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Cardiac Community College of Philadelphia Nursing 132 Spring 2007 Community College of Philadelphia Nursing 132 Spring 2007

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Anatomy and Physiology Review Structures Chambers Valves Arteries Physiology Direction of flow Preload Afterload Structures Chambers Valves Arteries Physiology Direction of flow Preload Afterload

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Coronary Circulation

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Structure Epicardium Myocardium Endocardium Chambers Right and Left Atria Right and left Ventricles Valves Atrioventricular Tricuspid - Separates RA from RV Mitral - Separates LA from the LV Semilunar Pulmonic Separates RV from the Pulmonary Arteries Aortic Separates LV from the Aorta Structure Epicardium Myocardium Endocardium Chambers Right and Left Atria Right and left Ventricles Valves Atrioventricular Tricuspid - Separates RA from RV Mitral - Separates LA from the LV Semilunar Pulmonic Separates RV from the Pulmonary Arteries Aortic Separates LV from the Aorta

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Physiology Blood flow through the heart http://www- medlib.med.utah.edu/kw/pharm/hyper_heart1.h tml http://www- medlib.med.utah.edu/kw/pharm/hyper_heart1.h tml Cardiac conduction Automaticity Blood flow through the heart http://www- medlib.med.utah.edu/kw/pharm/hyper_heart1.h tml http://www- medlib.med.utah.edu/kw/pharm/hyper_heart1.h tml Cardiac conduction Automaticity

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Electrophysiology Nodes Pathway Automaticity Electrophysiology Nodes Pathway Automaticity

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Cardiac conduction

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Basic EKG Interpretation What is an EKG and what does it measure/record? PQRST Measuring boxes Horizontal measure time: small box 0.04 seconds Large box 0.20 seconds Vertical voltage: small box 1mm or 0.1 mV large box 5mm or 0.5 mV What is an EKG and what does it measure/record? PQRST Measuring boxes Horizontal measure time: small box 0.04 seconds Large box 0.20 seconds Vertical voltage: small box 1mm or 0.1 mV large box 5mm or 0.5 mV

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P wave Atrial depolarization Small, smooth, rounded No taller than 2.5 mm No wider than 0.11 sec Atrial depolarization Small, smooth, rounded No taller than 2.5 mm No wider than 0.11 sec

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Q wave First downward deflection Should be less than 0.03 seconds in duration and less than 25% of the R wave Indicates myocardial infarction First downward deflection Should be less than 0.03 seconds in duration and less than 25% of the R wave Indicates myocardial infarction

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QRS Complex Represents ventricular depolarization

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T wave Ventricular repolarization Usually rounded Should be same direction as QRS Inverted T waves can be a sign of ischemia Peaked T waves can be a sign of hyperkalemia Ventricular repolarization Usually rounded Should be same direction as QRS Inverted T waves can be a sign of ischemia Peaked T waves can be a sign of hyperkalemia

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U wave Small rounded wave not always present, thought to be part of ventricular repolarization

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PQRST

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Chronic Stable Angina

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Angina (Stable Chronic) Most common sign of ischemic heart disease Myocardial oxygen demand is increased by exercise, smoking, eating heavy foods, weather extremes, emotional distress, etc Atherosclerosis causes progressive fixed narrowing of the arterial lumen Relieved by rest or pharmacological interventions Goal is to prolong survival, reduce disease progression Most common sign of ischemic heart disease Myocardial oxygen demand is increased by exercise, smoking, eating heavy foods, weather extremes, emotional distress, etc Atherosclerosis causes progressive fixed narrowing of the arterial lumen Relieved by rest or pharmacological interventions Goal is to prolong survival, reduce disease progression

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Acute Coronary Syndrome (ACS) Unstable Angina (UA) Non-ST Elevated Myocardial Infarction (NSTEMI) ST Elevation Myocardial Infarction (STEMI) Penumbra Unstable Angina (UA) Non-ST Elevated Myocardial Infarction (NSTEMI) ST Elevation Myocardial Infarction (STEMI) Penumbra

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Unstable Angina (UA) / Non-ST Elevated Myocardial Infarction (NSTEMI) Imbalance between myocardial oxygen supply and demand UA occurs at rest without exertion Reduced myocardial perfusion Release of biochemical markers vs. no release of biochemical markers Imbalance between myocardial oxygen supply and demand UA occurs at rest without exertion Reduced myocardial perfusion Release of biochemical markers vs. no release of biochemical markers

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Evaluation and management Stratification High risk Intermediate Low risk Stratification High risk Intermediate Low risk

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Immediate Management History, PE, 12 Lead EKG, initial cardiac markers Assign to 1 of 4 categories Definite or Possible Cont. EKG monitoring Cardiac markers In facility observation Repeat EKG and cardiac markers 6-12 hours History, PE, 12 Lead EKG, initial cardiac markers Assign to 1 of 4 categories Definite or Possible Cont. EKG monitoring Cardiac markers In facility observation Repeat EKG and cardiac markers 6-12 hours

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EKG and cardiac markers normal follow up stress test as outpatient acceptable Definite ACS admit to hospital Chest pain unit if available Hospital Care Nursing Management Minimize or eliminate ischemia Administer meds Educate Discharge teaching EKG and cardiac markers normal follow up stress test as outpatient acceptable Definite ACS admit to hospital Chest pain unit if available Hospital Care Nursing Management Minimize or eliminate ischemia Administer meds Educate Discharge teaching

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ST Elevation Myocardial Infarction (STEMI) MI occurs as a result of thrombotic occlusion of one or more of the coronary arteries ******* CP is most common symptom, severe, doesnt go away Diagnosis EKG Cardiac markers PE, History MI occurs as a result of thrombotic occlusion of one or more of the coronary arteries ******* CP is most common symptom, severe, doesnt go away Diagnosis EKG Cardiac markers PE, History

