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201 Cards in this Set
- Front
- Back
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Modifiable Risk factors (associated with CAD)
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Cholesterol abnormalities
smoking HTN Diabetes Obesity physical inactivity |
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Non-Modifiable Risk factors (associated with CAD)
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fam hx
Age gender(men earlier) Race (african americans have a higher incidence) |
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What is the most beneficial risk factor to modify in regards to CAD?
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Reducing cholesterol to decrease risk of CAD
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What is the goal range for Total cholesterol?
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Less than 200
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What is the goal range for HDL?
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Greater than 40
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What is the goal range for LDL?
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Less than 100
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If the patient already has CAD what is the goal range for LDL?
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Less than 70
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Dietary measures to reduce cholesterol
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Weight loss
Increased fiber antioxidants dark leafy greens, Omega-3 fatty acids such as fish and plant source decrease lipid levels. |
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What two types of diets are good to reduce cholesterol?
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Mediterranean diet (olive oils,fish, nuts) is the best, also
DASH diet (grains, fruit, veg, poultry, fish, nonfat dairy, nuts, seeds) |
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4 subclasses of Antihyperlipidemics?
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Statins
Fibric acid derivatives Nicotinic acid Bile acid sequestrants |
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Prototype statin?
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lovastatin
All statins end in "statin" |
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Example of Fibric acid derivatives?
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fenobribrate, gemfibrozil
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Example of Nicotinic acid?
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niacin
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Example of Bile acid sequestrants?
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cholestyramine
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What is the only Antihyperlipidemic subclass that will decrease overall mortality rate?
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The Statins
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What do that statins do to lipid levels?
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Lowers LDL, triglycerides, & Total cholesterol; raises HDL
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How do statins work?
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They inhibit synthesis of cholesterol
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Statins cause an increase adverse effect of what?
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muscle weakness and "rabdomylosis"- break down of muscle fibers, myalgia
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Why do statins need to be taken with a meal?
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They are highly protein bound so if not taken with a meal they can quickly reach toxic levels
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What food can't statins be taken with and why?
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Do not take with grapefruit! It inhibits the P450 system which slows metabolism of the meds and make more available to the body, which can increase risk of toxicity
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Are statins a prn drug or a lifelong drug, and why?
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Lifelong commitment, if they are stopped abruptly a 3 fold rebound effect will happen and most likely cause an MI
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Is diet still important even though pt is taking a statin?
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Yes, it is not a substitute for diet change!
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Fibrates (fibric acid) work to..
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Decreased triglyceride production in liver
and Increases HDL |
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Fibrates (fibric acid) have to be used in conjunction with
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diet and exercise
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What to monitor when pt is on Fibrates (fibric acid) therapy?
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Monitor trigylceride & cholesterol levels
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Adverse effects of Fibrates (fibric acid)
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G: abd pain, diarrhea
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When to take Fibrates (fibric acid)
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Take 30 min. ac meals
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Nicotinic acid- niacin- is most effective at...
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increasing HDL
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Nicotinic acid- niacin- also decreases...
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LDL & Tri
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Niacin Adverse Effects:
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GI upset,
flushing of face & neck, pruritus, hyperglycemia |
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Take niacin with or without meals?
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with meals!!
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How do Bile Sequestrants work?
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Binds with bile acids in the GI tract forming an insoluble complexincreased clearance of cholesterol
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Bile Sequestrants ultimately decrease...
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LDL
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Adverse effects of Bile Sequestrants (cholestyramine)
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Abd discomfort, CONSTIPATION, nausea
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When to give Bile Sequestrants (cholestyramine)
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Give AC meals; give other meds 1hr before or 4-6hrs after this med
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How to admin Bile Sequestrants (cholestyramine)
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Mix (dry powder) with water or noncarbonated drinks
Mix for patients! They have been known to just put the dry powder in their mouths. |
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Why should Bile Sequestrants be used with extreme caution in children?
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Intestinal obstruction!!
