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Submitted to:

Mr. Julius A. Riazonda


Submitted by: GROUP 1
Bunal, Christian Wilcyn A.
Management (Nursing, Medical, NCPs)
Collantes, Joanne
Manifestations (History, Pathophysiology, PE)
Conte, Michelle D.C.
Overview, Epidemiology and Diagnostics
Dela Cruz, Cristina S.
Management (Nursing, Medical, NCPs)
Macavinta, Joseph Celrin III V.
Discharge Plan and Research Integration
Rodriguez, Arianne
Manifestations (History, Pathophysiology, PE)
Ischemic heart disease may be manifested clinically as either chronic
stable angina or an acute coronary syndrome. Acute coronary syndrome
(ACS) refers to a spectrum of clinical presentations ranging from those for
ST-segment elevation myocardial infarction (STEMI) to presentations found
in nonST-segment elevation myocardial infarction (NSTEMI) or in unstable
angina (UA). It is almost always associated with rupture of an
atherosclerotic plaque and partial or complete thrombosis of the infarct-
related artery. Symptoms are similar in each of these syndromes (except
sudden death) and include chest discomfort with or without dyspnea,
nausea, and diaphoresis. Diagnosis is by ECG and the presence or absence
of serologic markers. Treatment is antiplatelet drugs, anticoagulants,
nitrates, beta-blockers, and, for STEMI, emergency reperfusion via
fibrinolytic drugs, percutaneous intervention, or, occasionally, coronary
artery bypass graft surgery (Warnica, ND). NSTEMI and UA are
indistinguishable at initial evaluation and the entity of UA is receding as
the sensitivity of biomarkers of myocardial injury increases.

(2017). Retrieved 1 May 2017, from http://www.merckmanuals.com/en-ca/professional/cardiovascular-


disorders/coronary-artery-disease/overview-of-acute-coronary-syndromes-acs
Unstable Angina (acute coronary insufficiency, preinfarction angina,
intermediate syndrome) is defined as one or more of the following in
patients whose cardiac biomarkers do not meet criteria for MI: (1) Rest
angina that is prolonged (usually > 20 min), (2) New-onset angina of at
least class 3 severity in the Canadian Cardiovascular Society (CCS)
classification and (3) Increasing angina, ie, previously diagnosed angina
that has become distinctly more frequent, more severe, longer in duration,
or lower in threshold (eg, increased by 1 CCS class or to at least CCS class
3)
ECG changes such as ST-segment depression, ST-segment elevation, or T-
wave inversion may occur during unstable angina but they are transient. Of
cardiac markers, CK is not elevated but cardiac troponin, particularly when
measured using high-sensitivity troponin tests (hs-cTn), may be slightly
increased. Unstable angina is clinically unstable and often a prelude to MI
or arrhythmias or, less commonly, to sudden death.
(2017). Retrieved 1 May 2017, from http://www.merckmanuals.com/en-ca/professional/cardiovascular-
disorders/coronary-artery-disease/overview-of-acute-coronary-syndromes-acs
NonST-segment elevation MI (NSTEMI, subendocardial MI) is myocardial
necrosis (evidenced by cardiac markers in blood; troponin I or troponin T
and CK will be elevated) without acute ST-segment elevation. ECG changes
such as ST-segment depression, T-wave inversion, or both may be present.

ST-segment elevation MI (STEMI, transmural MI) is myocardial necrosis


with ECG changes showing ST-segment elevation that is not quickly
reversed by nitroglycerin or showing new left bundle branch block. Cardiac
markers, troponin I or troponin T, and CK are elevated.

Both types of MI may or may not produce Q waves on the ECG (Q wave MI,
non-Q wave MI).

Our group will focus on Non-ST-segment elevation Myocardial Infarction


and Unstable Angina. (2017). Retrieved 1 May 2017, from http://www.merckmanuals.com/en-ca/professional/cardiovascular-
disorders/coronary-artery-disease/overview-of-acute-coronary-syndromes-acs
Health data compiled from more than 190 countries show heart disease remains the No. 1
global cause of death with 17.3 million deaths each year, according to Heart Disease and
Stroke Statistics 2015 Update: A Report From the American Heart Association. That
number is expected to rise to more than 23.6 million by 2030, the report found.

According to World Health Organization, Cardiovascular Diseases (CVDs) are the number 1
cause of death globally: more people die annually from CVDs than from any other cause.
An estimated 17.5 million people died from CVDs in 2012, representing 31% of all global
deaths. Of these deaths, an estimated 7.4 million were due to coronary heart disease and
6.7 million were due to stroke. Over three quarters of CVD deaths take place in low- and
middle-income countries. Out of the 16 million deaths under the age of 70 due to non-
communicable diseases, 82% are in low and middle income countries and 37% are caused
by CVDs. Most cardiovascular diseases can be prevented by addressing behavioral risk
factors such as tobacco use, unhealthy diet and obesity, physical inactivity and harmful use
of alcohol using population-wide strategies. People with cardiovascular disease or who are
at high cardiovascular risk (due to the presence of one or more risk factors such as
hypertension, diabetes, hyperlipidemia or already established disease) need early detection
and management using counseling and medicines, as appropriate.
1. (2017). Retrieved 1 May 2017, from 1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4958723/
2. Cardiovascular diseases (CVDs). (2017). World Health Organization. Retrieved 1 May 2017, from
http://www.who.int/mediacentre/factsheets/fs317/en/
3. Writing Group Members , Mozaffarian D, Benjamin EJ, et al. Executive Summary: Heart Disease and Stroke Statistics--2016
Update: A Report From the American Heart Association. Circulation 2016;133:447-54. 10.1161/CIR.0000000000000366
Stroke remains the No. 2 cause of death in the world. The stroke death rate
the number of deaths per 100,000 people went down between 1990
and 2010. However, the number of people having first and recurrent
strokes each year went up, reaching 33 million in 2010.

The 2016 Heart Disease and Stroke Statistics update of the American Heart
Association (AHA) has recently reported that 15.5 million persons 20
years of age in the USA have CHD (2), whilst the reported prevalence
increases with age for both women and men and it has been estimated
that approximately every 42 seconds, an American will suffer for an MI.

In 2010, the Department of Health listed the Top 10 Leading Causes of


Morbidity in the Philippines include Hypertension as 4th and Diseases of
the heart as 10th. This is also classified as top 1 leading cause of mortality
in our country. 1.
2.
(2017). Retrieved 1 May 2017, from 1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4958723/
Cardiovascular diseases (CVDs). (2017). World Health Organization. Retrieved 1 May 2017, from
http://www.who.int/mediacentre/factsheets/fs317/en/
3. Writing Group Members , Mozaffarian D, Benjamin EJ, et al. Executive Summary: Heart Disease and Stroke Statistics--2016
Update: A Report From the American Heart Association. Circulation 2016;133:447-54. 10.1161/CIR.0000000000000366
Department of Health Top Mortality in 2010
MORTALITY: TEN (10) LEADING CAUSES
NUMBER AND RATE/100,000 POPULATION
Philippines
5-Year Average (2005-2009) & 2010
5-Year Average 2010*
CAUSES (2005-2009)
Number Rate Number Rate
1. Diseases of the Heart 88,299 99.4 102,936 109.5
2. Diseases of the Vascular System 58,761 66.2 68,553 72.9
3. Malignant Neoplasms 44,627 50.3 49,820 53.0
4. Pneumonia 37,865 42.6 45,591 48.5
5. Accidents** 35,005 39.5 36,329 38.6
6. Tuberculosis, all forms 25,296 28.6 24,714 26.3
7. Chronic lower respiratory diseases 21,586 24.4 22,877 24.3
8. Diabetes Mellitus 20,964 23.6 21,512 22.9
9.Nephritis, nephrotic syndrome and 12,321 13.9 14,048 14.9
nephrosis
10. Certain conditions originating in the 12,257 13.8 12,086 12.9
perinatal period
Note: Excludes ill-defined and unknown causes of mortality
* reference year
** External causes of Mortality
MORTALITY: TEN (10) LEADING CAUSES
NUMBER AND RATE/100,000 POPULATION
Philippines
5-Year Average (2004-2008) & 2009
5-Year Average(2004-2008) 2009*
CAUSES
Number Rate Number Rate
1. Diseases of the Heart 82,290 94.5 100,908 109.4
2. Diseases of the Vascular 55,999 64.3 65,489 71.0
System
3. Malignant Neoplasms 43,185 49.6 47,732 51.8
4. Pneumonia 35,756 41.1 42,642 46.2
5. Accidents** 34,704 39.9 35,990 39.0
6. Tuberculosis, all forms 25,376 29.2 25,470 27.6
7. Chronic lower respiratory 20,830 24.0 22,755 24.7
diseases
8. Diabetes Mellitus 19,805 22.7 22,345 24.2
9.Nephritis, nephrotic syndrome 11,612 13.4 13,799 15.0
and nephrosis
10. Certain conditions originating
in the perinatal 12,590 14.5 11,514 12.5
period
Note: Excludes ill-defined and unknown causes of mortality
* reference year
** External causes of Mortality
Name : C******, F*** Hospital Number : 3******
Address : Paco, Manila Age/Sex : 56/F
Admitting : NSTEMI Date of Admission : 4/2/2017
Diagnosis CAD, NSR
HCVD, LVH
Bronchial asthma, partly
controlled
DM suspect
CLINICAL ABSTRACT
This is a case of a 56/F who came in due to difficulty of breathing.

