so let's talk about troponin um it really is the cornerstone for lab studies as far as a cardiac [Music] biomarker so when the tissue dies then this enzyme is released and so troponin is the most specific for heart injury than any of the other tests so and it also remains elevated for a longer period of time so there's a troponin 1 and a troponin t and i don't you don't need to know the breakdown of those you just need to know troponin um there's also something that's new called the high sensitivity troponin so just know that the values are a little different so high sensitivity troponin elevations can detect over 50 percent of the patients that are suspected to have a myocardial infarction upon admission patients who present late after the onset of their symptoms that high sensitivity troponin can be 70 so just know when you're out there in the trenches that there's um this this newer high sensitivity troponin and again the the numbers are are different so here's the high sensitivity um if it's normal if it's below 14 and troponin levels are typically zero to 0.04 so uh the one of the things that they're saying is more beneficial with the high sensitivity troponin is that even really small areas of an mi can be detected so those that dead tissue so we're probably going to be seeing more high sensitivity troponins being used by by labs so cpk that's another one that of course is um really general so if you're i don't know hit by a car or something like that you're going to have a lot of muscle damage and that is going to increase in your cpk if your patient has rhabdomyosis and they've had all this muscle breakdown cpk is one of the one of the big things that we look at but again it's just generalized muscle where if we want to find out specifically if we've had muscle damage in our heart that's going to be cpkmb or sometimes it's called ck twos those rise in about four to eight hours they peak in about 12 to 24 hours and then they can return normal in two to three days so it is the most specific isos enzyme as far as revealing cardiac damage so again our gold standard is troponin but a lot of times they will get ck enzymes as well so ldh is another thing that they'll probably dry draw but it's again not as specific so what lab is your gold standard it's going to be a troponin okay let's talk about treatment so we of course want to assess your patient we want to get them in a semi fowler's position as far as nclex goes oxygen is going to be one of the most important things that we're going to to do for the patient right because this is ischemia so they say they want the saturation above 94 some articles now are showing that 90 is adequate um so this is newer information and this is where we kind of get into trouble with nclex so if a patient had 94 or greater in in clinical right now we probably wouldn't give them oxygen in the nclex world we're giving them oxygen so just know that the difference there id access is going to be really important getting aspirin on board as soon as possible this aspirin should be chewed and swallowed it's imperative for platelet aggregation and then of course we want diagnostic testing how about a 1280kg get the troponin and then as far as if the patient has continued chest pain we want to control that with a nitroglycerin drip we can use the tabs as well so if the patient has a blood pressure that's pretty high i would start with those tabs if the blood pressure drops you know to significantly below 20 millimeters of mercury i probably would quickly move to a nitroglycerin drip you just have tighter control with the dose that you're giving remember that a nitro tab has 400 micrograms of nitroglycerin that's a boatload of nitro so if your blood pressure drops significantly with that you can move to a nitro drip so remember that nitroglycerin decreases both preload and afterload it's mostly a venous vasodilator so big preload it does dilate the coronary arteries a bit so it does decrease afterload as well this overall just decreases the workload of the heart and would increase the perfusion then to the heart so analgesics can be used as well remember that nitroglycerin is not an analgesic it decreases pain because it's helping with oxygenation so you can use an actual analgesic opioid which would be morphine or fentanyl just know that in the literature today morphine is falling more and more out of favor so we're kind of moving more towards fentanyl and that's because of um oh the blood pressure dropping mostly a hemodynamic reason so go fentanyl and then you can just titrate the dose that's listed here on this slide is really more morphine so that's two to four milligrams uh every five minutes so fentanyl typically we use about 50 micrograms of fentanyl and then we give 25 to 50 and a total might be around 150 micrograms in 30 minutes so we need to be pretty aggressive with our titration of nitroglycerin remember we're titrating to pain and blood pressure if that blood pressure is up and the patient still has chest pain increase that dose of nitro if the blood pressure drops to 90 or below that nitroglycerin has to be decreased if not discontinued depending on how much you're giving aspirin if the patient has severe chest pain for two hours that's usually an acute coronary syndrome so get that aspirin in as soon as possible it really is a lifesaver so a tab of 325mg is is huge they have the baby aspirin as well but somewhere between 160 to 325 one simple therapy is associated with a 35 35-day mortality reduction yeah exceeding 20 percent so uh it it's absolutely got that anti-platelet action makes the platelets less sticky and it is a lifesaver so we always ask did the patient get the aspirin yeah so kind of talked about nitro already again it really does decrease venous return so it decreases preload and afterload again way more preload the goal of giving nitroglycerin is to have no pain remember when you're treating chest pain if they have it it's an indicator of ischemia to the myocardium we don't like it so make sure that we have no pain you know sometimes patients will say oh do i have a 2 that's still not ok expect a headache with nitroglycerin causes vasodilation and so they will almost always have a headache and you can treat that with acetaminophen a little tylenol watch that blood pressure if the patient drops below