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Acute coronary syndrome, Myocardial infarction, Valvular disease,…

- - - - chest pain when it spasms
      - treat with CCB to keep from spasm
- - - - accompanied by SOB, n/v, diaphoresis, dysrhythmias, and/or pallor
- - - - occludes
- - - - I, AVL, V5, V6
  - - - II, III, AVF
  - - - ECG reciprocal changes in V1 and V2 or posterior leads (15 lead)
- - - - may radiate to back, neck, jaw or left arm
- - - - 4th gen <0.4 is normal
      - 5th gen <14 is normal
- - - - Assess headache
      - dilate arteries so prob won't help if full MI
      - causes hypotension
        
        monitor BP, titrate SBP >80. Give bolus instead of stopping for low BP
  - - - performed within 90 minutes of arrival/presentation
    - - cardiac cath care plus
        
        Pre procedure
        
        monitor labs (CBC, chemistries especially BUN/CR because nephrotoxic dye, PT and INR, cardiac enzymes)
        
        chest pain?
        
        ECG
        
        aspirin + heparin drip
        
        Hold metformin for 1-3 days before if they have it
        
        NPO except meds
        
        Post procedure
        
        bed rest flat 2-8 hours
        
        monitor same labs
        
        Chest pain?
        
        ECG
        
        post cath care plus may include sheath care (continuous IV infusion to keep it open)
        
        frequent distal circulation/perfusion
        
        Grion site and retroperitoneal checks for bleeding
        
        rehydrate
        
        I/O cath or foley if they can't void
        
        Teaching
        
        conscious sedation, will feel uncomfortable, will lay on hard surface, what happens after
    - - MI
      - coronary vasospasm
      - abrupt vessel closure (most common within 3 months of procedure)
      - other vascular complications like damage or lasserations
    - - vessels around occlusioin
      - Antherctomony
  - - - chose cath OR fibrinolytics not both
    - - bleeding, NO ANTIDOTE
    - - if they have been having S/S for under 12 hours, ST elevation in touching leads, or new LBBB
    - - active bleeding
      - recent hemorrhagic CVA or ischemic CVA within 3 months
      - intracranial tumor
      - head trauma
      - aoric dissection
      - uncontrolled BP
      - bleeding/clotting problems
      - CPR is a relative risk, benefits may outweigh risks
    - - Postadmin
        
        neuro check
        
        bleeding or body fluids?
        
        no injections for 24 hours
        
        Assess infusion site for bleeding and bruising
        
        Administer platelets as ordered
      - desirable outcomes
        
        Decreased ST segment
        
        Reperfusion dysrhythmias (PCV and VT)
        
        Treat with amiodarone if needed
        
        good sign
        
        Decreased CP
      - Preadmin
        
        get 2 large bore IVs before because you can't stick them after
- - - - leujocytosis, low grade fever, malaise, pericardial friction rub
      - caused from irritation of sac around heart
      - resolves on its own
- - - - heart open diseased/damaged valve removed or repaired
      - prosthetic valve sewn in
      - patient placed on bypass
  - - - catheter through femoral artery guided up to heart
      - compressed tissue heart valve is placed on balloon cath
      - balloon inflated to secure valve in place
      - Nursing; same as PTCA, cardiac monitor for dysrhythmias, assess for perfusion, monitor heart failure
      - complications: peri procedural stroke due to dislodging clots on the valve (can be reduced by device that catches emboli)
- - - - lifelong
  - - - prevention
        
        good oral hygiene
        
        antibiotics before high risk surgery and dental work
        
        avoid URI for 2 months post op
      - report any TIA's embolic events
        
        observe for side effects from warfarin
      - Occurs within 2 months of surgical repair
- - - - S3
        
        early diastole (after S2), stiff failing ventricle/can't stretch
      - S4
        
        late diastole (before S1), atria contract forcing blood into noncompliant vent
      - S2
        