HISTORY OF PRESENT ILLNESS


Few minutes PTA, patient had sudden onset chest pain 10/10, left sided, non-
radiating, associated w/ cold clammy extremities, nausea, diaphoresis and
difficulty of breathing. Persistence of symptoms prompted consult and
subsequent admission.
A. PATTERN OF HEALTH PERCEPTION AND HEALTH MANAGEMENT
How do you describe your current health? Poor.
What do you do to improve or maintain our health? None.
ADL / Independent/ Dependent (level): Just seating and occasional walking independently.
(Mobility, feeding, hygiene, dressing, grooming, toileting)
Preferred time for personal care / bath: Any time.
Assistance required / provided by: Family member.
How do you link lifestyle choices and health/ How big is the problem in financing health care for you?
No, we have health care cards so it is not much a problem on our part.
Can you name current medications you are taking and their purpose? Di ko maalala.
Do allergies, what do you do to prevent these problems? Wala naman.
What do you know about medical problems in your family? Nung pumunta kami sa doctor at nalaman
ko ang aking kalagayan.
Have there been any important illnesses or injuries in your life? Wala naman.
Difficulty of breathing affects the patients current health status which is poor. She was an independent
person regarding her hygiene and grooming. Since this is her first major illness, she thinks that she
cant see her love ones again.
B. NUTRITIONAL METABOLIC PATTERN
What is your usual diet (type) Pork, fatty and salty foods
Are there cultural / religious restrictions? No cultural and religious restrictions.
Can you recall and state your meal composition and feeding pattern?
Carbohydrates / Proteins, Fats: Rice, pork and beef, fruits, water 1. 5-2 liters a day most of all
vegetables.
Water / Vitamins and minerals: Centrum.
Food supplements: Meron akong vitamins.
Hows your appetite? Are there any changes you observed? Meron, madalas akong mawalan ng gana
kasi nahihirapan akong huminga.
Do you experience nausea / vomiting / heartburn / ingestion? Oo.
How do you manage it, is it relieved or not? Kumonsulta kami sa doctor.
Can you recall and state the highest / lowest weight you have? Before admission my weight was 110
lbs and my highest weight upon admission is 130 lbs
Last Meal / intake: Yung pagkain dito sa ospital. Kanin, tinolang manok at saging.
C. PATTERNS OF ELIMINATION
Usual voiding pattern? Frequency? Characteristics: Color / Odor?: Yellowish, 2 to 3 times a day
aromatic in nature.
Do you experience any discomforts: pain, burning, and difficulty voiding? How do you manage it?
Wala naman.
Usual bowel pattern? Frequency? Characteristics: color / consistency / odor? 2 to 3 times a day.
Do you experience any discomforts diarrhea, constipation, bleeding and hemorrhoids? How do you
manage it? : Wala naman.
Laxative used? None, just drink water
Do you perspire heavily, in what occasion / condition? No.
Do you have any disease of the digestive system, urinary system or skin? None.
D. PATTERN OF ACTIVITY & EXERCISE
System or musculoskeletal system
How do you describe your weekly activity and leisure, exercise and recreation? No, I cant do exercises
anymore. I feel weak most of the time. I usually sit outside our house door.
Do you have any disease that affects cardio-respiratory system or musculoskeletal system? Not that
were aware of.
Do you experience fatigue / weakness, pain after the activity? Yes, most of the time, I feel weak.
E. COGNITIVE PERCEPTUAL PATTERN
Do you have sensory deficit (sight, smell, auditory, taste and vision)? Are they corrected? No.
Can this person express her/himself clearly and logically? Yes
Does the person have any disease that affects mental sensory function? None
Do you experience pain? How do you manage it? None
If this person has pain, describe it and its causes.
The patient had no sensory deficit so far, but she experienced DOB thats why she was subsequently
admitted

F. PATTERN OF SLEEP AND REST


Describe your sleeping pattern? Hours / naps / aids / insomnia related to: Madalas akong inaantok
pero paputol-putol naman ang tulog ko. Di ako nakakakumpleto ng 6-8 oras na tulog sa gabi.
Do you feel tired upon waking up?. Minsan.
Do you experience any problem falling asleep? Minsan.
What do you think caused it? Hindi ko alam, baka yung highblood ko.
Do you feel rested and relaxed? Minsan din
Patient usually sleep 3 to 4 hours of sleep during the night and 1 to 2 hours during the day.
G. PATTERN OF SELF PERCEPTION & SELF CONCEPT
Do you think that is anything about your appearance and self? I dont know, but I notice that I became
thinner.
Are you comfortable with your appearance? Opo
Describe what you feel right now? : Nanghihina ako.
What are the traits that youre proud of? Mahilig akong kumanta.
What are the traits that you think that needs changes and improvements? : I dont know.
Are you open for changes? In what condition and how? Yes, I can change my haircut.
At her age, I can say that she is contented with herself and dont think any problem at all. She is open in
changes and willing to cooperate in promoting her health.
H. ROLE-RELATIONSHIP PATTERN
How do you describe various roles in life (family, friends, community)? good relationship with my
family and friends.
Has, or does this person now have positive role models for these role? Opo.
Which relationships are most important to you at present?. Sa panginoon at sa aking pamilya.
Are you currently going through any big changes in role or relationship? Minsan, napapasin ko na
madalas akong nagiging iritable
At this time she has a good relationship with her family members. I noticed that her family understands
her well.
I. SEXUALITY-REPRODUCTIVE PATTERN
Are you in a relationship? How many children do you wish to have? Can you say that you are sexually
active? I have 3 kids. Im too old and weak for sexual activity.
Do you use protection? not applicable -
Do you use birth control method? Do you have sexual concern / difficulties? not applicable -
Recent change in frequency / interest? not applicable -
Female: age of menarchy, cycle, duration, no of pad, LMP, pregnant now, menopause, vaginal
mammogram pap test. nung 14-taong gulang ako nag simula magkaregla. Menopause na ako ngayon
Male: Penile discharge, prostate disorder, circumcised, vasectomy, practicing self examination: - not
applicable -
Female: At her age I think that she is contented with her sex life when she is still a strong person, but
because of her age, she thinks that she is too old for those kind of activity.
J. PATTERN OF COPING & STRESS TOLERANCE
Have you experienced any discomforts in life? What condition brought it? When I do have a chest Pain and
when I lose my husband.
How do you usually cope with problems? Sinusunod ko yung sinabi ng doctor na wag masyadong mag isip-
isip ng mga bagay-bagay.
Do these actions help of make things worse? Hindi, nakakabawas pa sya
To whom would you go if you have problems? Sa Panginoon at sa aking pamilya.
Have you undergone treatment for emotional distress? No
She was saddened when she lost her husband. I believe that she accepted it as the saddest part of her life and
she was able to recover on a timely manner now. I realized that her health is deteriorating so I shouldve given
it more importance. Emotional distress? Not necessary.
K. PATTERN OF VALUES AND BELIEF
What principle in life did you learn as a child? Do you think that its still important? On what condition/s? I
believe that everyone has the right to be respected and to be respectful as well. As I have aged I became
particular that my children always use po at opo when they were talking to me and to other person that is
older than them.
Do you belong in any cultural, ethnic, religious, regional, or other groups? Hindi, pero Katoliko ako.
Does this give any influence on your health behavior/s? Opo, lagi akong nagbabasa ng bible.
What support systems so you have currently? Wala
She has a strong faith in our Lord and practicing Filipino gestures and beliefs.
MODIFIABLE FACTORS NON MODIFIABLE FACTORS
-Diabetes Mellitus with or without insulin Age 56 years old and above
resistance Gender: Female
-Cigarette smoking -Familial History of Heart Diseases
-Hypercholesterolemia= Increase level of LDL
and decreased HDL
-Increase Blood Pressure
-Obesity=BMI greater than 30kg/m
-Stressors
-Alcohol use
-Sedentary Lifestyle

Disrupted atherosclerotic plaque at coronary artery

Total occlusion of artery (atheroma)

Plaques become unstable and dislodge


Thrombus formation in the artery

Plaque ruptures at coronary blood vessels

Impaired blood flow creating infarct and low


oxygen supply and demand to myocardium DIAGNOSTIC EXAMS FINDINGS:
-Troponin level=detectable 3- 6hours
post MI
Signs and Symptoms
-Increase CKMB
-Chest Pain
-Increase myoglobin levels
-Persistent Shortness of
Ischemia -ECG RESULTS
breath
*ST and T wave abnormalities
-Body Malaise and dizziness
-Neck Vein Distention
Troponin rise and fall=NSTEMI
Cellular injury
Ischemia to heart Normal or undetermined ECG+normal
muscle=MYOCARDIAL INFARCT Troponin=UNSTABLE ANGINA
SIGNS AND SYMPTOMS MECHANISM FOR DEVELOPMENT

Chest Pain Impaired blood flow creating infarct and low oxygen supply and
demand to myocardium

Neck Vein Distention Deterioration of the heart to pump which yields to congestion
Difficulty of Breathing Decrease supply and demand to the heart muscle due to infarct
Body Malaise Poor oxygenation to the heart muscle that causes inability to propel
blood to different parts of the body

Dizziness Decrease in oxygenation perfusion


PAST MEDICAL HISTORY FAMILY HISTORY PERSONAL AND SOCIAL HISTORY
(+) hypertension: Losartan 50mg (+) hypertension, (+)CAD - (+)2.5 pack years smoker
OD, Amlodipine 10mg/tab maternal Occasional Alcoholic beverage drinker
(+)bronchial asthma since 15y.o. (+) diabetes mellitus- Denies illicit drug use
maintained on salbutamol tab siblings
and rotacap No allergies
No diabetes mellitus No previous PTB
No allergies treatment
No previous PTB treatment No CKD, CVD, CAD

REVIEW OF SYSTEMS

No fever, no loss of appetite


No cough, no colds
(+) PND, (+) 2pillow orthopnea, no palpitations
No abdominal pain, no changes in bowel movement
No melena, no hematochezia, no hematemesis
No dysuria, no oliguria, no gross hematuria
PHYSICAL EXAMINATION
General: Awake, coherent, in distress
Vital Signs: BP = 100/60 HR=81 bpm RR= 17cpm
T=36.0oC O2sat = 96% GCS = 15
Parts Findings Normal Findings
Head Examination -Eyes: Anicteric sclerae, pink palpebral -Eyes: Sclera-white Conjunctiva- pink
conjunctiva Fundoscopyo Red Reflex: present o Disc:
round, sharp margins, nl color o Vessels: nl
caliber, A/V ratio ~ o Background: abn
pigmentation, hemorrhages or exudates o
Macula: visualized
-Neck: flat neck veins, no carotid bruit, no -Neck: Active ROM: nl flexion, extension,
cervical lymphadenopathy lateral rotation and tilting Trachea:
midline, mobile Thyroid: non-palpable or
palpable, nl size & consistency, lesions
Suprasternal Notch: pulsation
Parts Findings Normal Findings
Thoracic Inspection -Inspection: Symmetric left and right; Equal Observation: symmetrical expansion with respiration
chest expansion, no retractions Percussion: spinal tenderness, CVA (costovertebral
-Palpation: No mass, no tenderness angle) tenderness (Comment of findings regarding CVA
-Percussion: Sonor tenderness under abdomen
-Auscultation: bronchovesicular breath sounds
Cardiac Examination - A dynamic precordium, normal rate, regular Neck Veins- JVD at 45 Carotid Arteries:
rhythm, no murmurs Palpation (Amplitude and Contour)- nl upstroke &
amplitude bilaterally
Auscultation: bruits Precordium:
Inspection- lifts or heaves - PMI not visible
Palpation- parasternal impulses, thrills PMI-
palpable in 5th ICS, MCL; nl size
Auscultation: S1- heard best at apex, nl intensity
S2- heard best at base, nl splitting, A2 > P2 Extra
Sounds- S3, S4 Murmurs- murmurs
Parts Findings Normal Findings
Abdominal Flat, normoactive bowel sounds, Observation: scaphoid scars, striae Auscultation: nl bowel
Examination soft, nontender sounds, bruits Palpation: Superficial- tenderness, masses,
guarding Deep- tenderness, masses Liver: Palpation- liver
edge not palpable
Percussion - Size- ~10 cm in R midclavicular line Spleen:
Palpation- non palpable Kidneys: Left- non palpable Right- non
palpable * CVAC Femoral Pulses: Palpation- 4 / 4 bil equal
Auscultation- bruits
Extremities Full and equal pulse, no cyanosis, Upper: Nails- cyanosis, clubbing Palms- nl color, texture
no edema Muscles- nl size Joints (including ROM) Interphalangeal- nl ROM
deformities Wrists- flexion = 90, = extention 70, radial deviation =
20, ulnar deviation = 50 Elbows- flexion = 160 Radial pulse- 2+,
nl and symmetric Lower: Nails- nl ( cyanosis, clubbing)
Muscles- nl size Joints (including ROM) Ankle- dorsiflex = 20,
plantar flexion = 40, eversion = 20, inversion = 20 Knee- flexion =
130 Hip- flexion = 100, internal rotation = 40, ext rotation = 40
Pulses: o Posterior Tibial- 2+ bil equal
CBC Normal Value 4/2/17 Normal Value 4/7/17
WBC 4.5-11.0 x 10 9/L 18.50 5.2-12.4 12.0
Neutrophils 0.50-0.60 0.62 40-74 69.7
Lymphocytes 0.25-0.50 0.25 19-48 22.5
Monocytes 3.4 -9 7.8
Eosinophil 0-7 0
Basophil 0-15 0
RBC M: 4.6 -6.2 x 10 12/L 4.7 4.2-6.1 5.10
F: 120-160mg/dl 131 12-18 15.5
Hgb M: 140-170 mg/dl
F: 0.37-0.48 0.41 37-52 43.3
Hct M: 0.40-0.51
MCV 80-99 84.8
MCH 27-31 30.5
MCHC 33-37 35.9
RDW 11.5-14.5 11.7
Platelet 150-450 x 10 9/L 330 150-450 346

