1

(Acute Coronary Syndrome)

(Percutaneous Coronary Intervention)

.. 2552

(Acute Coronary Syndrome)
(Percutaneous coronary intervention : PCI)

..

..

(Acute Coronary Syndrome)
(Percutaneous Coronary Intervention)

2552

Acute Coronary Syndrome

(Percutaneous Coronary Intervention : PCI)

-
- (Indications)
- (Contraindications)
-
- PCI
-
-
-
3

1
2
3
4
6
9
10
11
11
11
12
12
14
18
18
19

20

27
34
35
36

1 ACS
2
3
4
5

vulnerable plaque inflammatory process

Chest pain
(Cardiac Catheterization Laboratory)

7
8
9
10
11

coronary artery stent

stent stent coronary artery
Rotablator Rotablator Atherectomy
Intravascular ultrasound

2
4
7
8
11
13
14
15
15
17
17

.. 2535
(Percutaneous Coronary Intervention : PCI)

( :
..2550)
(Acute Coronary Syndrome : ACS)


(Acute Coronary
Syndrome) (Percutaneuos Coronary Intervention ) 4

PCI

1.
2.
3.
4.

(PCI)

1.
2.

1
( Acute Coronary Syndrome )

(Acute Coronary Syndrome ACS )

90
(atheromatous plaque rupture)

3 2,9,10,11,12,29,30
1. Unstable angina ( UA)
(Electrocardiogram - ECG) ST segment elevation ST segment depression T wave inversion
cardiac biomarkers (negative)
2. Non-ST-Elevation myocardial infarction (Non Q-wave MI NSTEMI )
ST segment elevation ST depression T wave inversion cardiac
biomarkers positive
Q wave
3. ST- Elevation MI (STEMI) ST
segment elevation cardiac biomarkers positive

Yes

No

1 ACS ( European Society of Cardiology ACS guidelines 2002)

2,9,10,14,15,16

(Development of atherosclerosis) 3
1 Fatty streak macrophage smooth muscle
cells (intima)
premature infant
2 Fibrous plaque Mature plaque
extracellular lipid core smooth muscle cell, macrophage form cell
fatty streak plaque
fibrous plaque collagen smooth muscle cells
fibrin, fibrinogen, albumin, white blood cell, calcium lipoprotein
3 Ruptured plaque complicated plaque plaque
glycoprotein llb/llla receptor (GP llb/llla) fibrinogen

UA, NSTEMI STEMI

fibrinolysis




(plaque rupture)

thrombus hypercoagulability 9,13,14,15,17
1.
2. plaque vulnerable plaques plaques fibrous cap
foam cell, macrophage subendothelium
plaques
-

- plaques

-

- subendothelium fibrous cap

foam cell

Atherothrombosis: a Generalized and

Progressive Process
Normal

Fibrous
plaque

Fatty
streak

Plaque
AtheroAtherorupture/
sclerotic
fissure &
plaque
thrombosis

Unstable
angina

ACS

MI

Ischemic
stroke/TIA

Clinically silent
Stable angina
Intermittent claudication

Critical
leg
ischemia
Cardiovascular
death

Increasing age
ACS, acute coronary syndrome; TIA, transient ischemic attack

2
( : www.drchander.com/diagnoseCAD.html : 2009)

2
3,6,8,13,14,18,19,20

1.

/


140/90

2.

Cholesterol

( )

LDL-C

( ) ( ) ( ) (
) LDL-C 100 ./.
HDL-C

LDL-C HDL-C HDL-C
HDL-C
HDL-C 45 mg/dl

( Triglycerides)
Cholesterol
Cholesterol
3. 20
(sudden death) (nicoti)

4.

5.

(body mass index / BMI)

2 22.9
90

80
6. HDL
10-30 30 3-4



7.

10

40
4 -20

8. norepinephrine
epinephrine lipid metabolism serum lipid

1. ( .. 2546)
35-44 5 - 6
54

40 55

2.

