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Care of Patients with Acute Coronary Syndromes, Exams of Nursing

Dallas International University (DIU)Nursing

An overview of coronary artery disease (CAD) and acute coronary syndromes, including chronic stable angina, non-ST-segment elevation MI (NSTEMI), and ST elevation MI (STEMI). It discusses the causes, symptoms, and treatment options for each condition, as well as risk factors for metabolic syndrome and genetic risk. The document also highlights the importance of patient-centered care and the unique challenges faced by women with ischemic heart disease.

Typology: Exams

2023/2024

Available from 11/07/2023

johnwise 🇺🇸

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Care of patients with Acute Coronary Syndromes



Coronary artery disease (CAD) // Coronary Heart Disease

oCoronary artery disease (CAD), AKA Coronary heart disease (CHD) or simply heart disease, is

the single largest killer of American men and women in all ethnic groups.

oA broad term that includes Chronic stable angina & Acute coronary syndromes.

oIt affects the arteries that provide blood, oxygen, & nutrients to the myocardium. When blood flow

through the coronary arteries is partially or completely blocked, ischemia & infarction of the

myocardium may result.

oWhen the arteries that supply the myocardium (heart muscle) are diseased, the heart cannot

pump blood effectively to adequately perfuse vital organs and peripheral tissues.

oWhen perfusion is impaired, the patient can have life-threatening signs & symptoms and possibly

death.

oOver the past decade there has been a decrease in the death rate from CAD due to:

Increasingly effective treatment.

Increased awareness/emphasis on reducing major cardiovascular risk factors



Major Cardiovascular Risk Factors: Hypertension, Smoking, High Cholesterol.

o

However, some coronary events occur without common risk factors.

•Ischemia (Lack of oxygen)

oOccurs when insufficient oxygen is supplied to meet the requirements of the myocardium.

•Infarction (Necrosis, or Cell death)

oOccurs when severe ischemia is prolonged and decreased perfusion causes irreversible damage

to tissue.

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 Coronary artery disease (CAD) // Coronary Heart Disease o Coronary artery disease (CAD), AKA Coronary heart disease (CHD) or simply heart disease, is the single largest killer of American men and women in all ethnic groups. o A broad term that includes Chronic stable angina & Acute coronary syndromes. o It affects the arteries that provide blood, oxygen, & nutrients to the myocardium. When blood flow through the coronary arteries is partially or completely blocked, ischemia & infarction of the myocardium may result. o When the arteries that supply the myocardium (heart muscle) are diseased, the heart cannot pump blood effectively to adequately perfuse vital organs and peripheral tissues. o When perfusion is impaired, the patient can have life-threatening signs & symptoms and possibly death. o Over the past decade there has been a decrease in the death rate from CAD due to:  Increasingly effective treatment.  Increased awareness/emphasis on reducing major cardiovascular risk factors  Major Cardiovascular Risk Factors: Hypertension, Smoking, High Cholesterol. o However, some coronary events occur without common risk factors.

Ischemia (Lack of oxygen) o Occurs when insufficient oxygen is supplied to meet the requirements of the myocardium.
Infarction (Necrosis, or Cell death) o Occurs when severe ischemia is prolonged and decreased perfusion causes irreversible damage to tissue.

 Chronic Stable Angina Pectoris

Angina pectoris is chest pain caused by a temporary imbalance between the coronary arteries' ability to supply oxygen and the cardiac muscle's demand for oxygen.
Ischemia (lack of oxygen) that occurs with angina is limited in duration & does not cause permanent damage of myocardial tissue.
Angina may be of two main types : (1) Stable angina & (2) Unstable angina.  Chronic Stable Angina (CSA) o Chest discomfort that occurs with moderate to prolonged exertion in a pattern that is familiar to the patient. o The frequency, duration, and intensity of symptoms remain the same over several months. o CSA results in only slight limitation of activity and is usually associated with a fixed atherosclerotic plaque. o It is usually relieved by: Nitroglycerin or Rest & often is managed with Drug therapy.  Rarely does CSA require aggressive treatment.  Unstable Angina

There are two types of MI:

Non–ST-segment elevation MI (NSTEMI)
ST elevation MI (STEMI).

