Myocardial Infarction notes John Miller Angina: Acute, chronic, or spasm Atherosclerosis o Acute Rupture of lesion causes platelet and thrombus formation. Causes acute myocardial infarction (AMI) or unstable angina. o Chronic Greater than 75% of lumen occluded Fixed (calcified) or fibrotic Increased myocardial oxygen demand Precipitating factors: exercise, emotion, cold exposure o Spasm Angina: Atherosclerotic lesions o Timeline for Developing Atherosclerosis Phase I: Initial lesion and fatty streak (infancy and childhood); Preatheroma (less than 30 years old) Phase II: atheroma (30+); fibroatheroma (40+) Phase III: complicated lesion: rupture of plaque and thrombi formation with partial occlusion of vessel (40+); Angina Phase IV: more occlusion (40+); unstable angina, MI, sudden death Phase V: calcification or fibrosis of lesion; angina; MI Angina: Collaterals, dilation, occlusion Collateral circulation o More than one artery supplying a muscle. o Takes time to develop in response to low flow , seen more in older clients. o Collateral arteries grow and perfuse areas needing more blood, but only in long term disease. Coronary arteries usually dilate when need more blood flow. o Perfuse the heart only during diastole. o With disease, arteries cannot dilate effectively. Most MI's o Occur with less than 70% occlusion because they are more vulnerable to rupture and thrombosis. Angina: Patterns Stable (classic): stable pattern of characteristics in previous slide, relieved with rest and/or nitroglycerin. Unstable (pre-infarction): triggered by unpredictable exertion, increasing in frequency and severity, may occur at night. Spasm: similar to but longer than stable angina, often occurs at night Angina: Zones of ischemia, injury, infarction (MI) Inner zone is the zone of infarction and necrosis, not reversible. Middle zone is hypoxic injury, can infarct or stay ischemic. Outer zone is ischemia, which is reversible. Angina Causes: Increased CO or oxygen need Increased cardiac output o Exercise, emotion, after a large meal Increased myocardial need for oxygen o Hypertrophy 2 Angina: Risk factors Nonmodifiable risk factors o Heredity: family history, African American women more at risk than other women. o Age: early as 20s, symptoms occur after 40, most die after 65, men earlier but women catch up after menopause Contributing risk factors o Stress o Homocysteine level: Inflammatory responses that destabilized plaque within the artery wall. o Menopause Estrogen replacement not advised. Angina: Modifiable risk factors Smoking doubles the rate in men and triples the rate in women. Hypertension is seen at younger ages in African Americans and is more severe. High LDL cholesterol, high triglycerides, low HDL Obesity Diabetes Physical inactivity Responses to stress Angina assessment: Classic o Onset: quick or slow, related to activity, may think is indigestion. o Location: most retrosternal or slightly left of the sternum. o Radiation Usually to left shoulder and down upper arm. May travel down inner aspect of the left arm to elbow, wrist, inner aspect of 4th and 5th fingers. May travel down to right shoulder, neck, jaw, back or epigastric area. Occasionally may only feel the radiation part. Rarely is pain located only in a small part of the sternal area. More classic angina o Duration: usually less than 5 minutes, after a large meal or anger, may last 15-20 minutes. o Sensation: squeezing, burning pressure, bursting pressure o Severity: mild or moderate, discomfort, not pain, rarely severe; less than MI o Relieving and aggravating factors, treatment Relieved by rest and/or nitroglycerin. Increased with activity/stress. Not relieved by food or antacids; Not affected by deep breathing or position change. Angina assessment: Silent Silent Ischemia and Non-Chest Pain o Most common presentation in many women, elderly, diabetics, Asians and others o Characteristics: dyspnea, pallor, sweating, faintness, palpitations, dizziness, nausea and vomiting o Presentation Women: epigastric pain, dyspnea, or back pain Older adults: dyspnea, fatigue, syncope 3 Angina diagnostic tests Electrocardiogram (ECG) and exercise electrocardiography. o May be