Download Clinical Manifestations of ACS Myocardial Infarction (MI)

Focus on
Coronary Artery Disease and
Acute Coronary Syndrome
(Relates to Chapter 34,
“Nursing Management: Coronary
Artery Disease and Acute Coronary
Syndrome,”
in the textbook)
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Coronary Artery Disease and
Acute Coronary Syndrome
• A type of blood vessel disorder that
is included in the general category
of atherosclerosis
• Begins as soft deposits of fat that
harden with age
• Referred to as “hardening of
arteries”
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Coronary Artery Disease and
Acute Coronary Syndrome
• Atherosclerosis (cont’d)
• Can occur in any artery in the body
• Atheromas (fatty deposits)
• Preference for the coronary arteries
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Coronary Artery Disease and
Acute Coronary Syndrome
• Cardiovascular diseases are the
major cause of death in the
United States
• Heart attacks are still the leading
cause of all cardiovascular disease
deaths and deaths in general
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Progression of Atherosclerosis
Fig. 34-2
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Coronary Artery Disease
Etiology and Pathophysiology
Fatty streaks
Fibrous plaque
• Result = narrowing of vessel lumen
Complicated lesion
• Continued inflammation can result in plaque
instability, ulceration, and rupture
• Platelets accumulate and thrombus forms
• Increased narrowing or total occlusion of lumen
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Development of
Collateral Circulation
Fig. 34-3
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Risk Factors for CAD
• Risk factors can be categorized as
• Nonmodifiable risk factors
• Age
• Gender
• Ethnicity
• Family history
• Genetic predisposition
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Risk Factors for CAD
• Risk factors can be categorized as
• Modifiable risk factors
• Elevated serum lipids
• Hypertension
• Tobacco use
• Physical inactivity
• Obesity
• Diabetes
• Metabolic
syndrome
• Psychologic
states
• Homocysteine
level
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Risk Factors for CAD
Health Promotion
• Identification of people at high risk
• Health history, including use of
prescription/nonprescription medications
• Presence of cardiovascular symptoms
• Environmental patterns: diet, activity
• Values and beliefs about health and illness
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Risk Factors for CAD
Health Promotion
• Health-promoting behaviors
• Physical fitness
30 minutes >5 days/week
• Regular physical activity contributes to:
• Weight reduction
• Reduction of BP
• increase in HDL cholesterol
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Risk Factors for CAD
Health Promotion
• Health-promoting behaviors
• Nutritional therapy
• Therapeutic Lifestyle
Changes
• Omega-3 fatty acids
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Risk Factors for CAD
Health Promotion
• Health-promoting behaviors
• Cholesterol-lowering drug therapy
• Drugs that restrict lipoprotein
production: Statins, niacin
• Drugs that increase lipoprotein removal:
Bile acid sequestrants
• Drugs that decrease cholesterol
absorption: Ezetimibe (Zetia)
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Risk Factors for CAD
Health Promotion
• Health-promoting behaviors
• Antiplatelet therapy
• ASA
• Clopidogrel (Plavix)
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Clinical Manifestations of CAD
Chronic Stable Angina
• Etiology and Pathophysiology
• Reversible (temporary) myocardial
ischemia = angina (chest pain)
• O2 demand > O2 supply
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Clinical Manifestations of CAD
Chronic Stable Angina
• Etiology and Pathophysiology
• Primary reason for insufficient blood
flow is narrowing of coronary arteries
by atherosclerosis
• For ischemia to occur, the artery is
usually 75% or more stenosed
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Clinical Manifestations of CAD
Chronic Stable Angina
• Intermittent chest pain that occurs
over a long period with the same
pattern of onset, duration, and
intensity of symptoms
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Clinical Manifestations of CAD
Chronic Stable Angina
• Pain usually lasts minutes
• Subsides when the precipitating factor
is relieved
• Pain at rest is unusual
• ECG may reveal ST segment depression
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Location of Chest Pain
(Angina)
Fig. 34-7
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Chronic Stable Angina
Types of Angina
• Prinzmetal’s (variant) angina
• Occurs at rest usually in response to
spasm of major coronary artery
• Seen in patients with a history of
migraine headaches and Raynaud’s
phenomenon
• Spasm may occur in the absence of
CAD
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Chronic Stable Angina
Types of Angina
• Prinzmetal’s (variant) angina
• When spasm occurs
• Chest pain
• Marked, transient ST segment
elevation
• May occur during REM sleep
• May be relieved by moderate
exercise
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Chronic Stable Angina
Nursing and Collaborative Management
• Drug therapy: Goal:
and/or O2 supply
O2 demand
• Short-acting nitrates: Sublingual
• Long-acting nitrates
• Nitroglycerin ointment
• Transdermal controlled-release
nitroglycerin
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Chronic Stable Angina
Nursing and Collaborative Management
• Drug therapy: Goal: O2 demand and/or
O2 supply
• β-Adrenergic blockers
• Calcium channel blockers
• If β-adrenergic blockers are poorly tolerated,
contraindicated, or do not control anginal
symptoms
• Used to manage Prinzmetal’s angina
