Carmela Lea Mira, RN

Objectives
• Differentiate between the various
pathologic processes of acute coronary
syndrome
• Describe the physical manifestations
most commonly associated with the
various types of acute coronary
syndromes.
• Compare and contrast the various types
of acute coronary syndromes
• Establish a prioritized plan of care for
patients with acute coronary syndrome
Objectives
• Identify risk factors that predispose
clients to the development of heart
failure.
• Compare and contrast the clinical
manifestations for right and left sided
heart failure.
• Identify appropriate nursing interventions
for caring for a patient with heart failure.
• Describe prevention approaches that can
be instituted in the critical care
environment.
 ACUTE
CORONARY
SYNDROME
Acute Coronary
Syndrome
Collective term for the signs and
symptoms associated with myocardial
ischemia with or without infarction
Substernal Pressure,
SOB
chest pain heaviness or
crushing

Nausea Diaphoresis Dizziness

ACUTE MYOCARDIAL
INFARCTION
• Condition wherein the heart is deprived
of oxygen
• Caused by plaque rupture or as a
sustained episode of decreased oxygen
supply  cell death

• Most common cause: CAD

Classification: Severity

• Site of infarct: anterior, inferior, lateral or

posterior.
• Pre-established collateral circulation
• Depth and extent of muscle affected.
• Transmural
• Nontransmural

• Zones(infarction, hypoxic injury, ischemia)

Pathophysiology
 Signs and Symptoms
Substernal Pressure,
SOB
chest pain heaviness or
crushing

Nausea Diaphoresis Dizziness

Tachycardia Hypertension Anxiety

Palpitations Decreased CO Murmur

ST segment
Fever
Elevation
COMPLICATIONS
ASSESSMENT AND
DIAGNOSTICS
CARDIAC ENZYMES
ENZYME EARLIEST PEAK RETURN TO
RISE BASELINE
CK 2–6 18 – 36 3 – 6 Days
Hours Hours
CK – MB 4–8 15 – 24 3 – 4 Days
Hours Hours
MYOGLOBIN 0.5 – 1 6–9 12 Hours
Hour Hours
TROPONIN I 1–6 7 – 24 10 – 14
AND T Hours Hours Hours
MANAGEMENT
• ECG, VS, Pulse oximetry
• CBC, Basic Lipid Chemistry
• Liver function test, coagulation panel
• O2 and IV access

CCU
•Pulmonary Artery Catheter
•IABP
•Revascularization
•CABG
MANAGEMENT: Pain

Nitroglycerin
Morphine
 MANAGEMENT:
Thrombolytic Therapy
Thrombolytic Reperfusion
CONTRAINDICATIONS
Streptokinase
RELATIVE
Tissue plasminogen
Uncontrolled HTN
ABSOLUTE
Halt infarction process activator
Current use of
Aortic dissection Reteplase
anticoagulants
Prev. cerebral Alteplase
Known bleeding
hemorrhage
Traumatic head injury
Known history
Salvage of amount
greatest AVM of
Major surgery in past 3
or Cerebral aneurysm
myocardial muscle
weeks
Active internal bleeding
Internal bleeding (past 6
Thromboembolic stroke
months)
Intracranial neoplasm
Pregnancy
Active PUD
MANAGEMENT: Anti-
coagulant Therapy
RN ROLES

ACUTE RN INTERVENTIONS:
AIM: Reducing myocardial oxygen
demand and increasing supply
Rapid and focused physical assessment
VS monitoring
Oxygen supplementation
Administer medications
Monitor I & O
Stool Softener
Emotional support, maintain quiet and calm non-
stimulating environment
RN ROLES

LONG TERM RN INTERVENTIONS:

AIM: Prevent subsequent
coronary events and maintain
physical functioning
Comprehensive and extensive counselling
Educate on decreasing risk
Lifestyle changes
Nutritional modification
 HEART
FAILURE
HEART FAILURE

• Weak heart muscle

• Problems in pumping ability
Coronary Artery Myocardial
Disease Infarction

Valvular heart
Hypertension
disease
TYPES

SYSTOLIC HEART FAILURE DIASTOLIC HEART FAILURE

• Impaired ability to • Impaired ability to relax

contract and empty • Thickening of
• Ejection fraction <40% myocardial wall but not
• Heart enlargement enlarged.
• Decreased perfusion to
kidney  RAAS
Stimulation
TYPES
Left –Sided Heart Failure Right – Sided Heart Failure
• Pulmonary signs and • Systemic signs and
symptoms symptoms
• Dyspnea • Edema
• Orthopnea • Weight gain
• Nocturia • Ascites
• Fatigue • Liver Enlargement
• Cardiomegaly • JVD
• Tachypnea • Splenomegaly
• Tachycardia • Increased CVP
DIAGNOSTICS

• Echocardiogram
• Chest Xray
• ECG
• Radionuclide Ventriculography
• Brain Natriuretic Peptide
• Treadmill Stress Test
 CLASSIFICATION
• NYHA Functional Classification System
Class I – Ordinary physical Stage A – Patients at high risk for developing
activity causes no symptoms HF
of HF
Stage B – Patients with cardiac structural
Class II – Ordinary Physical abnormalities or remodeling who have not
Activity causes HF Symptoms developed HF
• AHA/ ACC Staging System

Class III – Less than ordinary
activity causes signs and
symptoms of HF
Class IV – HF symptoms even
at rest
Stage C – Patients with current or prior
symptoms
Stage D – Patients with known HF and
presence of advanced symptoms even with
appropriate medical care
 TREATMENT
• Treat the underlying cause if: valvular
problem or occluded artery
CHRONIC HEART FAILURE

ACUTE HEART FAILURE Emphasis: Stabilizing the

Oxygenation
Possible mechanical ventilation
Administer IV medications:
Diuretics, venous dilators,
inotropes
disease, breaking the vicious
cycle of compensation, and
preventing the permanent
changes of remodeling
GOAL: increase quality of life
and decrease hospital
readmissions
PHARMACOLOGIC
THERAPY
• ACE Inhibitors
• ARBs
• Beta-blockers
• Diuretics
• Antiarrhythmics: Digoxin and
Amiodarone
• Aldosterone blockers
ACE INHIBITORS

• Decrease the preload by preventing Na

and H2O reabsorption.
• Indirect vasodilation

• Side effect: hypotension, light

headedness, cough

• Example: Captopril, Enalapril, Fosinopril

Beta Blockers
• Blocks SNS effects
• Decreases heart rate, BP and
vasoconstriction
• Side effect: fatigue

• Contraindication: Asthma, COPD, and

conduction disorders.

• Example: carvedilol, metoprolol, bisoprolol

Diuretics

• Prevent and treat symptoms of fluid

overload

• Side effects: hypotension, dizziness,

nocturia and hypokalemia.

• Sample: furosemide, bumetanide,

torsemide
Other medications

• Digoxin
• Nitroglycerin
• Morphine
NONPHARMACOLOGIC
TREATMENT
• Control BP levels
• Stop smoking
• Limit sodium intake
• Lose weight (if necessary)
• Limit alcohol intake
• Adequate rest
• Minimize stress
• Weigh daily
• Moderate exercise
OTHER TREATMENT
OPTIONS
• Cardiac Resynchronization Therapy
• Heart transplantation
• LVAD