4. STATINS aka: (COENZYME INHIBITOR)
Mevacor, Zocor, Lipitor
BLOCKS BIOSYNTHESIS OF CHOLESTEROL
• HIGH FIRST PASS EFFECT
*MONITOR LFT
•SIDE EFFECTS
•N/V/D & ABDOMINAL CRAMPS
•MYALGIA, ARTHRALGIA,Cataracts
•HEADACHES, DIZZINESS, INSOMNIA
•Liver and kidney dysfunction
5. Angina Pectoris
Episode of chest pain or pressure due to
insufficient artery flow of oxygenated blood.
Myocardial 02 demand exceeds 02 supply. CAD
is the most common cause.
One coronary artery branch becomes completely
occluded; therefore, 02 is not perfused to the
myocardium, resulting in transient ischemia and
subsequent retrosternal pain.
6. Angina Pectoris
Precipitating Factors: Warning Sign for MI
Clinical Signs & Symptoms: do not occur until lumen is
75% narrowed. Sternal pain: mild to severe. May be
described as heavy, squeezing, pressing, burning,
crushing or aching. Onset sudden or gradual. May radiate
to L. shoulder and arm. Radiates less commonly to R.
shoulder, neck, jaw. Pt may have weakness/numbness of
wrist, arm, hands. pain usually short duration and relieved
by removal precipitating factors,rest or NTG. Can be
gradual (CAD) or sudden(vasospasm)
Associated Symptoms: dyspnea, N & V, tachycardia,
palpitations, fatigue, diaphoresis, pallor, weakness,
syncope, factors
7. Types of Angina
Stable: There is a stable pattern of onset, duration and
intensity of sx, pain is triggered by a predictable
degree of exertion or emotion.
Variant Angina (Prinzmetal's)
Cyclical, may occur at rest.
Ventricular arrhythmia, brady arrhythmia and
conduction disturbances occur.
Syncope associated with arrhythmia may occur
Nocturnal Angina only at night. Possible associated
with REM sleep.
Unstable Angina AKA Pre infarction angina
Pain is more intense, lasts longer
9. Medications for Angina
1. Nitrates decrease myocardial 02 demand via
peripheral vasodilation and reverse coronary
artery spasm thus increase 02 supply to
myocardial tissue.
2. Understanding how Nitrates Work: peripheral
vasodilation results in:
-decreased 02 demand
-decreased venous return to heart
-decreased ventricular filling which results
in decreased wall tension and thus
-decreased 02 demand
10. NTG Forms:
• SL (Nitrostat)
• Lingual Sprays - similar to SL in use (Nitrolingual)
• Sustained release capsules/tablets (Nitrobid)
• Ointments 2% (Nitrobid)- wear gloves when applying
• Transdermal Patch (Nitro-Dur)
• IV (Tridil) For attacks unresponsive to other tx
12. Acute Angina Treatment
Goal: Enhance 02 supply to myocardium:
M- Morphine for pain
O- Oxygen 4-6L as ordered
N- NTG sublingual, repeat q5 minutes x3
A- Aspirin to prevent platelet aggregation
13. Angina Treatment
The focus is to relieve acute attacks and prevent further
attacks.
1. Activity/exercise tolerance - a regular exercise
prescription is established after stress testing
and/or cardiac cath.
Baseline
Gradual increase
Avoid
Alternate
ADLS
NTG before exercise
14. Patient education
Lifestyle modifications for controllable risk
factors. Support groups are helpful,
Example: Weight watchers,
Smoke-enders, stress workshops, cardiac
rehabilitation. Supply patients with
information, name of contact person
and phone numbers
Identify precipitating factors for Anginal pain
Medication compliance
16. Beta-adrenergic Blockers
Therapeutic effect - decrease the rate
and force of the cardiac contraction
(resulting in decreased 02 demand)
and decrease vasoconstriction in the
myocardium and vasculature.
Mechanism of Action - inhibit circulating
catecholamines from stimulating beta
receptor sites. There are two type of
beta receptors (B1 & B2).