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What labs can be affected by Bile Sequestrants?
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They may cause a prolonged Prothrombin time
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Cad leads to ____ which leads to ______ which leads to ____
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Ischemia ……Necrosis……MI
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Does CAD happen quickly?
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No, it is a Progressive disease, will get worse, must be watched
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With CAD, Arteries supplying heart become _________ by plague from _________ -heart is O2 starved
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blocked
cholesterol |
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What is the outcome of blocked arteries from CAD?
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Outcome depends on how long blood flow is limited
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With a short duration of limited blood flow, the muscle becomes
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ischemic
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Is there any long term damage if the heart muscle becomes ischemic?
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Not if the blood flow is restored
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Chronic stable angina
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Predictable w/ moderate to prolonged exertion and relieved by rest and nitroglycerin. It results only in slight limitation of activity.
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Chronic stable angina Occurs w/ mod-prolonged _________
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exhertion
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Chronic stable angina Results in slight limitation of ______
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activity
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Chronic stable angina duration:
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usually 15 minutes or less
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Chronic stable angina is resolved with?
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rest and nitroglycerin
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Unstable angina is...
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anytime angina is not relieved by rest or nitroglycerin
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Which angina is due to demand ischemia?
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chronic stable angina
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Which angina is due to supply ischemia? (low supply)
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Unstable angina
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With unstable angina there is a severe drop in
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blood flow
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Which angina is a medical emergency?
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unstable angina, and it needs immediate attention
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Acute Coronary syndrome (ACS) includes...
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Unstable angina and
MI (STEMI and non-STEMI) |
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STEMI
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ST elevated myocardial infarction
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Non-ST elevation MI
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MI with no ST elevation
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Unstable angina is an increase in ___ deficiency with increase in ________
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O2
blockage |
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Unstable angina Occurs at rest or w/ minimal _____
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exhertion
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Unstable angina Duration:
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Lasting greater than 15 minutes
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Unstable angina Associated symptoms:
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SOB, diaphoresis, sweaty, pale, SCARED, "Overwhelming sense of impending doom"
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How can MIs be different for women or diabetics?
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They can show little or no symptoms, chest pain may be mild or absent, may feel pain somewhere else like jaw
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Myocardial Infarction
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Vessel blocked & blood flow is abruptly interrupted --> lack of O2--> infarction
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Infarction= ?
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irreversible tissue death
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How long does it take for permanent damage during a myocardial infarction?
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6 hours and after
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Need to treat MI pts within _____ hrs
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4-6 hrs
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After 6 hours of MI, myocardium will become permanently damaged and is replaced with?
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Scar tissue
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When myocardium is replaced with scar tissue after an MI, this Permanently changes size & shape of left ventricle, this is called
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Ventricular remodeling
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Does the scar tissue contract or conduct electrical activity after ventricular remodeling?
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No.
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Ventricular remodeling decreases ____ and increases chances for _______ for cases of Heart Failure
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function
mortality |
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After 6 hours of MI, the heart turns ___ and ______
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blue and enlarged
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After 48 hours of MI, the heart tissue turns
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Grey
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Most MIs are a result of?
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atherosclerosis of a coronary artery, rupture of plaque, thrombosis, and occlusion of flow
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How do we build up Collateral circulation?
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Through exercise
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How can collateral circulation be a problem with children with cardiac problems?
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It can be the cause of death, kids are too young to have built up their collateral circulation yet
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The extent of the MI injury can really depend on ____ _____
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Collateral circulation
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Other causes of MI
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Vasospasm
Blood loss Low BP Rapid HR Cocaine (it overworks the heart) |
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What is the main branch of artery to the entire left ventricle?
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Left Main
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Which artery is associated with the highest mortality rate if blocked during an MI?
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LAD- Left Anterior Descending
Supplies ant. LV, vent. septum, some RV & pap muscles, cordae tendinea |
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What patients may come in with non typical MI symptoms?