Acute Coronary Syndrome 9,14,21,22

ACS plaque lipidladen plaque thin cap
subendothelium plaque
plaque
1. Plaque rupture plaque
fibrinogen cross-link platelet
coagulation system thrombin
2. Unstable plaque


3. Microemboli microemboli distal thrombin
cardiac troponin
(non-ST elevated MI)
4. Occlusive thrombus
Q wave MI thrombin

11

3 vulnerable plaque inflammatory process

( : Yeghiazarians et al. N Eng J Med.2003 ; 342:101-114)

( Acute Coronary Syndrome )

1.
2. (Sudden cardiac death)
3. (Acute pulmonary edema)

chest pain chest discomfort

The ACC/AHA guideline 2007 3
typical , atypical noncardiac pain
1. Typical angina 3
(substernal chest pain)
5-10

nitroglycerine
2. Atypical angina (probable) 2 typical angina
3. Non-cardiac chest pain 1 typical angina

12
A

4 Chest pain
A
E
B
F
C
G
D
H

(Angina pectoris) 22 P-Q-R-S-T

P-QRS-T

P : Precipitating

exercise, activity, emotional exertion ,

eating

Q : Quality

R : Radiation
S : Severity

pain scale
(0-10)

sharp, dull, achieving, pressure, tightness

T : Timing

13

10,11,28

Acute myocardial infarction sudden cardiac death
3
1. ( Pharmacologic therapy )
2. (Percutaneous Coronary Intervention (PCI))
3. (Coronary artery bypass graft (CABG))
( Pharmacologic therapy )

3
1. Anti-ischemic drugs
- Nitrates Isosorbride dinitrate,ISDN, Nitroglycerine, Isosorbride 5- Mononitrate
- Beta-blocker Atenolol, Propanolol, Metropolol, Bisoprolol, Carvidiol,
- Calcium-blockers Amlodipine, Felodipine, Nifidipine, Diltiazem, Verapamil
2. Antiplatelets Aspirin Ticlopidine, Clopidogrel
3. Anticoagulants Unfractionated heparin, Low-molecular weight heparin (LMWH) ,
Glycoprotein (GP) IIB/IIIa inhibitors
(Percutaneous Coronary Intervention : PCI)

Percutaneous Transluminal Coronary

Angioplasty (PTCA)
Percutaneous Transluminal Coronary Intervention (PCI)
(Coronary artery bypass graft : CABG)

(Acute Coronary Syndrome )

(Percutaneous
coronary intervention : PCI) 2 3

14

(Coronary Angiography : CAG)

Angioplasty .. 1977
Andreas R. Gruentzig (Cardiac Catheterization
Laboratory)

(
2 )
( "")

4-6

15

5 (Cardiac Catheterization Laboratory)

(Percutaneous Coronary Intervention : PCI)5

(Stent)

PCI
1. recurrent MI
2.
3.

(Indications)
1.
2.
3.
4.
5.
6.
7.
8.
9.

Recurrent angina/ischemia at rest or with low-level activities despite intensive antiischemic therapy
Elevated TnT or TnI
New or presumably new ST-segment depression
Recurrent angina/ischemia with CHF symptoms, an S3 gallop, pulmonary edema, worsening rales,
or new or worsening MR
High-risk findings on noninvasive stress testing
Depressed LV systolic function (EF < 0.40 on noninvasive study)
Hemodynamic instability
Sustained ventricular tachycardia
PCI within 6 months or prior CABG

16

10.
11.
12.
13.

Thallium scan showing evidence of ischemia in more than moderate area of myocardium
Patients undergoing surgery for valvular heart disease.
Post-cardiac transplant surveillance
Post thrombolytic therapy

(Contraindications)
1. Bleeding diathesis anticoagulants
2. Uncontrol hypertension BP > 180/110 mmHg
3. Active infection clinical SIRS29 (Systemic Inflammatory Response Syndrome)
- Tempurature > 38 < 35
- Heart rate > 90 BPM
- Respiratory rate > 20 / PaO2 < 32 mmHg
- WBC > 12,000 cells/mm3 < 4,000 cells/mm3 > 10 percent immature (band) forms
4. Refractory arrhythmia Ventricular fibrillation ,Ventricular tachycardia
5. Active GI bleeding
6. Cerebrovascular accident 2-3
7.
8. Renal failure creatinine clearance 30 ml/min
9. Severe electrolyte imbalance ( Hyperkalemia : K+ > 5.5 mmol/L) digitalis intoxicity
(digitalis level > 1 ng/ml)30
10. Severe heart failure Class III-IV ()
11. Severe anemia

1. Femoral artery
2. Radial artery

1. (Femoral artery)

10-15

2 4-6

17

8-12

2. (Radial artery)


(radial artery)

6-8

80%-90%

18

PCI 5
1.