17. Beta-adrenergic Blockers
B1 receptor stimulation by catecholamines
results in increased HR & myocardial
contractility so, blocking the B1 effect
results in slowed HR & decreased
myocardial contractility.
Cardio-selective
Excess blockade can result in bradycardia,
heart block, heart failure and/or
hypotension.
atenolol (Tenormin)
metoprolol (Lopressor, Toprol)
18. Beta-adrenergic Blockers
B2 receptor stimulation by catecholamines results
in dilation of the bronchial tree, the coronary
arteries and the peripheral vasculature
Blocking the B2 effect results in
bronchoconstriction, coronary artery
vasoconstriction and peripheral vascular
constriction.
Drugs that have a B2 blockade effect are
used cautiously/contraindicated in clients
with COPD.
Non-selective Beta Blockers - Block B1 and B2
receptors
propanolol (Inderal)
carvedilol (Coreg)
19. Beta-adrenergic Blockers
Side Effects - many may be predicted based upon
understanding the mechanism of action.
Hypotension Bradycardia
Heart Failure Weakness/Fatigue
Depression Impotence
Hypoglycemia Hallucinations
Patient Teaching:
Use with caution in clients prone to coronary artery
spasm due to vasoconstrictive effects.
Contraindicated in clients with CHF and second or third
degree heart block due to the rate slowing and
reduction in contractility.
Non-selective beta blockers contraindicated with COPD.
Do not abruptly discontinue beta blockers
20. Calcium Channel Blockers
Action - inhibit flow of Ca+ across cell
membrane. Ca+ is essential for cardiac
stimulation, conduction, contractility and relax
vascular smooth muscle which results in
decreased 02 demand and increased
coronaryblood supply
VASODILATION
Indications: angina, HTN, arrhythmia
Drugs-
verapamil (Calan, Isoptin)
diltiazem (Cardizem)
nifedipine (Procardia)
amlodipine (Norvasc)
21. Calcium Channel Blockers
Side Effects of Calcium Channel Blockers
Constipation (with Verapamil)
Dizziness
Facial Flushing
HA
Edema of ankles/feet
Bradycardia
Hypotension
22. Epinenepherine (adrenalin)
Vasoconstriction- Increase BP
Alpha, Beta 1 and Beta 2 agonist
Decrease congestion of nasal mucosa
Catacholamine- produced by……
Tx of AV block and cardiac arrest
23. ACE INHIBITORS –The “prils”
Angiotensin Converting Enzymes Inhibitors
Action: Blocks production of Angiotensin II in kidneys
Indications: HF, HTN, MI, DM neuropathy
Causes: Vasodilation (mostly arteriole)
Decreased BP
Excretion of Na and H2O (but not K)
Ex.: captopril (Capoten)
enalapril (Vasotec)
fosinopril (Monopril)
ramapril (Altace)
SE : ortho hypotension, dry cough, hyperkalemia
24. Angiotensin Receptor Blockers-
ARBs
Action- Block the binding of Angiotensin II
to it’s receptor in the vascular and adrenal tissues
Examples: candesartan (Atacand)
losartan (Cozaar)
25. Cardiac Glycoside
digoxin (Lanoxin)
Action :+Inotropic effect
Increases force of myocardial contraction
- Chronotropic effect- decreases HR
Tx: heart failure, afib
Nsg: Apical Pulse for 1 full minute, hold for <60,
same time daily
Monitor Dig levels 0.5-0.8 ng/ml
Monitor K levels
Monitor for Dig toxicity: anorexia, fatigue,
weakness, vision changes (halos)
26. Myocardial Infarction
Leading cause of death in US
Thrombosis in atherosclerotic artery causes 90%
of MIs.
