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    Acute Coronary Syndromes 2015

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    A 55-year-old man presents with severe chest pain radiating down his left arm and jaw along with nausea, sweating, and a sense of doom. His vital signs show a heart rate of 110 bpm and blood pressure of 150/100 mmHg. The document outlines the immediate assessment and treatment for this patient including obtaining an ECG, IV access, oxygen supplementation, aspirin, nitroglycerin, and morphine as needed. General treatment of acute coronary syndromes is also reviewed including the uses of oxygen, aspirin, nitroglycerin, morphine, beta-blockers, heparin, ACE inhibitors, fibrinolytic therapy, antiplatelet agents, percutaneous coronary interventions, and

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    Acute Coronary Syndromes 2015

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    prototypeallhell
    58 views26 pages
    A 55-year-old man presents with severe chest pain radiating down his left arm and jaw along with nausea, sweating, and a sense of doom. His vital signs show a heart rate of 110 bpm and blood pressure of 150/100 mmHg. The document outlines the immediate assessment and treatment for this patient including obtaining an ECG, IV access, oxygen supplementation, aspirin, nitroglycerin, and morphine as needed. General treatment of acute coronary syndromes is also reviewed including the uses of oxygen, aspirin, nitroglycerin, morphine, beta-blockers, heparin, ACE inhibitors, fibrinolytic therapy, antiplatelet agents, percutaneous coronary interventions, and

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    Acute Coronary Syndromes 2015 Lecture

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    A 55-year-old man presents with severe chest pain radiating down his left arm and jaw along with nausea, sweating, and a sense of doom. His vital signs show a heart rate of 110 bpm and blood pressure of 150/100 mmHg. The document outlines the immediate assessment and treatment for this patient including obtaining an ECG, IV access, oxygen supplementation, aspirin, nitroglycerin, and morphine as needed. General treatment of acute coronary syndromes is also reviewed including the uses of oxygen, aspirin, nitroglycerin, morphine, beta-blockers, heparin, ACE inhibitors, fibrinolytic therapy, antiplatelet agents, percutaneous coronary interventions, and

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    58 views26 pages

    Acute Coronary Syndromes 2015

    Uploaded by

    prototypeallhell
    A 55-year-old man presents with severe chest pain radiating down his left arm and jaw along with nausea, sweating, and a sense of doom. His vital signs show a heart rate of 110 bpm and blood pressure of 150/100 mmHg. The document outlines the immediate assessment and treatment for this patient including obtaining an ECG, IV access, oxygen supplementation, aspirin, nitroglycerin, and morphine as needed. General treatment of acute coronary syndromes is also reviewed including the uses of oxygen, aspirin, nitroglycerin, morphine, beta-blockers, heparin, ACE inhibitors, fibrinolytic therapy, antiplatelet agents, percutaneous coronary interventions, and

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    Acute Coronary

    Syndromes
    N60B
    Spring 2015
    1

    Case Scenario
    A 55-year-old man presents with a chief complaint
    of severe (10 out of 10) substernal chest pain. He
    has pain radiating down his left arm and up into his
    jaw, nausea, and a profound sense of impending
    doom. He is covered with small beads of sweat.
    Vital signs: TEMP = 37.2C; HR = 110 bpm;
    BP = 150/100 mm Hg; RESP = 12
    Describe your immediate assessment.
    Describe your immediate general treatment.
    2

    Items of Immediate Assessment (<10 min)


    Check vital signs with automatic or standard BP cuff
    Determine oxygen saturation
    Obtain IV access
    Obtain 12-lead ECG
    Obtain a brief, targeted history and perform a physical
    examination; focus on eligibility for fibrinolytic therapy
    Obtain blood sample for initial cardiac marker levels

    Cardiac-specific troponins I and T increase 3 or 4 hrs after


    injury, stay elevated for 10 to 14 days.
    Baseline Cardiac troponin I <0.03 ng/mL and troponin T
    <0.20ng/mL

    Initiate electrolyte and coagulation studies, BNP


    3

    Immediate General Treatment

    Oxygen at 4 L/min
    Aspirin 160 to 325 mg
    Nitroglycerin SL or spray
    Morphine IV (if pain not relieved
    with nitroglycerin)

    Oxygen Used in
    Acute Coronary Syndromes
    Why?
    Increases supply of oxygen to ischemic tissue
    When?
    Always when AMI is suspected
    How?
    Start with nasal cannula at 2-4 L/min
    maintain O2 sat greater than 90%
    Remember: oxygen-IV-monitor
    Watch Out!
    Rarely COPD patients with hypoxic
    ventilatory drive will hypoventilate
    5

    Nitroglycerin: Actions
    Decreases pain of ischemia
    Increases venous dilation
    Decreases venous blood return to heart
    Decreases preload and cardiac
    oxygen consumption
    Dilates coronary arteries
    Increases cardiac collateral flow

    Nitroglycerin: Indications
    Class I: First 24 to 48 hours in patients with
    ST-segment elevation or depression including

    LV failure (acute pulmonary edema or CHF)


    Elevated BP (especially with signs of LV failure)
    Large anterior infarction
    Persistent ischemia

    Suspected ischemic chest pain


    Unstable angina (change in angina pattern)
    Acute pulmonary edema (if BP >90 mm Hg systolic)
    7

    Nitroglycerin: Dose
    Sublingual: 0.3 to 0.4 mg; repeat every 5 minutes
    Spray inhaler: 2 metered doses at 5-minute intervals
    IV infusion: 12.5 to 25 g bolus, 10 to 20 g/min
    infusion, titrated

    Nitroglycerin: Precautions
    Use extreme caution if systolic BP <90 mm Hg
    Use extreme caution in RV infarction
    Suspect RV infarction with inferior ST changes
    Limit BP drop to 10% if patient is normotensive
    Limit BP drop to 30% if patient is hypertensive
    Watch for headache, drop in BP, syncope,
    tachycardia
    Tell patient to sit or lie down during administration
    9