(Guiding catheter)
(Diagnostic catheter)

2. Stent
(stent)

10-15 () 4-6

19

8 coronary artery stent

( : www.desertendovascular.com/procedures/arteria. : 2009)

Stent nitinol,stainless steel cobalt

chromium artery
stent

stent
stent 2-4
8-38 stent
50

9 stent stent coronary artery

( : www.britannica.com/EBchecked/topic-art/171942./ www.csmc.edu/2344.html :2009)

20

stent 2
1. Bare-Metal Stents (BMS)
2. Drug-eluting Stents (DES)
Bare-Metal Stents stents ..1977
elastic recoil instent restenosis
stents Drug-eluting Stents (DES)
Drug-eluting Stents Coated Medicated Stent
polymer stent injury
Cytotoxin drug Actinomycin D, Paclitaxel Cytostatic
drug Dexamethasone , Sirolimus (Rapamycin) (proliferative)
smooth muscle cell extracellular matrix instent restenosis

1. Sirolimus drug-eluting stents CYPHER stents

Sirolimus (Rapamycin)
reject
DNA 30
stents
2. Paclitaxel - eluting stents (PES) TAXUS Paclitaxel antiproliferative compounds
3. Zotarolimus- eluting stents ENDEAVER Zotarolimus
Sirolimus
(Drug Eluting Stent)


30-40 10-15

3. Rotational Atherectomy (Rotablator)

Rotablator
10

10
140,000 200,000

21

micro embolization no reflow infarction flow

( TIMI grade 2 flow ) regional wall hypokinesia
Rotablator

10 Rotablator Rotablator Atherectomy

( : www.angiocardio.com/rota.htm. / www.nyheart.net/procedures_Rotablator.html :2009)

4. Intravascular Ultrasound (IVUS)

IVUS
Invasive / PCI

11 Intravascular ultrasound
( : www.galaxyprogramme.org/atherosclerosis-studies/ :2009)

22

(1-2)

(Restenosis)
""

30-40
6
10-15 6 PCI
Clopidogrel , Aspirin stent
thrombosis








5 10,000 2 100
5 1,000

1 1,000

23

0.5- 3

1. Cardiac arrhythmias Ventricular fibrillation, Prolonged ventricular tachycardia

Defibrillation, Cardioversion Bradyarrhythmias Pacemaker
2. 24
2.1 24 (Early complications)
- Groin bleeding
- Retroperitoneal bleeding
- Hematoma
- Femoral neuropathy
- Vasovagal reaction
2.2 24 (Late complications) 1-30 PCI
- Femoral pseudoaneurysm
- Arteriovenous fistula
- Femoral artery thrombosis
- Embolism
- Femoral vein thrombosis
3. Infection
4. sudden death 0.1 - 0.45
5. (Cerebrovascular events ) stroke 0.03 - 0.25
6.

24

(PCI)

2 1
2

1




/ /

Before the procedure (Cath Lab) ()

1. 6
2.
3.
4. (warfarin) 3
5. X-ray Anti HIV , Hepatitis

6. Glucophage

7. Aspirin

8. 2
9.

25

10.

Day of the procedure (Cath Lab) ()

1.
2.
3.
4.

5.

During procedure (Cath Lab) ()

1.
4%chlohexidine
2.

3. dorsalis pedis pulse posterial tibial

pulse radial pulse

4.

5. (Level of consciousness)
6.

7.

8.

9.

10.
hypotension Cardiac tamponade

26

11.

After the procedure (Intermediate Cardiac Care Unit : ICCU) ()

Intermediate Cardiac Care Unit (ICCU)
ST Segment

1. 15
95
2.
3.
4. Dorsalis pedis , Posterial
tibial Radial capillary refill
capillary refill 2
5. bleeding, hematoma
echymosis
6. 6
30
7.
8. discharge 8

9.
Aspirin, Clopidogrel
10. stent
PCI Anti-platelet 2 Aspirin Clopidogrel
Aspirin stent BMS Clopidogrel 1
DES Clopidogrel 1
stents

11.

27

2
(ER)
(Acute Coronary Syndrome) hemodynamic instability
(cardiac arrest)
(serious arrhythmias)
ER Cath Lab CCU /


Primary PCI door to
balloon time 90 30



Before the procedure (ER) ()
1. ACS
2. (ECG 12 leads) 10

3.
ACS
4.

5. ( Cath Lab)
( STEMI - large anterior wall MI cardiogenic shock,
heart failure)
6.
4% chlohexidine
7. Electrolyte, BUN, Creatinine, CBC, Anti HIV, Hepatitis
8.
9. On EKG monitoring ( arrhythmias)
10.
11. MONA4
- M = : Morphine 2-3 mg IV dilute 10 ml
- O = 2 - 4 / keep Sat O2 92%

28

- N = NTG NTG IV drip

- A = Aspirin (160 - 325 mg) , Clopidogrel (75 mg) sig 4 tabs oral stat
- IV fluid cardiac marker Lab
electrolytes , BUN , Cr , coagulogram , CBC , AntiHIV
12. (Cath Lab)
13. /

During procedure ( Cath Lab) ()

1.
resuscitation , monitor , defibrillation
2.

