Coronary Artery Disease

Coronary Artery Disease MYOCARDIAL INFARCTION

Case scenario A 46-year- old man is brought to the emergency department after experiencing crushing substernal chest pain, which was unrelieved by rest or nitroglycerin. He is pale, cool, clammy, and diaphoretic. He complains of inability to take a deep breath and nausea. His blood pressure is 105/80 mmhg, heart rate 92bpm and respirations 28 per minute.

Diagnostic Procedures • Cardiac Marker Studies • • • •

Cardiac Enzyme Analysis (CPK and CPK-M) Lactic Dehydrogenase (LDH) Troponin I Myoglobin

• Imaging Studies • Echocardiography

• • • • •

MRI (Magnetic Resonance Imaging) Transesophageal Echocardiograph Chest X-ray Cardiac Catheterization and Angiography Digital Subtraction Angiography

Cardiac Marker Studies Cardiac Enzyme Analysis (CPK and CPK-M) -The CPK isoenzymes test measures the different forms of creatine phosphokinase (CPK) in the blood. CPK is an enzyme found mainly in the heart, brain, and skeletal muscle.

Cardiac Enzyme Analysis (CPK and CPK-M) CPK: Male- 55-170 U/L; 50- 325 mu./ml Female- 30-135U/L; 50-250 mu./ml Highly sensitive, specific and cost effective, accurate indication of Myocardial Infarction -Onset:5-6hrs -Considerations: Factors that can affect test results include cardiac catheterization, intramuscular injections, recent surgery, and vigorous and prolonged exercise or immobilization. Isoenzyme testing for specific conditions is about 90% accurate.

Lactic Dehydrogenase (LDH) LDH is a blood test that measures the amount of lactate dehydrogenase (LDH). -Onset:12hrs, Peak:48hrs Return to Normal: 10-14 days NV: 100-225 mu./ml *LDH1 most sensitive indicator of Myocardial Infarction

Troponin I Troponin is released during MI from the cytosolic pool of the myocytes. Its subsequent release is prolonged with degradation of actin and myosin filaments. The troponin test can be used as a test of several different heart disorders, including myocardial infarction. • detectable in 3-4hrs • Peak: 4-24hrs • remains elevated for 1-3wks

Myoglobin Myoglobin tests are done to evaluate a person who has symptoms of a heart attack (myocardial infarction) or other muscle damage. • rises in 1-3hrs • Peak: 4-12hrs • Normal by 12-24hrs; also elevated in renal and musculoskeletal disease.

Myoglobin Preparation: This test requires 5 ml of blood. Collection of the sample takes only a few minutes. A urine myoglobin test requires 1 ml of urine collected into a urine collection cup. Aftercare: Discomfort or bruising may occur at the puncture site or the person may feel dizzy or faint. Pressure to the puncture site until the bleeding stops reduces bruising. Warm packs to the puncture site relieve discomfort.

Imaging Studies Echocardiography -uses sound waves to produce an image of the heart -uses ultrasound to assess cardiac structure and mobility *instruct the patient to remain still, in supine position. *Head of Bed is elevated to 15 degrees to 20 degrees (greater than 20 degrees-orthopnea)

Magnetic Resonance Imaging (MRI) -detect and define between healthy and diseased tissues. -use strong magnetic field and waves. -can actually show the heart beating and blood flowing.

Magnetic Resonance Imaging (MRI) Pre-procedural tee: • secure consent, procedure will last 4560min. • remove all metals • clients with pacemaakers, prosthetic valves/ implanted clips or wires are not eligible. • assess if the patient is claustrophobic, it makes a loud, knocking noise.

Transesophageal Echocardiograph -allows ultrasonic imaging of the valves, cardiac structures and great vessels via esophagus.

Transesophageal Echocardiography Pre-procedural Tee: • NPO(4-6hrs) • Remove dentures and other oral prosthetics • Assess for the history of esophageal surgery or allergy to anesthetics. • Keep suction and resuscitation equipment available. • Topical spray anesthesia is administered to depress gag reflex. • Place client in chin-to-chest position to facilitate endoscope.

Transesophageal Echocardiograph

Post-procedural Tee: • NPO until gag reflex returns • Place in lateral or semi-fowlers position • Throat lozenges to relieve sore throat soreness • Observe for laryngeal edema, cardiac dysrrhythmias, pharyngeal bleeding and hypoxia

Chest X-ray

To determine overall size and configuration of the heart and size of the cardiac chambers.