    Morphine Sulfate:
    Actions, Indications
    Why? (Actions)
    To reduce pain of ischemia
    To reduce anxiety
    To reduce extension of ischemia by reducing
    O2 demands
    When? (Indications)
    Continuing pain
    Evidence of vascular congestion (acute
    pulmonary edema)
    Systolic blood pressure >90 mm Hg
    No hypovolemia
    10

    Morphine Sulfate:
    Dose, Precautions
    How? (Dose)
    2 to 4 mg titrated to effect
    Goal: Eliminate pain
    Watch out for (Precautions)
    Drop in blood pressure, especially in patients with
    Volume depletion
    RV infarction
    Depression of ventilation
    Nausea and vomiting (common)
    Bradycardia
    Itching and bronchospasm (uncommon)
    11

    Aspirin: Actions
    Why? (Actions)
    Blocks formation of thromboxane A2
    (thromboxane A2 causes platelets to aggregate
    and arteries to constrict)
    These actions will reduce
    Overall mortality from AMI
    Nonfatal reinfarction
    Nonfatal stroke
    12

    Aspirin:
    Indications, Dose, Precautions
    When? (Indications) As soon as possible!
    Standard therapy for all patients with new pain suggestive
    of AMI
    Give within minutes of arrival
    How? (Dose) 160- to 325-mg tablet taken as soon as possible
    Watch Out! (Precautions)
    Relatively contraindicated in patients with active peptic
    ulcer disease or asthma
    Contraindicated in patients with known aspirin
    hypersensitivity
    Bleeding disorders
    Severe hepatic disease
    13

    -Blockers
    Mechanism of action
    Blocks catecholamines from binding to
    -adrenergic receptors
    Reduces HR, BP, myocardial contractility
    Decreases AV nodal conduction
    Decreases incidence of primary VF

    14

    -Blockers
    Absolute
    Contraindications
    Severe CHF/PE
    SBP <100 mm Hg
    Acute asthma
    (bronchospasm)
    2nd- or 3rd-degree
    AV block

    Cautions

    Mild/moderate CHF
    HR <60 bpm
    History of asthma
    Type 1 Diabetes

    15

    Heparin
    Mechanism of action
    Indirect thrombin inhibitor
    Indications
    PTCA or CABG
    With fibrin-specific lytics
    High risk for systemic emboli
    Conditions with high risk for systemic
    emboli, such as large anterior MI, atrial
    fibrillation, or LV thrombus
    16

    ACE Inhibitors
    Mechanism of action
    Reduces BP by inhibiting angiotensin-converting
    enzyme (ACE)
    Alters post-AMI LV remodeling by inhibiting
    tissue ACE
    Lowers peripheral vascular resistance
    by vasodilatation
    Reduces mortality and CHF from AMI
    17

    Fibrinolytic Therapy
    Breaks up the fibrin network that binds clots together
    Indications: ST elevation >1 mm in 2 or more
    contiguous leads or new LBBB or new BBB that
    obscures ST
    Time of symptom onset must be <6 hours
    Caution: fibrinolytics can cause death from brain
    hemorrhage
    Agents differ in their mechanism of action, ease of
    preparation and cost
    1 agent currently available: alteplase (tPA, Activase)
    18

    Antiplatelet Agents
    Blocks glycoprotein IIb/IIIa receptors on platelets
    Blocked receptors cannot attach to fibrinogen
    Fibrinogen cannot aggregate platelets to platelets
    Indications: ACS with NO ST-segment elevation:
    NonQ-wave MI
    Unstable angina managed medically
    UA undergoing PCI
    Examples: abciximab (ReoPro), eptifibitide (Integrilin),
    tirofiban (Aggrastat)
    19

    Three Percutaneous Coronary


    Interventions (PCIs)

    2. PTCA + stent
    placement

    1. PTCA:
    Percutaneous
    Transluminal
    Coronary Angioplasty

    3. Atherectomy:
    grinds away
    the plaque

    20

    Heart Disease in Women


    Heart disease is the leading
    killer of women in the United
    States and the second
    leading cause of death in
    most developed nations.
    --American Heart Association (2007)
    21

    Prognosis After MI
    38% of women die within first year
    Compared to 25% of men
    35% of women will have second MI within 6
    years
    Compared to 18% of men

    Source: Wenger 2004

    22

    Stress

    Puts a woman at greater risk for CVD and


    poorer outcomes
    Depression also may increase risk or deter her
    from seeking medical help
    Consider screening women with CAD for
    depression and refer for treatment as needed
    23

    Signs and Symptoms in Women


    Number one symptom is SOB!
    Other symptoms include: fatigue, GI symptoms, changes in
    sleep patterns
    Older women or those with diabetes may not have chest pain
    May also have:
    Heaviness, squeezing, or pain in left chest, abdomen,
    midback, or shoulder
    Arm pain
    Palpitations or pain thats sharp or fleeting

    24

    And the Answer is.


    Differences in physiological vascular
    function. The coronary endothelial and
    microvascular reactivity are the believed key
    players.

    WISE Study
    25

    Websites on Sex-Based Differences in


    Health and Disease
    Society for Womens Health Research:
    Overview of sex-based differences
    http://www.womenshealthresearch.org/hs/links.htm
    http://www.womenshealthresearch.org/hs/healthfacts.htm
    Centre for Research in Womens Health
    http://www.crwh.org/
    National Center for Gender Physiology at the University of
    Missouri
    http://www.genderphysiology.org
    Partnership for Gender-Specific Medicine
    http://cpmcnet.columbia.edu/dept/partnership/
    26

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