3.
4. dorsalis pedis pulse posterial tibial
pulse radial pulse

5. ECG Monitoring lead II arrhythmias Ventricular tachycardia

PVC
6. hemodynamic status
7.
8.
hypotension cardiac tamponade
9.

After the procedure ( )

I : (Cardiac Care Unit : CCU)
1. Cardiac
Care Unit (CCU) ECG Monitoring

(AHA/ACC : 2002 )
5 3 Ventricular fibrillation Ventricular tachycardia
2. 15
1-4
3. heart failure , stent restenosis , renal failure ,

29

vascular complications
4. cardiac marker
5.

-
(Intra aortic balloon pump)
- () (
)
6.
-
-
6-12
- 3-4 keep O2 saturation 92% 6
-
-
7.
8. Dorsalis
pedis , Posterial tibial Radial capillary refill

9. bleeding, hematoma
echymosis
10. 6
30
11.
- CBC APTT ACT sheath APTT 50 sec
ACT 175 sec
- heparin 4
-
1) Set dressing
2) Syringe 10 cc. 1 , 1 21, 25 1
3) Transparent dressing
4) 1
5)
6) 5

30

- 30
- transparent dressing
- 5 2
- 6
-
12. CCU (ICCU)

II : Intermediate Cardiac Care Unit : ICCU /

1.
2. discharge 8

3.
ASA , Clopidogrel
4.

31

49
165 75

4
25 2551 22.30 .
29 2551 11.00 .

3 epigastrium
30

2 ( 20.00 )
30 (ER 22.00 )

-

T= 36.3 c , P = 62 BPM, RR = 26 BPM, BP = 110/70 mmHg ST
segment elevate in lead II,III, AVF , depress in lead I , AVL,V1-V2

1 / 20

1 3

ST elevation MI (Inferior wall MI)

32

Cardiac enzyme
CK-MB : 186 ng/ml ( 0-5 ) , Troponin T 4.19 ng/ml ( 0-0.1)
CBC
Hct 45.7% (37-52) , Hb 15.1 g/Dl (12-18)
WBC count 15.2 x 103 cells/cu.mm. (4-11)
Platelet count 294 x 103 cells/cu.mm. (150-440)
Chemistry
BUN 13 mg/dL ( 7-20) , Cr 0.9 mg/dL ( 0.5-1.5)
Sodium 138 mmol/L (135-145) , Potassium 3.9 mmol/L (3.5-5.0)
Cholride 105 mmol/L (98-107) , Bicarbonate 24 mmol/L (22-29)
FBS 129 mg/ d L( 76-110) , Cholesteral 230 mg/d L (100-200)
Triglyceride 414 mg/d L (50-200)

1. ASA 160 - 325 mg , Plavix (75 mg) sig 4 tab oral stat
2. Primary PCI
CAG Right dominant
RCA (mid) diffuse 100% total occlusion lesion
RCA (ostial) discrete 30% lesion
PTCA c Stent (mid RCA)
C.C.U.
on O2 canula 3 L/MIN ,
artery sheath , dorsalis pedis pulse , capillary refill
T:36.5 c, P: 74 /min R : 22 /min, BP : 110/80 mmHg O2 sat 98%
ST segment elevate in lead II,III, AVF

ASA gr V sig 1 tab oral OD

Plavix (75 mg) sig 1 tab oral OD
Lipitor (20mg) sig 1 tab oral OD
Propanolol ( 10 ) 1 tab oral 8 hr.
4 ACT (Activate clotting time) 124 off sheath
hematoma, echymosis , bleeding

33

( chest pain ) T : 36.3 37.8 c, P : 70-80 /min

R : 20 - 24 /min, BP : 100-110/60-80 mmHg

1
PCI

1.
2.
3.

1. PCI
2.
3. Log roll 2
4.
5.
6. PCI

7.
8.

Anticoagulant PCI

1. PCI
2.

1. PCI

34

2. Hematoma , echymosis PCI

3.
4. 20 / baseline
5. 16 20 /
6. Hct Coagulogram

1. EKG monitoring , O sat monitoring 15 1 30

2 1
2. PCI
PCI bleeding hematoma ,echymosis 1020 Hct 4-6
30 PCI
sheath 6
Pressure dressing PCI
PCI
3.
3.1 Content NG tube coffee ground NG tube
coffee ground
3.2 melena
4.
4.1 Glasgow coma scale pupil

4.2
4.3
5. hematuria
6. Retroperitoneal bleeding
hematocrit drop
7.
8. CBC , Coagulogram , ACT
9. hematoma retroperitoneal bleeding

10.
hematocrit < 30%

35

3

PCI

1.
2.