RBC MORPHOLOGY (4/4/17) CHEST X-RAY (PA) (4/2/2017)


90% non crenated Cardiomegaly
10% Crenated Tortuous Atheromatous Aorta
Clinical Chemistry Normal Values 4/2/17 4/3/17 4/4/17 4/5/17 4/6/17 4/7/17
BUN 13-43 mg/dl 36.59
Crea 0.60-1.40 1.1
Na 135-148 mEq/L 137 133.20
K 3.5-5.3 2.61 4.27
Cl 110.6
iCa 0.5-1.5 mg/dL 1.4
tCa 8.6 10.2 mmol/L 7.79 2.11
Mg F: 1.90-2.50 mmol/l 1.69 2.21 2.21 1.76
M: 1.8-2.6

ALT < 49 U/L 30.30


AST < 46 U/L 21
FBS 65-115 mg/dl 98.75
TC < 200 mg/dl 330.21
TG < 200 mg/dl 222.69
HDL 40-60 66.04
LDL 66-178 219.63
VLDL 18.18-75.00 44.54
Trop I < 15.6 ng/L 13334.5
HBA1c <6.0 6.31
URINALYSIS 4/4/17 Bleeding Parameters Normal values 4/2/17
Color Amber PT 10-16 seconds 11.7
Trans Turbid Control 10-16 seconds 13.1
EC Few % activity 70-130 % 111.97
MT Few INR 0.85-1.15 0.89
AU Few APTT 24-39 seconds 34
WBC 0-2 Control 24-39 seconds 25.3
RBC Abundant
Albumin +2 ABG Normal Values 4/4/17
Sugar Neg
pH 7.35-7.45 7.550
Specific Gravity 1.030
pH 5.0 pCO2 35-45 mmHg 27.30
Bacteria Abundant pO2 80-100 mmHg 77.20
HCO3 22-26mEq/L 24.20
BE -2 to +2 mEq/L 3.20
O2sat 93-100 % 94.70
TCO2 25.10
SBC 27.20
ECHOCARDIOGRAM
2d echo Findings:
Normal left ventricular dimensions with hypokinesia of the mid to apical segments of the anterior wall and lateral wall and apical
inferior wall and IVS and mid posterior wall.
Dilated LA
Normal RA and right ventricular dimensions with adequate contractility of the right ventricular free wall
Intact interatrial and interventricular septum
Thickened rcc and ncc with no rom
Structurally normal mitral valve, tricuspid valve and pulmonic valve.
Normal aortic root and main pulmonary artery dimension
No thrombus
No PE

Doppler study:
Normal color flow across the MV TV AV and PV
Reversed mitral inflow velocity ratio
E/e = 7 by tissue Doppler imaging suggestive of grade 1 diastolic dysfunction
PAP = 2mmHG by pat

Conclusions:
Normal LV with multi segmental wall motion abnormality with moderately depressed systolic function
Doppler evidence of relaxation abnormality
Dilated LA
Aortic sclerosis
Normal PAP

Suggest Treadmill stress test for diagnostic for coronary artery disease risk stratification and functional capacity assessment and/or
coronary angiography
ELECTROCARDIOGRAM
ELECTROCARDIOGRAM
Cardiac markers:
Cardiospecific isoenzyme CK-MB (creatine kinase myocardial band), and
cardiospecific proteins troponin T and troponin I rises in blood in NSTEMI.
These are released from damaged heart muscle cells during and after
attack. CK-MB starts to rise at 4-6 hours and falls to normal within 48-72
hours. Troponin T and troponin I start to rise at 4-6 hours and remain high
for up to two weeks.

Troponin levels confirm the diagnosis of infarction. Test is more specific


than CK-MB or myoglobin and is the best marker for musculoskeletal
injury, small MI, or late (>2 to 3 days) MI. The 99th percentile is the cut-off
value used to determine acute MI. Troponins rise 4 to 6 hours after onset
of infarction, peak at 18 to 24 hours, and may persist for 14 days or longer.
Full blood count:
WBC (white blood cell) count is usually elevated. ESR (Erythrocyte
sedimentation rate) and CRP (C-reactive protein) may also elevate. C-
reactive protein (CRP) is a marker of inflammation that is elevated
following ACS, and persistently elevated levels after discharge are
associated with increased long-term cardiovascular risk.
Hemoglobin and hematocrit measurements may help to evaluate a
secondary cause of NSTEMI (i.e., acute blood loss, anemia) and to
evaluate thrombocytopenia to estimate risk of bleeding.

Chest X-ray:
Assess for signs of lung edema. Pneumonia, esophageal rupture, aortic
dissection, and pneumothorax can mimic cardiac ischemia and may be
diagnosed with a CXR.
Echocardiography:
Echocardiography uses sound waves to produce images of the heart. It
is done for assessing the function of heart chamber and for detecting
important complications. The most common abnormalities on the 12-
lead echocardiogram (ECG) are ST-segment depression and T wave
inversion; they are more likely to be present while the patient is
symptomatic.

Brain natriuretic peptide (BNP) or N-terminal pro-BNP (NT-pro-BNP)


Measurement of BNP or NT-pro-BNP may be considered to supplement
assessment of global risk in patients with suspected acute coronary
syndrome
Angiography
Urgent and immediate angiography (without non-invasive risk
stratification) for failure of stabilization with intensive medical
treatment is warranted.
Indications include recurrent symptoms (refractory angina), ischemia
despite adequate medical treatment, high risk (e.g., CHF, malignant
ventricular arrhythmias), or non-invasive test findings (significant left
ventricular dysfunction, ejection fraction <0.35, large anterior or
multiple perfusion defects).
Non-therapeutic angiography is not indicated as a routine diagnostic
test without clinical features or laboratory evidence of NSTEMI. Renal
failure is a relative contraindication and patients with contrast allergy
must be pre-medicated prior to angiography.
Coronary CT angiography (CCTA)
May provide non-invasive evaluation of coronary anatomy and
atherosclerosis. Renal failure is a relative contraindication. Patients with a
contrast allergy should be pre-medicated prior to angiography.
Due to the high negative predictive value of CCTA, evidence suggests that
CCTA is useful in patients with low to moderate risk of NSTEMI. When
compared with the standard care of low-risk patients (observation, serial
enzymes followed by stress testing) CCTA reduced time to diagnosis,
reduced length of emergency department stay, and had similar
safety. CCTA is not indicated for patients with high-risk features (i.e.,
ischaemic ECG changes, positive cardiac markers.
Stress Testing
Stress testing, including treadmill exercise testing, may be useful and is
recommended in patients with low and intermediate pre-test probability
with a normal ECG and normal high sensitivity biomarkers to assist with
assessing need for an invasive strategy.

Types of Stress Testing


1. Dobutamine or adenosine stress test: This is for people unable to
exercise. The patient will take a drug to make the heart respond as if
he is exercising. This way, the doctor can still determine if there are
blockages in the arteries.
2. Stress echocardiogram: An echocardiogram (often called "echo") is a
graphic outline of the heart's movement. A stress echo can accurately
visualize the motion of the heart's walls and pumping action when the
heart is stressed; it may reveal a lack of blood flow that isn't always
apparent on other heart tests.