A region of the myocardium is abruptly deprived
of blood supply due to restricted coronary blood
flow
Ischemia results and may lead to necrosis within
6 hours
JCAHO Core Measures for AMI (4/10)
27. Gender Differences in MI
Females, when compared to males:
-present with MI later in life
-have poorer prognosis and high morbidity
-are 2x as likely to die in the first weeks
-are more likely to die from the first MI
-have higher rates of unrecognized MI
-NSTEMI MI vs STEMI
29. Location of MI
Depends on which artery is affected
LV receives most of the CA supply and so it is the
most affected
Left Anterior Descending (LAD)
Left Circumflex artery (LCA)
Right Coronary Artery (RCA)
30. General Types of MI
Transmural-invades full thickness of myocardium
Subenedocardial-invades partial thickness
31. Collateral Circulation
A network of blood vessels present at birth that
can dilate and become functional a/r/o coronary
artery occlusion and ischemia. “collateral
circulation”
Natural “bypass” mechanism helps decrease the
size of the MI
32. Risk Factors and Etiology
CAD and its risk factors
Any situation requiring increased O2 in the
presence of decreased O2 supply.
Non atherosclerotic coronary artery occlusions
33. Effects of MI
Cell death
Contractility in the affected areas reduced or
absent
Electrical instability
39. Diagnosis of MI
Based on 2 out of 3 criteria
1. Chest pain indicative of ischemic heart disease
2. Characteristic EKG changes (ST elevation)
3. Marked rise and eventual decline in serum
markers of cardiac injury
48. Antiarrhythmics
Class IA- Na channel blockers
Class IB- Na channel blockers
Class II- Beta blockers
Class III- Amiodarone
Class IV- Ca Channel blockers
50. Post MI Cardiac rehab
Begins in acute phase and continues indefinitely
as outpatient
Includes:
education
activity progression
counseling
medical management
51. Non-Pharmacologic Therapy
Percutaneous transluminal coronary angioplasty
(PTCA)
Dilates coronary arteries obstructed by plague.
30% restenosis rate within first 6 months.
Patient Criteria
Non-calcified lesions less than 2 cm. The ideal
candidate would have less than a one year
history of angina and be able to undergo
coronary artery by-pass grafting if necessary.
Patients with calcified lesions or lesions in
branch vessels are not considered good
candidates
52. Non-Pharmacologic Therapy
Cardiac Catheterization/ Balloon Angioplasty
Performed in the cardiac cath lab. A catheter
with a balloon tip is passed into the obstructed
artery and is alternately inflated and deflated to
increase arterial diameter and perfusion.
Complications
Arterial rupture, spasm, emboli, MI
Post-procedure care
53. Other Procedures
Coronary Artery Stents
Stainless steel mesh stent is placed in lumen to
prevent restenosis after angioplasty. Requires
anticoagulation and antiplatelet tx to prevent
local-thrombosis.
Coronary Laser Surgery
Laser can destroy atherosclerotic plaque.
Research is being conducted in transluminal
laser angioplasty to coronary arteries.
Atherectomy - surgical removal of atheroma.
54. Coronary Artery By-Pass Grafting (CABG)
Procedure - Surgical revascularization to increase
coronary blood flow.
Patients with severe disease may not be
candidates. Longevity after surgery still being
debated. Surgery does not cure atherosclerosis
and patients must still control risk factors
55. Post-op CABG
Post-Operative Nursing Assessments & Care
Cardiovascular function
Respiratory function - pt may be on mechanical
ventilator for short time.
Renal Function
Neurologic Function
Peripheral Vascular Function
Fluid & Electrolyte Balance
Pain management
Psychological Status
Safety - Pt may be restrained to present self
extubation
56. Cardiac Tamponade of CABG
Etiology - heart is compressed by fluid within the
pericardial sac. Ventricular filling is thus impaired
resulting in decreased cardiac output and
circulatory collapse.