normal, may have ST elevation or depression Scans: CT, MRI Angina Interventions Eliminate chest pain. o Nitroglycerin SL or spray Prevent reoccurrence. o Antianginal medications prophylactically Beta blockers, calcium channel blockers, nitrates (including oral or topical nitroglycerin), ACE inhibitors o Heart catheterization (arteriogram) with intervention (angioplasty or atherectomy with stent) to reduce blockage (PCI). o Elective coronary artery bypass surgery Reduce risk factors Reduce BP if hypertensive. Reduce hyperlipidemia with diet, statins, niacin; low saturated and trans fats Exercise and weight control: 30 minutes 5-6 days a week Stop smoking Control or prevent (Type II) diabetes Nitroglycerin Repeat every 5 minutes if pain not relieved for a total of 3 doses as long as BP greater than 90 systolic or whatever is ordered Keep in a dark bottle without light or moisture for up to six months. Do not keep in bathroom. Pain relived by NTG = angina, not MI, radiating or not Preinfarction angina = unstable angina, requires hosp. Classic or vasospastic does not ACE Inhibitors and Calcium Channel Blockers Captopril (ACE inhibitor) o Decreases afterload, increasing contractility and cardiac output, vasodilates and decreases BP. Diltiazem (Calicum channel blocker) Dilates coronary arteries and decreases pain. Angina interventions: Teaching Heavy pain, not knife like Not necessarily having MI Pain will occur if I overexert myself Interventions prior to angioplasty Elective (not emergency) procedure o Permit, teaching, NPO, also sign a consent for emergency coronary artery bypass graft surgery (CABG) Post procedure care Similar to arteriogram 4 Coronary artery bypass graft (CAB or CABG) o Open heart Heart and Lung Bypass to have blood field for surgery Reoxygenates, removes CO2 Pumps the blood Rewarms or cools, filters blood Complications o Bleeding caused by hemodilution and damage to RBCs o Longer pump times cause more complications. Heart bypass surgery explained https://youtu.be/YU-AB_THem8 Coronary artery bypass donor graft Donor graft o Internal mammary artery (IMA) o Saphenous vein o Radial artery Off bypass (pump) CABG Off bypass CABG, Mid-CABG o Smaller incision for median sternotomy o Devices and medications reduce heart movement. o Less recovery time and cost but outcome may not be as good o Less complications: ventilation, stroke, atrial fibrillation, pulmonary problems Minimally Invasive Direct Coronary Artery Bypass (MIDCAB) https://youtu.be/kVc9vXKSh2Q Surgery Risks Women have smaller arteries, may contribute to more complications. Non-surgical techniques have reduced need for surgery (angioplasty with stent or medically treated with medications) o Survival rates same as medically treated. Surgery complications Same as other surgeries Intraoperative stroke MI Blood clots Multiple organ failure Death Shock Postcardiotomy delirium Pericardial tamponade 5 Preoperative interventions Explain details of surgery and recovery o A&P of heart review o Arteriogram results discussion with MD o Prep: antimicrobial shower, shave area o Ventilator for several hours, suctioning o Frequent v.s. and other assessments o Chest tubes, NG tube, foley, multiple IV lines, ECG monitor o Pain medication, blood transfusions o Chair 1st POD. o Noise, short rest periods Introduce to staff and recovery / ICU area. Cardiac surgery preoperative, FHS provider orders https://www.chifranciscan.org/uploadedFiles/For_Physicians/Provider_Orders/30400016%20CARDIAC%20SU RGERY%20PREOPERATIVE2016.04.25.pdf Postoperative interventions: Activity Activity o ICU Turned frequently, chair after extubation o Intermediate Care Unit Ambulation 3-4 times per day Out of bed for all meals. o Goals Keep systolic BP and HR within parameters to keep graft patent No significant dysrhythmias during activity. No pain during. Cardiac surgery postoperative ICU, FHS provider orders, https://www.chifranciscan.org/uploadedFiles/For_Physicians/Provider_Orders/30400017%20RECEIVING%20C ARDIAC%20SURGERY2016.04.25.pdf Interventions in ICU: ECG, other monitoring Hemodynamic assessment o HR, heart chamber pressures: CVP and cardiac output ECG Intra aortic balloon pump if needed