Cardiac Catheterization and Angiography Purpose: • evaluate function • measure heart chamber pressures • measure Oxygen Saturation • Biopsy • Performing electrophysiologic studies Complication: • Acute hemorrhage • Transient Arrhythmias • Nausea and Vomitting

Cardiac Catheterization and Angiography

Cardiac Catheterization and Angiography Before the Procedure: • NPO (6-8hrs) • Mild IV or oral sedative will be given; local anesthesia to the insertion site. • Warm, light headedness or nausea will be felt after the contrast medium is injected. • cough or breathe deeply as instructed during the test • metallic taste After the procedure: • Dye will be eliminated • Supine for several hours; report chest pain • Femoral: leg straight 12hrs or as ordered. Head elevation not more than 30 degrees. • Brachial: arm straight for at least 24hrs or as ordered • Check insertion site- weak or absent pulse indicates embolus

Digital Subtraction Angiography -a type of fluoroscopy technique used in interventional radiology to clearly visualize blood vessels in a bony or dense soft tissue environment. Images are produced using contrast medium by subtracting a pre-contrast image or the mask from later images, once the contrast medium has been introduced into a structure. After the DSA: -the individual needs to lie still for about 6 hours to prevent bleeding.

Digital Subtraction Angiography

Patient Management Medical management • Immediate assessment • 12 lead ECG stat! ,10min • Measure Oxygen and saturation • Obtain initial serum cardiac cardiac marker level • Evaluate initiate electrolyte and coagulation studies • Chest x-ray within 30mins.

IMMEDIATE GENERAL TREATMENT 1. Morphine- Drug of choice as analgesic for episodes of M.I ACTION- Cardiac workload to decrease body’s demand for oxygen - dilates bronchioles to enhance oxygenation - given if pain is unrelieved by Nitroglycerin - Monitor B.P may cause unexpected Hypotension 2. Oxygen at 4 LPM via facemask 3. Nitroglycerin (Nitrates)- sublingual or spray (0.3- 0.4mg) for 3 times@ 5 mins. Interval ACTION: - decrease myocardial oxygen consumption Contraindications: Hypotension, Bradycardia <60 bpm 4. Aspirin- 160-325 mg (initially)

Additional Adjunctive Therapies • Beta blockers-reduces myocardial oxygen consumption by blocking BAdrenergic sympathetic stimulation in the heart NURSING CONSIDERATIONS: Monitor BP, ECG, HR, never discontinue abruptly • Thrombolytics – Heparin – Enoxaparin (Lovenox Available bedside Meds as Antidote: 1. Aminocaproic Acids 2. Protamine Sulfate 3. Vitamin K (Aqua Mephyton)

Nursing Consideration for Thrombolytics Regimen: • Minimize the number of times the patient’s skin is punctured • Avoid I.M injections as much as possible • Check for signs and symptoms of bleedingepistaxis, rashes, petichiae, gingical bleeding • Apply direct pressure @ puncture sites • Assess coagulation profile prior to administration • Monitor and watch out for decrease BP, increase heart rate and decrease hemoglobin and hematocrit profile.

Additional Adjunctive Therapies ACE Inhibitors ACTION- promotes vasodilation and diuresis by decreasing preload and decreasing afterload= decrease cardiac workload NURSING MANAGEMENT ASSESSMENT • Renal fluid, electrolyte • Monitor baseline date: ECG, BP, HR, RR • Evaluate liver function • Monitor and watch out for hypotension, hypovolemia, Hyperkalemia • Prior to initiation of ACE inhibitors, hyperkalemia is first corrected • Not given when potassium is 5.0 mEq/L • Weigh patient daily to report rapid weight gain and assess for feet and hand edema.

SURGICAL APPROACH FOR M.I:

2. PTCA- Percutaneous Transluminal Coronary Angioplasty 2. CABG- Coronary Artery Bypass Grafting

NURSING MANAGEMENT IN GENERAL FOR M.I PATIENTS: • Initiate an I.V line • limit hydration • Oxygenation, keep patient in high fowlers o fowler’s position • Keep patient well rested • Monitor ECG ad hemodynamic procedure • Assess urine output of 4 • Monitor patient oxygen saturation • Watch out for crackles, cough, increased RR and edema • INSTITUTE DIET: low salt, low fat- no caffeine added • Give stool softener- prevents Valsalva Maneuver

NURSING MANAGEMENT IN GENERAL FOR M.I PATIENTS:

Health Teaching about: • Ways of controlling cholesterol abnormalities through dietary measures and physical activity • Cessation of smoking • Managing hypertension • Controlling DM

Prepared by:

ANTOLIN, RANDOLPH O. CERRERA, CHRISTINE JANE D. CUACHIN, ROSEMARIE CAGUIOA, MARIVIC ENGNAN, MARY JHANE D. FALLEJO, JESSICA MARIE P. PERMEJO, NESSIE A.

Thank you! God Bless Us…