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Women, elderly, DM pts
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Angina vs MI
Onset? Onset? Relieved by? Relieved only by? Duration: Duration: ___ associated symptoms _____ associated symptoms |
Stress/exertion Sudden onset
Relieved by nitro Relieved only by opiods Duration: <15min Duration: >30 Few associated symptoms Many associated symptoms |
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Angina symptoms
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chest pain
anxiety indigestion confused |
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MI symptoms
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SOB
Diaphoresis Major pain (burning, crushing, pressure) feeling of impending doom Shaky, anxious, nervous, restless pale, cool, clammy, dizzy Nausea, fatigues, jaw pain |
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When assessing HR with MI pt, it is common to hear...
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S3 sound
or, S4 sound in HF pts |
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What to assess first for MI pts?
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VITALS!
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What is the protocol for drugs in pts presenting with MI?
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MONA
morphine O2 Nitroglycerin Aspirin |
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What do we hook MI pt up to right away?
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EKG- 12 Lead
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What is a stress test?
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Treadmill while attached to EKG, Heart pts
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What are Nuclear scans?
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For MI pts- assesses heat and cold, decreased blood flow will show up as cold spots, can show where the MI is happening. Uses a radiotracer injection
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MUGA
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A type of nuclear scan, it is a study of blood pooling
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What is a nonstress test?
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It is a way way to stress the heart with drugs to see how much it can withstand. This is in place of the treadmill
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If pt is going to cath lab they need to be _____
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NPO
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Echocardiogram
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A test that uses sound waves to create a moving picture of the heart. The picture is much more detailed than a plain x-ray image and involves no radiation exposure.
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what is the protocol for giving nitroglycerin?
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Ntg q 15 min X 3, if no relief admin morphine
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When do we hold nitroglycerin?
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When BP is less than 100/xx (systolic)
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Why is smoking a risk factor for MI?
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CO2 from smoking decreases O2 in the blood and
the nicotine increases catecholamines (adrenaline) which increases the HR, and vasoconstricts to increase BP and cardiac workload |
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Smoking is also found to cause....
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endothelial dysfunction and vessel wall thinkness
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History risk factors for MI
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Smoking
HTN Diabetes Obesity Alcohol Emotional stress Oral contraceptives Metabolic syndrome |
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What lab is the most cardiac specific isoenzyme (marker)??
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CK-MB
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What is the normal limit for CK-MB and when does it peak?
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Nl=<5%
Peaks w/in 24hrs |
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Why is CK-MB not the best lab test for MI?
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By the time the marker is elevated enough, the MI is already far too gone (MI need to be treated within 6 hours, CK-MB peaks within 24 hours... that does not really help!)
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What are the labs that are associated with MI?
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CK-MB
Troponin Myoglobin LDH, CRP, WBC’s |
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Is Troponin cardiac specific?
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Yes
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Troponin is detected when?
Normal limit? |
Detected w/in few hrs during MI
Nl= <0.1 |
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When is myoglobin detected?
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Increases w/in few hrs. peaks w/in 12 hrs
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Why are WBCs elevated with an MI?
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The injury to the cardiac muscle elevates WBCS by day 2
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What is CRP?
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an inflammatory marker which shows tissue inflammation, it is NOT CARDIAC SPECIFIC
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What is LDH?
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lactic acid that is released into the blood when muscle is damaged, it is not cardiac specific
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What are the 3 main drugs used to treat angina? And, how do they work?
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Nitrates
Beta Blockers Calcium Channel Blockers All used to decrease O2 demands |
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What meds are adjunct therapy for angina?
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Aspirin, clopidogrel, heparin, antihyperlipids, ACE inhibitors
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How do the adjunct therapy meds work to treat angina?
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used to slow down progression of CAD, prevent complications, or minimize symptoms
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What do nitrates do?
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Dilate vascular smooth muscle & both venous & arterial vessels (more relaxation on venous side)
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How does venous dilation (from ntg) help in regards to the workload of the heart?