Clinical Signs
Pulsus Paradoxus Blood Pressure
Neck Veins Heart Sounds
Respirations Mental Status
Pain
Treatment
Thoracotomy Pericardiocentesis
57. NCLEX TIME
Modifiable risk factors associated with CAD include:
A. age, weight, cholesterol level
B. Smoking, diet, BP
C. Family hx, weight, BP
D. Blood glucose, activity level, family hx
58. NCLEX TIME
A patient has just returned from cardiac cath. Which
nursing intervention is most appropriate?
A. Assist pt to ambulate to the BR
B. Restrict fluids
C. Monitor peripheral pulses
D. Insert an indwelling catheter
59. NCLEX TIME
A 63 man is resuscitated successfully after
cardiac arrest. Blood studies show that he is
acidotic. Why?
A. Decreased tissue perfusion causes lactic
acid production
B. The pt typically has an irregular heart beat
C. The pt was treated inappropriately with Na
Bicarb
D. Fat forming ketoacids are breaking down
60. NCLEX TIME
Rosie is preparing her client for discharge
following his inpatient stay with angina, which
is now stable. Rosie is reviewing both
modifiable and nonmodifiable risk factors.
Select all factors below that are
nonmodifiable.
A.Age
B.Gender
C.Obesity
D.Family history
E.Hypertension
61. NCLEX TIME
Following her inferior wall MI, Mrs. Green is quiet,
reserved, and avoiding contact with her family.
Understanding the psychosocial aspects of ACS,
which intervention would be best for the nurse to
do first?
A.Have the client’s cardiologist write for a
psychiatric referral.
B.Provide an atmosphere of acceptance.
C.Foster mechanisms to suppress anger and
hostility.
D.Provide factual information to the client’s family
alone.
62. NCLEX TIME
When Rosie is assessing her client with chest
pain, she is evaluating whether or not the
client is suffering from angina or MI. Which
symptom would be indicative of an MI?
A.Substernal chest discomfort
B.Chest pain brought on by exertion or stress
C.Substernal chest discomfort relieved by
nitroglycerin or rest
D.Substernal chest pressure relieved only by
opioids
63. NCLEX TIME
All of the following clients are being cared for on the
coronary care “stepdown” unit. When making client
assignments, which client will be best for the charge
nurse to assign to a new graduate RN who has
completed 6 months of orientation to the unit?
A.A client who has a new diagnosis of heart failure and
needs discharge teaching about medications
B.A client who has just returned to the unit after having a
coronary arteriogram and has orders for vital signs
every 15 minutes
C.A client with a history of angina who is requesting
nitroglycerin for left anterior chest pain
D.A client who has many questions about the
electrophysiology studies that are scheduled
64. NCLEX TIME
4.An RN and an LPN who both have several years of
experience in the intensive care unit are caring for a
group of clients. Which task will be most appropriate for
the RN to delegate to the LPN?
A.Obtaining pulmonary artery wedge pressures every
hour for a client admitted with pulmonary edema
B.Monitoring vital signs and assessing the catheter
insertion site for a client who returned from a coronary
arteriogram an hour ago
C.Teaching the family members of a client who is
scheduled for myocardial nuclear perfusion imaging
about the procedure
D.Completing the admission assessment for a client
admitted to the unit with acute coronary syndrome
65. NCLEX TIME
The nurse is caring for a client who has been
admitted with chest pain of unknown etiology. All
of the following laboratory tests are obtained.
Which test results require the most immediate
action by the nurse.
A.Troponin T is elevated.
B.Creatinine kinase is decreased.
C.Myoglobin is increased.
D.High-density lipoproteins are decreased.
66. Cardiac Case Study
A 57yo male is admitted to your unit c/o dull pain
in the left side of his chest and radiating to his
neck. There’s no diaphoresis or SOB. Risk
factors include hypercholesteremia and a 70
pack year hx of smoking.
PE reveals BP 140/86, HR 110, normal heart
sounds and clear lungs bilat. Cardiac markers
drawn ½ hour after the onset of pain show
Myoglobin 45mcg. Troponin I at 0.01ng/mL and
CPK-MB of 10u/L. EKG shows nonspecific ST
wave changes in the anterior leads.