1. pulse
2. warm cyanosis
3.
4.

1.
1.1. 4 extremetries sheath

1.2. cyanosis keep warm

pulse doppler

1.3. Angle Brachial Index (ABI) PCI

2.
Glasgow coma scale, pupil

3.


BP HR RR
lower extremity deep venous thrombosis (DVT)
D-dimer

36

O2
stent restenosis

1.
2.

1.



2.
3.

4.
( O2 saturation ) keep O2 saturation > 92 %
5.
6. 12 leads

7. cardiac marker
8.

9.

1.

37

2.
3.

1.

2.
3.

4.
5.


6.

7.

8. valium

1. /

2.
3.

1.
2.
3.
4.
5.
6.

1.

38

2.

3.


4.
-
-
-
-
-
-
-
-
5.

6.

39

Functional Class New York Heart Association ( .. 1987)

4 class
Class I
Class II
Class III
Class IV

MET > 4.5

MET = 3 - 4.5

MET = 1.5 - 3

MET = 1.0-1.5

1 MET ( Metabolic Equivalent )

3.3-3.5 ./ ./

40

1.

.. 2550
2. 2536. .
, . 2546
3.
.
. .
. 2536
4. . Practice Points in Critical Care :Acute Coronary Syndrome 31-32
5. . Coronary Artery Stents.
6. Martinez LG, House-Fancher MA. Chapter 32. Nursing management coronary artery disease. On:
Lewis SM, Heitkemper MM, Dirksen SR, editors. Medical-surgical nursing: Assessment and
management clinical problems. 5th ed.St. Louis :Mosby;2000.p.841-86
7. Burrell LO. Chapter 22. Nursing management of adult with coronary heart disease. In: Burrell LO,
editor. Adult nursing in hospital and community setting. Norwalk, Connecticut: Appleton&Lange;
1992. p. 419-35
8. Jacobson MS, Kohn MR, Neinstein LS. Chapter 12. Cardiac risk factors and hyperlipidemia. In:
Neinstein LS,editor. Adolescent health care: A practice guide.4th ed. Philadelphia: Lippincott
William & Wilkins: A Wolter Kluwer;2002. p. 273-303
9. Barkley TW. Chapter 10. Coronary artery disease. In: Barkley TW.,Myers CM, editors. Practice
guideline for acute care nurse practitioners. Philadelphia: W.B. Saunders; 2001.p. 102-17
10. Braunwald et al. ACC/AHA Practice Guideline : Unstable angina and Non ST Elevation Myocardial
Infarction. 2002. p. 4-7
11. Cummins, R.O. et al. The Acute Coronary Syndrome, Part 1: Guidelines for Management of Patients
With Possible or Probable Acute Myocardial Infarction. In ACLS :Principles and Practice. American
Heart Association. 2003.p.377-428
12. Cummins, R.O. et al. Guideline 2000. for Cardiopulmonary resuscitation and Emergency
Cardiovascular Care. International Consensus on Science. American Heart Association. 2000
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Clinics of North America. 35 (12).2000
14. Bucher L Acute Myocardial Infarction. In Bucher L& Melander S. Critical Care Nursing. W.B.
Saunders. 1999.p.227-56
15. Covan MJ. Pathogenesis of atherosclerosis. In Underhill SL. Et al. ( editor) Cardiac nursing. 3rd
edition. Philadelphia : Lippincott company.1995.p.184-92

41

16. Fole , E. Why do plaque rupture ? Circulation.86.1992 p 30- 42.

17. Jennifer R. and Reimer K. Pathology of acute myocardial ischemia. Hospital practice. 15(1).1989.
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18. Antman,E.M & Braunwald,E. Acute myocardial infarction. In Braunwald,E.(Ed.). Heart disease: A
text book of Cardiovascular Medicine.( 5th edition) .Philadelphia : W.B. Aaunders. 1990.p.11841288
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Saunders. 1999.p. 201-18
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1996
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Cardiac Nursing. 3rd edition. Piladelphia : Lippincott company ;1995.p.483-505
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Revascularization. In Roubin, G.S. (Ed.) : Interventional Cardiovascular Medicine Principle &
Practice.(2nd ed.), New York : Churchill Livingstone;1994
25. Adapted from Intervention Cardiovascular Medicine Principle & Practice , by Agrawal S.K.. &
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42

31. ACC/AHA 2002 Guideline Update for the Management of Patients With Unstable Angina and NonST-segment Elevation Myocardial Infarction. A Report of the American College of Cardiology /
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