Unstable Angina (Nursing)

00:00 Okay, so your hip to the groove that unstable angina is a medical emergency.

00:05 We put an ambulance there riding on two wheels just to remind you.

00:08 But unstable angina is likely the result of severe coronary artery disease that got complicated by either of vasospasm or a clot.

00:17 So the arteries were already narrowed by severe coronary artery disease, but we made it worse when it had a vasospasm that particular spot or a clot broke off traveled right to the narrow part and that started to block it off.

00:30 So the clot can be a rupture of plaque plus platelet aggregation, then you end up with a thrombus which is just another word for clot.

00:39 So, can you picture in your mind what that look like on our drawings? Good every time you have your brain pause and recall you're doing a great job encoding and studying with us as you go.

00:50 So we know it's a medical emergency.

00:52 We put the pictures back up there for you again just to remind you because repetition is always good when you're studying.

00:59 Look at the difference between infarct and unstable angina both have atherosclerosis both have a clot, But an infarct that clot has now blocked off the majority if not, absolutely all of the blood supply.

01:14 So how will this be different than exertional angina? Well, even at rest the patient is going to have angina or chest pain.

01:22 This might be different.

01:23 They may never had exertional angina before but all of a sudden they're feeling it or their regular angina.

01:30 They're a patient who's had a history of angina.

01:33 It's much more intense.

01:34 It's very different.

01:36 Now I want to give you a little side note sometimes diabetic patients don't feel or sense A lot of angina.

01:43 The damage is still going on and that always made me nervous when I had a diabetic patient who told me they had chest pain that absolutely got my attention.

01:53 However, just remember most people will feel it but some patients don't or present and just unusual symptom presentation but we're talking about the classic progression and what you really will most often see.

02:08 So you know the difference between unstable angina in infarct both how the arteries look and what it feels like but these are clues that patients need to understand like hey, this is when you need to seek medical attention because this is a medical emergency.

02:21 So they have chest pain or angina arrest.

02:24 Maybe they have exertional angina, even if they've never experienced it before this could be a sign or their existing angina that they've experienced before is much worse.

02:35 Bottom line, something is different from their normal.

02:40 I want you to understand this concept about balance.

02:43 We talked about a lot in with most diagnosis.

02:46 But in order to not have chest pain or ischemia, whatever the heart needs or demanding is what the body needs to supply if for some reason they are arteries can't supply the amount of oxygen that the heart needs at the moment.

03:02 That's when you have ischemia.

03:04 So our goal in treating this is to maintain oxygen supply and decreased oxygen demand.

03:10 That's why when someone has chest pain you want them to lie down and rest.

03:14 You don't want them to keep on just going on with you activity.

03:17 So we want to decrease the oxygen demand which sometimes is enough to maintain an adequate oxygen supply just have to seal each patient responds.

03:27 So unstable angina can be result of severe coronary artery disease that's complicated by a vasospasm or a clot, you got that.

03:35 We know what the clot can be can be a rupture of the plaque plus the plaque and platelet aggregation, that's what gives us a thrombus, again just another name for a clot.

03:45 So if we're going to prevent infarction, we've got to look at what is the big picture? How do we take care of these patients? What we call that anti ischemic therapy.

03:55 We've got somebody we know is having chest pain.

03:57 What do we do with a patient who has unstable angina? So for those of you in ER you're going to become pros at this because this patient gets triage or prioritize right to the top of the list because with heart patients time is tissue.

04:14 Now, we're talking about a much longer-term implication if we can't rescue that heart muscle, so we think about things for anti ischemic therapy, like nitroglycerin, might consider beta blocker oxygen if the pulse ox is low and we're going to look at possibly an ACE inhibitor or an ARB if they can't handle an ACE because they have this left ventricular dysfunction.

04:38 So these are considered anti ischemic therapy.

04:41 Now I know a lot of you have heard of MONA, morphine, oxygen, nitro and aspirin right? That's going to be in there to we're just giving you an overview of some of the treatment plans and anti ischemic therapy.

04:54 So antiplatelet therapy, we're going to give an aspirin and might consider an other antiplatelet but oftentimes, it's just a basic aspirin that a patient is given.

05:04 For anticoagulant therapy, we're going to look at low molecular weight heparin, a direct thrombin inhibitor, or or even unfractionated heparin so that decision will be made by the healthcare provider.

05:16 Now the worst not shouldn't say the worst but the most intense therapy the one that has the most significant risk is thrombolytics.

05:25 So after the patient has gone through diagnostics and all the contraindications for risk of hemorrhage have been ruled out.

05:31 They can't have a recent trauma, recent surgery, you know recent GI bleeding anything that would put this patient at increased risk for hemorrhage will be excluded from receiving a thrombolytic.

05:44 Because thrombolytics (boom) they are clot busters.

05:48 So since they blow up clots everywhere, we want to keep the patient safe know that this is an increased risk for hemorrhage.

05:55 So you screen the patient.

05:56 It's also important that a thrombolytic be given within a tight window of time usually within four hours of onset because the goal of treating ischemia, unstable angina is to prevent infarct.

06:08 If it's greater than four hours that tissue is likely not viable now.

06:12 So it's not worth the risk of restoring perfusion or blood supply for tissue that isn't viable.

06:19 Okay so we've kind of coming at this from a different angle, right? We're talking here about antiplatelet therapy, anticoagulant therapy and if deemed safe and appropriate thrombolytic therapy, and when thrombolytics work, they are amazing in what they can do.

06:36 Now let's talk about why we give beta blockers.

06:39 Well you what a beta blocker does right? It's a drug that hits those beta receptors on the heart.

06:44 We also have receptors on the lungs, beta 2 are on the lung, beta 1 or on the heart.

06:50 But if I give a beta blocker medication, it binds with those receptors on the heart.

06:56 Now the hearts job those receptors on the heart is to make it pump harder and faster, but if I have a beta blocker, a medication there it's not going to cause that response it will block that response of the heart beating faster and harder.

07:12 Well if I'm in unstable angina, I'm not getting enough oxygen for what I'm demanding.

07:18 So if I slow the heart down make it rest by not beating as fast or beating as hard the hardest not going to need as much oxygen.

07:27 That's why it's considered and treating unstable angina.

07:32 Now beta blockers also used after an MI for the same purpose because it will decrease the workload of the heart and it's been shown through research that if a patient post MI goes home on a beta blocker, it can reduce their mortality after having a heart attack.

07:47 So one of the most common drugs to control ischemia in patients with stable coronary artery disease is a beta-blocker.

07:54 It's a long-term effect.

07:57 So if someone goes home on a beta blocker the idea is that we're going to reduce future attacks of angina because the heart doesn't have to work as hard.

08:05 It's slow down and not pumping is hard because they've been given a beta blocker.

08:11 Now oxygen, we want to watch this carefully look at their oxygen saturation.

08:16 If it's less than 90 percent or they're showing us other signs of respiratory distress, then we would give oxygen.

08:23 Used to be a given everyone who rolled in morphine, oxygen, nitro, aspirin.

08:27 We just gave those immediately but now we've really found that it's not helpful to the patient to have oxygen unless they need it.

08:35 So that's something that's relatively new in the long history of things.

08:39 So keep that in mind.

08:40 We don't just automatically put oxygen on we make sure that saturation is less than 90% or the patient is in significant respiratory distress.