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Chapter 40
Care of Patients with Acute Coronary Syndromes
Mrs. Marion Kreisel MSN, RNAdult Health 2Fall 2011

Coronary Artery Disease
Includes stable angina and acute coronary syndromesIschemiainsufficient oxygen supply to meet the requirements of the myocardiumInfarctionnecrosis or cell death that occurs when severe ischemia is prolonged and decreased perfusion causes irreversible damage to tissue

Coronary Blood Flow

Chronic Stable Angina Pectoris
Strangling of the chestTemporary imbalance between the coronary arterys ability to supply oxygen and the cardiac muscles demand for oxygenIschemia limited in duration and does not cause permanent damage to myocardial tissueChronic stable angina: Pain usually relieved with Sublingual NTGUnstable angina

Acute Coronary Syndromes
Patients who present with either unstable angina or an acute myocardial infarction

ST Segment Elevation and MI
ST elevation MI (STEMI) traditional manifestationNonST elevation MI (non-STEMI) common in womenUnstable angina

Unstable Angina Pectoris
New-onset anginaVariant (Prinzmetals) anginaPre-infarction angina

Myocardial Infarction
Most serious acute coronary syndromeOccurs when myocardial tissue is abruptly and severely deprived of oxygenOcclusion of blood flowNecrosisHypoxia Subendocardial MI, transmural MI, inferior wall MIVentricular remodeling

Nonmodifiable Risk Factors
AgeGenderFamily historyEthnic background

Modifiable Risk Factors
Elevated serum cholesterolCigarette smokingHypertensionImpaired glucose toleranceObesityPhysical inactivityStress

Laboratory Assessment
Troponin T and troponin ICreatine kinase-MB (CK-MB)MyoglobinImaging assessment12-lead electrocardiogramsCardiac catheterization

Acute Pain
Interventions include:Provide pain-relief modalities, drug therapy.Decrease myocardial oxygen demand.Increase myocardial oxygen supply.

Pain Management
NitroglycerineMorphine sulfateOxygenPosition of comfort; semi-Fowlers positionQuiet and calm environmentDeep breaths to increase oxygenation

Ineffective Tissue Perfusion (Cardiopulmonary)
Interventions include:Drug therapy (aspirin, thrombolytic agents)Restoration of perfusion to the injured area often limits the amount of extension and improves left ventricular function.Complete sustained reperfusion of coronary arteries in the first few hours after an MI has decreased mortality.

Heparin for Acute Coronary Syndrome

Thrombolytic Therapy
Fibrinolytics dissolve thrombi in the coronary arteries and restore myocardial blood flow.Tissue plasminogen activatorReteplaseTenecteplase

Thrombolytic Drugs; Clot Dissolving Drugs

Other Drugs
Glycoprotein (GP) IIB/IIIa inhibitorsOnce-a-day beta-adrenergic blocking agentsAngiotensin-converting enzyme inhibitors or angiotensin receptor blockersCalcium channel blockersRanolazine

Percutaneous Transluminal Coronary Angioplasty (PTCA)

Activity Intolerance Interventions
Cardiac Rehabilitation:Phase 1Phase 2Phase 3

Ineffective Coping Interventions
Assess the patients level of anxiety, but allow expression of any anxiety and attempt to define its origin.Give simple explanations of therapies, expectations, and surroundings and explanations of progress to help relieve anxiety.Provide coping enhancement.

Potential for Dysrhythmias
Dysrhythmias are the leading cause of death in most patients with MI who die before they can be hospitalized.Interventions include:Identify the dysrhythmias.Assess hemodynamic status.Evaluate for discomfort.

Cardiogenic Shock
Necrosis of more than 40% of the left ventricleTachycardiaHypotensionBlood pressure