i bc27f85be50b71b1 (17 page)

1-9 provides a schemaric of possible clinical courses for parients

admirred wirh chesr pain.

CARDIAC SYSTEM

4 1

Table I-B. Myocardial lnfarcrions (MIs)

Possible

Occluded

Ml/Wall

Coronary

Affecred

Artery

Possible Complications

Anterior MY

Left coronary

Left-sided CHF, pulmonary edema, bunanterior left

dle branch block, AV block, and venventricle

tricular aneurysm (which can lead to

CHF, dysrhythmias, and embolism)

Inferior MU

Right coro

AV blocks (which can result in bradycarinferior left

nary (RCA)

dia) and papillary muscle dysfunction

venrricle

(which can result in valvular insufficiency and eventually CHF)

Anterolateral

Lefr anterior

Brady or rachyarrhythmias, acute ventric

Mllantero·

descending

ular sepral defecr

lateral left

(LAD), cirventricle

cumnex

Anrerosepral

LAD

Brady or tachyarrhythmias, ventricular

Mllsepral

aneurysm

regionberween left

and right

ventricles

Posterior Mll

RCA, circum

Bradycardia, heart blocks

posterior

flex

heart

Right venerieu

RCA

Right ventricular failure (can lead to left

lar MI

ventricular failure and therefore cardiogenic shock), heart blocks, hepacomegaly, peripheral edema

Transmural M l

Any artery

Full wall thickness MJ, as above

(Q-wave MI)

Subendocar

Any artery

Partial wall thickness Ml, as above,

dial MI

pocencial to extend to transmural MJ

(non-Qwave MI)

AV = atrioventricular; CHF = congestive heart failure; LAD = left amerior descending;

RCA = righr coronary anery.

Source: Data from SL Woods, ES Sivarajian-Froelicher. S Underhill-Moner (cds). Cardiac Nursing (4th ed). Philadelphia: Lippincon. 2000.

....

N

} hUmu wilh ST EkVJlion � � >-

l

ikely 10 !We ill with . Q ....... y.e Ml

They

g

ue abo (:OIl$ickm;l for

TlvomboIytic Thc:npy Of

'"

RevascularbauOQ procedures while in

I'

"dR.

i::

Ru1e In VlI. Rule

OutMI

J:

Delefmined by

�

Biochemical

"

M.mn

�

g

'"

IfpaDmIIlal:

If palienI bal lIO

o

If patient bas:

,.

Ifpatierlllw:

.........,. .....

compIicatiol'lJ and;

RCCllnull iJc:hcnua

�

",""", £CO

PAP>20mmHO

HoWoMI

CHF

J:

No Rest

S3 GoIIop

No bcbernic pWI

-<

"""M

Hypocensloa

H",....,....

SIIbIe Rhythm

�

""",.......

No Noaurnal

"""""' Sf aw.g.,

NoCHP

�

"""M

•

Heart block

""""'"

r

No Heart Block

May be considefeld:

Prior MI

HcmodyrwuicaUy

HiJh RiKICompIica&cdlUnst.ble

i

May be oonsid0=4:

......

lDw Riu I Stable

"'-y be oonsidered:

MI)'bc�:

�

Hip Rw - f\st1hcr Medical

Low RisklSUibIe

�

Wort-Up

�

Medical I SUtJical Tn:atmcnt

will dqIcDd on compUcabon.

Out oICCU 24.36

OiagnGAies will likely

Mly UI:IdI::r:to

HOIU1 af\c:r 1Idmiuion.

incNde. calheterizarion.

NoniJ!va5I."

Treatma'li ml)' Include IOIDI:;

StralTm

1f$tl,)'II uat»e and

or

� MD IDII)'

farm of�wioo.

C......,

�dlc:l4-4

I..mJIb of nay iI variabk.

Anmogaphy

CABO;

"""' _ ..

Ulu&lly

Uncomplicakd

OUI.,.rimt manqcmml

Dl5Chuged

-

III 1·2

die 4-7 days

Horpil&lization

0.,.

IOdacftuerisJr:

and atabilix

for-Klirit)'

CARDIAC SYSTEM

43

Clinical Tip

• (ST) depression, on a patient's ECG, of approximately

1-2 mm is generally indicative of ischemia.

• ST elevation is generally indicative of myocardial injury

or infarction.

Rhythm and Conduction Distl/ybance

Rhythm and conduction disturbances can range from minor alterations with no hemodynamic effects to life-threatening episodes with rapid hemodynamic compromise.·,s,7 Refer to Chapter

Appendix I -A for a description of atrial, ventricular, and junctional rhythms and AV blocks. Refer also to Chapter Appendix 1-8

for examples of common rhythm disturbances. Physical therapists

need to be able to identify abnormalities in the ECG to determine

patient tolerance to activity. In particular, physical therapists

should understand progressions of common ECG abnormalities so

they can identify, early on, when the patient is not tolerating an

intervention. (Refer to the Physical Therapy Intervention section

for the ECG discussion.)

.... Figure 1-9. Possible clinical course of patients admitted with chest pain.

(CABC = corollary artery bypass graft; CHF = cOl1gest;ve heart failure; CCU

= coronary care unit; die :: discharge; ECC :: electrocardiogramj h/o :: history

0(; MI :: myocardial infarctio1l; PAP = pulmonary arterial presmre; PTCA =

percutaneous translumjllal coronary angjoplasty; ST Elevatjon = electrocardiogram that shows elevatioll of the ST segment.) (Data from American College of Cardio/ogy/Americall Heart Associatioll. 1999 Update: ACCIAHA guidelines for the manageme11t of patiellls with acute myocardial infarction:

executive summary and recommendations. Circulation 1 999; 1 00: 1 016-1 030;

American College of Cardiology/American Heart Association. ACCIAHA

guidelines for the management of patients with acute myocardial infarction. J

Am Coli Cardiol 1 996;28:1328-1428; alld American College of Cardio/ogy/

American Heart Association. A CCiA HA guidelines for the management of

patients with ltltstable angina and Ilon-ST segment elevation myocardial

infarctioll. J Alii Coli CardioI 2000;36:971-1 048.)