Learning Outcomes

1. Relate the etiology and pathophysiology of coronary artery disease (CAD), chronic stable angina, and acute coronary syndrome (ACS) to the clinical manifestations of each disorder.

2. Describe the nursing role in promoting therapeutic lifestyle changes in patients at risk for CAD.

3. Distinguish the precipitating factors, clinical manifestations, and interprofessional and nursing care of the patient with CAD and chronic stable angina.

4. Explain the clinical manifestations, diagnostic studies, complications, and interprofessional and nursing care of the patient with ACS.

5. Outline drug therapy used to treat patients with CAD, chronic stable angina, and ACS.

6. Prioritize key components to include in the rehabilitation of patients recovering from ACS and coronary revascularization procedures.

7. Distinguish the precipitating factors, manifestations, and interprofessional and nursing care of patients who are at risk for or have had sudden cardiac death.

Terms

acute coronary syndrome (ACS)

• Acute coronary syndrome is a term that describes a range of conditions related to sudden, reduced blood flow to the heart.

angina

• Chest Pain

atherosclerosis

• Atherosclerosis begins as soft deposits of fat that harden with age, often referred to as “hardening of the arteries.”

chronic stable angina

• Chronic stable angina refers to chest pain that occurs intermittently over a long period of time with a similar pattern of onset, duration, and intensity of symptoms.

collateral circulation

• network of specialized “endogenous bypass vessels” that is present in most tissues and provides protection against ischemic injury caused by ischemic stroke, coronary atherosclerosis, peripheral artery disease and other conditions and diseases.

coronary artery disease (CAD)

• Coronary artery disease (CAD) is a type of blood vessel disorder in the general category of atherosclerosis.

coronary revascularization

• procedure that can restore blood flow in blocked arteries or veins.

metabolic equivalent (MET)

• 1 MET is the amount of O2 needed by the body at rest—3.5 mL of O2 per kilogram per minute, or 1.4 cal/kg of body weight per minute. The MET determines the energy costs of various exercises

myocardial infarction (MI)

• myocardial infarction (MI) occurs because of an abrupt stoppage of blood flow through a coronary artery with a thrombus caused by platelet aggregation

percutaneous coronary intervention (PCI)

• non-surgical procedure used to treat the blockages in a coronary artery; it opens up narrowed or blocked sections of the artery, restoring blood flow to the heart.

Prinzmetal’s angina

• Prinzmetal’s angina (variant angina, vasospastic angina) is a rare form of angina that often occurs at rest without increased physical demand.

stent

• a tubular support placed temporarily inside a blood vessel, canal, or duct to aid healing or relieve an obstruction.

sudden cardiac death (SCD)

• Sudden cardiac death (SCD) is an abrupt, unexpected death resulting from a variety of cardiac causes. Over 350,000 adults have an out-of-hospital cardiac arrest every year.

unstable angina (UA)

• Chest pain that is new in onset, occurs at rest, or occurs with increasing frequency, duration or less effort than the pt’s chronic stable angina pattern

• SCD = abrupt unexpected death resulting from variety of cardiac causes

Etiology and Pathophysiology

• SCD = occuring within 1 hour of symptoms onset

  • abrupt loss of CO and cerebral blood flow

  • may have history or not of heart disease

• SCD = first manifestation of CAD in up to 50% people but can occur without evidence of CAD

• CAD main cause of SCD in US in adults over 35

• Acute ventricular dysrhythmias cause most cases of SCD and may or may not be associated with acute MI

• Many SCD survivors have a history of a prior (old) MI that caused LV dysfunction and a reduced LVEF. These dysrhythmias have a high rate of recurrence

• LV dysfunction (EF <30%) is the most common criterion to help guide decisions about implantable cardioverter-defibrillators (ICD) implantation

• The use of ICDs for primary and secondary prevention has significantly reduced the incidence of SCD from VT and VF

• strctural heart disease= risk factor for SCD

Clincial Manifestation

• some symptoms within 1 hour of an SCD event

  • angina, palpitations, dizziness, or lightheadedness’

• people who experience SCD because of CAD fall into 2 groups:

  • 1) prior old MI

  • 2) acute MI

• SCD more common in those with old MI → Survivors have continued electrical instabilty from scarred heart muscle

  • referred for an ICD for secodnary prevention

• Acute MI → udnergo 40 days of max medical therapy to see if reveroy in EF before ICD implated

Interprofessional and Nursing Care

• SCD survival → need diagnostic to determine if also had acute MI

  • Serial analysis of ardiac biomarkers and ECGs are done to rule out ACS

• catheterization can ID significant CAD was cause of SCD event

  • PCI or CABG surgery may be needed because significant CAD may be a reversible cause of SCD

• if no reversible cause is ID and EF is low normal → useful to know if pt are likely to have recurrence

• dysrhythmias → obtain electrophysiology study (EPS) - under fluoroscopy to reproduce lifethreatening dysrhythmias

  • For patients with syncope suspected to be caused by ventricular dysrhythmias, an outpatient wearable cardiac monitor (e.g., Holter monitor) can be used for up to 48 hours or a Mobile Cardiac Outpatient Telemetry (MCOT) (e.g., CardioNet) may be worn up to 30 days. An implantable cardiac loop recorder (e.g., LINQ) may be implanted and left in place up to 3 years.

• The most common approach to preventing a recurrence of SCD and improving survival is the use of an ICD.

  • Drug therapy with an antiarrhythmic such as amiodarone may be used with an ICD to decrease episodes of ventricular dysrhythmias if the patient is receiving multiple ICD shocks due to the dysrhythmias.

• Some patients at risk for SCD may use a wearable cardioverter-defibrillator (e.g., LifeVest) as a bridge to ICD or heart transplantation

  • The wearable cardioverter-defibrillator is a personal external defibrillator that has 2 main parts: a garment and monitor. The garment is worn under clothing. It has electrodes that continuously record the patient’s ECG and deliver a shock, if needed

  • If the patient has VT or VF, the device sounds an alarm to confirm that the patient is unresponsive

• Rapid CPR and defibrillation with an automatic external defibrillator (AED), combined with early advanced cardiac life support, has improved long-term survival rates for a witnessed arrest due to ventricular dysrhythmias

• Be alert to the patient’s psychosocial adaptation to this sudden “brush with death.” Many patients develop a “time bomb” mentality

Key Points

CORONARY ARTERY DISEASE

• Coronary artery disease (CAD) is a type of blood vessel disorder included in the general category of atherosclerosis. Atherosclerosis is characterized by lipid deposits within the intimal wall of an artery.

