Chapter 38

Care of Patients with Acute Coronary

Syndromes

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 Concepts
 The priority concept in this chapter is
 PERFUSION
 The interrelated concept in this chapter is
 COMFORT

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 Coronary Artery Disease
 Includes stable angina, acute coronary
syndromes
 Ischemia
 Insufficient oxygen supply to meet requirements of
myocardium
 Infarction
 Necrosis or cell death that occurs when severe
ischemia is prolonged and decreased perfusion
causes irreversible damage to tissue

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 Chronic Stable
Angina (CSA) Pectoris
 “Strangling of the chest”
 Temporary imbalance between coronary
artery’s ability to supply oxygen and cardiac
muscle’s demand for oxygen
 Ischemia limited in duration and does not
cause permanent damage to myocardial
tissue

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 Perfusion Concept Exemplar:
Acute Coronary Syndrome (ACS)
 Pathophysiology
 Acute coronary syndrome
• Unstable angina
• Acute myocardial infarction
 Believed that atherosclerotic plaque in
coronary artery ruptures, resulting in platelet
aggregation, thrombus formation, or
vasoconstriction

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 Unstable Angina
 New-onset angina
 Variant (Prinzmetal’s) angina
 Pre-infarction angina
 Patients present with ST changes on 12-lead
ECG, but will not have changes in troponin or
CK levels

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 Myocardial Infarction
 Most serious acute coronary syndrome
 Myocardial tissue abruptly and severely
deprived of oxygen
 Occlusion of blood flow
Ischemia ➡ injury ➡ necrosis

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 Myocardial Infarction (Cont.)
 Divided by ACC/AHA
 Non-ST elevation MI (NSTEMI)
 ST elevation MI (STEMI)

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 Etiology and Genetic Risk
 Non-modifiable
 Age
 Gender
 Family history
 Ethnic background

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 Modifiable Risk Factors
 Elevated serum cholesterol
 Cigarette smoking
 Hypertension
 Impaired glucose tolerance/DM
 Obesity
 Excessive alcohol
 Limited physical activity
 Stress

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Interprofessional Collaborative Care
 Assessment: Noticing
 History
 Physical assessment
• Pain assessment
• BP and HR
• Heart rhythm and heart sounds
• Peripheral pulses
• Skin temperature
 Psychosocial assessment
• Denial
• Fear or anxiety

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 Assessment: Noticing
 Laboratory
 Troponin T and troponin I
 Imaging assessment
 12-lead electrocardiograms
 Cardiac catheterization

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 Analysis: Interpreting
 Acute pain
 Decreased myocardial tissue perfusion
 Decreased functional ability
 Decreased ability to cope
 Potential for dysrhythmias
 Potential for heart failure

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 Planning and Implementation:
Responding
 Pain management
 Nitroglycerin
 Morphine sulfate
 Oxygen
 Position of comfort; semi-Fowler’s position
 Quiet and calm environment

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 Planning and Implementation:
Responding (Cont.)
 Increasing tissue perfusion
 Drug therapy
• ASA
• Glycoprotein (GP) IIb/IIIa inhibitors
• Antiplatelets
• Beta blockers (BBs)
• Angiotensin receptor blockers (ARBs)
• Angiotensin converting enzyme inhibitors (ACEIs)
• Reperfusion therapy
• Thrombolytic therapy
 Percutaneous coronary intervention

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 Planning and Implementation:
Responding (Cont.)
 Increasing functional ability
 Cardiac rehabilitation
 Increasing ability to cope
 Identifying and managing dysrhythmias
 Dysrhythmias are the leading cause of prehospital
death in most patients with ACS.

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Monitoring/Managing Heart Failure
 Decreased cardiac output due to heart failure is
a common complication after an MI
 Monitor for cardiogenic shock
Cold, clammy skin, poor peripheral pulses, agitation,
pulmonary congestion, tachypnea, hypotension,
tachycardia, decreased urine output
 Hemodynamic monitoring

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Percutaneous Coronary Intervention

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Coronary Stent

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Coronary Artery Bypass
Graft Surgery

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Coronary Artery Bypass
Graft Surgery (Cont.)