a 90 you're not getting pro perfusion anywhere let alone in the heart so we have to discontinue it at that point that would we would call the provider and hopefully maybe get a fluid bolus or something that it's a it's a big vasodilator specifically venus so kind of talked about the morphine and the fentanyl that also um is to help decrease with anxiety okay let's talk about thrombolytics so these can be used but again the definitive treatment is a cardiac cath but remember there are patients that are live way out in rural areas and there's no way they're going to get into a cardiac cath within that narrow window of time that's when clot busters or thrombolytics can be used and the number one clot buster for mi is techno place or tnk it's used to lyse or just bust up the thrombus so there's about a six hour window for these meds to be effective and they like them even earlier than that after six hours reversible tissue damage occurs uh irreversible i should say and um they're no longer effective so the best results are going to be within 30 minutes of that chest pain the results are crazy dramatic at times side effects are bleeding the worst bleeding that can occur after a thrombolytic would be an intracranial hemorrhage so you really need to make sure that you get consent and the patient understands that bleeding is a big side effect including a brain bleed so it's scary stuff but they can really be miraculous so next slide is just a before and after the thrombolytic you can see the st elevation just going way down which is amazing so then continued treatment the patients typically on more medications that will decrease platelet aggregation so maybe this glycoprotein 2b 3a inhibitors they might be used the p2y2 adp inhibitor that is the copitigrill or plavix really common plavix is interesting though we have to have a certain enzyme in our liver a subset of an enzyme in order to convert that so other inhibitors might be used berlinta is an example of another platelet drug heparin can definitely be used that's an anticoagulant that will help further clotting occur uh let's see uh calcium channel blockers they can help dilate the coronary arteries they also can reduce vasospasm so um you know pick your pick your ccb that it's going to be provider dependent with which one they like we can get some decreased blood pressure bradycardia and it is a negative inotropic drug so it might just decrease the contractility a little bit so we have to be really mindful of that beta blockers they're used a lot and specifically metropololol if the heart rate's up or the blood pressure's up beta blocker is going to be used so that's going to decrease the heart rate and decrease that myocardial contractile contractility and so the fastest one that we use is esmolol metropololol is just more common so it also can help decrease cardiac remodeling so it's a negative chronotropic negative inotropic so you know we gotta watch the blood pressure on this one this beta blocker absolutely has to be cardio selective so a non-selective beta blocker is not going to be helpful here so i just want to mention a little bit more about that beta blocker remember specifically it's going to decrease the workload of that left ventricle so beta blockers also decrease your response to adrenaline so if you get really stressed and your catecholamines and your sympathetic response is up beta blocker is going to decrease your your response to those so it's not going to increase the workload of the heart then it will decrease it so let's just go over that treatment again so o2 get the aspirin in get some sublingual nitroglycerin watching the blood pressure and the pain if that pain persists and maybe iv nitroglycerin then using maybe iv morphine or fentanyl to reduce pain and it also helps to decrease the cardiac workload as well iv beta blockers to control heart rate and again they would only be used if the heart rate and the blood pressure were up and then thrombolytic therapy if the patient's a distance away from a cardiac cath so techno place or tnk is the drug of choice with that and then cardiac cath with stenting so post-mi interventions remember watch for those pvcs so definite uh ekg monitoring we want to monitor vital signs of course make sure those are okay typically bed rest um you know at least really light activity for 24 to 36 hours stool softeners we want to prevent constipation using the valsalva maneuver now liquid diet initially they almost always now don't do this um but it used to be that they'd like to do that because you you didn't want to put extra stress on the body with a lot of mesenteric decreased perfusion i've seen patients before eat a pretty big meal after an mi and they just turn pale and green and then puke and that's because again they're just not getting great perfusion to their guts so and then just trying to stay away from foods that are really high in sodium is a good idea especially initially like oh celery carrots can be foods that have a lot of kind of hidden salt in them canned foods ketchup etc so and then post mi interventions okay just progressive ambulation is really key and monitoring your vital signs cardiac rehab is a really awesome thing if your hospital has that program it's a supervised outpatient exercise so you've got somebody right there kind of making you more accountable and kind of pushing you but at the same time helping you back off if you're maybe you know doing too much or you're exerting yourself it's a planned exercise program so you're going to avoid kind of a stressful environment they're they're quite beneficial long-term drug therapy i think instruction of cpr for the family everybody should be certified um and then talk about sex i mean it's something that's really normal in life and so a lot of patients won't ask about it they'll be curious about it though and so typically when a patient can walk up two flights of stairs or walk about three to four miles without being um short of breath then um sex can can resume um use of viagra and other medications for erectile dysfunction those are contraindicated used to be that they would space those between you know using a nitroglycerin type product for 24 hours and now they're just saying nope use a viagra when you're on any sort of nitroglycerin or even just using it prn is contraindicated