3. Nuclear stress test: This helps figure out which parts of the heart are
not working well. A small amount of radioactive substance will be
injected into you. The doctor will use a special camera to see rays
emitted from the substance in the body. This will give him clear
pictures of the heart tissue on a monitor. These pictures are done at
rest and after exercise. The doctor will be able to spot areas of your
heart that arent getting enough blood. The test could last to up to 4
hours to allow enough time for the radioactive substance to flow
through the body.
NURSING ACTIONS RATIONALE
Teach the patient and relatives on how to take Proper daily monitoring of the patients BP will let
their blood pressure properly and have them to you screen for any episodes of hypertension,
record it for monitoring. If not feasible check the Assess if the patient is suitable for any sport or
nearest health care center near to them and have certain occupations and reduce any
the health care workers take their BP. cardiovascular risk.
Give a list of all the patients medications with This will help the patients and their relatives not
indicated time of intake for guidance and proper to forget to give the medications on time.
maintenance.
Orient the patient and relatives on the proper diet Regular exercise and the consumption of a
and exercises that are allowed for the patient. healthy diet can lead to a number of patients
benefits, including increased energy, happiness,
health and even a long life. Exercise and diet are
pivotal to determining a persons overall health.
Re-iterate the importance of follow up check-up Follow up check-up will help the doctors to
and routine laboratory examinations. continuously monitor the patients current
condition and avoid further complications.
NURSING ACTIONS RATIONALE
Note response to activity and Over exertion increases oxygen consumption/ demand and
promote rest appropriately can compromise myocardial function.
Provide small/ easily digested meals. Large meals may increase myocardial workload and cause
vagal stimulation, resulting in bradycardia/ ectopic beats.
Have emergency equipment/ Sudden coronary occlusion, lethal dysrhythmias, extension of
medications available infarct and unrelenting painare situations that may
precipitate cardiac arrest requore immediate life-saving
therapies
Encourage active/passive leg exercises, Enhances venous return, reduces venous stasis and
avoidance of isometric exercises. decreases risk of thrombophlebitis, however isometric
exercises can adversely affect cardiac output by increasing
myocardial work and oxygen consumption
Assess for Homans sign (pain in the Indicators of deep vein thrombosis (DVT),although DVT can
calf on dorsiflexion), erythema, edema be present without a positive Homans sign.
Instruct patient in application, periodic Limits venous stasis, improves venous return reduces risk of
removal of anti embolic hose when thrombophlebitis in patient who is limited in activity.
used
Drug/Drug Mode of Action Indications/ Patient Teaching
Classification Contraindications
DRUG: Inhibits the cyclooxygenase and INDICATIONS: 1. Instruct patient to Take
Aspirin 80mg tab thus the prostaglandin synthesis. Aspirin is similarly efficient as paracetamol on immediately after meals with
PO ODPC The drug has analgesic, anti- trivial acute pain (e.g. headaches, dental pain, a full glass of water unless
inflammatory and antipyretic or colds). However, it is also used for chronic patient is fluid restricted and
DRUG effects. states of pain, e.g. for cancer patients and (in 2. Check if patient has allergy
CLASSIFICATION: high doses) for rheumatic fever. For other with aspirin
Nonsteroidal Anti- Through its effect on the rheumatic diseases (chronic polyarthritis, 3. Warn patients taking
Inflammatory Drug thrombocyte-cyclooxygenase it osteoarthritis, etc.) and for dysmenorrhea prescription drugs to check
(NSAID) inhibits the formation of a highly aspirin is not as efficient or not as well with doctor before taking OTC
effective platelet (thrombocyte) tolerated as other prostaglandin synthesis combination containing
aggregator and a vasoconstrictor inhibitors such as ibuprofen. aspirin.
(thromboxane A2). Since the 4. Watch out for petechiae,
platelets do not synthesize In small doses (30 to 300 mg/day) aspirin bleeding gums, signs of GI
proteins, the effect remains serves in the prevention of thromboembolic bleeding.
demonstrable as long as the angiopathies. Its use is well documented as a 5. Maintain adequate fluid
affected thrombocytes live (7-10 secondary prophylaxis for coronary heart intake.
days). disease (after a myocardial infarction or a 6. Individuals taking oral blood
bypass operation), after transient ischemic thinners or anticoagulants, for
Prevention of MI and Stroke. attacks and cerebrovascular accidents and for example, warfarin,
Prophylactic treatment of peripheral occlusive arterial disease. (Coumadin) should avoid
thromboembolic disorders. For the aspirin because aspirin also
secondary prevention of CV CONTRAINDICATIONS thins the blood, and excessive
disease in DM patients. Active peptic ulcer. Hypoprothrombinemia or blood thinning may lead to
other coagulation disorders. serious bleeding.
Drug/Drug Mode of Action Indications/ Patient Teaching
Classification Contraindications
DRUG: prevents blood clots by irreversibly INDICATIONS: 1. Tell your doctor if you are
Clopidogrel 75mg binding to the P2Y12 receptor on Clopidogrel is used for preventing strokes, allergic to it; or if you have
tab PO OD platelets, preventing adenosine heart attacks, and death in individuals who any other allergies.
diphosphate (ADP) from activating have had a previous stroke, unstable angina, 2. Tell your doctor your medical
DRUG platelets. It belongs to a class of heart attack or have peripheral arterial disease history, especially of: bleeding
CLASSIFICATION: drugs called P2Y12 inhibitors. The (PAD). The combination of clopidogrel and conditions, recent surgery,
Anti-platelet risk of heart attacks and strokes aspirin is better than aspirin or clopidogrel serious injury/trauma, liver
(which usually are caused by blood alone in preventing another heart attack but disease, bleeding disease.
clots) is increased in patients with the risk of bleeding is higher. 3. It may take longer than usual
a recent history of stroke or heart . for bleeding to stop if you
attack, and patients with have a cut or injury. Use
peripheral vascular disease. It is CONTRAINDICATIONS caution with sharp objects
used to reduce the risk of heart Allergy to drug like safety razors or nail
attacks and strokes in these kidney diseases cutters and avoid activities
patients. Lactose intolerance 4. Limit alcoholic beverages.
Liver Diseases, Daily use of alcohol,
Patient taking Proton pump inhibitors especially when combined
Stomach problems with this medicine, may
Pregnant women increase your risk for stomach
bleeding.
5. During pregnancy, this
medication should be used
only when clearly needed.
Drug/Drug Mode of Action Indications/ Patient Teaching
Classification Contraindications
DRUG: Atorvastatin reduces levels of INDICATIONS: Do not take atorvastatin if you
Atorvastatin "bad" cholesterol (low-density Atorvastatin is used to treat high cholesterol, are pregnant or breast-feeding,
40/80mg tab PO lipoprotein, or LDL) and and to lower the risk of stroke, heart attack, or or if you have liver disease.
ODHS triglycerides in the blood, while other heart complications in people with type Avoid eating foods that are
increasing levels of "good" 2 diabetes, coronary heart disease, or other high in fat or cholesterol.
DRUG cholesterol (high-density risk factors. Atorvastatin is only part of a
CLASSIFICATION: lipoprotein, or HDL). complete program of
HMG CoA CONTRAINDICATIONS treatment that also includes
reductase Muscle Damage Due to Auotimmunity, diet, exercise, and weight
inhibitors, or Stroke caused by Bleeding in the Brain control. Follow your diet,
"statins." Liver Failure, Liver Problems, medication, and exercise
Kidney Disease routines very closely.
Serious Muscle Damage that may Lead to Do not take if you are allergic
Kidney Failure to it
Recent Operation To make sure atorvastatin is
Loss of Memory safe for you, tell your doctor if
High Blood Sugar you have: muscle pain or
Abnormal Liver Function Tests weakness; history of liver
Injury disease; history of kidney
Pregnancy disease; history of stroke
A Mother who is Producing Milk and (including TIA or "mini-
Breastfeeding stroke"); a thyroid disorder; or
Untreated Decreased Level of Thyroid if you drink more than 2
Hormones alcoholic beverages daily.
Muscle Pain or Tenderness with Increase
Creatine Kinase
Habit of Drinking Too Much Alcohol
Drug/Drug Mode of Action Indications/ Patient Teaching
Classification Contraindications
DRUG: There are two isoforms of ACE: the somatic isoform, INDICATIONS: You should not use
Enalapril 5mg tab which exists as a glycoprotein comprised of a single Enalapril is used to treat high enalapril if you are allergic
PO OD polypeptide chain of 1277; and the testicular isoform, blood pressure to it
which has a lower molecular mass and is thought to play (hypertension) in adults and If you have diabetes, do
DRUG a role in sperm maturation and binding of sperm to the children who are at least 1 not use enalapril together
CLASSIFICATION: oviduct epithelium. month old. with any medication that
ACE inhibitor. ACE Somatic ACE has two functionally active domains, N and contains aliskiren.
stands for C, which arise from tandem gene duplication. Although Enalapril is also used to treat You may also need to avoid
angiotensin the two domains have high sequence similarity, they play congestive heart failure in taking enalapril with
converting distinct physiological roles. The C-domain is adults. aliskiren if you have kidney
enzyme. predominantly involved in blood pressure regulation disease.
while the N-domain plays a role in hematopoietic stem Enalapril is also used to treat Do not use enalapril if you
cell differentiation and proliferation. a disorder of the ventricles are pregnant.
ACE inhibitors bind to and inhibit the activity of both (the lower chambers of the Enalapril can pass into
domains, but have much greater affinity for and heart that allow blood to breast milk and may harm
inhibitory activity against the C-domain. Enalaprilat, the flow out of the heart). This a nursing baby. You should
principle active metabolite of enalapril, competes with disorder can decrease the not breast-feed while you
ATI for binding to ACE and inhibits and enzymatic heart's ability to pump blood are using this medicine
proteolysis of ATI to ATII. Decreasing ATII levels in the to the body.
body decreases blood pressure by inhibiting the pressor
effects of ATII. CONTRAINDICATIONS
Enalapril also causes an increase in plasma renin activity Pregnancy,
likely due to a loss of feedback inhibition mediated by Angioneurotic edema
ATII on the release of renin and/or stimulation of reflex following other ACE
mechanisms via baroreceptors. Enalaprilat's affinity for inhibitors
ACE is approximately 200,000 times greater than that of Bilateral renal artery
ATI and 300-1000 times greater than that enalapril. stenosis.
Drug/Drug Mode of Action Indications/ Patient Teaching
Classification Contraindications
DRUG: Trimetazidine inhibits -oxidation of INDICATIONS: You should not use if
Trimetazidine fatty acids through inhibition of Angina pectoris. you are allergic to it
35mg tab PO BID long-chain 3-ketoacyl-CoA thiolase, CONTRAINDICATIONS Take the drug after
which enhances glucose oxidation. Parkinson's disease, parkinsonian symptoms, eating with a full glass
DRUG It ensures proper functioning of tremors, restless leg syndrome and other of water.
CLASSIFICATION: ionic pumps and transmembrane movement related disorders.
Anti-Anginal Drugs Na-K flow by preventing decrease in Severe renal impairment (CrCl <30 mL/min).
intracellular ATP levels. Lactation.

DRUG: Carvedilol is a non selective - INDICATIONS: Advise patient for


Carvedilol 6.25mg adrenergic blocking agent which Hypertension, proper diet,
tab PO BID causes vasodilation by blocking the Angina pectoris, regular exercise, and
activity -1 receptors. It exerts Heart failure lifestyle modification.
DRUG antihypertensive effect partly by Left ventricular dysfunction works best if you take it
CLASSIFICATION: reducing total peripheral resistance Post MI with food.
Beta-Blockers and vasodilation. CONTRAINDICATIONS Take at the same time
Bronchial asthma or related bronchospastic every day. Do not skip
conditions. doses or stop taking
AV block 2nd and 3rd degree. carvedilol without first
Sick sinus syndrome or severe bradycardia. talking to your doctor.
Cardiogenic shock. Stopping suddenly may
NYHA class IV heart failure. make your condition
COPD w/ bronchial obstruction. worse.
Metabolic acidosis. Diabetics should closely
Severe peripheral arterial circulatory disturbances. monitor blood sugar
Severe hepatic impairment.
Drug/Drug Mode of Action Indications/ Patient Teaching
Classification Contraindications
DRUG: Similar to other nitrites and organic nitrates, INDICATIONS: You should not use if you are
ISMN 30mg tab PO Isosorbide Mononitrate is converted to nitric oxide Preventive & long-term allergic to it.
BID (NO), an active intermediate compound which treatment of angina pectoris, Try to rest or stay seated when
activates the enzyme guanylate cyclase (Atrial severe CHF & pulmonary HTN. you take this medicine (may
DRUG natriuretic peptide receptor A). This stimulates the CONTRAINDICATIONS cause dizziness or fainting).
CLASSIFICATION: synthesis of cyclic guanosine 3',5'-monophosphate Hypersensitivity to nitro- Do not crush, chew, or break an
Anti-Anginal Drugs (cGMP) which then activates a series of protein compd. extended-release tablet.
kinase-dependent phosphorylations in the smooth Acute circulatory failure Swallow it whole.
muscle cells, eventually resulting in the (shock, circulatory
dephosphorylation of the myosin light chain of the collapse)
smooth muscle fiber. The subsequent release of Cardiogenic shock
calcium ions results in the relaxation of the smooth Significant hypotension
muscle cells and vasodilation. (systolic BP <90 mmHg).

