ACTIVITY 5: ACUTE CORONARY SYNDROME

INTRODUCTION
An acute coronary syndrome (ACS) is a constellation of symptoms and signs that result
from obstruction of the coronary arteries. Common signs and symptoms include chest pain,
dyspnea, and electrocardiographic abnormalities. The most common cause of acute coronary
syndrome is blockage of the coronary artery from cholesterol rich plaque and thrombus. In acute
coronary syndrome, a previously quiescent plaque has ruptured, exposing the lipid core, inciting
platelet activation and aggregation with subsequent thrombus formation. When the
atherothrombotic material is totally occlusive with complete cessation of blood flow through the
artery, the acute coronary syndrome is termed ST-Elevation myocardial infarction (STEMI). If
the occlusion is partially obstructive and there is no evidence of myocardial injury (e.g., elevated
cardiac troponin), the ACS is termed unstable angina, but if cardiac injury is detected with a
partial obstruction, then the term to describe the ACS is non-ST segment myocardial infarction
(NSTEMI). ACS unrelated to plaque rupture can infrequently be seen from coronary vasospasm,
embolization, or spontaneous coronary dissection.

1. CAUSES AND RISK FACTORS

Acute coronary syndrome usually results from the buildup of fatty deposits (plaques) in
and on the walls of coronary arteries, the blood vessels delivering oxygen and nutrients to heart
muscles. When a plaque deposit ruptures or splits, a blood clot forms. This clot blocks the flow
of blood to heart muscles. When the supply of oxygen to cells is too low, cells of the heart
muscles can die. The death of cells resulting in damage to muscle tissues is a heart attack
(myocardial infarction). Even when there is no cell death, the decrease in oxygen still results in
heart muscles that don't work the way they should. This change may be temporary or permanent.
When acute coronary syndrome doesn't result in cell death, it is called unstable angina.
The risk factors for acute coronary syndrome are the same as those for other types of
heart disease. Acute coronary syndrome risk factors include: Aging, High blood pressure, High
blood cholesterol, Cigarette smoking, Lack of physical activity, Unhealthy diet, Obesity or
overweight, Diabetes, Family history of chest pain, heart disease or stroke, History of high blood
pressure, preeclampsia or diabetes during pregnancy and COVID-19 infection.
 2. PATHOPHYSIOLOGY (DIAGRAM FORM)

Plaque disruption or erosion

Thrombus formation with or without embolization

Acute cardiac ischaemia

No ST segment elevation ST segment elevation

Elevated markers of Elevated markers of

Markers of
myocardial necrosis myocardial necrosis
myocardial
necrosis not
elevated

ST segment elevation MI

Non - ST segement ( Q waves usually present )

Unstable angina
elevation MI (Q waves
usually absent)

Acute coronary syndrome

3. DIAGNOSIS

If you have signs or symptoms associated with acute coronary syndrome, an emergency room
doctor will likely order several tests. Some tests may be done while your doctor is asking you
questions about your symptoms or medical history. Tests include:
Electrocardiogram (ECG). Electrodes attached to your skin measure the electrical
activity in your heart. Abnormal or irregular impulses can mean your heart is not working
properly due to a lack of oxygen. Certain patterns in electrical signals may show the general
location of a blockage. The test may be repeated several times.
Blood tests. Certain enzymes may be detected in the blood if cell death has resulted in
damage to heart tissue. A positive result indicates a heart attack.
Other tests may be done to learn more about your condition, rule out other causes of symptoms,
or to help your doctor personalize your diagnosis and treatment.
Coronary angiogram. This procedure uses X-ray imaging to see your heart's blood
vessels. A long, tiny tube (catheter) is threaded through an artery, usually in your arm or groin, to
the arteries in your heart. A dye flows through the tube into your arteries. A series of X-rays
show how the dye moves through your arteries, revealing any blockages or narrowing. The
catheter may also be used for treatments.
Echocardiogram. An echocardiogram uses sound waves, directed at your heart from a
wand-like device, to produce a live image of your heart. An echocardiogram can help determine
whether the heart is pumping correctly.
Myocardial perfusion imaging. This test shows how well blood flows through your
heart muscle. A tiny, safe amount of radioactive substance is injected into your blood. A
specialized camera takes images of the substance's path through your heart. They show your
doctor whether enough blood is flowing through heart muscles and where blood flow is reduced.
Computerized tomography (CT) angiogram. A CT angiogram uses a specialized X-ray
technology that can produce multiple images — cross-sectional 2-D slices — of your heart.
These images can detect narrowed or blocked coronary arteries.
Stress test. A stress test reveals how well your heart works when you exercise. In some
cases, you may receive a medication to increase your heart rate rather than exercising. This test is
done only when there are no signs of acute coronary syndrome or another life-threatening heart
condition when you are at rest. During the stress test, an ECG, echocardiogram, or myocardial
perfusion imaging may be used to see how well your heart works.
4. MEDICAL MANAGEMENT

