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73 Cards in this Set

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CHEST PAIN, ACUTE CORONARY SYNDROME
CHEST PAIN, ACUTE CORONARY SYNDROME
Define Pain
A sensation that can range from mild, localized discomfort to agony. Pain has both physical and emotional components. Pain is mediated by specific nerve fibers that carry the pain impulses to the brain.
Define Visceral
Pertaining to the viscera or their outer covering.
Define Pleuritic
Pertaining to the pleural layer of the lungs.
Define Ischemia
Inadequate blood supply to a region of the body.
Define Murmur
An unusual “whooshing” sound created by blood flow through a heart valve, by blood flow through a narrowed chamber, or by an unusual connection between the chambers, as seen with congenital heart disease.
Define Arrhythmias
Abnormal patterns of cardiac contractions.
Define Flutter
To vibrate in irregular spasms.
Define Fibrillation
very rapid irregular contractions of the muscle fibers of the heart resulting in a lack of synchronism between heartbeat and pulse
Define Coarctation
A stricture or narrowing especially of a canal or vessel (as the aorta)
Define Atherosclerosis
Formation of fatty plaques in the walls of arteries, restricting blood flow to deep tissues.
Define Necrosis
The death of cells or tissue from disease or injury.
Define Infarction
The formation of an infarct, an area of tissue death, due to a local lack of oxygen.
Define Aneurism
an abnormal blood-filled bulge of a blood vessel and especially an artery resulting from weakening (as from disease) of the vessel wall
Define Tamponade
A life-threatening situation in which there is a large amount of fluid (usually blood) inside the pericardial sac around the heart that it interferes with the performance of the heart. The excess fluid acts to compress and constrict the heart.
Define Vegetations
An abnormal growth upon a body part. (ie. Fibrin vegetations on the mitral valve)
Define Patent
Open, unobstructed, or affording free passage.
Define Occlusion
The partial or complete obstruction of a passage.
Define Palpitation
Unpleasant sensations of irregular and/or forceful beating of the heart.
Define Emboli
Abnormal particles circulating in the blood, such as an air bubble or clot.
Explain how gender, sex, age and diabetes can effect the presentation of a patient with ASVD.
Advanced age, female gender, and a history of diabetes mellitus are associated with more atypical presentations. However, there is no evidence that AMI patients should be evaluated differently in the ED as a result of age or gender.
Describe the approach to a patient with chest pain and explain why the history is so important to making a diagnosis.
chest pain, and hx should include OPQRST. In addition, sxs such as NV, diaphoresis, dyspnea, lightheadedness, syncope, and palpitations, may be helpful.
What symptom would make the diagnosis of acute coronary syndrome (ACS) less likely?
In the ED, cardiac risk factors are poor predictors of cardiac risk for myocardial infarction or other ACS.
Understand which lab and imaging studies will be helpful for AMI
12 lead EKG, CK-MB, troponin I or T, sestamibi scanning
Explain why serial determinations for AMI may be needed.
serial measurements are more sensitive and accurate than initial single measurements and serial sampling every 2-3 h is validated for rapid exclusion of AMI in acute CP pt's
Know what EKG changes one would expect to find in a patient with acute myocardial infarction (AMI), exertional angina, and unstable angina (UA). Understand why serial tracings may be helpful
ST segment elevated on initial ECG in 50% pt's. 1/2 won't have ST segment changes on initial ECG. Most other pt's without ST elevation will have ST depression and/or T wave inversions. 1-5% with AMI have normal initial ECG
What is the importance of creatine kinase MB isoenzyme for ACS
most commonly used marker in ACS, serial rise in CK-MB above 5X's baseline followed by fall to baseline is considerred diagnostic for AMI
What is the importance of serum troponin I or T in diagnosing AMI
elevated levels accepted as diagnostic for AMI
What is the importance of sestamibi scanning for the ACS pt
useful in pt who doesn't have serial ECG or serum marker changes of AMI and is not a candidate for standard stress testing
Identify what the following findings on physical examination may reveal about the patient with ACS: Bradycardia
more common with inferior wall MI. anterior wall infarction, bradycardic rhythms or heart block is extremely poor prognostic sign
Identify what the following findings on physical examination may reveal about the patient with ACS: Diminished 1st & 2nd heart sounds
due to poor myocardial contractility
Identify what the following findings on physical examination may reveal about the patient with ACS: New systolic murmur
an ominous sign, because it may signify papillary muscle dysfunction, flail leaflet of the mitral valve with resultant mitral regurgitation, or a ventricular septal defect.