DRUG: Lactulose promotes peristalsis by producing an INDICATIONS: Advise to drink plenty of fluid
Lactulose 30cc PO osmotic effect in the colon w/ resultant distention. Constipation, Hepatic while taking this medicine.
ODHS In hepatic encephalopathy, it reduces absorption encephalopathy Explain that lactulose may take
of ammonium ions and toxic nitrogenous 2-3 days to take effect.
DRUG compounds, resulting in reduced blood ammonia CONTRAINDICATIONS May be taken with or without
CLASSIFICATION: concentrations. Galactosaemia food. May be taken w/ meals to
Laxatives, GI obstruction reduce GI discomfort. Dilute w/
Purgatives Digestive perforation or water, milk, or fruit juice to
risk of digestive improve taste.
perforation.
Patient on low galactose
diet.
Drug/Drug Mode of Action Indications/ Patient Teaching
Classification Contraindications
DRUG: Ipratropium bromide-salbutamol fixed-dose INDICATIONS: Teach the patient pursed-lip
Ipratropium + combination (FDC) maximizes the response Management of reversible breathing, diaphragmatic
Salbutamol neb Q8 to treatment in patients with bronchial bronchospasm associated with breathing, and chest
and PRN asthma and chronic obstructive pulmonary obstructive airways diseases splinting
disease (COPD) by increasing Chronic obstructive pulmonar The solution is intended for
DRUG bronchodilation through two distinctly disease (COPD) on a regular inhaled inhalation with suitable
CLASSIFICATION: different mechanisms, i.e., anticholinergic bronchodilator who continue to nebulizing devices and
Anticholinergic/ (parasympatholytic) and Beta-agonist have evidence of bronchospam and should not be taken orally.
Beta- agonist (sympathomimetic) effetcs. Simultaneous who require a second After use, discard any
administration of both an anticholinergic bronchodilator. remaining solution and clean
(ipratropium bromide) and beta- CONTRAINDICATIONS your nebulizer.
sympathomimetic (salbutamol sulfate) Hypertropic obstructive
produce a greater bronchodilator effect cardiomyopathy or tachyarrhytmia
than when either drug is used alone. Hypersensitivity

DRUG: Omeprazole is a substituted benzimidazole INDICATIONS: Take immediately before a


Omeprazole 40mg gastric antisecretory agent and is also Zollinger-Ellison syndrome, Gastric meal.
TIV OD known as PPI. It blocks the final step in and duodenal ulcers, Gastro- Observe for allergic reactions
gastric acid secretion by specific inhibition oesophageal reflux disease, NSAID- Do not crush or chew capsules
DRUG of H+/K+ ATPase enzyme system present on associated ulceration Patient may experience
CLASSIFICATION: the secretory surface of the gastric parietal CONTRAINDICATIONS anorexia; small frequent meals
Antireflux Agents cell. Both basal and stimulated acid are Concomitant use w/ rilpivirine, may help to maintain adequate
& Antiulcerants inhibited. nelfinavir and atazanavir. nutrition.
Report severe headache,
unresolved severe diarrhea, or
changes in respiratory status.
Drug/Drug Mode of Action Indications/ Patient Teaching
Classification Contraindications
DRUG: Furosemide inhibits reabsorption of Na and INDICATIONS: Advise patient to take drug with
Furosemide 20mg Cl mainly in the medullary portion of the Acute pulmonary edema food to prevent GI upset inform
TIV Q8 ascending loop of Henle. Excretion of K and patient of possible need for
ammonia is also increased while uric acid CONTRAINDICATIONS potassium or magnesium
DRUG excretion is reduced. It increases plasma- Hypersensitivity to furosemide supplement
CLASSIFICATION: renin activity, plasma-norepinephrine and and sulfonamides. Anuria or Furosemide can pass into breast
Diuretics plasma-arginine-vasopressin renal failure, Addison's disease, milk and may harm a nursing baby.
concentrations. hypovolaemia or dehydration, This medicine may also slow
precomatose state associated breast milk production. Tell your
w/ liver cirrhosis. doctor if you are breast-feeding a
baby

DRUG: Magnesium sulfate decreases levels of INDICATIONS: Tell your doctor if you drink
Magnesium Sulfate acetylcholine in motor nerve terminals. It Reduction of cerebral oedema, alcohol or caffeine drinks regularly,
2gms TIV as also acts on the myocardium by decreasing Torsades de pointes, Eclampsia, if you smoke, or if you use any
incoporation the rate of SA node impulse formation and Muscle stimulating effects of street drugs.
prolonging the conduction time. barium poisoning Inform if you experience side
DRUG effect such as: feeling like you
CLASSIFICATION: CONTRAINDICATIONS might pass out; sweating, anxiety,
Dermatologicals / Heart block, severe renal cold feeling; flushing (warmth,
Laxatives, impairment, myocardial redness, or tingly feeling); weak or
Purgatives / damage. shallow breathing; extreme
Anticonvulsants / drowsiness, feeling very weak; or
Electrolytes numbness or tingly feeling around
your mouth, muscle tightness or
contraction, overactive reflexes.
Drug/Drug Mode of Action Indications/ Patient Teaching
Classification Contraindications
DRUG: Captopril competitively inhibits the INDICATIONS: The drug should be administered 1
Captopril 25mg tab conversion of angiotensin I (ATI) to Diabetic nephropathy, Post- hour before or 2 hours after
PRN for BP angiotensin II (ATII), thus resulting in myocardial infarction, meals. It may be crushed if the
>160/100mmHg reduced ATII levels and aldosterone Hypertension, Heart failure patient has difficulty swallowing.
secretion. It also increases plasma renin Inform the patient that Captopril
DRUG activity and bradykinin levels. Reduction of CONTRAINDICATIONS tablets may have a slight sulfur
CLASSIFICATION: ATII leads to decreased Na and water Angioedema related to previous odor (like rotten eggs).
ACE retention. This promotes vasodilation and ACE inhibitor treatment, Instruct the patient to notify the
Inhibitors/Direct BP reduction. hereditary or idiopathic physician immediately when the
Renin Inhibitors angioneurotic oedema. following manifestations are
Concomitant use w/ aliskiren in experienced: chest pain, swelling
diabetic patients. Pregnancy. of the face, eyes, lips, tongue,
arms, or legs. difficulty breathing
or swallowing. fainting, rash

DRUG: Isosorbide dinitrate relaxes vascular INDICATIONS: Dissolve tablet under the
ISDN 5mg tab SL smooth muscles by stimulating cyclic-GMP. Heart failure, Management of tongue, between the cheek and
PRN for chest pain It decreases left ventricular pressure angina, Acute angina gum, or between the lip and
(preload) and arterial resistance (afterload). gum.
DRUG CONTRAINDICATIONS Do not eat or drink while the
CLASSIFICATION: Severe hypotension or anaemia, tablet is dissolving.
Anti-Anginal Drugs hypovolaemia, heart failure due to
obstruction, or raised intracranial
pressure due to head trauma or
cerebral haemorrhage.
Drug/Drug Mode of Action Indications/ Patient Teaching
Classification Contraindications
DRUG: Potassium chloride is a major cation of the INDICATIONS: Administer oral drug after meals or
Potassium intracellular fluid. It plays an active role in the Hypokalaemia, Prophylaxis of with food and a full glass of water to
Chloride tab PO conduction of nerve impulses in the heart, hypokalaemia and mild K decrease GI upset.
TID brain and skeletal muscle; contraction of deficiency you may experience these side
cardiac skeletal and smooth muscles; effects: Nausea, vomiting, diarrhea.
DRUG maintenance of normal renal function, acid- CONTRAINDICATIONS Report tingling of the hands or feet,
CLASSIFICATION: base balance, carbohydrate metabolism and Hyperchloraemia, severe unusual tiredness or weakness,
Electrolytes gastric secretion. renal or adrenal insufficiency. feeling of heaviness in the legs,
severe nausea, vomiting, abdominal
pain, black or tarry stools, pain at IV
injection site

