STABLE ANGINA PECTORIS

MYOCARDIAL INFARCTION

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Other term/s Cause

chest pain It is caused by inadequate blood flow to the myocardium, due to a narrowing of the coronary arteries as a result of arteriosclerosis. May be a sign of coronary artery disease.

heart attack A dynamic process by which one or more regions of the heart experience a severe and prolonged decrease in oxygen supply due to insufficient coronary blood flow; subsequently, necrosis or death to myocardial tissue occurs. If blood flow is not restored to the heart muscle within 20 to 40 minutes, irreversible death of the heart muscle will begin to occur

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Sign & Symptoms chest pain 1. Charact er

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Substernal chest pain, pressure, heaviness, or discomfort. Other sensations include squeezing, aching, burning, choking, strangling and/or cramping pain. Pain may be mild or severe and typically presents with a gradual buildup of discomfort and subsequent gradual fading. May produce numbness or weakness in arms, wrists, or hands. Located behind middle or upper sternum; patient will generally make a fist over the site of the pain (+ Levine sign) rather than point to it with his fingers. Usually radiates to neck, jaw, shoulders, arms, hands, and posterior intrascapular area. Pain occurs more commonly on left side. 2-15 minutes after stopping the activity Nitroglycerin relieves pain within 1 minute.

Crushing, squeezing or dull pain Severe, diffuse, steady substernal pain

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Location

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Radiatio n

May radiate to the arms (usually left), shoulders, neck, back, and/or jaw.

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Duration

Continuous for 15 minutes Unrelieved vasodilator opioids by rest therapy, or sublingual but requires

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Precipita ting factors

Exposure to weather extremes Eating a heavy meal Sexual intercourse Women may experience atypical symptoms of chest pain: jaw pain, shortness of breath, or indigestion. Diaphoresis increase in BP tachycardia dyspnea indigestion nausea Fatigue Shortness of breath Dizziness

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Atypical symptoms

Epigastric or abdominal stress, dull aching or tingling sensation, SOB, extreme fatigue Diaphoresis, cool clammy skin, facial pallor HTN or hypotension Bradycardia or tachycardia PVC or PAC Palpitations, severe anxiety, dyspnea Disorientation, confusion, restlessness Fainting, marked weakness N/V, hiccups Impending doom dizziness

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Other symptoms

1. Diagnostic Evaluation

Silent ischemia: no complaints of Pin with documentedevidence between myocardial O2 supply and demand (ST depression of 1mm or more) Commonly occurs during 1st hours after awakening due to increased in SNS activity Increased heart rate & BP Blood viscosity Resting ECG ST-T arrhythmias, Q waves Nitroglycerin test wave changes,

Silent MI: no complaints of pain which may occur in geriatric patients. Hypotension Low body temperature SOB Vague complaints of discomfort, mild perspiration, strokelike symptoms, dizziness, change in sensorium ECG Ischemia: ST depression and T-wave inversion Injury: ST elevation Tissue necrosis: Q wave Cardiac Markers Troponin I and Troponin T CKMB CBC- elevated WBC MRI or echocardiogram cardiac muscle dysfunction Cardiac catheterization

1. a. Management Drug therapy

Blood test to rule out anemia, modifiable risk factors for CAD (HTN, obesity, increased lipid level, lifestyle) Cardiac markers CRP, homocysteine, lipoprotein ( increased level associated with 2-fold risk in developing CAD) Cardiac catheterization

Nitrates - vasodilation Beta-adrenergic blockers inhibit sympathetic stimulation of receptors in conduction system of the heart and heart muscle Beta-blockers are the preferred first-choice treatment for helping to prevent angina. They make the heart beat slower and with less force. This means that the heart needs less blood and oxygen after exercise, so angina is prevented or occurs less frequently. Ca-channel blockers - work by relaxing the muscles that make up the walls of your arteries, increasing the blood supply to the heart. ACE inhibitor - used to reduce your blood pressure. Having high blood pressure (hypertension) also means that your heart will have to work harder than usual, which can strain the heart muscles and increase your risk of heart failure or having a heart attack. Antilipid agents Antiplatelet agents Folic Acid andcomplexes homocysteine level increase

Morphine via IV Oxygen via NC/ FM Nitrates reduce preload by decreasing blood return to heart and decreasing oxygen demand Aspirin Thrombolytic agents such as streptokinase Anti-arrhythmic such as amiodarone

a. Surgery

Statins are a type of medication used to lower your blood cholesterol level. This will help prevent further damage to your coronary arteries and should reduce the risk of a heart attack or stroke occurring. Statins work by blocking the effects of an enzyme in your liver that is used to make cholesterol.

Surgery may also be recommended if your symptoms fail to respond to treatment with medication.

Emergency CABG Percutaneous coronary interventions

coronary angioplasty, a tiny wire with a sausage-shaped balloon at the end is put into a large artery in your groin or arm. Using Xrays to guide it, the wire is passed through your blood vessels, up to your heart, and into the narrowed section of the affected coronary artery. The balloon is blown up inside the narrowed part of the artery in order to open it wide. A stent (short, wire mesh tube) is usually inserted into the artery to help keep it open afterwards. Complications of a coronary angioplasty are rare, but potentially serious. They include: heart attack: estimated to occur in 1 in 100 cases stroke: estimated to occur in 1 in 200 cases death: estimated to occur in 1 in 500 cases

within 30 minutes of initial diagnosis. ST segment elevation myocardial infarction (STEMI), there are two treatment options: a combination of medication to dissolve the blood clot and restore the flow of blood to the heart (this is known as thrombolysis) surgery to widen the coronary artery, which is usually done using a technique called coronary angioplasty

Coronary Artery bypass graft - new channel through which the blood can be directed past the blocked part of the artery. Complications of CABG are rare but potentially serious. They include: heart attack: estimated to occur in 1 in 50 cases stroke: estimated to occur in 1 in 50 cases Transmyocardial revascularization use of laser beams to form small channels in myocardium Percutaneous coronary interventions such as Intracoronary stenting and Percutaneous transluminal angioplasty Coronary revascularization Treatment for stable angina has three goals: to provide immediate symptoms of angina to prevent symptoms future relief from of the

episodes

angina

to reduce your risk of having a heart attack or stroke

More heart attacks occur between 4:00 A.M. and 10:00 A.M. because of the higher blood levels of adrenaline released from the adrenal glands during the morning hours. Increased adrenaline, as previously discussed, may contribute to rupture of cholesterol plaques.

Lippincott W&W., Manual of Nursing Practice 9th ed., chapter 13. Cardiac disorders., pp. 384-393