        diastole, semilunar valves close (aortic and pulmonic)
      - Summation gallop
        
        all 4
      - S1
        
        systole, AV valve close (mintral and tricuspid)
    - - Diastolic
        
        aortic and pulmonic regurgitation
        
        tricuspid and mitral stenosis
      - Systolic
        
        aortic and pulmonic stenosis
        
        tricuspid and mitral regurgitation
    - - inflamed pericardia areas rub together
      - high pitch and raspy
- - - - thoracic: tracheal deviation, tracheal tug, chest pain (full and deep)
        
        transverse: difference in brachial BP >20, pulse deficit from side to side, mimics stroke, hoarseness, cough, dysphagia, cerebral ischemia (stroke symptoms because it goes to upper body)
        
        descending: back pain, spinal stroke (numbness and tingling)
        
        ascending: difficulty swallowing, speaking, chest pain, SOB, N/V, aortic murmur (heart attack symptoms because coronary artery)
      - Abdominal: most common, usually forms below renal artery
        
        abdominal pain or tenderness (don't palpate once DX), abdominal bruit, wide abdominal pulsations, back or pelvic pain, ankle brachial index weak pedal pulses, lower leg ischemia
        
        most common s/s is nothing
      - peripheral: femoral and iliac
        
        signs of decreased perfusion distal to the aneurysm (6 P's)
- - - - bruising on back, decreased UO, decreased BP, increased abd girth, increased HR
- - - - reduce oxygen consumption of heart by decreasing workload
        
        in heart failure patients will increase CO
- - - - can cycle 1:1, 1:2, 1:3...
        
        outcomes
        
        decrease cardiac workload by decreasing afterload
        
        increase contractility and CO 8-10%
        
        increase coronary perfusion and o2 supply myocardium
        
        uses
        
        cardiogenic shock, bridge to transplant (buy time), treat HF, treat MI
        
        timing
        
        inflation and deflation with cardiac cycle is critical, controlled by nurses with console
        
        complications
        
        infection
        
        decreased CO from improper synchronization
        
        bleeding at femoral artery insertion site
        
        balloon rupture
        
        ischemia in affected leg (check 6 ps)
        
        balloon slipping forward
        
        balloon back or out
        
        weaning
        
        gradually reduce assist ration ever 4-6 hours while monitoring hemodynamics
        
        nursing
        
        monitor UO
        
        assess bleeding
        
        monitor heart rhythm, hemodynamics, and vs
  - - - can be permanent or temporary
      - complications
        
        bleeding
        
        tamponade
        
        emboli
        
        heart failure
        
        cannula obstruction
        
        infection
        
        organ failure
        
        dysrhythmias
      - can be external (transcutaneous) or internal (implant)
      - nursing
        
        weak pulses expected
        
        low BP
        
        sedation
        
        perfusion assessment (6 p's and cap refill)
- - - - causes sudden cardiac arrest
    - - treat heart failure, septal ablation, ventricular reduction, ICD
  - - - decreased ejection capability
    - - treat HF, treat cause, heart transplant, ICD
- - - - impaired cardiac relaxation and impaired ventricular filling
      - ventricles don't relax and fill well/poor stretch
      - worse
    - - reduced contractility, ejection fraction <40%
  - - - fluid backs up into peripheral system
        
        JVD, edema, ascites, increased CVP and RAP
    - - fluid backs up into pulmonary system
        
        pulmonary symptoms: crackles, decrease o2 sat, increased RR, increased PA pressure, pulmonary edema, orthopnea
    - - both from ventricular MI or severe left sided left untreated
- - - - increased CO then decreased CO once comesation is exhausted
    - - increased angiotensin II
        
        increased vasoconstriction and aldosterone
        
        increased fluid retention and afterload
        
        increased CO then decreased CO once comesation is exhausted
    - - increased fluid retention by kidney
        
        increased prelaod
        
        increased CO then decreased CO once comesation is exhausted
    - - myocardial dilation
        