• CAD is a progressive disease that develops in stages over many years. When it becomes symptomatic, the disease process is usually well advanced.

• Normally, some arterial collateral circulation exists within the coronary circulation. The growth and extent depends on the inherited predisposition to develop new blood vessels and the presence of chronic ischemia.

• Many risk factors have been associated with CAD.

• Nonmodifiable risk factors include age, gender, ethnicity, and genetics.

• Modifiable risk factors include high serum lipids, high BP, tobacco use, physical inactivity, obesity, diabetes, metabolic syndrome, psychologic states (e.g., anger, depression), high homocysteine level and substance use.

• High serum lipid levels are one of the most firmly established risk factors for CAD.

• High-density lipoproteins (HDLs) carry lipids away from arteries to the liver for metabolism.

• High serum HDL levels are desirable.

• Physical activity, eating more healthy fats, losing weight, moderate alcohol intake and quitting smoking help increase HDL levels.

• High low-density lipoprotein (LDL) levels correlate most closely with an increased incidence of atherosclerosis and CAD. Therefore, low serum LDL levels are desirable.

• Hypertension increases the risk of CAD, stroke, peripheral vascular disease, heart failure, and death.

• The risk of developing CAD is much higher in those who smoke tobacco or use smokeless tobacco than in those who do not.

• The incidence of CAD is 2 to 4 times greater among people who have diabetes, even those with well-controlled blood glucose levels.

INTERPROFESSIONAL AND NURSING CARE: CORONARY ARTERY DISEASE

• Prevention and early treatment of CAD involve a multifaceted approach and must be ongoing throughout the lifespan.

• Management risk starts with controlling or changing the additive effects of modifiable risk factors.

• A regular physical activity program should be implemented.

• Diet should limit saturated fats and cholesterol and emphasize complex carbohydrates (e.g., whole grains, fruits, vegetables) and fiber.

• A complete lipid profile is recommended every 5 years beginning at age 20.

• Guidelines recommend the following groups of people receive statin therapy:

• Patients with known CVD

• Patients with primary elevations of LDL cholesterol levels greater than or equal to 190 mg/dL

• (e.g., familial hypercholesterolemia)

• Patients between 40 and 75 years old with diabetes and LDL cholesterol levels between 70 and 189 mg/dL

• Patients between 40 and 75 years old with LDL cholesterol levels between 70 and 189 mg/dL and a 10-year risk for CVD of at least 7.5%

• The statins are the most widely used drugs. Niacin, fibric acid derivatives, bile-acid sequestrants, PCSK9 inhibitors, and other agents are options.

• Antiplatelet therapy with low-dose aspirin is recommended for people at risk for CAD. For people who are aspirin intolerant, alternatives (e.g., clopidogrel [Plavix]) are considered.

GERONTOLOGIC CONSIDERATIONS: CORONARY ARTERY DISEASE

• • The incidence of heart disease is greatly increased as one ages and is the leading cause of death in older adults. Strategies to reduce CAD risk are effective in this age group. Aggressive treatment of hypertension and hyperlipidemia helps stabilize plaques in the coronary arteries of older adults, and quitting smoking helps decrease the risk for CAD at any age. Encourage the older patient to consider a planned program of physical activity.

CHRONIC STABLE ANGINA

• Chronic stable angina refers to chest pain that occurs intermittently over a long period with the same pattern of onset, duration, and intensity of symptoms.

• Some patients may deny feeling pain, but describe a pressure, heaviness, discomfort, or ache in the chest. Some describe only shortness of breath.

• Although most angina pain occurs substernally, it may radiate to the jaw, neck, shoulders and/or arms.

• Anginal pain usually lasts for only a few minutes and often subsides when the precipitating factor is relieved. Pain at rest is unusual.

PRINZMETAL’S ANGINA

• Prinzmetal’s angina is a rare form of angina that often occurs at rest, usually in response to spasm of a major coronary artery. When spasms occur, the patient has angina and transient ST segment elevation.

• Prinzmetal’s angina may be seen in patients with a history of migraine headaches and Raynaud’s phenomenon.

• Tobacco, alcohol, amphetamines, and cocaine use may precipitate coronary artery spasm.

• The pain may be relieved by moderate exercise or it may disappear spontaneously.

• Calcium channel blockers and/or nitrates are used to treat angina associated with coronary artery spasm.

MICROVASCULAR ANGINA

• • In microvascular angina, chest pain occurs in the absence of significant CAD or coronary spasm of a major coronary artery. The pain is related to myocardial ischemia associated with atherosclerosis or spasm of the small distal coronary vessels.

INTERPROFESSIONAL AND NURSING CARE: CHRONIC STABLE ANGINA

• Chronic stable angina can progress or develop into unstable angina or an acute coronary syndrome. Therefore, any change in the usual pattern of angina should be evaluated.

• The treatment of chronic stable angina is aimed at decreasing oxygen demand and/or

• increasing oxygen supply and reducing CAD risk factors.

• In addition to antiplatelet and lipid-lowering drug therapy, the most common drugs used to manage chronic stable angina are nitrates, ACE inhibitors, -blockers, and calcium channel blockers.

• Short-acting nitrates are first-line therapy for the treatment of an acute episode of angina. Nitrates dilate peripheral blood vessels, coronary arteries, and collateral vessels.

• Angiotensin-converting enzyme (ACE) inhibitors and -blockers are used to manage chronic stable angina.

• ACE inhibitors result in vasodilation and decreased blood volume as well as reduction in the risk of MI, stroke, and death. They have a role in limiting ventricular remodeling in patients who have had a myocardial infarction (MI).

• -blockers decrease myocardial contractility, heart rate, systemic vascular resistance, and BP, which reduce myocardial oxygen demand and relieve anginal symptoms.

• β1 receptors are found in the heart.