DRUG: Levocetirizine is an active isomer of cetirizine INDICATIONS: May be taken with or without food.
Levoetirizine + which selectively competes w/ histamine for Montelukast+Levocetirizine a Do not consume alcohol while
Monteleukast H1-receptor sites on effector cells in the GI combined therapy is taking Montelukast + Levocetirizine
5/10mg / tab PO tract, blood vessels and respiratory tract. prescribed for the systemic
treatment of allergic reactions
DRUG Montelukast is a selective leukotriene such as chronic urticaria,
CLASSIFICATION: receptor antagonist that inhibits the effects of obstructive airway diseases
Antiasthmatic & cysteinyl leukotrienes in the airways. Cysteinyl and rhinitis.
COPD Preparations leukotrienes and leukotriene receptor CONTRAINDICATIONS
/ Antihistamines & occupation have been correlated w/ the allergy to either or both
Antiallergics pathophysiology of asthma, including airway drugs
oedema, smooth muscle contraction, and hepatic impairment
altered cellular activity associated w/ the NSAID allergy
inflammatory process, which contribute to children less than six
the signs and symptoms of asthma. months of age.
Drug/Drug Mode of Action Indications/ Patient Teaching
Classification Contraindications
DRUG: In asthma, and in chronic obstructive airways INDICATIONS: Shake the inhaler well for 5 seconds
Formoterol + disease (COPD) such as chronic bronchitis, the Asthma, Chronic obstructive before each use.
Beclomethasone airways tighten due to inflammation and can pulmonary disease (COPD). Inhale this medication by mouth as
6/100 mg MDI 2 also be blocked by mucus. This makes it directed , twice daily (in the morning
Puffs BID difficult for air to get into and out of the CONTRAINDICATIONS and evening, ).
lungs. Beclometasone is used in these lung People with known The prescribed dose is 2 puffs, wait
DRUG conditions to prevent the inflammation and sensitivity or allergy to any at least one minute between them. If
CLASSIFICATION: excess mucus formation, and therefore help ingredient. you are using other inhalers at the
Corticosteroid / prevent asthma attacks, wheezing and same time, wait at least 1 minute
Long-acting beta 2 shortness of breath. between the use of each medication,
agonist or and use this drug last.
bronchodilator. In asthma and COPD there is narrowing of the Gargle and rinse your mouth with
airways. By relaxing and opening the airways, water after using this medication to
formoterol makes it easier to breathe. help prevent irritation and yeast
Formoterol starts to work in one to three infections (thrush) in the mouth and
minutes and its effects last for about 12 throat. Do not swallow the rinse
hours. water.
Clean the inhaler once a week with a
Inhaling the medicines allows them to act dry cloth. Do not take the inhaler
directly in the lungs where they are needed. It apart.
also reduces the potential for side effects in
other parts of the body, as the amount
absorbed into the blood through the lungs is
lower than if it is taken by mouth.
Drug/Drug Mode of Action Indications/ Patient Teaching
Classification Contraindications
DRUG: Morphine is a INDICATIONS: This medication may cause withdrawal reactions,
Morphine phenanthrene derivative Acute pulmonary edema, Pain especially if it has been used regularly for a long time
2mg/amp TIV PRN which acts mainly on the associated with myocardial or in high doses. In such cases, withdrawal symptoms
for severe chest CNS and smooth infarction (such as restlessness, watery eyes, widened pupils,
pain muscles. It binds to sweating, runny nose) may occur if you suddenly stop
opiate receptors in the CONTRAINDICATIONS using this medication. To prevent withdrawal
DRUG CNS altering pain Respiratory depression, reactions, your doctor may reduce your dose
CLASSIFICATION: perception and obstructive airway disease, gradually. Consult your doctor or pharmacist for more
Cough & Cold response. Analgesia, delayed gastric emptying, details, and report any withdrawal reactions right
Preparations / euphoria and acute abdomen, heart failure away.
Analgesics (Opioid) dependence are thought secondary to chronic lung When this medication is used for a long time, it may
to be due to its action at disease, known or suspected not work as well. Your doctor may need to increase
the mu-1 receptors while paralytic ileus, your dose or change your medication. Talk with your
resp depression and phaeochromocytoma. doctor if this medication stops working well.
inhibition of intestinal Along with its benefits, this medication may rarely
movements are due to cause abnormal drug-seeking behavior (addiction).
action at the mu-2 This risk may be increased if you have abused alcohol
receptors. Spinal or drugs in the past. Use this medication exactly as
analgesia is mediated by prescribed to lessen the risk of addiction.
morphine agonist action Tell your doctor if your pain persists or worsens.
at the K receptor.
Drug/Drug Mode of Action Indications/ Patient Teaching
Classification Contraindications
DRUG: acts mainly at the limbic INDICATIONS: Use of barrier contraceptives is advised
Diazepam system and reticular Management of anxiety disorders or for while using this drug; if you become or wish
5mg/amp TIV PRN formation; may act in short-term relief of symptoms of anxiety to become pregnant, consult with your
for anxiety or spinal cord and at Acute alcohol withdrawal; may be useful health care provider.
agitation supraspinal sites to in symptomatic relief of acute agitation, You may experience these side effects:
produce skeletal muscle tremor, delirium tremens, hallucinosis Drowsiness, dizziness (may lessen; avoid
DRUG relaxation; potentiates Antiepileptic: Adjunct in status driving or engaging in other dangerous
CLASSIFICATION: the effects of GABA, an epilepticus and severe recurrent activities); GI upset (take drug with food);
Benzodiazepine, inhibitory convulsive seizures (parenteral); adjunct dreams, difficulty concentrating, fatigue,
Anxiolytic, neurotransmitter; in seizure disorders (oral) nervousness, crying (reversible).
Antiepileptic, anxiolytic effects occur CONTRAINDICATIONS
Skeletal muscle at doses well below hypersensitivity to benzodiazepines
relaxant (centrally those necessary to cause Psychoses
acting) sedation, ataxia; has acute narrow-angle glaucoma
little effect on cortical Shock
function. Coma
acute alcoholic intoxication
pregnancy (cleft lip or palate, inguinal
hernia, cardiac defects, microcephaly,
pyloric stenosis when used in first
trimester; neonatal withdrawal syndrome
reported in newborns)
lactation.
ASSESSMENT DIAGNOSIS PLANNING
Objective: Decreased Cardiac Short term goal:
Increased heart rate, output may be related Within 3 days of nursing intervention, the
dysrhythmias, ECG changes to altered myocardial patient will report decreased episodes of
Chest pain contractility changes dyspnea, angina.
Changes in BP possibly evidenced by
(hypertension) hypertension and
chest pain.
Extra heart sounds (S3, S4) Long term goal:
Decreased urine output Within 5 days of nursing interventions, patient
Diminished peripheral will display vital signs within acceptable limits,
pulses dysrhythmias absent/controlled and no
symptoms of failure (e.g. , hemodynamic
parameters within acceptable limits, urinary
output adequate)

Within 7 days of nursing interventions, patient


can participate in activities that reduce cardiac
workload.
INTERVENTIONS RATIONALE EVALUATION
INDEPENDENT Short term goal:
Auscultate apical Tachycardia is usually present Within 3 days of nursing intervention, the
pulse; assess heart (even at rest) to compensate patient will report decreased episodes of
rate and rhythm for decreased ventricular dyspnea, angina.
contractility. GOAL MET
Note heart sounds. S1 and S2 may be weak Long term goal:
because of diminished Within 5 days of nursing interventions, the
pumping action. Murmurs may patient will display vital signs within
reflect valvular acceptable limits, dysrhythmias
incompetence/stenosis. absent/controlled and no symptoms of failure
(e.g. , hemodynamic parameters within
acceptable limits, urinary output adequate)
Monitor blood In early, moderate or chronic Within 7 days of nursing interventions,
pressure HF, BP may be elevated patient can participate in activities that reduce
because of increased SVR. In cardiac workload.
advanced HF, the body may no GOAL MET
longer be able to compensate,
and profound/irreversible
hypotension may occur.
INTERVENTIONS RATIONALE
INDEPENDENT
Inspect skin for cyanosis, Pallor is indicative of diminished peripheral perfusion secondary to
pallor inadequate cardiac output, vasoconstriction, and anemia.
Monitor urine output, noting Kidneys respond to reduced cardiac output by retaining water and
decreasing output and sodium. Urine output is usually decreased during the day because of
dark/concentrated urine. fluid shifts into tissues but may be increased at night because of fluid
returns to circulation when patient is recumbent.
Monitor blood pressure In early, moderate or chronic HF, BP may be elevated because of
increased SVR. In advanced HF, the body may no longer be able to
compensate, and profound/irreversible hypotension may occur.
Note changes in sensorium, May indicate inadequate cerebral perfusion secondary to decreased
e.g., lethargy, confusion, cardiac output.
Provide quiet environment, Psychological rest helps reduce emotional stress, which can produce
explain medical/nursing vasoconstriction, elevating BP and increasing heart rate/work
management; help patient
avoid stressful situations;
listen/ respond to expressions
of feelings/fears.
INTERVENTIONS RATIONALE
INDEPENDENT
Elevate legs, avoiding pressure under Decreases venous stasis and may reduce incidence of
knee, encourage active/passive exercises. thrombus/embolus formation.
Increase ambulation/activity as tolerated.
COLLABORATIVE Increases available oxygen for myocardial uptake to
Administer supplemental oxygen as combat effects of hypoxia/ischemia
needed rehabilitation program
Administer medications like Beta Useful in treatment of HF by blocking the cardiac effects
adrenergic receptor antagonists as of chronic adrenergic stimulation. Many patients
ordered experience improved activity tolerance and ejection
fraction.
Monitor/replace electrolytes Fluid shifts and use of diuretics can alter electrolytes
(especially potassium and chloride) which affect cardiac
rhythm and contractility.
ASSESSMENT DIAGNOSIS PLANNING
Subjective: Activity Intolerance Short term goal:
Patient verbalized ang bigat ng R/T cardiac Within 3 days of nursing intervention, the
dibdib ko parang may naka dysfunction, changes patient will be able to tolerate activities of daily
dagan at nahihirapan akong in oxygen supply and living without any complains of dyspnea and
huminga. consumption as chest pain and will be able to utilize breathing
evidenced by techniques and energy conservation techniques
shortness of breath effectively.
Objective: Long term goal:
Increased heart rate and Within 5 days of nursing interventions, the
blood pressure patient will be able to increase and achieved
Dyspnea wit exertion desired activity level progressively with no
Pallor intolerance symptoms noted and normal vital
Fatigue and body weakness signs.
Ischemic ECG changes
INTERVENTIONS RATIONALE EVALUATION
INDEPENDENT Short term goal:
Monitor and record heart Trends determine patients Within 3 days of nursing intervention,
rate and rhythm and BP response to activity and may the patient will be able to tolerate
changes before, during, and indicate myocardial oxygen activities of daily living without any
after activity for any deprivation that may require complains of dyspnea and chest pain
abnormalities. Notify decrease in activity level/return and will be able to utilize breathing
physician of any significant to bedrest, changes in techniques and energy conservation
changes in the vitals. medication regimen, or use of techniques effectively.
supplemental oxygen. GOAL MET
Identify causative factors Alleviation of factors that are Long term goal:
leading to intolerance of known to create intolerance can Within 5 days of nursing interventions,
activity assist with development of an the patient will be able to increase and
activity level program. achieved desired activity level
progressively with no intolerance
symptoms noted and normal vital signs.
GOAL MET
INTERVENTIONS RATIONALE
INDEPENDENT
Encourage rest and limit activity on basis Reduces myocardial workload/oxygen consumption,
of pain/adverse cardiac response. Provide reducing the risk of complications.
non-stress diversional activities.
Instruct patient in energy conservation To decrease energy expenditure and fatigue.
techniques.
Instruct patient to avoid increasing Activities that require holding the breath and bearing
abdominal pressure like straining during down (Valsalva Maneuver) can result in bradycardia and
defecation. rebound tachycardia with elevated BP.
Explain pattern of graded increase of Progressive activity provides a controlled demand on
activity level. the heart, increasing strength and preventing
overexertion.
DEPENDENT
Assist patient with ambulation as ordered, To gradually increase the body to compensate for the
with progressive increases as patients increase in overload.
tolerance permits.
COLLABORATIVE
Refer to cardiac rehabilitation program. Provides continued support/additional supervision and
participation in recovery and wellness process.
Medicare states that discharge planning is a process used to decide what a patient
needs for a smooth move from one level of care to another. Only a doctor can
authorize a patient's release from the hospital, but the actual process of discharge
planning can be completed by a social worker, nurse, case manager, or other person.
Ideally, and especially for the most complicated medical conditions, discharge
planning is done with a team approach.