Non- ST-Segment elevation MI (NSTEMI)

Patients typically have ST and T-wave changes on a 12-lead ECG. o This indicates myocardial ischemia.
Initially Troponin may be normal, but it elevates over the next 3 to 12 hours.
The combination of changes on the ECG & elevation in cardiac troponin indicates Myocardial cell death or necrosis.
Causes of NSTEMI : o Coronary vasospasm o Spontaneous dissection o Sluggish blood flow due to narrowing of the coronary artery.
Important to note that changes in ECG along with elevation of troponin should always be assessed in conjunction with the clinical presentation & history of the patient.
Patients with elevated troponin and ECG changes without typical symptoms of acute coronary syndrome (chest discomfort, shortness of breath, nausea) typically have a condition other than CAD (such as sepsis), causing the imbalance between myocardial oxygen supply & demand.

ST elevation MI (STEMI)

Patients typically have ST elevation in two contiguous leads on a 12-lead ECG. o This indicates MI/necrosis.
STEMI is attributable to rupture of the fibrous atherosclerotic plaque leading to platelet aggregation & thrombus formation at the site of rupture. - The thrombus causes an abrupt 100% occlusion to the coronary artery, is a MEDICAL EMERGENCY & requires immediate revascularization of the blocked coronary artery.

Workload demands on the myocardium.

Obvious physical changes do not occur in the heart until 6 hours after the infarction, when the infarcted region appears blue and swollen. o These changes explain the need for intervention within the first 4 to 6 hours of symptom onset!
After 48 hours, the infarcted area turns gray with yellow streaks as neutrophils invade the tissue & begin to remove the necrotic cells. (“Most crucial time/risk for myocardial rupture Due to weakness of myocardium.
By 8 to 10 days after infarction, granulation tissue forms at the edges of the necrotic tissue.
Over a 2- to 3-month period, the necrotic area eventually develops into a shrunken, thin, firm scar. o Scar tissue permanently changes the size & shape of the entire left ventricle, called Ventricular remodeling.  Remodeling may: Decrease Left Ventricular Function, Cause Heart failure, and Increase Morbidity & Mortality. o The scarred tissue does not contract, or conduct electrically.  Thus this area is often the cause of Chronic ventricular dysrhythmias surrounding the infarcted zone. (“ Stabilizes heart, but does not function as regular heart tissue” ).  The patient's response to an MI also depends on which coronary artery or arteries were obstructed & which part of the left ventricle wall was damaged: o Anterior, Septal, Lateral, Inferior, or Posterior.  Right Coronary Artery (RCA) o Supplies most of the SA and AV nodes, as well as the right ventricle & inferior or  Left Anterior Descending (LAD) Artery o Obstruction of LAD causes Anterior or Septal MIs. o Because it perfuses the anterior wall & most of the septum of the left ventricle. o Patients with Anterior wall MIs (AWMIs) have the Highest Mortality Rate because they are most likely to have left ventricular failure & dysrhythmias from damage to the left ventricle.  Circumflex Artery o Supplies the lateral wall of the left ventricle and possibly portions of the posterior wall or the Sinoatrial (SA) and Atrioventricular (AV) nodes. o Patients with obstruction of the circumflex artery may experience a Posterior Wall MI (PWMI) or a Lateral Wall MI (LWMI) & Sinus Dysrhythmias.

o It is important to obtain a “right-sided” ECG to assess for right ventricular involvement.  Patient-Centered Care

- Many women with symptomatic ischemic heart disease or abnormal stress testing DO NOT have abnormal coronary angiography.

Studies implicate Microvascular Disease or Endothelial Dysfunction or Both as the causes for risk for CAD in women.
Endothelial dysfunction: The inability of the arteries & arterioles to dilate due to lack of nitric oxide production by the endothelium. o Nitric oxide is a relaxant of vascular smooth muscle.
Women typically have smaller coronary arteries & frequently have plaque that breaks off & travels into the small vessels to form an embolus (clot).
Positive remodeling, or outward remodeling (Lesions that protrude outward), is more common in women. o This outpouching may be missed on coronary angiography.

 Etiology and Genetic Risk  Atherosclerosis is the Primary Factor in the Development of CAD.  Metabolic syndrome, also called syndrome X, has been recognized as a risk factor for cardiovascular (CV) disease. o This health problem increases the risk for developing Diabetes & CAD. o Prevalence is higher in Mexican Americans, American Indians, & Alaska Native people living in the southwestern United States. o Management is aimed at reducing risks, managing hypertension, and preventing complications.  Patients who have THREE of the following factors are diagnosed with metabolic syndrome. o Hypertension o Decreased HDL-C (usually with high LDL-C) o Increased Level of Triglycerides o Increased Fasting Blood glucose (caused by diabetes, glucose intolerance, or insulin resistance). o Large waist size (excessive abdominal fat causing central obesity). Indicators of Risk Factors for Metabolic Syndrome