• β2 receptors are found in blood vessels, lungs, and liver.

• Some β-blockers are referred to as cardioselective β-blockers because they only block β1 receptors.

• Calcium channel blockers can be used if patients are intolerant of -blockers

• Common diagnostic tests for a patient who describes chest pain or when a patient with chronic stable angina has a change in the anginal pattern include:

• 12-lead ECG to look for any changes that may show ACS

• Laboratory tests (e.g., cardiac biomarkers) to identify if the patient is experiencing an

• ACS

• Echocardiogram to look for resting left ventricular wall motion abnormalities

• Exercise or pharmacologic stress test if the ECG and cardiac biomarkers are negative

• Cardiac catheterization with possible balloon angioplasty and stent (percutaneous coronary intervention [PCI])

• PCI may be done at the same time as the catheterization or later.

• There are 2 types of stents: bare metal stents and drug-eluting stents. Drug-eluting stents reduce the risk of in-stent re-stenosis (overgrowth of the intimal lining) but need a minimum of 12 months of dual antiplatelet therapy.

• After catheterization with or without PCI, your major responsibilities involve (1) monitoring for signs of recurrent angina; (2) frequent assessment of vital signs, including HR and rhythm; (3) evaluation of the insertion site for signs of bleeding; (4) neurovascular assessment of the extremity used; and (5) maintenance of bed rest per agency policy.

• Coronary revascularization with coronary artery bypass graft (CABG) surgery is recommended for patients who do not respond to medical management, have left main coronary artery or 3vessel (3 different coronary arteries) disease, are not candidates for PCI, or have failed PCI with ongoing chest pain. CABG may be the revascularization option for patient with diabetes, LV dysfunction, and/or CKD.

• For patients having CABG surgery, care is provided in the ICU for the first 24 to 36 hours, where ongoing monitoring of the patient’s ECG and hemodynamic status is critical.

• After transfer from the ICU, postoperative care focuses on monitoring for dysrhythmias, providing wound care, managing pain, preventing complications (e.g., venous thromboembolism, bleeding, atelectasis, pneumonia), and patient teaching.

ACUTE CORONARY SYNDROME

• Acute coronary syndrome (ACS) develops when ischemia is prolonged and not immediately reversible. ACS includes the spectrum of non-ST elevation acute coronary syndrome (unstable angina and non–ST-segment-elevation myocardial infarction

• [NSTEMI]) and ST-segment-elevation myocardial infarction (STEMI).

• Unstable angina (UA) is chest pain that is new in onset, occurs at rest, or has a worsening pattern from the patient’s chronic stable angina pattern. UA is unpredictable and must be treated immediately.

MYOCARDIAL INFARCTION

• Myocardial infarction (MI) occurs because of an abrupt stoppage of blood flow through a coronary artery, causing irreversible myocardial cell death. Serum cardiac biomarkers are released into the blood.

• STEMI, caused by an occlusive thrombus, results in ST elevation in the ECG leads facing the area of infarction. It requires immediate treatment with PCI (first line) or thrombolytic

• (fibrinolytic) therapy (in hospitals not capable of performing PCI) to limit the infarct size.

• NSTEMI, caused by a nonocclusive thrombus, often causes ST depression and/or T wave inversion in the ECG leads facing the area of infarction. Patients usually undergo cardiac catheterization with possible PCI within 12 to 72 hours if there are no contraindications.

• The acute MI evolves over hours to days.

• MIs mostly affect the left ventricle and are described based on the location of damage.

• Severe, immobilizing chest pain not relieved by rest, position change, or nitrate administration may mean the patient is having an MI. The pain is usually described as a heavy, pressure, tight, burning, constriction, or crushing feeling, often associated with shortness of breath.

• Complications after MI can occur.

• Dysrhythmias are the most common complication. Ventricular tachycardia and ventricular fibrillation the most common cause of death for patients in the prehospital period.

• Other complications include heart failure, cardiogenic shock, papillary muscle dysfunction or rupture, ventricular aneurysm, ventricular septal or free wall rupture, and pericarditis.

• Primary diagnostic studies used to determine whether a person has a STEMI, an NSTEMI or

• UA include an ECG and serum cardiac biomarkers.

• ST elevation in the leads facing the infarcted area is seen with STEMI.

• ST depression and/or T wave inversion in the leads facing the infarcted area is seen with NSTEMI or UA.

• The definitive answer to distinguish between UA and NSTEMI comes from the cardiac biomarkers. They are high with an NSTEMI and normal with UA.

• If the patient is experiencing a STEMI, the patient must get to the cardiac catheterization laboratory within 90 minutes of presentation in a PCI capable hospital or receive thrombolytic therapy within 30 minutes in agencies without PCI capability.

INTERPROFESSIONAL AND NURSING CARE: ACUTE CORONARY SYNDROME

• Rapid diagnosis and treatment for a patient with ACS is necessary to preserve cardiac function.

• For patients with UA/NSTEMI, cardiac catheterization with possible percutaneous coronary intervention (PCI) (i.e., balloon angioplasty/stent) is considered once angina is controlled or if angina returns or increases in severity.

• For patients with STEMI, reperfusion therapy is the recommended treatment of choice.

• Cardiac catheterization is used to find and assess the severity of the blockage(s). A PCI is then performed to open the artery to limit the infarction size.

• Thrombolytic therapy aims to limit the infarction size by dissolving the thrombus in the coronary artery to reperfuse the heart muscle.

• Drug Therapy

• Initial management of the patient with ACS includes antiplatelet therapy (e.g., chewable aspirin for UA patients plus clopidogrel or ticagrelor [for STEMI and NSTEMI patients]), IV NTG, and atorvastatin (Lipitor).

• Systemic anticoagulation with either subcutaneous LMWH or IV UH is only started on patients with UA or NSTEMI since STEMI patients go quickly to the cardiac catheterization laboratory.

• Glycoprotein IIb/IIIa inhibitors may be used if PCI is anticipated.

• Oral -blockers are started within 24 hours if there are no contraindications and should be continued indefinitely.

• Calcium channel blockers may be used if the patient is intolerant of β-blockers but must be used cautiously because they can decrease contractility.