        from increased preload but overstretched and weakens
        
        becomes more spherical
      - myocardial hypertrophy
        
        from increased work but heart overgrows its blood supply
    - - Increased NA excretion
- - - - 200 ml for 2 consecutive hours
      - sudden output of >500ml unless with truning or activity
  - - - secure pacing wires and be prepared to use temp pacemaker box if needed
- - - - treats CAD, median sternotomy approach, one or more blocked coronary arteries bypassed by a blood vessel graft to restore blood flow to the heart
        
        common bypass vessels
        
        saphenous vein: easy access, multiple grafts, increase infection and edema, decrease long term patency
        
        radial artery: good patency, tends to spasm
        
        internal mammary (thoracic) artery: best long term patency/survival, requires chest tube, increases pain
    - - for some patients who require bypass graft to the left anterior descending (LAD) artery thru small thoracotomy incision. May also use endoscopic, video assisted, or robot assisted technologies
        
        potential advantages: smaller incision (3-4 inches) and scars, reduced infection
        
        risk, less bleeding, less pain and trauma, decreased length of stay, and decreased recovery time
        
        disadvantages: not all arteries are accessible thru this technique
  - - - on pump
        
        cardiopulmonary bypass machine or heart lung machine
        
        advantages: better surgical precision in still, bloodless heart
        
        adverse: bleeding, clotting, edema, electrolyte imbalances, neurocognitive changes (pump brain), renal/pulmonary/GI changes, anemia
        
        functions: circulate, cool/warm, filter, oxygenate blood
        
        increase adverse effects with increase time of CBP
      - off pump
        
        stabilize portions of the heart thru median sternotomy or key hold incisions during surgery while it remains beating
        
        Bypasses are connected to diseased coronary arteries in stabilized are while the rest of the heart keeps pumping, no cardiopulmonary bypass machine needed
        
        used in patients who are not good candidates to be on pump (severe COPD)
        
        advantages: decrease stroke, renal failure and need for blood transfusion, less cognitive and neuro changes
  - - - heart muscle exposed thru chest wall incision
        
        high energy, computerized carbon dioxide laster creates 20-40 one millimeter wide channels in the ischemic left ventricle
        
        outer channels close but channels remain open inside the heart to improve blood flow
        
        may promote angiogenesis/growth of new capillaries
        
        channels act as bloodlines. When the ventricle contracts, it sends blood through the channels to heart muscle
  - - - open heart repair similar to CABG and valve repair surgeries
      - percutaneous closure: closure devices are placed with cardiac cath like procedure
  - - - care similar to CBAG and traditional valve repair
- - - - APACHE (acute physiological and chronic health evaluation)
      - SOFA (sepsis related organ failure system)
- - - - CO maintained
        
        hopefully treat during this stage because it goes unrecognized after
        
        Compensatory mechanism
        
        sympathetic response
  - - - results in
        
        cell damage
        
        autolysis and blood pooling
        
        thrombi/emboli, hypotension, and interstitial edema
        
        hypotension and electrolyte imbalances + hemodynamic changes
      - inflammatory response
        
        release of mediators are produced
        
        (bradykinins, histamines, endorphins, prostaglandins, myocardial depressant factor and oxygen free radicals)
  - - - MODS
        
        Nursing management (all types)
        
        correct electrolyte imbalances
        
        manage dysrhythmias
        
        minimize energy expenditure/reduce oxygen demand
        
        nutrition: feed gut when you can, TPN if gut is dead
        
        pulmonary hygiene
        
        infection control
        
        oxygenation: supplemental o2, intubation and mechanical ventilation
        
        skin care and hygiene
        
        meds!
        