Prevention of Coronary Artery Disease

 Patient and Family Education: Preparing for Self-Management (Text of Chart 38-1)  Prevention of Coronary Artery Disease  Smoking/Tobacco Use

If you smoke or use tobacco, quit.
If you don't smoke or use tobacco, don't start.  **Diet
Consume sufficient calories for your body to include:** o 5% to 6% from saturated fats. o Avoiding trans fatty acids. o Limit your cholesterol intake to less than 200 mg/day. o Limit your sodium intake as specified by your health care provider, or under 1500 mg/day, if possible.  Cholesterol
Have your lipid levels checked regularly.
If your cholesterol and LDL-C levels are elevated, follow your HCP’s advice, including taking statin medications as indicated.  Physical Activity - If you are middle-age or older or have a history of medical problems, check with your HCP before starting an exercise program.
Exercise periods should be at least 40 minutes long with 10-minute warm-up and 5-minute cool- down periods. - If you CANNOT exercise moderately 3 to 4 times each week , Walk daily for 30 minutes at a comfortable pace. (30 mins of walking/day)
If you CANNOT walk 30 minutes daily, Walk any distance you can (ex: Park farther away from a site than necessary; Use the stairs, Not the elevator, to go one floor up or two floors down).  Diabetes Mellitus
Manage your diabetes with your HCP.  Hypertension
Have your blood pressure checked regularly.
If your blood pressure is elevated, follow your HCP’s advice.
Continue to monitor your blood pressure at regular intervals.  Obesity

 Patient-Centered Care

Several groups have a higher genetic risk for CAD than others. o African-American & Hispanic women have higher CAD risk factors than white women of the same socioeconomic status.
The leading cause of death for both men and women in the Euro-American population is cardiovascular disease, even though they may not have genetic predispositions to developing cardiovascular risk factors
Age is the most important risk factor for developing CAD in women. o The older a woman is, the more likely it is that she will have the disease.
When compared with men, women are usually 10 years older when they have CAD.
Only 56% of women are aware that heart disease is the leading cause
of death in women, and even fewer can identify the symptoms of a heart attack.
Women who have MIs have a greater risk for dying during hospitalization. - When they are older than 40 years , women are more likely than men to die within 1 year after their MI. o If women do survive, they are less likely to participate in cardiac rehabilitation programs.  Incidence & Prevalence “ Heart Disease = leading cause of death in women. Only 56% know it’s # killer” - The average age of a person having a first MI is 65.1 years for men and 72 years for women.
Many patients who survive MIs are not able to return to work.  CAD is the leading cause of premature, permanent disability in the United States and the world. - 95 % of sudden cardiac arrest victims die before reaching the hospital, largely because of Ventricular Fibrillation (V fib). o To help combat this problem, automatic external defibrillators (AEDs) are found in many public places, such as in shopping centers and on airplanes.

o Some patients with diagnosed CAD have AEDs in their homes or at work.

 Physical Assessment/Signs and Symptoms

Rapid assessment of the patient with chest pain or other presenting symptoms is crucial.
Differentiate among the types of chest pain & identify the source.
Question the patient to determine the characteristics of the alterations in comfort. o Patients may deny pain & report that they feel “pressure.”
Appropriate Questions to Ask Concerning the Discomfort Include: o Onset o Location o Radiation o Intensity o Duration o Precipitating & Relieving factors.
If pain is present, ask the patient if the pain is in the chest, epigastric area, jaw, back, shoulder, or arm.
Ask the patient to rate the pain on a scale of 0 to 10, with 10 being the highest level of discomfort.
Some patients describe the discomfort as tightness, a burning sensation, pressure, or indigestion.

 Patient-Centered Care

- Many women of any age experience Atypical angina. - Atypical angina: Manifests as Indigestion, Pain between the shoulders, an Aching jaw, or a Choking sensation that occurs with exertion. o These symptoms typically manifest during stressful circumstances or ADLs. o Women may curtail activity as a result of angina, and HCPs need to ask about changes in routine. - Symptoms in women typically include Chest discomfort, Unusual fatigue, and Dyspnea.

Angina pain is ischemic pain  It usually improves when the imbalance between oxygen supply and demand is resolved. o Ex: Rest reduces tissue demands, & nitroglycerin improves oxygen supply.
Discomfort from a Myocardial infarction (MI) DOES NOT usually resolve with these measures.
Ask about any associated symptoms, including: o Nausea o Vomiting o Diaphoresis o Dizziness o Weakness o Palpitations o Shortness of breath.  Key Features of Angina and Myocardial Infarction Angina Myocardial Infarction

Care of Patients with Acute Coronary Syndromes, Exams of Nursing

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 Patient-Centered Care