• ACE inhibitors are added after an MI if there are no contraindications. ACE inhibitors may help prevent ventricular remodeling after an MI. For patients intolerant of ACE inhibitors, angiotensin receptor blockers should be used.

• Nitrates may be used if the patient has persistent chest pain.

• Lipid lowering drugs are continued indefinitely if the patient can tolerate the drug.

• Stool softeners are given to aid bowel movement and prevent straining and the resultant vagal stimulation from the Valsalva maneuver.

• Dual antiplatelet therapy should continue for 1 year after an MI whether the patient receives a stent or not.

• Aspirin should be continued for life.

NURSING RESPONSIBLITIES: ACUTE CORONARY SYNDROME

• Initial treatment of a patient with ACS includes pain assessment and relief, physiologic monitoring, promotion of rest and comfort, alleviation of stress and anxiety, and assessment of the patient’s emotional and behavioral reactions.

• Nitroglycerin, morphine, and supplemental oxygen should be given as needed to eliminate or reduce chest pain.

• Continuous ECG monitoring, frequent vital signs, intake and output, and physical assessment should be done. Included is an assessment of heart and breath sounds and inspection for evidence of complications (e.g., early heart failure, dysrhythmias).

• Bed rest may be ordered for the first few days after an MI involving a large portion of the ventricle. A patient with an uncomplicated MI may rest in a chair within 8 to 12 hours after the event.

• Anxiety is common after ACS. Your role is to identify the source of anxiety, assist the patient in reducing it, and provide appropriate patient teaching.

• It is important to ensure adequate rest periods free from interruption. Comfort measures that can promote rest include a quiet environment, use of relaxation techniques (e.g., music therapy, guided imagery), and assurance that staff is nearby and responsive to the patient's needs.

• Patient teaching must occur at every stage of the hospitalization and recovery.

• In the hospital, the activity level is gradually increased.

• Depression is common among patients with CAD, and more so in women. Screen for depression in patients with CAD and recommend appropriate referrals.

• Ambulatory Care

• Cardiac rehabilitation restores a person to an optimal state of function in 6 areas: (1) physiological; (2) psychological; (3) mental; (4) spiritual; (5) economic; and (6) vocational.

• Patients should be referred to an outpatient or home-based cardiac rehabilitation program, but cardiac rehabilitation is significantly used.

• Provide sexual counseling for cardiac patients and their partners. The patient’s concern about resumption of sexual activity often produces more stress than the physiologic act itself.

• The inability to perform sexually after MI is common and sexual dysfunction usually decreases after several attempts.

• Patients should know that drugs used for erectile dysfunction should not be used with nitrates as severe hypotension may occur.

• Typically, it is safe to resume sexual activity 7 to 10 days after an uncomplicated MI.

SUDDEN CARDIAC DEATH

• Sudden cardiac death (SCD) is a sudden unexpected death occurring within 1 hour of symptom onset.

• The majority of SCD is caused by acute ventricular dysrhythmias (e.g., ventricular tachycardia, ventricular fibrillation). They may be associated with an acute MI or a prior (old) MI.

• Risk factors for SCD include ventricular dysrhythmias after a prior (old) MI, left ventricular dysfunction (EF less than 30%), LV hypertrophy, hypertrophic cardiomyopathy, myocarditis, and changes in the conduction system (e.g., prolonged QT syndrome).

• Patients who had a prior (old) MI and survive SCD are at risk for another SCD event because of the continued electrical instability of the scarred heart muscle that caused the first event to occur.

• Patients who have SCD associated with an acute MI undergo at least 40 days of maximal medical therapy to see if there is recovery in the EF before an ICD can be implanted.

• People who survive a SCD event need a diagnostic work-up to determine whether they had an acute MI. This includes cardiac biomarkers, ECG, and cardiac catheterization. Significant CAD may be a reversible cause, so patients may be referred for PCI or CABG surgery.

• If no reversible cause of SCD is identified, an electrophysiology study (EPS) may be done.

• The most common approach to preventing a recurrence and improving survival is the use of an implantable cardioverter-defibrillator (ICD).

• Survivors of SCD may develop a “time bomb” mentality, fearing the recurrence of cardiac arrest. They and their caregivers often become anxious, angry, hopeless, and depressed. They may need to deal with other issues, such as driving restrictions, role reversal, and change in occupation.

1. Recognize: Explain the pathogenesis of CAD. What risk factors contribute to its development? What risk factors were present in D.M.’s life?

• The pathogenesis of coronary artery disease (CAD) develops over many years and involves the development of atherosclerosis of the coronary arteries. The development of atherosclerosis occurs in 3 stages: (1) fatty streak, in which streaks of fat develop within the smooth muscle cells of the arteries; (2) raised fibrous plaque, in which endothelial injury results in the formation of a plaque composed of fatty lesions that are covered with collagen tissue, elastic fibers, and smooth muscle cells filled with fat; and (3) complicated lesion, in which the plaque consists of a core of lipid materials within an area of dead tissue that continues to grow by incorporating lipids, thrombi, damaged tissue, and calcium. The result is rigidity and hardening of the artery with total or partial occlusion of the artery by the lesion. Risk factors that contribute to atherosclerosis and coronary artery disease include both nonmodifiable and modifiable factors. Those factors that are not modifiable include age, gender, ethnicity, genetic predisposition, and family history of heart disease. Those factors that are modifiable include high serum lipids, hypertension, tobacco use, obesity, physical inactivity, diabetes, and stressful lifestyle. Risk factors present in D.M.’s life include a history of CAD (chronic stable angina), hypertension, obesity, physical inactivity, stress, and high serum total cholesterol and Hb A1C.

2. Analyze: Which coronary artery(ies) is (are) most likely occluded in D.M.’s coronary circulation?

• An inferolateral wall myocardial infarction (MI) is usually the result of blockages in the right coronary and circumflex artery.

3. Analyze: Explain the significance of the results of the laboratory tests and the 12-lead ECG finding.

• The high troponin level shows that myocardial cellular death has occurred. The high cholesterol level and Hb A1C are evidence of his increased risk for CAD. The premature ventricular contractions found on the ECG are common findings after MI and may occur because of myocardial ischemia, electrolyte imbalances, or SNS stimulation. The ST elevation in leads II, III, and aVF; V5, V6 represent myocardial death in the inferior and lower lateral wall of the left ventricle.