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With venous dilation, there is a decrease in the amount of returning blood to the heart, so the heart does not have to work as hard to pump all the returning blood through
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How does arterial dilation (from ntg) help in regards to the workload of the heart?
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Arterial dilation causes a decrease in systemic vascular resistance and arterial pressure, so the heart does not have to pump as hard against pressure/resistance.
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When the workload of the heart is decreased, the need for _____ is decreased
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O2
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Beta Adrengeric Antagonists
AKA
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Beta Blockers
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Beta blockers work by
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Preventing beta adrenergic receptors from sympathetic stimulation
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Beta blockers work to
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Slow heart
Decrease AV conduction Decrease CO Decrease systolic & diastolic BP (during rest and exercise) |
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How do we know if a drug is a beta blocker?
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All beta blockers end in "LOL"
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What typical BB is a NON-SELECTIVE blocker? (blocks both B1 and B2 receptors)
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Propranolol (Indural)
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What does propranolol work to do?
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decrease HR and contractility, slows conduction, suppresses automaticity
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Important pt teaching for Propranolol (Indural)?
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Self-monitor pulse/HR, teach about orthostatic hypotension, DO NOT STOP TAKING ABRUPTLY
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Propranolol (Indural) is used to treat...
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HTN, angina, cardiac arrhythmias, hyperthyroidism, and migraines
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What typical BB is a CARDIOSELECTIVE blocker? (blocks only B1 receptors)
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Metoprolol
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What are the A/E associated with beta blockers?
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Decreased BP, dizzy, HA, dysrhythmias
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What to monitor with pts on Beta Blockers?
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HR, BP, ausculate for wheezes & crackles.
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Major teaching for beta blockers?
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orthostatic hypotension (to prevent falls)
Taper dose when Dcing |
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What is a prototype Ca Channel Blocker?
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verapamil
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____ is needed to contract the heart
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Ca
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Calcium Channel Blockers stop Ca from moving across cell membrane, which results in...
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Decrease contraction
Depress automaticity Slows conduction |
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Do Ca Channel Blockers (Verapamil) increase or decrease afterload? How does it do this?
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DECREASE AFTERLOAD- it causes arterial dilation
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When are Ca Channel Blockers usually prescribed?
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If pt can not tolerate Beta Blockers OR
If symptoms not adequately controlled by Beta Blockers |
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What ASA/antiplatelets are used for MI pts?
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aspirin, Plavix- Keep blood from clotting
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What Fibinolytics/Thrombolytics are used in MI pts?
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t-PA-( Tissue Plasminogen Activator)
Streptokinase |
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Where is t-PA administered?
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done in cath lab, ER, ICU
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What does t-PA do?
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For Acute MI
- dissolves thrombi & restores coronary blood flow
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What to monitor when admin t-PA?
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neuro status, clotting labs, s/s internal bleed, stool & urine for occut blood.
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What are the ABSOLUTE contraindications for t-PA?
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Active internal bleeding
Recent Stroke (within 2 months) Recent surgery |
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What anticoagulants are used in MI pts?
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warfarin, heparin
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percutaneous transluminal coronary angioplasty (PTCA)
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catheter with a tiny balloon at its tip is inserted into coronary artery to be treated. Balloon is inflated once the catheter has been placed into the narrowed area of the coronary artery. Inflation of the balloon compresses the fatty tissue in the artery and makes a larger opening inside the artery for improved blood flow.
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In case of any MI, it is Hospital core measures to give _____ & prescribe at discharge
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ASA- aspirin
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What are Ace inhibitors used to treat?
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used to treat a number of heart-related conditions
including high blood pressure, heart failure, heart attack, and to prevent kidney damage associated with high blood pressure & DM
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What do Ace Inhibitors do?
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They REDUCE arterial pressure, PRELOAD and AFTERLOAD on the heart. Prevent vasoconstric. & water retention
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Ace Inhibitors end in "___"
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Prils
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What to monitor with Ace Inhibitor therapy?