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 Coronary Artery Bypass Graft

 Preoperative care
 Operative procedures
 Cardiopulmonary bypass
 Postoperative care
 Manage fluid and electrolyte imbalance
 Other potential complications
• Hypothermia
• Hypotension
• Cardiac tamponade
• Sternal infection
• Pain
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 Surgical Management
 Minimally invasive direct coronary artery bypass
(MIDCAB)
 Endoscopic vessel harvesting
 Transmyocardial laser revascularization
 Off-pump coronary artery bypass
 Robotic heart surgery

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 Care Coordination
and Transition Management
 Home care management
 Self-management education
 Risk factor modification
 Complementary and integrative health
 Drug therapy
 Sexual activity
 Seeking medical assistance
 Health care resources

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 Evaluation: Reflecting
 Evaluate the care of the patient with CAD based
on the identified priority patient problems.

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 Case Study
Paramedics arrive at the ED with a 78-year-old man who
presents with severe chest pain. In triage, he reports that he
experienced chest pain for several hours before calling 911. He
reports that he takes “heart medications” but he does not know
their names. He rates his chest pain as a 9 on a 0-to-10 scale.
Patient history includes an MI 6 years ago that resulted in stent
placement for severe CAD. One stent was placed in the LAD
and another in his circumflex artery. He states that his health
care provider told him he also has heart failure.

What laboratory tests do you anticipate the provider will order for
this patient?

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 Case Study (Cont.)
Two hours later, the patient is admitted to the cardiac
stepdown unit with orders for a saline lock, cardiac diet, and
oxygen at 2 L per nasal cannula with follow-up cardiac
enzymes, and 12-lead ECG in 6 hours. One hour later, the
patient reports severe shortness of breath. His oxygen
saturation has dropped to 88%, BP is 96/54, and his monitor
shows sinus tachycardia with a rate of 114. He reports mild
chest pain.

1. What do you suspect is happening to the patient at

this time?
2. The patient’s laboratory values include troponin T 0.6
mg/mL. What is your best interpretation of this
finding?

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 Case Study (Cont.)
You immediately notify the provider and within 45
minutes, the patient is transferred to the CCU for close
monitoring. He is in serious condition and has
developed crackles bilaterally, and his chest pain level
has increased.

What medications do you anticipate will be ordered for

this patient? (Select all that apply.)

A. Morphine
B. Furosemide (Lasix)
C. Atenolol (Tenormin)
D. Prednisone (Deltasone)
E. Acetaminophen (Tylenol)
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 Case Study (Cont.)
The next morning, the patient is taken to the cardiac
catheterization laboratory. The cardiologist finds that
there is an 80% blockage in the proximal LAD coronary
artery.

Which procedure is most likely to be performed to

correct this condition?

A. Coronary atherectomy
B. Coronary artery bypass graft surgery
C. PTCA with coronary artery stent placement
D. Percutaneous transluminal coronary angioplasty
(PTCA)

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 Case Study (Cont.)

The patient’s condition improves, and he is

returned to the cardiac stepdown unit. He is to
be discharged after 6 days in the hospital.

What patient teaching should you provide

before he is discharged from the hospital?

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 Chapter 38

Audience Response System Questions

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 Question 1
A woman has been experiencing atypical
angina. What symptoms would the nurse
anticipate? (Select all that apply.)

A. Vomiting
B. Indigestion
C. Aching jaw pain
D. Depression
E. Irregular bowel movements
F. Decreased patterns of activity
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 Question 2
Identify the laboratory test that is most specific for
myocardial infarction and cardiac necrosis.

A. Troponin
B. HDL
C. CK-MB
D. CK

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 Question 3
A patient presents to the ED and is diagnosed with an
acute MI. The patient’s spouse asks what type of
damage has been caused by the “heart attack.” What is
the appropriate nursing response?

A. “The pain is controlled, so there is no damage.”

B. “It will take years to know the extent of the
damage to the heart muscle.”
C. “The medication will dilate the blood vessels and
any damage will be corrected.”
D. “A heart attack evolves over several hours. We
won’t know the extent of the damage
immediately.”

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