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Ventricular Remodeling Changes in the size, shape, and thickness of the left ventricle involving both the infarcted and non-infarcted segments of the ventricle. Penumbra 1.68 million unique discharges for ACS in 2001, 30% estimate to have STEMI Ventricular Remodeling Changes in the size, shape, and thickness of the left ventricle involving both the infarcted and non-infarcted segments of the ventricle. Penumbra 1.68 million unique discharges for ACS in 2001, 30% estimate to have STEMI

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Management Pt contact with healthcare system Initiation of fibrinolytic therapy < 30 minutes Balloon inflation for PCI - < 90 minutes Pt contact with healthcare system Initiation of fibrinolytic therapy < 30 minutes Balloon inflation for PCI - < 90 minutes

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Choice of treatment decided by EM physician and resources of institution and surrounding institutions Contraindications to fibrinolytics Choice of treatment decided by EM physician and resources of institution and surrounding institutions Contraindications to fibrinolytics

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12 lead EKG completed and shown to experienced emergency physician WITHIN 10 minutes Cardiac Markers Troponin CK-MB Myoglobin Lab results should not delay treatment 12 lead EKG completed and shown to experienced emergency physician WITHIN 10 minutes Cardiac Markers Troponin CK-MB Myoglobin Lab results should not delay treatment

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Cardiac Enzymes Troponin, Myoglobin, CK-MB, Total CK

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What should be done? EKG Lab work Portable CXR Oxygen Nitroglycerin: 3 sublingual 0.04mg, IV if needed **** Phosphodiesterase inhibitor **** Morphine Sulfate: 2 4mg IV ASA chewed Beta blocker if not contraindicated ACE orally within 24 hours of STEMI for anterior infarct, pulm. congestion, LV EF < 40% EKG Lab work Portable CXR Oxygen Nitroglycerin: 3 sublingual 0.04mg, IV if needed **** Phosphodiesterase inhibitor **** Morphine Sulfate: 2 4mg IV ASA chewed Beta blocker if not contraindicated ACE orally within 24 hours of STEMI for anterior infarct, pulm. congestion, LV EF < 40%

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Patient Education Before Discharge Lifestyle changes Recognizing cardiac symptoms: calling 911 if symptoms not improving Family education about AED, CPR Lipid Management Weight Management Smoking cessation Lifestyle changes Recognizing cardiac symptoms: calling 911 if symptoms not improving Family education about AED, CPR Lipid Management Weight Management Smoking cessation

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Cont. Antiplatelet Therapy: ASA, Plavix ACE inhibitor if without contraindications Beta blockers: except low risk and contraindications Hypertension Control Diabetes Management No Hormone therapy Antiplatelet Therapy: ASA, Plavix ACE inhibitor if without contraindications Beta blockers: except low risk and contraindications Hypertension Control Diabetes Management No Hormone therapy

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Cont. Warfarin Therapy Physical activity: should be encouraged and prescribed appropriately / Rehab Follow up care with medical provider Warfarin Therapy Physical activity: should be encouraged and prescribed appropriately / Rehab Follow up care with medical provider

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See flow chart

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Questions????

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Cardiac Catheterization

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Percutaneous Coronary Interventions (PCI) Cardiac Catheterization PTCA (Percutaneous Transluminal Coronary Angioplasty / Angiography) PCI - Angioplasty, atherectomy, intracoronary stenting Web site http://www.heartsite.com/html/cath_4.html Cardiac Catheterization PTCA (Percutaneous Transluminal Coronary Angioplasty / Angiography) PCI - Angioplasty, atherectomy, intracoronary stenting Web site http://www.heartsite.com/html/cath_4.html

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Who undergoes PCI? Stable CAD Unstable angina NSTEMI STEMI Stable CAD Unstable angina NSTEMI STEMI

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What is a stent?

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http://www.cnn.com/2007/HEALTH/03/23/ stents.vs.drugs.ap/index.html

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Preprocedural Management What do you think? Informed consent Consent for CABG Education Hold Metformin (Glucophage), insulin etc NPO status Lab values - Which ones, and why?? What do you think? Informed consent Consent for CABG Education Hold Metformin (Glucophage), insulin etc NPO status Lab values - Which ones, and why??

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Postprocedural Managment What do you think? 12-Lead EKG Labs - Will CE be elevated? Hydrate Anticoagulation per institution Sheath removal Femstop Manual pressure Vascular closure devices Angioseal What do you think? 12-Lead EKG Labs - Will CE be elevated? Hydrate Anticoagulation per institution Sheath removal Femstop Manual pressure Vascular closure devices Angioseal

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SANDBAG Study Nurse to patient ratio of 1:1.5 or less maintained during sheath removal Sheaths removed within 4-6 hours Medicate for comfort, HOB can be 30 degrees Allowed to ambulate 8 hours after removal SANDBAGS ARE NOT EFFECTIVE TO MINIMIZE BLEEDING AND CAUSE DISCOMFOT *****Evidence-Based Practice******* Nurse to patient ratio of 1:1.5 or less maintained during sheath removal Sheaths removed within 4-6 hours Medicate for comfort, HOB can be 30 degrees Allowed to ambulate 8 hours after removal SANDBAGS ARE NOT EFFECTIVE TO MINIMIZE BLEEDING AND CAUSE DISCOMFOT *****Evidence-Based Practice*******

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Complications of PCI Abrupt Closure Acute Stent Thrombosis < 1% Vascular Spasm NSTEMI STEMI