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K (do not give if too high)
BP (can drop a lot) |
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What teaching for Ace Inhibitor Therapy?
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avoid salt substitutes (they contain a lot of K, can bring K to dangerous levels)
postural hypotension |
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What annoying side effect do the Ace Inhibitors cause?
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That annoying cough
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What meds does a pt need to be on post Percutaneous Coronary Intervention?
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Heparin (blood thinner) and Cardizem (Ca channel blocker) to prevent vasospasm
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What to watch for post Percutaneous Coronary Intervention?
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"Restenosing," When stent collapses
Watch for 1st 24 hours post procedure |
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Complications of PTCA
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Acute closure of vessel (causes chest pain)
Bleeding from insertion site Reaction to contrast medium used in angiography Monitor for hypotension, hypokalemia, and dysrhythmias Report any of these findings to physician IMMEDIATELY |
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Pre PTCA care
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Teaching, CONSENT, NPO
Baseline Vitals, Allergies? Place Large Bore IV- 18G Check Labs (Bun and CR critical to make sure kidneys can clear contrast) |
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Post PTCA care
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Monitor and observe puncture site for bleeding.
Closely observe VS and frequent checks of distal pulses in both limbs. Restricted bed rest, with limbs STRAIGHT for about 6-8hrs before ambulation unless special collagen plugs are used to seal the vessel Anticoagulant therapy such as heparin during and shortly after procedure. Antiplatelet drug prescribed for 1-3 months after procedure (patient may take aspirin on a permanent basis) |
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Goal of treatment of acute MI Pain... DECREASE _______ & INCREASE ________
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DECREASE DEMAND & INCREASE SUPPLY
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How to treat acute MI pain?
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Vitals, O2, IV, pain relief, drug therapy
MONA |
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What does MONA stand for?
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Morphine
O2 Ntg Aspirin |
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What activity for acute MI pain?
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Bed rest, BED rest, BED REST!
Seriously... BED REST! |
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What drug is absolutely contraindicated within 24 hours of giving nitroglycerin???
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Viagra
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MI Patient teachings?
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Diet (low fat, low salt)
Exercise (increase collaterall circ and lower cholesterol) Reduce Stress Teach about disease process Teach about meds (BB, statins, lipid lowering agents, aspiring, etc) Smoking cessation When to seek emergency care |
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Articulate the difference between percutaneous coronary interventional and coronary artery revascularization procedures.
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Percutaneous coronary intervention- non surgical stent
Coronary artery revascularization procedure- The surgical procedure places new blood vessels around existing blockages to restore necessary blood flow to the heart muscle. |
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What does ntg do to preload and afterload?
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Reduces both
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With ntg, Reflex ____________ may follow the drop in BP
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tachycardia
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Ntg, redistributes blood flow in heart which improves _________ to ________ areas.
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circulation
ischemic |
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How to position ots when admin ntg?
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Have pts. Lie down or sit to allow for rest and decrease O2 needs of heart
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How to store ntg?
|
Keep tabs in original dark bottle w. lid on
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What to monitor after admin ntg?
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Monitor for orthostatic hypotension
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After adming ntg, Treat any _______ that develops with ASA or acetaminophen until tolerance to AE occurs
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headache
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What should pts always do when having angina?
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Sit or lie down
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When should pts with angina seek medical attention?
|
If 3sublingual tabs don’t alleviate pain, seek immediate emergency medical attention
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What is the best route for ntg?
|
sublingual, it is immediatly available.
Ointments DON’T provide immediate relief of acute angina pain. Use prophylactically. |
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What to teach about applying ntg ointment?
|
Do not apply in places with excessive hair
|
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What to assess before admin ntg?
|
BP/HR
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Chronic stable angina is usually associated with...
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fixed atherosclerotic plaque
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Labs associated with CAD
|
elevated triglycerides, HDL LOL
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EKG changes associated with ischemia- Angina episode reveals...