Temporary pacemaker Cardiac surgery PCU postoperative, FHS provider orders, https://www.chifranciscan.org/uploadedFiles/For_Physicians/Provider_Orders/30400014%20PCU%20TRANSF ER%20POST%20CARDIAC%20SURGERY2016.04.25.pdf 6 Interventions in ICU: Ventilation Titrate O2 to 92% saturation ABG testing Ventilator care, suctioning IS and coughing every 1-2 hours Morphine IV for pain. Splint incision with pillows. Ambulate as tolerated after extubation. Interventions: Perfusion Monitor CT output hourly. o Report more than 100 ml/hour o Monitor for pericardial tamponade (elevated CVP or JVD; decreased CO, BP; pulsus paradoxus; muffled heart sounds; sudden stopping of CT drainage) Blood, FFP, PLT, crystalloid fluids, colloids to replace volume lost. o Autotransfusion of banked blood or chest drainage if possible Risk of infection Interventions: Pain Differentiate anginal from incisional pain o Chest and leg incisions o If coughing or deep breathing increases pain means that it is pleuritic or incisional, not angina Administer morphine and other opioids in anticipation of procedures and pain. Interventions in ICU for complications Frequent neurological assessment o Reorient frequently. o Explain procedures. Secure all lines, prevent client from pulling them out. Avoid physical restraints when possible. Explain that changes in mental acuity, agitation, confusion, and hallucinations are temporary. Organize nursing care to provide adequate sleep. Liberalize visitation times with family. Transmyocardial revascularization surgery Channels created with laser on the outside of the heart, which allow muscle perfusion from the ventricular chamber blood. Used for people who cannot have other types of operations. Acute Myocardial Infarction (AMI) Statistics o 1 million MI’s yearly in U.S. 45% of all AMI occur in those younger than 65. 5% occur in those younger than 40. 50% die before reach hospital, 50% wait more than 2 hours. Women have a higher in hospital mortality due to less treatment provided for MI. African Americans, Hispanics, Native Americans have higher death rates. Acute Coronary Syndrome (ACS) o Includes angina and MI Pathophysiology of MI Transmural infarction 7 o o Infarct expansion in the first few hours up to 6 weeks. Remodeling of the ventricle occurs, changing the structure and function. Increased with tachycardia, ventricular dilation, increase preload (renin-angiotensin) May last for years, causing CHF Coronary arteries and MI location Right coronary artery (RCA) o Inferior (left ventricular) MI o Right ventricular MI Left (main) coronary artery (LCA or LMCA) o Left circumflex artery (LCX) Posterior (left ventricular) MI Lateral (left ventricular) MI o Left anterior descending (LAD) Anterior (left ventricular) MI Worst prognosis- due to size Septal (left ventricular) MI Clinical manifestations of MI Chest pain o Similar to angina but more severe and unrelieved by NTG. o May radiate to neck, jaw, shoulder, back, left arm. o May be present near epigastrium, simulating indigestion. o Often not present in women, elderly, diabetics. Other clinical manifestations of MI Seen more in women, diabetics, elderly Atypical chest, stomach, back or abdominal pain Nausea or dizziness SOB, dyspnea Unexplained anxiety, weakness, fatigue Palpitations, cold sweat, paleness Assessment: Location of MI 12 lead ECG Angiography o Will be done with PCI, if performed. Diagnostic tests: ECG changes Stages of changes o First: ST elevation or depression o Next: T wave inversion o Later: large Q waves (normally small or absent) May have normal ECG in first few hours after MI. 8 Laboratory tests: Elevated enzymes Troponin T o Onset: 3-6 hr, peak: 24 hr, duration: 14-21 days o Detect MI occurring much earlier. o troponin T & I have greater sensitivity and specificity than CK-MB. Troponin I o Onset: 7-14 hr, peak: 24 hr o Extremely sensitive to cardiac muscle. CK-MB isoenzyme o Onset: 3-6 hr, peak: 12-18 hr o Elevated in PTCA, thrombolytics. Interventions for MI Prior to EMS management: call first, call fast o Chew aspirin 325 mg. Reduces mortality 23%. o Elevate head, loosen clothing around neck o AED ready if available. ED / EMS o Reduced myocardial