Stable angina

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• Often becomes chronic based on the level of coronary artery disease, intermittent but predictable exacerbation (usually on exertion)
• More of an achy pain, oxygen demand has exceeded what is available, usually ends with the stopping of activity, extremely chronic cases may require vasodilators
• Causes a slight ST depression on EKG
• Chest pain longer than 30 minutes is most likely a myocardial infarction
• Medications -- nitroglycerin (sublingual, okay to give to NPO patients, causes all vessels in body to open so patient must sit down)
• Silent ischemia -- no pain
• Nocturnal bouts are usually very quick
• Decubitus -- only occurs while laying down
• Microvascular -- small vessel spasms
• All types are treated with rest and nitroglycerin

Variant Angina

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• Specifically is caused by a spasm in a vessel
• Usually occurs at rest and can stop with exercise or on its own
• Main goal is to keep cardiac output up
• Most common in patients with other spasm disorders, not necessarily CAD patients
• Causes a very small and quick ST elevation
• Medications: Calcium channel blockers, cardizem

Unstable Angina

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• Most serious
• Caused by a sustained lack of blood flow
• New with no previous issues usually
• Occurs with rest
• Unpredictable
• Also known as a myocardial infarction or acute coronary syndrome
• Requires intervention
• STEMI -- full occlusion, causes a rise in ST wave
• non-STEMI -- partial occlusion, does not cause a rise in ST wave

• Men feel more classic heart attack symptoms, usually have a very obvious MI
• Women feel more vague symptoms (malaise, nausea, vomiting), common pain in jaw and/or shoulder

• Chest x-ray -- check structures for enlargement
• EKG -- check rhythms
• Enzymes -- troponin shows 4 to 6 hours after MI, 0.05 or higher

• Used for suspected MI
• Morphine
• Oxygen
• Nitroglycerin
• Aspirin

• Thrombolytic therapy -- not possible if pain has lasted more than 6 hours, causes a bleed risk, not used if going to cath lab, IV agent is injected straight into vessels (TPA)
• Cath lab -- patient must be in the lab in 60 minutes and removed within 90, used to both diagnose and treat clots, a large vessel is entered in order to view other vessels, patient must lay flat for 4 to 6 hours after cath lab (Percutaneous coronary intervention), closure devices are used to secure artery for healing
• If cath lab is not possible (multiple diseased vessels, tried previously and failed, difficult area to access) open heart surgery will be performed
• If any sort of dye is used for imaging, glucophage must be held for at least 24 hours ahead of injection and for at least 48 hours previously to prevent kidney injury
• Angioplasty -- surgically opening the vessel and placing a stent, PTCA -- "balloon"
• CABG (bypass) -- rough on body, grafts/stents usually last 8 to 10 years, high clot risk (patients are heparinized), organs are affected due to lack of perfusion, kidney failure is possible but patients usually return to normal function within one year

• Kidney failure, function usually returns within a year
• Dysrhythmia, incredibly common
• Fluid deficiency
• Pain
• Angina
• Heart Failure
• Cardiogenic shock
• Stroke
• Infection
• Death

• 12 lead EKG
• Oxygen
• Nitroglycerin
• Aspirin
• Morphine
• Cardiac enzyme testing
• Chest x-ray

• Risks -- hypertension, age, smoking, CAD, high cholesterol 
• Left sided failure will cause right sided failure
• Acute decompensated heart failure -- the most severe
• Compensation of the heart -- increased heart rate by the SNS, increased preload causes stretching which causes decreased contractions, BNP is released (high BNP indicates heart failure), compensation leads to increased heart failure
• Objective data -- decreased urine output, edema, JVD, increased heart rate
• Subjective data -- Shortness of breath, fatigue, increased weight, cough
• Pulmonary edema symptoms -- coughing, tachycardia, shortness of breath, frothy sputum, caused by left sided heart failure backup

• Dysrhythmias
• Pleural effusion
• Left ventricle thrombus
• Hepatomegaly
• Renal Failure
• Death

• ACE inhibitor (used first)
• Diuretics
• Cardiac resynchronization therapy -- used to get the atria and the ventricles pumping in unison
• LVAD -- life vest, left ventricular assistance device
• ICD -- implantable cardioverter defibrillator

• Used to jumpstart the heart to pump if it fails to do so, can read node failures
• AAI -- atrial pacing and sensing, good for lack of SA node function
• VVI -- ventricular pacing and sensing, on demand use, picks up inappropriate rhythms
• DDDR -- dual pacing, dual sensing, covers atria and ventricles
• CRT -- helps chambers work simultaneously
• Temporary -- power source is outside of the body, patient is under anesthesia on placement, infection risk, possible hematomas, threads through a vein, pneumothroax risk, usually used on severe MI or CABG patients
• Permanent -- used for AV blocl, heart failure, AFIB, SA node dysfunction

• Failure to sense natural heart contractions
• Failure to capture -- impulse is not strong enough to make heart contract
• Causes -- faulty device, wire problem, dying battery, incorrect programming, dislodging

• Picks up abnormal rhythms and shocks them out
• Used for people who have survived sudden cardiac death or have a history of sustained VTACH
• Antitachycardic -- shocks at too fast
• Antibradycardic -- shocks at too slow