M - Medications
E Exercise / Activity
T Treatment and Therapy
H - Home Teaching(s) and Housing
O Outpatient Follow-ups
D - Diet
S - Spirituality and Sexuality

McHugh Schuster, P. Concept Mapping: A Critical Thinking Approach to Care Planning (2nd ed., pp. 80-82).
MEDICATIONS
Aspirin 80mg/tab Uminom ng isang tableta isang beses kada araw pagkatapos
manganghalian
Clopidogrel 75mg/tab Uminom ng isang tableta isang beses kada araw pagkatapos
manganghalian
Atorvastatin 80mg/tab Uminom ng isang tableta isang beses bago matulog
Enalapril 5mg/tab Uminom ng isang tableta isang beses sa umaga
Captopril 25mg/tab Uminom ng isang tableta kapag ang Blood Pressure ay 160/100mmHg
o higit pa
Carvedilol 6.25mg/tab Uminom ng isang tableta 2 beses kada araw
ISMN 30mg/tab Uminom ng isang tableta 2 beses kada araw
Trimetazidine 35mg/tab Uminom ng isang tableta 2 beses kada araw
ISDN 5mg/tab Maglagay ng isang tableta sa ilallim ng dila kapag sumasakit ang
dibdib
Formoterol + Beclomethasone 2 puffs 2 beses kada araw
6/100 mg MDI
Levoetirizine + Monteleukast Uminom ng isang tableta isang beses kada araw sa loob ng 6 pa na
5/10mg / tab araw
Enoxaparin 0.6cc Magtusok ng sa 0.6ml sa taba kada 12 oras sa loob ng 3 araw
Blood thinners help prevent blood clots. Clots can cause strokes, heart attacks, and death. The
following are general safety guidelines to follow while you are taking a blood thinner:
Watch for bleeding and bruising while you take blood thinners. Watch for bleeding from your gums
or nose. Watch for blood in your urine and bowel movements. Use a soft washcloth on your skin,
and a soft toothbrush to brush your teeth. This can keep your skin and gums from bleeding. If you
shave, use an electric shaver. Do not play contact sports.
Do not start or stop any medicines unless your healthcare provider tells you to. Many medicines
cannot be used with blood thinners.
Tell your healthcare provider right away if you forget to take the medicine, or if you take too much.
Warfarin is a blood thinner that you may need to take. The following are things you should be
aware of if you take warfarin.
Foods and medicines can affect the amount of warfarin in your blood. Do not make major
changes to your diet while you take warfarin. Warfarin works best when you eat about the
same amount of vitamin K every day. Vitamin K is found in green leafy vegetables and certain
other foods. Ask for more information about what to eat when you are taking warfarin.
You will need to see your healthcare provider for follow-up visits when you are on warfarin.
You will need regular blood tests. These tests are used to decide how much medicine you need.

Myocardial Infarction (Discharge Care) - What You Need to Know. (2017). Drugs.com. Retrieved
30 April 2017, from https://www.drugs.com/cg/myocardial-infarction-discharge-care.html
Heart medicines help decrease blood pressure, control your heart rate, and help
your heart function better.

Nitroglycerin opens the arteries to your heart, increases oxygen levels, and can
decrease chest pain. You may get your nitroglycerin as a pill, a patch, or a paste.
Ask your healthcare provider or cardiologist how to safely take this medicine.

Aspirin helps prevent clots from forming and causing blood flow problems. If
healthcare providers want you to take aspirin daily, do not take acetaminophen or
ibuprofen instead. Do not take more or less aspirin than healthcare providers say
to take. If you are on another blood thinner medicine, ask your healthcare
provider or cardiologist before you take aspirin for any reason.

Myocardial Infarction (Discharge Care) - What You Need to Know. (2017). Drugs.com. Retrieved
30 April 2017, from https://www.drugs.com/cg/myocardial-infarction-discharge-care.html
Cholesterol medicine decreases cholesterol and the amount of plaque in
your blood.

Do not take certain medicines without asking your healthcare provider


first.

Take your medicine as directed. Contact your healthcare provider if you


think your medicine is not helping or if you have side effects. Tell him or
her if you are allergic to any medicine. Keep a list of the medicines,
vitamins, and herbs you take. Include the amounts, and when and why you
take them. Bring the list or the pill bottles to follow-up visits. Carry your
medicine list with you in case of an emergency.
Myocardial Infarction (Discharge Care) - What You Need to Know. (2017). Drugs.com. Retrieved
30 April 2017, from https://www.drugs.com/cg/myocardial-infarction-discharge-care.html
Do not smoke. If you smoke, it is never too late to quit. Smoking increases your risk of another MI.

Exercise. Ask your healthcare provider or cardiologist about the best exercise plan for you. Exercise
makes your heart stronger, lowers blood pressure, and helps prevent an MI. The goal is 30 to 60
minutes a day, 5 to 7 days a week. Ask your healthcare provider or cardiologist how often and how long
to exercise.

Maintain a healthy weight. Ask your healthcare provider or cardiologist how much you should weigh.
Ask him to help you create a weight loss plan if you are overweight.

Manage your stress. Stress may slow healing and lead to illness. Learn ways to control stress, such as
relaxation, deep breathing, and music. Talk to someone about things that upset you.

A physical activity history or an exercise test to guide initial prescription is beneficial. Guided/modified
by an individualized exercise prescription, patients recovering from UA/NSTEMI generally should be
encouraged to achieve physical activity duration of 30 to 60 minutes per day, preferably in the form of
7 (but at least 5) days per week of moderate aerobic activity, such as brisk walking, supplemented by
an increase in daily lifestyle activities (e.g., walking breaks at work, gardening, and household work).
Myocardial Infarction (Discharge Care) - What You Need to Know. (2017). Drugs.com. Retrieved
30 April 2017, from https://www.drugs.com/cg/myocardial-infarction-discharge-care.html
Go to cardiac rehabilitation as directed. This is a program run by specialists who
will help you safely strengthen your heart and prevent more heart disease. This
plan includes exercise, relaxation, stress management, and heart-healthy
nutrition. Healthcare providers will also check to make sure any medicines you are
taking are working. The plan may also include instructions for when you can drive,
return to work, and do other normal daily activities.

Cardiac rehabilitation/secondary prevention programs are recommended for


patients with UA/ NSTEMI, particularly those with multiple modifiable risk factors
and/or those moderate- to high-risk patients in whom supervised exercise training
is particularly warranted.

Myocardial Infarction (Discharge Care) - What You Need to Know. (2017). Drugs.com. Retrieved
30 April 2017, from https://www.drugs.com/cg/myocardial-infarction-discharge-care.html

(2017). Retrieved 30 April 2017, from


http://jaccjacc.cardiosource.com/DataSupp/ACCF/2011_UA_NSTEMI_PocketGuide.pdf
Depression. It is reasonable to consider screening UA/NSTEMI patients for depression
and refer for treatment when indicated.

Hormone Therapy. Hormone therapy with estrogen plus progestin, or estrogen alone,
should not be given de novo to postmenopausal women after UA/NSTEMI for
secondary prevention of coronary events. Postmenopausal women who are already
taking estrogen plus progestin, or estrogen alone, at the time of UA/NSTEMI in
general should not continue hormone therapy. However, women who are more than 1
to 2 years past the initiation of hormone therapy who wish to continue such therapy
for another compelling indication should weigh the risks and benefits, recognizing the
greater risk of cardiovascular events and breast cancer (combination therapy) or
stroke (estrogen). Hormone therapy should not be continued while patients are on
bedrest in the hospital.

Myocardial Infarction (Discharge Care) - What You Need to Know. (2017). Drugs.com. Retrieved
30 April 2017, from https://www.drugs.com/cg/myocardial-infarction-discharge-care.html

(2017). Retrieved 30 April 2017, from


http://jaccjacc.cardiosource.com/DataSupp/ACCF/2011_UA_NSTEMI_PocketGuide.pdf
Home Teachings: Effective discharge planning means you must
spend time with a client making sure they understand how to take
their medication at home. You go over with them how to deal with
loneliness or anxiety when discharged, and what to do in crisis at
home.

Housing: Plan for safe and available housing to prevent cycling back
into acute care services. The treatment field needs fewer residential
and hospital beds and more shelters and supportive housing and
living environments.

For those returning home: Remember to help families and


significant others cope with the effects of their loved ones illness,
and understand how to be supportive at home.
At the time of hospital discharge, patients should have a clear plan for follow-
up with a physician to assess recovery and symptoms and to reinforce
secondary preventive measures. Low-risk medically treated patients and re-
vascularized patients usually should be seen within two to six weeks, whereas
higher-risk patients should be seen within one to two weeks.

Eat a heart healthy diet. Get enough calories, protein, vitamins, and minerals
to help prevent poor nutrition and promote muscle strength. You may be told
to eat foods low in cholesterol or sodium (salt). You also may be told to limit
saturated and trans fats. Eat foods that contain healthy fats, such as walnuts,
salmon, and canola and soybean oils. Eat foods that help protect the heart,
including plenty of fruits and vegetables, nuts, and sources of fiber.

Maintain a healthy weight. Ask your healthcare provider or cardiologist how


much you should weigh. Ask him to help you create a weight loss plan if you
are overweight.
Braunwald, S. (2017). Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction:
Part II. Coronary Revascularization, Hospital Discharge, and Post-Hospital Care - American Family
Physician. Aafp.org. Retrieved 30 April 2017, from http://www.aafp.org/afp/2004/0801/p535.html
Spirituality: Mindfulness meditation and spiritual practices are now taking an appropriate
place in the continuum of services. Help connect people to their communities of faith. This
can provide daily support and healing complementary to, and equally effective as,
traditional healthcare methods.

Sexuality: Like spirituality, sexuality has been a neglected area in treatment and service
planning. Address sexual orientation and preferences; side effects of medications on libido
and sexual function; and the variety of sexual dysfunctions.
Sexual counseling for cardiac patients and their partners should be provided. The
patients concern about resumption of sexual activity often produces more stress than
the physiologic act itself.
The inability to perform sexually after MI is common and sexual dysfunction
usually decreases after several attempts.
Patients should know that drugs used for erectile dysfunction should not be used
with nitrates as severe hypotension may occur.
Typically, it is safe to resume sexual activity 7 to 10 days after an uncomplicated MI.
Braunwald, S. (2017). Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction:
Part II. Coronary Revascularization, Hospital Discharge, and Post-Hospital Care - American Family
Physician. Aafp.org. Retrieved 30 April 2017, from http://www.aafp.org/afp/2004/0801/p535.html
Cardiovascular Disease is the major cause of death worldwide which is almost a third of all deaths
globally in 2013. The most of CVD deaths were from coronary heart disease (CHD) (Cao, Zhao, Bu,
Zhao, & Yu, 2016). Acute coronary syndrome (ACS) is used to describe a range of acute myocardial
ischemia, where reduced blood flow to the coronary arteries, usually caused by an acute plaque
event leading to an impediment, results in myocardial infarction (MI). (Fhadil, Wright, & Antoniou
2015). Ever since the redefinition of myocardial infarction in the year 2000, a new entity has
entered the field: non-ST-elevation MI (NSTEMI). STEMI and NSTEMI share the release of specific
myocardial necrosis markers which define them clinically as acute MI and set them apart from
unstable angina, an acute coronary syndrome which does not qualify as MI (Bode, & Zirlik, 2007).
ST-segment elevation myocardial infarction (STEMI) is the complete blockage of a coronary artery,
and non-ST elevation myocardial infarction (NSTEMI) and unstable angina (UA), where a partial
blockage of the artery occurs (Fhadil, Wright, & Antoniou, 2015).