4. Plan: Give a rationale for each treatment measure ordered for D.M.

• Oxygen is applied to ensure the adequacy of oxygen supply to the heart muscle.

• Continuous ECG monitoring allows for a constant readout of the heart rate and rhythm. It also allows for detection of dysrhythmias (e.g., atrial fibrillation, premature ventricular contractions, ventricular tachycardia) and return of ST segment elevations to baseline.

• Aspirin is used as an antithrombotic agent to prevent platelet aggregation around thrombi and atherosclerotic lesions.

• Eptifibatide (Integrilin) is a glycoprotein IIb/IIIa inhibitor (antiplatelet agent) used to prevent platelet aggregation around thrombi and atherosclerotic lesions. It should not delay D.M. getting to the cardiac catheterization laboratory.

• Weight-based IV heparin is an anticoagulant used to prevent further extension of the existing thrombi or new clot formation. It only would be used if D.M. does not go directly to the cardiac catheterization laboratory.

• IV nitroglycerin decreases preload and afterload while increasing the myocardial oxygen supply. IV nitroglycerin is usually titrated to relieve pain. Because hypotension is a common side effect, BP is closely monitored during this time, and parameters should be established.

• IV morphine is a vasodilator and decreases cardiac workload by lowering myocardial oxygen consumption, reducing contractility, and decreasing BP and HR. In addition, morphine can help reduce pain, anxiety, and fear.

• Vital signs and pulse oximetry are monitored frequently (according to agency policy) during the acute phase of an MI to evaluate the patient’s response to treatments and detect the development of complications (e.g., heart failure, cardiogenic shock).

• PCI is the first line of treatment for patients with confirmed STEMI (i.e., definitive ECG changes of ST elevation and/or positive cardiac biomarkers). The goal is to open the affected artery within 90 minutes of arrival to a facility with an interventional cardiac catheterization lab.

  • In this situation, D.M. will have a cardiac catheterization within 90 minutes of arrival to find and assess the severity of the blockage(s), determine the presence of collateral circulation, and evaluate left ventricular function. With actual visualization of the coronary artery system and left ventricular function, treatment modalities most beneficial to the patient are selected. Usually PCI with the placement of a stent(s) is performed on the artery responsible for the infarction. If other arteries have significant blockage, they are stented later.

5. Prioritize: What are the priority nursing interventions for D.M. before PCI? Immediately after PCI?

• Before PCI

  • Perform all required activities needed to prepare patient for rapid and safe transfer to the cardiac catheterization laboratory (e.g., IV access, blood work, 12-lead ECG).

  • Explain all interventions to patient, including preparations for transfer to the cardiac catheterization lab.

  • Give drugs to relieve pain as ordered and monitor their effectiveness.

  • Titrate supplemental oxygen as ordered.

  • Monitor continuous ECG.

  • Frequently monitor vital signs, including pulse oximetry.

  • Assess heart and breath sounds.

  • Provide support to help him deal with anxiety and other emotions related to his MI.

  • Offer to bring caregiver(s) to bedside and explain all activities.

• After PCI

  • Monitor for signs of recurrent angina.

  • Monitor vital signs, including pulse oximetry.

  • Assess heart and breath sounds.

  • Monitor continuous ECG.

  • Monitor catheter insertion site for signs of bleeding.

  • Perform neurovascular assessment of involved extremity.

  • Maintain bed rest per agency policy.

6. Act: Identify activities you can delegate to assistive personnel (AP).

• Vital signs, including pulse oximetry

• Provide oral hygiene as needed

• Assist with getting out of bed and toileting

• Assist with feeding, as ordered

• Obtain capillary blood glucose level according to agency policy

7. Evaluate: What outcomes would show that interprofessional care was successful?

• Transfer of D.M. to the cardiac catheterization laboratory within 90 minutes. Successful placement of stents in blocked arteries. No bleeding from the catheter insertion site or any other complication after PCI. Resolution of chest pain. Stable vital signs and heart rhythm. Patient requesting information about lifestyle changes.

Review Questions

1. Which information would the nurse include in teaching a patient about CAD? (select all that apply)

• a. Diffuse involvement of plaque formation in coronary veins

• b. Abnormal levels of cholesterol, especially low-density lipoproteins

• c. Accumulation of lipid and fibrous tissue within the coronary arteries

• d. Development of angina due to a decreased blood supply to the heart muscle

• e. Chronic vasoconstriction of coronary arteries leading to permanent vasospasm

• Atherosclerosis is the major cause of coronary artery disease (CAD). It is characterized by a focal deposit of cholesterol and lipids, primarily within the intimal wall of the artery. The endothelial lining of the coronary arteries becomes inflamed from the presence of unstable plaques and the oxidation of low-density lipoprotein (LDL) cholesterol. Fibrous plaque causes progressive changes in the endothelium of the arterial wall. The result is a narrowing of the vessel lumen and a reduction in blood flow to the myocardial tissue.

2. After teaching a patient about ways to decrease risk factors for CAD, which patient statement indicates to the nurse that further instruction is needed?

• a. “I can keep my blood pressure normal with medication.”

• b. “I would like to add weightlifting to my exercise program.”

• c. “I can change my diet to decrease my intake of saturated fats.”

• d. “I will change my lifestyle to reduce activities that increase my stress.”

• Risk factors for coronary artery disease include high serum levels of lipids, high BP, tobacco use, physical inactivity, obesity, diabetes, metabolic syndrome, certain psychologic states, and high homocysteine levels. Weight lifting is not a cardioprotective exercise. An example of health-promoting regular physical activity is brisk walking (3 to 4 miles/hr) for at least 30 minutes 5 or more times each week.

3. A hospitalized patient with a history of chronic stable angina tells the nurse they are having chest pain. Which information about ischemia would the nurse use as a basis for planning care?

• a. It will always progress to myocardial infarction.

• b. It can be relieved by rest, nitroglycerin, or both.

• c. It is often associated with vomiting and extreme fatigue.

• d. It indicates that irreversible myocardial damage is occurring.