        vasodilators
        
        nitroprusside, ntg, ace inhibitors
        
        inotropes/inodilators
        
        amrinone, milrinone, dobutamine
        
        anticoagulants
        
        vasoconstrictors
        
        dopamine, norepi, epi
        
        psychosocial support of patient and family
        
        ETCO2 and increased lactic acid
        
        Hemodynamic monitoring (art best for all, PA for cardio)
- - - - blood loss, dehydration, fluid shifts
    - - all hemodynamic pressures decrease but SVR increases
    - - decrease in circulating volume
    - - stop volume loss and restore volume
      - IVF: NS or LR
      - Blood products
      - Colloids
  - - - MI, cardiomyopathy, valve failure, myocarditis, aneurysms, dysrhythmias
    - - pulmonary congestion, crackles
      - elevated cardiac enzymes/proteins
      - low CO/CI, Map < 65, high PAOP, high CVP, increased SVR
      - enlarged heart
      - JVD
      - dysrhythmias
      - murmurs
    - - pump failure
        
        inadequate blood flow and oxygen delivery
    - - as above plus VAD, IABP< or impella (help heart)
      - treat underlying cause: reperfusion (M ,valve repair (valve prob), ventriculoplasty (HF)
  - - - vasodilation
        
        decrease in venous return
        
        decrease CO and CI
        
        decrease tissue perfusion
        
        Types!
        
        Anaphylactic
        
        3 more items...
        
        Septic shock/SIRS
        
        9 more items...
        
        Neurogenic
        
        3 more items...
- - - - rise 4-6 hours, peak in 24
      - serial Q6-8 h x 3 to tule out / in ischemai or infarction
- - - - position L side down so heart is closer to probe
        
        for esophagus: they will have sore throat after, watch them swallow before they eat
  - - - heart scanned to see where it stops
      - NPO for 4-6 hours before, hold beta blockers (allow heart to respond how it would)
      - radioactive tracer injected into IV
      - teach: will take multiple sets of scans before and after being stressed with meds or exercise, lay still for scans, no caffeine before (even decaf)
  - - - differences: radioactive tracer is N23-ammonia, test is not as long, done on a PET camera
      - considerations same as nuclear
- - - - usually viral (COVID, coxsackie, adenovirus, HIV, influenza)
  - - - treatment
        
        manage heart failure
        
        steroids/NSAIDS NOT effective
        
        heart transplant: has higher rate of rejection
        
        rare: pacemaker or ICD
  - - - palpitations
      - fatigue
      - chest discomfort
      - often delayed, begin after infection subsides
      - slight increased in cardiac enzymes and proteins
      - dyspnea
- - - - decreased CO
  - - - acute presentation within 1 week of infection
      - subacute presentation may take up to 4 weeks fever
      - night sweats
      - weight loss
      - tachycardia
      - dysrhythmia
      - hypotension
      - hemodynamics - use cautiously, may further damage valves + PAP, 1CVP, I CO HF like symptoms
      - murmur
      - splenomegaly
      - petechiae
      - splinter hemorrhages
      - Osler's nodes Dain
      - Janeway lesions (palm) no pain
      - musculoskeletal complaints
      - systemic or pulmonary emboli
      - neuro changes - HA, mycotic (infected) aneurysms
  - - - prophylactic antibiotics for high or moderate risk patients with vvalvular disease or mechanical valves before and after select invasiv eprodecures
      - bronchoscopy, biopsy of urinary tract, t&a, TURP, gyn procedures, or dental work
- - - - worse with deep breath or laying down
      - chest pain is relieved by sitting up and leaning forward
  - - - large effusions can lead to pericardial tamponade
    - - what is it
        
        fluid compresses heart and impairs filling of the chambers and ventricular ejection
      - assessments
        
        narrowing pulse pressure (Systolic close to diasolic)
        
        tachycardia
        
        beck's triad
        
        elevated CVP and JVD
        
        muffled heart sounds
        
        decreased BP and pulse pressure
        
        hemodynamic measurements
        
        as effusions increase CO decreases
        
        pressures in all heart chambers elevate and equalize
      - management
        
        pericardiocentesis
        
        needle inserted into pericardial sac to drain effusion
        
        done with cardiac emergency
        
        echo used to guide catheter tip
        
        around 100 mls withdawn
        
        pericardiectomy
        
        surgical window made in pericardial sac
    - - constrictive pericarditis
        
        heart failure