Unstable angina is a common manifestation of coronary heart disease. Unstable angina is a crucial
phase of this disease with widely variable symptoms and prognoses. Thoracic pain may mark the
onset of acute myocardial infarction. It typically occurs at rest and has a sudden onset, sudden
worsening, and stuttering recurrence over days and weeks. Unstable angina which is a potentially
life-threatening event is relatively more harmful than stable angina pectoris. (Cao, Zhao, Bu, Zhao,
& Yu, 2016)

Bode, C., & Zirlik, A. (2007). STEMI and NSTEMI: the dangerous brothers. European Heart Journal, 28(12), 1403-1404. http://dx.doi.org/10.1093/eurheartj/ehm159
Cao, S., Zhao, W., Bu, H., Zhao, Y., & Yu, C. (2016). Ligustrazine for the Treatment of Unstable Angina: A Meta-Analysis of 16 Randomized Controlled Trials. Retrieved 5 May 2017, from
https://www.hindawi.com/journals/ecam/2016/8617062/
Fhadil, S., Wright, P., & Antoniou, S. (2015). Non-ST elevation acute coronary syndrome: an update. Pharmaceutical Journal. Retrieved 5 May 2017, from http://www.pharmaceutical-journal.com/learning/learning-
article/non-st-elevation-acute-coronary-syndrome-an-update/20069326.article
As unstable angina and NSTEMI often have indistinguishable clinical presentation, they are
collectively termed non-ST elevation acute coronary syndrome (NSTE-ACS) in the latest guidance
from the American College of Cardiology (ACC) and American Heart Association (AHA). Similar to
the term ACS, this is a collective term recognizing the similarities in presentation and outcome in
patients presenting with NSTEMI and high risk UA (Fhadil, Wright, & Antoniou, 2015).

With the creation of the NSTEMI as a new clinical entity, the need for data regarding prognosis and
treatment options arose. By definition, STEMI and NSTEMI are only different with respect to the
reflection of acute myocardial ischemia and necrosis in the ECG. Clinical history, physical
examination, electrocardiogram (ECG) changes and biochemical markers of myocardial necrosis
(e.g. troponin) are all used to identify patients with suspected NSTE-ACS (Fhadil, Wright, &
Antoniou, 2015). Progress in the treatment of MI has been rapid in the past years; however, most
studies focused on STEMI. Most recently, individual trials and meta-analyses have been published
that address NSTEMI as a unique entity. In fact, there are now numerous studies underway that
will define the short- and long-term benefits of various antithrombotic approaches as well as
those of an early invasive vs. conservative strategy. (Bode, & Zirlik, 2007).

Bode, C., & Zirlik, A. (2007). STEMI and NSTEMI: the dangerous brothers. European Heart Journal, 28(12), 1403-1404. http://dx.doi.org/10.1093/eurheartj/ehm159
Cao, S., Zhao, W., Bu, H., Zhao, Y., & Yu, C. (2016). Ligustrazine for the Treatment of Unstable Angina: A Meta-Analysis of 16 Randomized Controlled Trials. Retrieved 5 May 2017, from
https://www.hindawi.com/journals/ecam/2016/8617062/
Fhadil, S., Wright, P., & Antoniou, S. (2015). Non-ST elevation acute coronary syndrome: an update. Pharmaceutical Journal. Retrieved 5 May 2017, from http://www.pharmaceutical-journal.com/learning/learning-
article/non-st-elevation-acute-coronary-syndrome-an-update/20069326.article
According to Fhadil, Wright, & Antoniou (2015), the aim of treatment for all patients presenting
with is immediate symptomatic relief of ischemia and preventing further MI and death. Recently,
conventional medicine has consisted of antiplatelet agents, anticoagulant agents, nitrates, beta-
adrenergic blockers, calcium channel blockers, and inhibitors of the renin-angiotensin-aldosterone
system. Although these treatments are widely used in the acute relief of secondary angina
pectoris and the long-term prophylactic management of angina pectoris, chuanxiong might also be
useful for UA and for increased safety (Cao, Zhao, Bu, Zhao, & Yu, 2016).

According to Cao, Zhao, Bu, Zhao, & Yu, (2016), ligustrazine is a principal ingredient of chuanxiong
concerns regarding the evaluation of the effectiveness of ligustrazine in the treatment of UA.
Ligustrazine combined with conventional medicine was associated with an increased rate of
marked improvement in symptoms and an increased rate of marked improvement of ECG
compared with conventional Western medicine alone. Additionally, the use of ligustrazine was
associated with significant trends in the reduction of the consumption of nitroglycerin and the
level of fibrinogen when compared with conventional Western medicine alone.

Bode, C., & Zirlik, A. (2007). STEMI and NSTEMI: the dangerous brothers. European Heart Journal, 28(12), 1403-1404. http://dx.doi.org/10.1093/eurheartj/ehm159
Cao, S., Zhao, W., Bu, H., Zhao, Y., & Yu, C. (2016). Ligustrazine for the Treatment of Unstable Angina: A Meta-Analysis of 16 Randomized Controlled Trials. Retrieved 5 May 2017, from
https://www.hindawi.com/journals/ecam/2016/8617062/
Fhadil, S., Wright, P., & Antoniou, S. (2015). Non-ST elevation acute coronary syndrome: an update. Pharmaceutical Journal. Retrieved 5 May 2017, from http://www.pharmaceutical-journal.com/learning/learning-
article/non-st-elevation-acute-coronary-syndrome-an-update/20069326.article
Standard medical therapy includes sublingual or intravenous nitrates. Nitrates cause vasodilation,
decreasing cardiac preload and reducing ventricular wall tension. Morphine can also be used given
its vasodilatory properties and modest reductions in heart rate and systolic blood pressure. Oral
beta-blockers should be started within the first 24 hours provided blood pressure and heart rate
allow. Beta-blockers are introduced to prevent sudden cardiac death associated with the
development of complex ventricular arrhythmias and to decrease blood pressure, heart rate and
contractility, leading to a reduction in myocardial oxygen consumption, myocardial ischemia and
reinfarction. A single dose of nonenteric-coated, chewable aspirin should be given to all patients
with NSTE-ACS as soon as possible after presentation, and a maintenance dose of aspirin should
be continued indefinitely. The AHA/ACC guidance makes reference to evaluating a patients
bleeding risk and ensuring that, where relative contraindications to antiplatelet therapy exist, a
risk-benefit analysis of antiplatelet treatment is taken into account (Fhadil, Wright, & Antoniou,
2015).

Bode, C., & Zirlik, A. (2007). STEMI and NSTEMI: the dangerous brothers. European Heart Journal, 28(12), 1403-1404. http://dx.doi.org/10.1093/eurheartj/ehm159
Cao, S., Zhao, W., Bu, H., Zhao, Y., & Yu, C. (2016). Ligustrazine for the Treatment of Unstable Angina: A Meta-Analysis of 16 Randomized Controlled Trials. Retrieved 5 May 2017, from
https://www.hindawi.com/journals/ecam/2016/8617062/
Fhadil, S., Wright, P., & Antoniou, S. (2015). Non-ST elevation acute coronary syndrome: an update. Pharmaceutical Journal. Retrieved 5 May 2017, from http://www.pharmaceutical-journal.com/learning/learning-
article/non-st-elevation-acute-coronary-syndrome-an-update/20069326.article
Ligustrazine is a principal ingredient of chuanxiong. It has been shown to play a critical role in cardiovascular
treatments, mediated by inhibition of Ca2+ influx and by the release of intracellular Ca2+. It significantly inhibits L-
type calcium current in a concentration-dependent manner to make vasodilatory effect, to improve the situation
of myocardium ischemia. It also suppressed calcium transient and contraction in rabbit ventricular myocytes
under physiological and pathophysiological conditions. Besides, ligustrazine improves attenuation of oxidative
stress. Treatment by ligustrazine decreased reactive oxygen species (ROS) production and enhanced cellular
glutathione (GSH) levels. Ligustrazine treatment partially restored superoxide dismutase1 (SOD1) activity,
increasing in NO production. Recently, the oxidative stress has been shown to play a critical role in atherogenesis
(AS). The PPAR signal pathway is involved in the molecular mechanism of ligustrazine in the treatment of AS.
Although pharmacology research might indicate the cardiovascular protective effects of ligustrazine, the specific
outcomes of the effectiveness of ligustrazine have not been elucidated (Cao, Zhao, Bu, Zhao, & Yu, 2016).

Although ligustrazine and conventional antiangina treatments that include ligustrazine exhibited some benefit,
there are a number of limitations to this review. Limitations still contribute enlightenment to future studies.
Researchers can improve the methodology, such as allocation concealment, blinding method, treatment
duration, and long-term follow-up. Well-designed trials of ligustrazine in UA management will promote its
application correctly and our paper may stimulate appropriate evaluation on ligustrazine historically. The
addition of ligustrazine to conventional medicine possibly benefits unstable angina. However, quality evidence is
needed to further assess its efficacy and safety (Cao, Zhao, Bu, Zhao, & Yu, 2016)..

Bode, C., & Zirlik, A. (2007). STEMI and NSTEMI: the dangerous brothers. European Heart Journal, 28(12), 1403-1404. http://dx.doi.org/10.1093/eurheartj/ehm159
Cao, S., Zhao, W., Bu, H., Zhao, Y., & Yu, C. (2016). Ligustrazine for the Treatment of Unstable Angina: A Meta-Analysis of 16 Randomized Controlled Trials. Retrieved 5 May 2017, from
https://www.hindawi.com/journals/ecam/2016/8617062/
Fhadil, S., Wright, P., & Antoniou, S. (2015). Non-ST elevation acute coronary syndrome: an update. Pharmaceutical Journal. Retrieved 5 May 2017, from http://www.pharmaceutical-journal.com/learning/learning-
article/non-st-elevation-acute-coronary-syndrome-an-update/20069326.article