• Chronic stable angina is chest pain that occurs intermittently over a long period with the same pattern of onset, duration, and intensity of symptoms. The chest pain is relieved by rest or by rest and medication (e.g., nitroglycerin). The ischemia is transient and does not cause myocardial damage.

4. The nurse is caring for a patient who is 2 days post MI. The patient reports that chest pain when taking a deep breath. Which action would be a priority?

• a. Notify the provider STAT and obtain a 12-lead ECG.

• b. Obtain vital signs and auscultate for a pericardial friction rub.

• c. Apply high-flow O2 by face mask and auscultate breath sounds.

• d. Medicate the patient with an opiate analgesic and reevaluate in 30 minutes.

• Acute pericarditis is inflammation of the visceral and/or parietal pericardium. It often occurs 2 to 3 days after an acute myocardial infarction. Chest pain may vary from mild to severe. It is worsened by inspiration, coughing, and movement of the upper body. Sitting in a forward position often relieves the pain. The pain is usually different from pain associated with a myocardial infarction and is treated with different medications. Assessment of the patient with pericarditis may reveal a friction rub over the pericardium.

5. A patient is in the ICU with a diagnosis of NSTEMI. Which drugs would the nurse expect the patient to receive? (select all that apply)

• a. Oral statin therapy

• b. Antiplatelet therapy

• c. Thrombolytic therapy

• d. Prophylactic antibiotics

• e. Intravenous nitroglycerin

• When a patient presents with suspected ACS, antiplatelet therapy, IV NTG, and atorvastatin are drug treatments of choice. For patients with UA and NSTEMI, heparin (UH or LMWH) is recommended to prevent microemboli from forming and causing further chest pain. DAPT (e.g., aspirin and clopidogrel or ticagrelor [Brilinta]) also is recommended for NSTEMI patients (with or without a stent). Thrombolytic therapy and antibiotics are not indicated for NSTEMI.

6. A patient is recovering from an uncomplicated MI. Which rehabilitation guideline is a priority to include in the teaching plan?

• a. Refrain from sexual activity for a minimum of 3 weeks.

• b. Plan a diet program that aims for a 1- to 2-lb. weight loss per week.

• c. Begin an exercise program that aims for at least 5 30-minute sessions per week.

• d. Consider the use of erectile agents and prophylactic NTG before sexual activity.

• Physical activity should be regular, rhythmic, and repetitive, with the use of large muscles to build up endurance (e.g., walking, cycling, swimming, rowing). Physical activity sessions should be at least 30 minutes long. Teach the patient to begin slowly at personal tolerance (perhaps only 5 to 10 minutes) and build up to 30 minutes.

7. Which finding is the strongest predictor of risk for sudden cardiac death?

• a. Aortic valve disease

• b. Mitral valve disease

• c. Left ventricular dysfunction

• d. Atherosclerotic heart disease

• Left ventricular dysfunction (ejection fraction less than 30%) and ventricular dysrhythmias after myocardial infarction are the strongest predictors of sudden cardiac death (SCD).

A patient experienced sudden cardiac death (SCD) and survived. Which treatment would the nurse expect to be implemented to prevent an SCD recurrence at home?

• External cardiac pacemaker

• An electrophysiologic study (EPS)

• Medications to prevent dysrhythmias

• Implantable cardioverter-defibrillator (ICD)

• An ICD is the most common approach to preventing recurrence of SCD. An external pacemaker may be used in the hospital but will not be used for the patient living daily life at home. An EPS may be done to determine if a recurrence is likely and determine the most effective medication treatment. Medications to prevent dysrhythmias are used but are not the best prevention of SCD.

Which person would the nurse identify as having the highest risk for coronary artery disease (CAD)?

• A 60-yr-old man with low homocysteine levels

• A 45-yr-old man with a high-stress job who is depressed

• A 54-yr-old woman vegetarian with increased high-density lipoprotein (HDL) levels

• A 62-yr-old woman who has a sedentary lifestyle and body mass index (BMI) of 23 kg/m²

• The 45-yr-old depressed man with a high-stress job is at the highest risk for CAD. Depression and stressful states can contribute to the development of CAD. Elevated HDL levels and low homocysteine levels help to prevent CAD. Although a sedentary lifestyle is a risk factor, a BMI of 23 kg/m² depicts normal weight, and thus the patient with two risk factors is at greatest risk for developing CAD.

The nurse in the recovery room assesses the right femoral artery puncture site after the patient had a stent inserted into a coronary artery. The insertion site is not bleeding or discolored. Which action would the nurse take next to ensure the femoral artery is intact?

• Palpate the insertion site for induration.

• Inspect the patient’s right hip and back.

• Assess peripheral pulses in the right leg.

• Compare the color of the left and right legs.

• The best method to determine that the right femoral artery is intact after inspection of the insertion site is to logroll the patient to inspect the right hip and back for retroperitoneal bleeding. The artery can be leaking, and blood is drawn into the tissues by gravity. The peripheral pulses, color, and sensation of the right leg will be assessed per agency protocol.

The nurse prepares a discharge teaching plan for a patient who has recently been diagnosed with coronary artery disease (CAD). Which priority risk factor would the nurse plan to focus on during the teaching session?

• Type A personality

• Elevated serum lipids

• Family cardiac history

• High homocysteine levels

• Dyslipidemia is one of the four major modifiable risk factors for CAD. The other major modifiable risk factors are hypertension, tobacco use, and physical inactivity. Research findings related to psychologic states (i.e., type A personality) as a risk factor for coronary artery disease have been inconsistent. Family history is a nonmodifiable risk factor. High homocysteine levels have been linked to an increased risk for CAD.

The patient with angina tells the nurse, “While I was having a bowel movement, I started having the worst chest pain ever, like before I was admitted. After I called for a nurse, the pain went away.” Which question would be a priority for the nurse to ask the patient?

• “What precipitated the pain?”

• “Has the pain changed this time?”

• “In what areas did you feel the pain?”

• “What is your pain level on a 0 to 10 scale?”

• Using PQRST, the assessment data not volunteered by the patient is the radiation of pain, the area the patient felt the pain, and if it radiated. The precipitating event was going to the bathroom and having a bowel movement. The quality of the pain was “like before I was admitted,” although a more specific description may be helpful. Severity of the pain was the “worst chest pain ever,” although an actual number may be needed. Timing is supplied by the patient describing when the pain occurred and that he had previously had this pain.