• Angiotensin-converting enzyme inhibitors
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Chronic Stable Angina
Nursing and Collaborative Management
• Diagnostic Studies
• Health history/physical examination
• Laboratory studies
• 12-lead ECG
• Chest x-ray
• Echocardiogram
• Exercise stress test
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Chronic Stable Angina
Nursing and Collaborative Management
• Diagnostic Studies
• Cardiac catheterization
• Diagnostic
• Coronary revascularization:
Percutaneous coronary intervention
• Balloon angioplasty
• Stent
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Placement of a
Coronary Artery Stent
Fig. 34-9
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Pre- and Post-PCI
with Stent Placement
Fig. 34-10
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Acute Coronary Syndrome
• When ischemia is prolonged and not
immediately reversible, acute coronary
syndrome (ACS) develops
• ACS encompasses:
• Unstable angina (UA)
• Non–ST-segment-elevation myocardial
infarction (NSTEMI)
• ST-segment-elevation (STEMI)
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Relationship Between CAD,
Chronic Stable Angina, and ACS
Fig. 34-11
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Acute Coronary Syndrome
Etiology and Pathophysiology
• Deterioration of a once stable plaque
rupture
aggregation
• Result
platelet
thrombus
• Partial occlusion of coronary artery:
UA or NSTEMI
• Total occlusion of coronary artery:
STEMI
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Coronary Thrombogenesis
Secondary to Plaque Deterioration
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Clinical Manifestations of ACS
Unstable Angina
• Unstable angina
• New in onset
• Occurs at rest
• Has a worsening pattern
• UA is unpredictable and represents a
medical emergency
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Clinical Manifestations of ACS
Myocardial Infarction (MI)
• Result of sustained ischemia
(>20 minutes), causing
irreversible myocardial cell death
(necrosis)
• Necrosis of entire thickness of
myocardium takes 4 to 6 hours
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Acute Myocardial Infarction
Fig. 34-13
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Clinical Manifestations of ACS
Myocardial Infarction
• The degree of altered function depends
on the area of the heart involved and the
size of the infarct
• Contractile function of the heart is
disrupted in areas of myocardial
necrosis)
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Occlusion of the Left Anterior Descending
Coronary Artery, Resulting in MI
Fig. 34-12
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Clinical Manifestations of ACS
Myocardial Infarction
• Pain
• Total occlusion → anaerobic
metabolism and lactic acid
accumulation
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Clinical Manifestations of ACS
Myocardial Infarction
• Pain
• Described as heaviness, constriction,
tightness, burning, pressure, or
crushing
• Common locations: substernal,
retrosternal, or epigastric areas; pain
may radiate
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Clinical Manifestations of ACS
Myocardial Infarction
• Sympathetic nervous system
stimulation results in
• Release of glycogen
• Diaphoresis
• Vasoconstriction of peripheral blood
vessels
• Skin: ashen, clammy, and/or cool to
touch
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Clinical Manifestations of ACS
Myocardial Infarction
• Cardiovascular
• Initially, ↑ HR and BP, then ↓ BP
(secondary to ↓ in CO)
• Crackles
• Jugular venous distention
• Abnormal heart sounds
• S3 or S 4
• New murmur
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Clinical Manifestations of ACS
Myocardial Infarction
• Nausea and vomiting
• Can result from reflex stimulation of
the vomiting center by the severe pain
• Fever
• Systemic manifestation of the
inflammatory process caused by cell
death
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Myocardial Infarction
Healing Process
• Development of collateral circulation
improves areas of poor perfusion
• Necrotic zone identifiable by ECG
changes and nuclear scanning
• 10 to 14 days after MI, scar tissue is still
weak and vulnerable to stress
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Complications of
Myocardial Infarction
• Dysrhythmias
• Most common complication
• Present in 80% of MI patients
• Life-threatening dysrhythmias seen most
often with anterior MI, heart failure, or
shock
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Complications of
Myocardial Infarction
• Heart failure
• A complication that occurs when the
pumping power of the heart has
diminished
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Complications of
Myocardial Infarction
• Cardiogenic shock
• Occurs when inadequate oxygen and
nutrients are supplied to the tissues
because of severe LV failure
• Requires aggressive management
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Complications of
Myocardial Infarction
• Papillary muscle dysfunction
• Causes mitral valve regurgitation
• Condition aggravates an already
compromised LV
• Ventricular aneurysm
• Results when the infarcted myocardial
wall becomes thinned and bulges out
during contraction
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Complications of
Myocardial Infarction
• Acute pericarditis
• An inflammation of visceral and/or parietal
pericardium
• May result in cardiac compression, ↓ LV filling and
emptying, heart failure
• Pericardial friction rub may be heard
auscultation
on
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Diagnostic Studies
Unstable Angina and Myocardial Infarction
• Detailed health history and physical
• 12-lead ECG: Changes in QRS
complex, ST segment, and T wave can