Identify what the following findings on physical examination may reveal about the patient with ACS: Rales-
rales with or without S3 gallop, associated with L ventricular dysfunction & L-sided congestive heart failure
Identify what the following findings on physical examination may reveal about the patient with ACS: Jugular vein distention (JVD) and Peripheral edema
suggest right-sided congestive heart failure
Identify what the following findings on physical examination may reveal about the patient with ACS: Hypertension or Hypotension
BP can be normal, elevated (due to baseline hypertension, sympathetic stimulation, & anxiety) or decreased (due to pump failure or inadequate preload) Extremes of BP associated with worse prognosis
Identify what the following findings on physical examination may reveal about the patient with ACS: S3 & S4
present in 15-20% of pts with AMI. S4 common in pts with long-standing HTN or myocardial dysfunction.
What percent of dysrhythmias occur in AMI pt's
72 to 100 percent of AMI patients treated in the coronary care unit
What is the hemodynamic consequences of dysrhythmias
they are dependent on ventricular function. Pts with L ventricular dysfunction have relatively fixed stroke volume. They depend on changes in HR to alter cardiac output. optimal HR becomes narrowed with increasing dysfunction
What is the main consequence of dysrhythmias
they may impair hemodynamic performance, compromise myocardial viability by increasing myocardial oxygen requirements, & predispose to more serious rhythm disturbances by diminishing v-fib threshold
Where do many dysrhythmias occur
in the prehospital and ED settings
Discuss the following arrhythmias associated with ACS: Sinus tachycardia
quite prominent in pts with anterior wall AMI. Because increased myocardial oxygen use, persistent sinus tachycardia is associated with a poor prognosis
Discuss the following arrhythmias associated with ACS: Atrial premature contractions (PAC’s)
PAC's common. occur up to 50% AMI pts & not associated with increased mortality related to acute event
Discuss the following arrhythmias associated with ACS: Ventricular tachycardia
shortly after AMI often transient & doesn't portend poor prognosis. When v-tach occurs late in AMI, its usually associated with transmural infarction and L ventricular dysfunction, induces hemodynamic deterioration, & associated with mortality rate near 50%
Discuss the following arrhythmias associated with ACS: Ventricular fibrillation
occurring shortly after sx onset doesn't have large effect on mortality & prognosis. Delayed or secondary v-fib during hospitalization is associated with severe ventricular dysfunction & 75% in-hospital mortality
Discuss the following arrhythmias associated with ACS: Ventricular premature contractions (PVC’s)
common in patients with AMI. They do not appear to have much prognostic ability
Discuss presentation of CHF and pericarditis as complications of AMI
CHF can occur thru diastolic dysfunction alone or combined systolic and diastic dysfunction.
Discuss B-type natruiretic peptide (BNP) in setting of AMI
B-type natriuretic peptide is a powerful predictor of outcome, useful for risk stratification of pt's with non ST elevation MI and unstable angina. Elevated levels early in hospital course portend worse 30-day outcome
Discuss patients who post AMI pericarditis
10-20%, more common with transmural AMI, resultsfrom inflammation adjacent to pericardium on epicardial surface of transmural infarction, generally 2-4 days after.
Discuss pericardial friction rubs and AMI
more often with inferior wall and R. ventricular infarction because R. vent lies immediately beneath chest wall
Discuss pain associated with AMI
pain of pericarditis can be confused with infarct extension or post-AMI angina. Classically, discomfort of pericarditis is worse with deep inspiration and relieved by sitting forward
Define the effects of cocaine on the heart and its association with ACS.
Cocaine induces dysrhythmias, myocarditis, cardiomyopathy, and myocardial ischemia and infarction
Describe the treatment for the patient with the following: Persistent symptoms and ST segment elevation myocardial infarction (STEMI)
fibrinolytic therapy or mechanical reperfusion (angioplasty). antiplatelet agents, anticoagulants, antagonists, nitrates, & ACE inhib should be considered, based on sxs, vital signs, & presence or absence of heart failure.