The nurse providing postoperative care for a patient after coronary artery bypass graft (CABG) surgery would monitor for which common complication?

• Dehydration

• Paralytic ileus

• Atrial dysrhythmias

• Acute respiratory distress syndrome

• Postoperative dysrhythmias, specifically atrial dysrhythmias, are common in the first 3 days after CABG surgery. Although the other complications could occur, they are not common complications.

For which condition would the nurse expect that the patient would undergo percutaneous coronary intervention (PCI)?

• Chronic stable angina

• Left-sided heart failure

• Coronary artery disease

• Acute myocardial infarction

• PCI is indicated to restore coronary perfusion in cases of myocardial infarction. Chronic stable angina and coronary artery disease are normally treated with more conservative measures initially. PCI is not relevant to the pathophysiology of heart failure.

Which foods would the nurse encourage patients at risk for coronary artery disease (CAD) to include in their diets? (Select all that apply.)

• Tofu

• Walnuts

• Tuna fish

• Whole milk

• Orange juice

• Tuna fish, tofu, and walnuts are all rich in omega-3 fatty acids, which have been shown to reduce the risks associated with CAD when consumed regularly.

The nurse teaches a patient with high cholesterol about natural lipid-lowering therapies. The nurse determines further teaching is necessary when the patient makes which statement?

• “Omega-3 fatty acids are helpful in reducing triglyceride levels.”

• “I should check with my physician before I start taking any herbal products.”

• “Herbal products do not go through as extensive testing as prescription drugs do.”

• “I will take garlic instead of my prescription medication to reduce my cholesterol.”

• Current evidence does not support using garlic in the treatment of elevated cholesterol. Strong evidence supports the use of omega-3 fatty acids for reduction of triglyceride levels. Many herbal products are not standardized, and effects are not predictable. Patients should consult with their health care provider before starting herbal or natural therapies.

Which information would the nurse consider when caring for a female patient with suspected coronary artery disease?

• Fatigue may be the first symptom.

• Classic signs and symptoms are expected.

• Increased risk is present before menopause.

• Females are more likely to develop collateral circulation.

• Fatigue, rather than pain or shortness of breath, may be the first symptom of impaired cardiac circulation. Women may not exhibit the classic signs and symptoms of ischemia such as chest pain which radiates down the left arm. Neck, throat, or back pain may be symptoms experienced by women. Risk for coronary artery disease increases four times after menopause. Men are more likely to develop collateral circulation.

A patient admitted 24 hours ago with chest pain is diagnosed with a ST-segment-elevation myocardial infarction (STEMI). Which complication of myocardial infarction would the nurse anticipate?

• Dysrhythmias

• Unstable angina

• Cardiac tamponade

• Sudden cardiac death

• Dysrhythmias are present in 80% to 90% of patients after myocardial infarction (MI). Unstable angina is considered a precursor to MI rather than a complication. Cardiac tamponade is a rare event, and sudden cardiac death is defined as an unexpected death from cardiac causes. Cardiac dysfunction in the period following an MI would not be characterized as sudden cardiac death.

The nurse would assess a patient with reports of chest pain for which manifestations associated with a myocardial infarction (MI)? (Select all that apply.)

• Flushing

• Ashen skin

• Diaphoresis

• Nausea and vomiting

• S₃ or S₄ heart sounds

• During the initial phase of an MI, catecholamines are released from the ischemic myocardial cells, causing increased sympathetic nervous system stimulation. This results in the release of glycogen, diaphoresis, and vasoconstriction of peripheral blood vessels. The patient’s skin may be ashen, cool, and clammy (not flushed) because of this response. Nausea and vomiting may result from reflex stimulation of the vomiting center by severe pain. Ventricular dysfunction resulting from the MI may lead to the presence of the abnormal S₃ and S₄ heart sounds.

A male patient with coronary artery disease (CAD) has a low-density lipoprotein (LDL) cholesterol of 98 mg/dL and high-density lipoprotein (HDL) cholesterol of 47 mg/dL. What information would the nurse include in patient teaching?

• Increase intake of olive oil.

• Reduce total caloric intake.

• Consume a diet lower in fats.

• Maintain the normal lipid levels.

• For men, the recommended LDL is less than 100 mg/dL, and the recommended level for HDL is greater than 40 mg/dL. His normal lipid levels should be included in the patient teaching and reinforced. Assessing his need for teaching related to diet should also be done.

The nurse recognizes additional teaching is needed when the patient prescribed a low-sodium, low-fat cardiac diet selects which food?

• Baked flounder

• Angel food cake

• Canned chicken noodle soup

• Baked potato with margarine

• Canned soups are very high in sodium content. Patients need to be taught to read food labels for sodium and fat content.

A female patient with type 1 diabetes has chronic stable angina controlled with rest. She states that over the past few months, she has required increasing amounts of insulin. Which goal would the nurse implement when planning care to prevent cardiovascular disease progression?

• Exercise almost every day.

• Avoid saturated fat intake.

• Limit calories to daily limit.

• Keep Hgb A1C less than 7%.

• If the Hgb A1C is kept below 7%, this means that the patient has had good control of her blood glucose over the past 3 months. The patient indicates that increasing amounts of insulin are being required to control her blood glucose. This patient may not be adhering to the dietary guidelines or therapeutic regimen, so teaching about how to maintain diet, exercise, and medications to maintain stable blood glucose levels will be needed to achieve this goal.

Which prescribed antilipemic medications would the nurse question for a patient who has cirrhosis of the liver? (Select all that apply.)

• Niacin

• Cholestyramine

• Ezetimibe (Zetia)

• Gemfibrozil (Lopid)

• Atorvastatin (Lipitor)

• Ezetimibe (Zetia) should not be used by patients with liver impairment. Adverse effects of atorvastatin (Lipitor), a statin drug, include liver damage and myopathy. Liver enzymes must be monitored frequently, and the medication stopped if these enzymes increase. Niacin’s side effects subside with time, although decreased liver function may occur with high doses. Cholestyramine is safe for long-term use.