rule out or confirm UA or MI
• Serum cardiac markers
• Coronary angiography
• Others: Exercise stress testing,
echocardiogram
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Serum Cardiac Markers After MI
Fig. 34-15
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Collaborative Care
Acute Coronary Syndrome
• Emergency management
• Initial interventions
• Ongoing monitoring
• Emergent PCI
• Treatment of choice for confirmed MI
• Balloon angioplasty + drug-eluting
stent(s)
• Ambulatory 24 hours after the
procedure
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Collaborative Care
Acute Coronary Syndrome
• Fibrinolytic therapy
• Indications and contraindications
• Marker of reperfusion: Return of ST
segment to baseline
• Rescue PCI if thrombolysis fails
• Major complication: Bleeding
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Collaborative Care
Acute Coronary Syndrome
• Drug therapy
•
•
•
•
•
•
•
IV nitroglycerin
Morphine sulfate
β-adrenergic blockers
Angiotensin-converting enzyme inhibitors
Antidysrhythmia drugs
Cholesterol-lowering drugs
Stool softeners
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Collaborative Care
Acute Coronary Syndrome
• Nutritional therapy
Progress to
low-salt, low saturated fat,
low-cholesterol diet
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Collaborative Care
Acute Coronary Syndrome
• Coronary surgical revascularization
• Fail medical management
• Presence of left main coronary artery
or three-vessel disease
• Not a candidate for PCI (e.g., lesions are
long or difficult to access)
• Failed PCI with ongoing chest pain
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Collaborative Care
Acute Coronary Syndrome
• Coronary surgical revascularization
• Coronary artery bypass graft (CABG)
surgery
• Requires cardiopulmonary bypass
• Uses arteries and veins for grafts
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
CABG Surgery
Fig. 34-16
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Nursing Management
Chronic Stable Angina and ACS
• Nursing Assessment
• Subjective Data
• Health history
• Functional health patterns
• Objective Data
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Nursing Management
Chronic Stable Angina and ACS
• Nursing Diagnoses
• Acute pain
• Ineffective tissue perfusion
(cardiac)
• Anxiety
• Activity intolerance
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Nursing Management
Chronic Stable Angina and ACS
• Planning: Overall goals
•
•
•
•
Relief of pain
Preservation of myocardium
Immediate and appropriate treatment
Effective coping with illness-associated
anxiety
• Participation in a rehabilitation plan
• Reduction of risk factors
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Nursing Management
Chronic Stable Angina
• Health Promotion
• Therapeutic lifestyle changes to reduce
cardiac risk factors
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Nursing Management
Chronic Stable Angina
• Acute Interventions for anginal attack
• Rest
• Administration of supplemental oxygen
• 12-lead ECG
• Prompt pain relief first with a nitrate
followed by an opioid analgesic if needed
• Auscultation of heart sounds
• Comfortable positioning of the patient
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Nursing Management
Chronic Stable Angina
• Ambulatory and Home Care
• Patient teaching
• CAD and angina
• Precipitating factors for angina
• Risk factor reduction
• Medications
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Nursing Management
ACS
• Acute Intervention
• Pain: Nitroglycerin, morphine, oxygen
• Continuous monitoring
• ECG
• VS, pulse oximetry
• Heart and lung sounds
• Rest and comfort
• Balance rest and activity
• Begin cardiac rehabilitation
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Nursing Management
ACS
• Acute Intervention
• Anxiety
• Emotional and behavioral reaction
• Maximize patient’s social support
systems
• Consider open visitation
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Nursing Management
ACS
• Coronary revascularization: ICU for first
24 to 36 hours
• Pulmonary artery catheter for measuring CO,
other hemodynamic parameters
• Intraarterial line for continuous BP monitoring
• Pleural/mediastinal chest tubes for chest
drainage
• Continuous ECG monitoring to detect
dysrhythmias (esp. atrial dysrhythmias)
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Nursing Management
ACS
• Coronary revascularization: ICU for
first 24 to 36 hours
• Endotracheal tube connected to mechanical
ventilation
• Extubation within 12 hours
• Epicardial pacing wires for emergency
pacing of the heart
• Urinary catheter to monitor urine output
• NG tube for gastric decompression
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Nursing Management
ACS
• Coronary revascularization: Care is
focused on
• Assessing the patient for bleeding
(e.g., chest tube drainage, incision sites)
• Monitoring fluid status
• Replacing electrolytes PRN
• Restoring temperature (e.g., warming
blankets)
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Nursing Management
ACS
• Ambulatory and Home Care
• Patient teaching
• Physical exercise
• Resumption of sexual activity
• Emotional readiness of patient and
partner
• Physical expenditure
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Nursing Management
ACS
• Evaluation
• Relief of pain
• Preservation of myocardium
• Immediate and appropriate treatment
• Effective coping with illness-associated
anxiety
• Participation in a rehabilitation plan
• Reduction of risk factors
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Sudden Cardiac Death (SCD)
• Unexpected death from cardiac
causes
• Most deaths occur outside of
hospital
• CAD accounts for about 80% of
all SCDs
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.