damage if treat within first hour of chest pain or symptoms (door-datadecision-drug) Door to needle time of less than 30 minutes for thrombolytic therapy (start from pain onset). Door to angioplasty time of less than 1 hour. o Cardiac enzymes and 12 lead ECG within 10 minutes of arrival at the ED. Interventions for STEMI Acute Myocardial Infarction with ST Elevation (STEMI) o Adjunctive Treatment (not to delay fibrinolytic) Beta Adrenergic Blocker IV Nitroglycerin IV Heparin IV Aspirin, low dose, if not getting Fibrinolytics ACE inhibitors only after 6 hours and when stable. Interventions for less than 12 hours since symptoms Fibrinolytics (such as Alteplase), door to drug time should be less than 30 minutes. If fibrinolytic contraindicated, then angioplasty and stent (PCI: percutaneous coronary intervention) with cardiac bypass surgery backup. Door to balloon up time should be 90 +/- 30 minutes, with experienced and high volume facility. Myocardial Infarction and Coronary Angioplasty Treatment, Animation. https://youtu.be/T_b9U5gn_Zk 9 Interventions for more than 12 hours since symptoms High risk Recurrent symptoms Recurrent ischemia Depressed LV function Widespread EKG changes Prior MI, CABG, PCI o Coronary angiography to see if treatment will be possible o Treatment PCI CABG Clinically stable o ICU o Serial cardiac markers (enzymes), serial EKG, echocardiography to assess LV function o Start or continue adjunctive treatments Interventions for non-ST elevated MI (NSTEMI) Adjunctive treatment o Heparin IV o Glycoprotein IIb, IIIa receptor inhibitor o Nitroglycerin IV o Beta Adrenergic Blockers IV o ACE inhibitors Interventions for all MIs MONA= morphine+oxygen+nitroglycerin+aspirin o O2 titrated to 92% or higher pulse oximeter o ECG monitor: Watch for lethal ventricular dysrhythmias or heart block. o IV started with labs drawn for Troponin o Head of bed elevated to increase ventilation, decrease preload (workload on heart) o Aspirin 325 mg chewed o Treat pain Morphine if pain not relieved by SL nitroglycerin Relieves ischemia by reducing sympathetic stimulation and preload causing a reduced muscle demand for O2. Interventions to improve perfusion Anti-dysrhythmic therapy Emergency PCI (PTCA)-Percutaneous Coronary Intervention (angioplasty with stent, atherectomy) preferred over thrombolytics in medical centers with expertise. Emergency coronary artery bypass Interventions: Thrombolytics (fibrinolytics) Alteplase, within 12 hours of pain starting. Reperfusion effects o Normal ECG, relief of pain, ventricular dysrhythmias Contraindications: bleeding, CVA, surgery, trauma Most common complication: Bleeding ST Elevation MI (STEMI) Acute Coronary Syndrome (ACS) FHS Provider orders https://www.chifranciscan.org/uploadedFiles/For_Physicians/Provider_Orders/30400721_FHS_IP_ST_ELEVATI ON_MI_(STEMI)_ACUTE_CORONARY_SYNDROME_(ACS)_721_2014.pdf 10 Complications in MIs: Dysrhythmias Golden (first) hour after chest pain is when most die from death producing arrhythmias. o 1/2 of deaths in MI Common types o Frequent PVC’s to VT to VF to asystole is most common cause of death. o Heart block or symptomatic bradycardia Complications in MI: CHF, Shock Cardiogenic shock o From decreased contractility, arrhythmias, sepsis o Intra aortic balloon pump to decrease afterload Heart failure and pulmonary edema (S3) o 1/3 of all deaths, disables ¼ of men and ½ of women o Develops in hours or weeks. Complications in MI: PE, Tamponade Pulmonary embolism o Secondary to inactivity causing DVT Recurrent myocardial infarction o Within a few years Ventricular rupture and cardiac tamponade o Surgery to repair problem if survives. Pericarditis o Infarction rubs against pericardium causing inflammation Rehabilitation and Education in MI Diet changes, with a dietician’s assistance o Low fat, low sodium, low caffeine Weight loss Stop smoking. Aspirin, beta-blocker, ACE inhibitor, statin for standard drug regimen. Cardiac rehab program tailored to specific client needs. Rehabilitation and Education Strengthening the myocardium o Phase I (inpatient) o Phase II (immediate outpatient) Uncomplicated MI may go home on 4th day if home assistance, follow-up home nursing and a restful environment are available. o Phase III (intermediate outpatient) Rehab in MI: Phase I Bedrest for first 24 hours or less, unless complications of heart failure or dysrhythmias. Bedside commode Clear liquid unless nausea gone Passive ROM Dangle for brief periods Reposition every two hours. Reduce visitors and stimulation if needed. After first day, may ambulate to chair if no pain, dysrhythmias, or hypotension with dangling. Wireless telemetry for ECG monitoring. 