Describe the treatment for the patient with the following: Unstable angina or non-Q-wave infarcts without ST segment elevation or pt's with unstable angina or non-STEMI (NSTEMI)
antiplatelet agents, anticoagulants, possibly antagonists & nitrates. Pts refractory to these or scheduled for percutaneous coronary intervention (PCI) also benefit from glycoprotein (GP) IIb/IIIa antagonists
Discuss the following pharmacologic in the treatment of ACS. Discuss when each would be used and by which route of administration: Oxygen
may reduce ST elevation in pts with AMI. 2-4 LPM of oxygen via nasal cannula, even to pts with normal O2 sat. unstable angina or NSTEMI, O2 provided in pts with signs of hypoxia. goal to achieve immediate reperfusion & limit infarct size
Discuss the following pharmacologic in the treatment of ACS. Discuss when each would be used and by which route of administration: Nitroglycerin
AMI: IV nitro titrated to BP reduction rather than sx (chest pain) resolution.
ACC/AHA guidelines recommend use of IV nitro 1st 24-48 h for AMI, recurrent ischemia,CHF, or HTN
Discuss cautions of using Nitro
should be cautious for pts with inferior wall ischemia because 1/3 might have R. ventricular involvement
Discuss the following pharmacologic in the treatment of ACS. Discuss when each would be used and by which route of administration: Morphine
?
Discuss the following pharmacologic in the treatment of ACS. Discuss when each would be used and by which route of administration: Aspirin
give as soon as possible to all pts with ACSs. ASA alone has shown as efficacious as streptokinase alone, reduces mortality rate by 23%
Discuss the titration of IV nitrates after AMI.
titrated to blood pressure reduction rather than to symptom (chest pain) resolution
Discuss the titration of IV nitrates when they are used in UA
patients with UA who are not responsive to sublingual nitroglycerin tablets
Discuss the effects of nitrates on the following:
Vascular system
relax vascular smooth muscle in arteries, arterioles, & veins thru metabolic conversion of organic nitrates to nitric oxide
Discuss the effects of nitrates on the following:
coronary vascular
has vasodilator effects & increases global & regional myocardial blood flows. When obstructing atherosclerotic lesions contain intact vascular smooth muscle, it may dilate these vessels, improving blood flow
Discuss the effects of nitrates on the following: Cardiac work and oxygen requirements
Reduction in R & L ventricular filling pressures result from peripheral dilatation combined with afterload reduction that results from arterial dilatation, decrease cardiac work & myocardial oxygen requirements.
Discuss the effects of nitrates on the following: inferior MI-
Caution! should not be used for pts with R ventricular infarction. should be used very cautiously for pts with inferior wall ischemia, because 1/3 might have R ventricular involvement
Discuss the effects of nitrates on the following: Serious side effects-
hypotension, which may result in reflex tachycardia and worsening ischemia.
Discuss the effects of nitrates on the following: Mortality rate-
The mortality rate appears to be reduced by 35 percent with the use of nitrates.
Discuss the effects of nitrates on the following: Blood pressure-
in most studies, IV-nitro was titrated to 10% reduction in mean arterial pressure for normotensive pts & to 30 percent reduction in mean arterial pressure for hypertensive pts
Discuss beta-blockers regarding the following: Properties
Adrenergic antagonists have antiarrhythmic, anti-ischemic, and antihypertensive properties.
Discuss beta-blockers regarding the following: Effect on the heart during AMI
During AMI diminishes myocardial O2 demand by decreasing HR, systemic arterial pressure, and myocardial contractility
Discuss beta-blockers regarding the following: Current ACC/AHA guidelines for the use in AMI
all pts with STEMI who don't have contraindication to antagonists tx within 12 h of onset of infarction regardless if received fibrinolytic therapy
Identify the indications for fibrinolytic therapy
standard of care for pts with STEMI, but has limitations
Discuss two important limitations for fibrinolytic therapy
1: 0.5-1% pts have intracranial hemorrhage which usually results in death or stroke. 2: do not achieve early & complete restoration of coronary blood flow in 40-50% of pts
Discuss absolute as well as relative contraindications for fibrinolytic therapy.
Allergies, bleeding disorder, etc.