Which items would the nurse anticipate administering during emergent care for a patient with a suspected myocardial infarction (MI)?

• Oxygen, nitroglycerin, aspirin, and morphine

• Aspirin, nitroprusside, dopamine, and oxygen

• Oxygen, furosemide (Lasix), nitroglycerin, and meperidine

• Nitroglycerin, lorazepam (Ativan), oxygen, and warfarin (Coumadin)

• The American Heart Association’s guidelines for emergency care of the patient with chest pain include the administration of oxygen, nitroglycerin, aspirin, and morphine. These interventions serve to relieve chest pain, improve oxygenation, decrease myocardial workload, and prevent further platelet aggregation. The other medications may be used later in the patient’s treatment.

The patient has been discharged from the hospital after acute coronary syndrome (ACS) and is beginning a cardiac rehabilitation program. Which focus of care would the nurse plan for the early recovery phase of rehabilitation?

• Therapeutic lifestyle changes need to become lifelong habits.

• Activity level is gradually increased under supervision and monitoring.

• Physical activity started in the hospital will be progressed independently at home.

• Attention is on managing chest pain, anxiety, dysrhythmias, and other complications.

• In the early recovery phase after the patient is dismissed from the hospital, the activity level is gradually increased under supervision and with ECG monitoring. The late recovery phase includes therapeutic lifestyle changes that become lifelong habits. In the hospital, activity is dependent on the severity of the angina or myocardial infarction, and attention is focused on the management of chest pain, anxiety, dysrhythmias, and other complications. With early recovery phase, the cardiac rehabilitation team may suggest that some physical activity be initiated at home, but this is not always done.

An older adult patient with a history of prostate cancer and hypertension is in the emergency department with substernal chest pain. Which priority action will the nurse complete before administering sublingual nitroglycerin?

• Administer morphine sulfate IV.

• Auscultate heart and lung sounds.

• Obtain a 12-lead electrocardiogram (ECG).

• Assess for coronary artery disease risk factors.

• If a patient has chest pain, the nurse should institute the following measures: (1) administer supplemental oxygen and position the patient in upright position unless contraindicated, (2) assess vital signs, (3) obtain a 12-lead ECG, (4) provide prompt pain relief first with a nitrate followed by an opioid analgesic if needed, and (5) auscultate heart sounds. Obtaining a 12-lead ECG during chest pain aids in the diagnosis.

The nurse teaches a patient with chronic stable angina about nitroglycerin. Which patient statement would alert the nurse to a need for further teaching?

• “I will replace my nitroglycerin supply every 6 months.”

• “I can take up to 5 tablets every 3 minutes for relief of my chest pain.”

• “I will take acetaminophen (Tylenol) to treat the headache caused by nitroglycerin.”

• “I will take nitroglycerin 10 minutes before an activity that usually causes chest pain.”

• The recommended dose of nitroglycerin is one tablet taken sublingually (SL) or 1 metered spray for symptoms of angina. If symptoms are unchanged or worse after 5 minutes, the patient should be instructed to activate the emergency medical services (EMS) system. If symptoms are improved, repeat the nitroglycerin every 5 minutes for a maximum of 3 doses and contact EMS if symptoms have not resolved completely.

The nurse is teaching a patient recovering from a myocardial infarction. How would the nurse present the topic of resuming sexual activity?

• Delegated to the primary care provider

• Explained along with other physical activities

• Avoided because it is embarrassing to the patient

• Accomplished by providing the patient with written material

• Although some nurses may not feel comfortable discussing sexual activity with patients, it is a necessary component of patient teaching. It is helpful to consider sex as a physical activity and to discuss or explore feelings in this area when other physical activities are discussed. Although providing the patient with written material is appropriate, it should not replace a verbal dialogue that can address the patient’s questions and concerns.
  

The nurse is examining the electrocardiogram (ECG) of a patient just admitted with a suspected myocardial infarction (MI). Which ECG change is most indicative of prolonged or complete coronary occlusion?

• Sinus tachycardia

• Pathologic Q wave

• Fibrillatory P waves

• Prolonged PR interval

• The presence of a pathologic Q wave, as often accompanies STEMI, is indicative of complete coronary occlusion. Sinus tachycardia, fibrillatory P waves (e.g., atrial fibrillation), or a prolonged PR interval (first-degree heart block) are not direct indicators of extensive occlusion.

A patient returns to the unit after a cardiac catheterization. Which nursing care would the registered nurse delegate to the assistant personnel (AP)?

• Take vital signs and report abnormal values.

• Check for bleeding at the catheter insertion site.

• Prepare discharge teaching related to complications.

• Notify the health care provider of S-T segment changes.

• Vital signs should be delegated to the AP. Assessment of the site, preparation of discharge teaching, and reporting S-T elevation would be registered nurse scope of practice.

Which patient is at greatest risk for sudden cardiac death (SCD)?

• A 52-yr-old black man with left ventricular failure

• A 62-yr-old obese man with diabetes and high cholesterol

• A 42-yr-old white woman with hypertension and dyslipidemia

• A 72-yr-old Native American woman with a family history of heart disease

• Patients with left ventricular dysfunction (ejection fraction less than 30%) and ventricular dysrhythmias after myocardial infarction are at greatest risk for SCD. Other risk factors for SCD include: (1) male gender (especially blacks), (2) family history of premature atherosclerosis, (3) tobacco use, (4) diabetes, (5) high cholesterol levels, (6) hypertension, and (7) cardiomyopathy.

A patient has received a bolus dose and an infusion of alteplase (Activase) for an ST-segment elevation myocardial infarction (STEMI). Which finding would be used to evaluate the effectiveness of the medication?

• Presence of chest pain

• Blood in the urine or stool

• Tachycardia with hypotension

• Decreased level of consciousness

• Alteplase is a fibrinolytic agent that is administered to patients who have had a STEMI. If the medication is effective, the patient’s chest pain will resolve because the medication dissolves the thrombus in the coronary artery and results in reperfusion of the myocardium. Bleeding is a major complication of fibrinolytic therapy. Signs of major bleeding include decreased level of consciousness, blood in the urine or stool, and increased heart rate with decreased blood pressure.