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ST-depression, T-wave inversion or both. ST and T-waves usually subside when ischemia is resolved.
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EKG changes associated with ischemia- Variant angina, caused by coronary vasospasm reveals...
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Elevation of ST segment during angina
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Unusual MI symptoms in elderly and females
|
• Absent chest pain
• Confusion d/t poor cardiac output • Fatigue • SOB • Feeling of indigestion |
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Which med has a higher incidence of allergic reactions, t-PA or Streptokinase?
|
Streptokinase
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Difference between t-PA and Streptokinase?
|
T-pa: thrombolytic made from human DNA, used more often d/t ↓ occurrence of allergic reaction
Streptokinase: not derived from human DNA, higher instance of allergic reaction, more systemic bleeding |
|
|
Patient t-PA and Streptokinase postcare
|
monitor for bleeding, vitals BP, monitor LABS: CBC, PT/PTT/INR
implement fall precautions to avoid injury |
|
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Indicators of reperfusion
|
Rhythm changes- usually ventricular rhythms- irregular d/t overwhelming O2 causing heart to not know what to do and it beats irregularly until it accommodates to the reperfusion
|
|
|
EKG changes associated with infarction-
When infarction occurs, one of 3 EKG changes can be seen |
ST-Elevation MI (STEMI)
T-wave inversion Tachycardia Non-ST-Elevation (NSTEMI) (An abnormal Qwave) |
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What EKG changes do women have that present with MI?
|
women having an MI present with a NSTEMI or T-wave inversion
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Antiplatelets will do what to bleeding time?
|
Prolong it.
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What to monitor for in pts taking antiplatelets?
|
Monitor for signs of bleeding: gums, nose, stool, urine, surface scrapes, IV sites, incisions
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What labs to monitor for in pts taking antiplatelets?
|
Monitor PT/PTT/INR levels
Platelets |
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How to admin antiplatelets?
|
give with food to decrease GI irritation and possible GI bleeding
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what is an adverse effect of antiplatelets?
|
GI upset
|
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What risk to assess for with pts on antiplatelets?
|
Fall risk (orthostatic hypotension)
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What S/E go with ASA therapy?
|
GI distress/bleeding
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What social activities should pts avoid while on ASA therapy?
|
Smoking and drinking (GI upset and bleeding)
|
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What should ASAs be given with to minimize GI distress?
|
milk or food
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What labs to test for pts on long term ASA?
|
CBC, Plt count, Liver and renal function tests.
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What s/s to notify MD about in regards to ASA therapy?
|
Confusion, dizziness, drowsiness, seizures, wheezing, Black tarry stools, coffee ground like emesis, tinnitus, or blurred vision
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Lovastatin action?
|
HMG-CoA reductase inhibitor- inhibiting biosynthesis of cholesterol- decreasing progression of atherosclerosis
|
|
|
What does Lovastatin do for lipids?
|
Decreases LDL, triglycerides, and total cholesterol; raises HDL
|
|
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Is Lovastatin affected by the P450 system?
|
YES!!
|
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What is the 1 food that Lovastatin cannot be taken with?
|
Grapefruit
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Is Lovastatin short term or long term drug?
|
Lifelong medication
|
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What happens if Lovastatin is abruptly stopped?
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Abrupt discontinuation of medication can lead 3 fold rebound and ↑ risk of MI
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What adverse rxs from Lovastatin?
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Malasia- muscle weakness and the severe form Rabdomylosis- severe muscle weakening and deterioration
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Pt teaching for Lovastatin?
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-Lifelong medication regimen
-DO NOT ABRUBTLY STOP TAKING MEDICATION – increases risk of MI -Not used as a substitute for proper diet and exercise- low fat diet recommended -S/S: watch for muscle weakness and pain- report immediately to physician -DO not eat or drink any grapefruit products d/t its suppression of the p450 system- can increase risk of toxicity |