11 More phase I No isometric activity: moving up in bed unassisted, where muscles tense up with breath holding. Activity such as bathroom privileges will be increased gradually. Supervised walks, working up to 5-10 minutes. o Monitor HR, BP, fatigue level. HR should not increase more than 25% above resting. BP should not increase more than 25 mm systolic. o Dyspnea, chest pain, tachycardia, other dysrhythmias, exhaustion indicate too much activity. Client education on A&P, risk factors, management of disease, home activities, behavioral counseling. Monitor for electrolyte changes, such as potassium. Assess client for complications every 2-4 hours. Prevent constipation which can cause Valsalva and vagal stimulation (bradycardia). Phase II Starts 1-2 weeks after discharge, 3 times a week for 2-3 months. Goals o Restore or establish appropriate exercise ability, including leisure and occupational needs. o Provide additional education and support. Dietary counseling o Meet the psychological needs of client and family. Psychologist or social worker o Closely monitor for complications. 20-40 minutes sessions with close monitoring for symptoms, assessing the ECG and V.S., and stress testing. Emergency equipment: medications, defibrillator, etc. are available. More phase II Avoid exertion in cold weather, such as shoveling snow. Avoid hot baths or prolonged showers. Avoid lifting more than 20 pounds. Goal for walking is 2 miles in less than 1 hour. Supervised exercise at a cardiac rehabilitation center with exercise equipment, complication monitoring, and education. Large muscle exercises (aerobic) for 20-30 minutes 3-4 times a week, with warm up and cool down periods. May be able to return to work after 8-9 weeks. o Those with stressful or physically demanding jobs may have to work part-time or find less stressful work. Denial, minimization, acceptance Phase III Community exercise program (YMCA, other health clubs) Goals o Maintain or increase exercise abilities. o Maintain a long term follow up of risk reduction. o Encourage client responsibility for risk reduction. Home exercise is performed between sessions. Cardiac Rehabilitation Phase II, FHS orders https://www.chifranciscan.org/uploadedFiles/For_Physicians/Provider_Orders/30400835%20Cardiac%20Reha bilitation,%20Phase%20II%20(835)2015.12.07.pdf 12 Cardiac Rehab Adult Wellness Program, FHS Provider Orders https://www.chifranciscan.org/uploadedFiles/For_Physicians/Provider_Orders/30400923%20Cardiac%20Reha bilitation%20-%20Adult%20Wellness%20Program%20(923)2015.12.08.pdf Sexual activity Impotence, premature or delayed ejaculation o Avoid erectile dysfunction medications if taking other vasodilators. Reduced libido (in men and women) o Possibly be due to medications, depression, or fears by the patient and his or her partner of precipitating a cardiac event. Maximum heart rate during sexual intercourse averages 120 bpm, which is similar to heart rates associated with other routine activities in and around the house. The hemodynamic response is greater with an unfamiliar sex partner, in unfamiliar surroundings, after eating, or after consuming alcohol. Adapting less strenuous positions — for example, using a side-to-side arrangement rather than the missionary position — can reduce cardiac stress. Patients may start sexual activity 2-3 weeks following an uncomplicated myocardial infarction. They must be instructed to report any untoward symptoms to the physician or to a member of the rehabilitation team. Cardiac Rehabilitation http://emedicine.medscape.com/article/319683-overview#a5 Cardiac Rehab: The Patient Experience St. Luke's Heart Health and Rehabilitation Center https://youtu.be/XfQDFESD3V4