The immediate goals of treatment for acute coronary syndrome are as follows:

- Relieve pain and distress

- Improve blood flow
- Restore heart function as quickly and as best as possible.

Long term treatment goals are to improve overall heart function, manage risk factors and
lower risk of heart attack. A combination of drug and surgical procedures amy be used to meet
these goals.
Depending on the diagnosis, medications for emergency or ongoing (or both) care may
include the following:
Thrombolytics (clot busters) help dissolve a blood clot that’s blocking the artery.

Nitroglycerin improves blood flow by temporarily widening blood vessels.

Antiplatelet drug help prevent blood clots from forming and include aspirin, clopidogrel
(Plavix), prasugrel (Effient) and others.
Beta blockers help relax your heart muscle and slow heart rate.

Angiotensin-converting enzyme (ACE) inhibitors widen blood vessels and improve blood
flow, allowing the heart to work better.
Angiotensin receptor blockers (ARBs) help control blood pressure and include irbesartan
(Avapro), losartan (Cozaar) and others.
Statins lower the amount of cholesterol moving in the blood and may atabilize plaque
deposits, making them less likely to rupture.
Surgeries includes: angioplasty and stenting, coronary bypass surgery.
5. NURSING INTERVENTION

Relieving Pain and Other Signs and Symptoms of Ischemia

 Administer oxygen in tandem with medication therapy to assist with relief of symptoms
(inhalation of oxygen reduces pain associated with low levels of circulating oxygen).
 Assess vital signs frequently as long as patient is experiencing pain.
 Assist patient to rest with back elevated or in cardiac chair to decrease chest discomfort
and dyspnea. Improving Respiratory Function
 Assess respiratory function to detect early signs of complications.
 Monitor fluid volume status to prevent overloading the heart and lungs.
 Encourage patient to breathe deeply and change position often to prevent pooling of fluid
in lung bases.

Promoting Adequate Tissue Perfusion

 Keep patient on bed or chair rest to reduce myocardial oxygen consumption.

 Check skin temperature and peripheral pulses frequently to determine adequate tissue
perfusion.

Reducing Anxiety

 Develop a trusting and caring relationship with patient; provide information to the patient
and family in an honest and supportive manner.
 Ensure a quiet environment, prevent interruptions that disturb sleep, use a caring and
appropriate touch, teach relaxation techniques, use humor, and provide spiritual support
consistent with the patient’s beliefs. Music therapy and pet therapy may also be helpful.
 Provide frequent and private opportunities to share concerns and fears.
 Provide an atmosphere of acceptance to help patient know that his or her feelings are
realistic and normal.

Monitoring and Managing Complications

 Monitor closely for cardinal signs and symptoms that signal onset of complications.
Promoting

Home- and Community-Based Care

Teaching patients self-care

 Identify the patient’s priorities, provide adequate education about heart-healthy living,
and facilitate the patient’s involvement in a cardiac rehabilitation program.
  Work with the patient to develop a plan to meet specific needs to enhance compliance.

Continuing care

 Provide home care referral if warranted.

 Assist the patient with scheduling and keeping follow-up appointments and with adhering
to the prescribed cardiac rehabilitation regimen.
 Provide reminders about follow-up monitoring, including periodic laboratory testing and
ECGs, as well as general health screening.
 Monitor the patient’s adherence to dietary restrictions and to prescribed medications.
 If the patient is receiving home oxygen, ensure that the patient is using the oxygen as
prescribed and that appropriate home safety measures are maintained.
 If the patient has evidence of heart failure secondary to an MI, appropriate home care
guidelines for the patient with heart failure are followed.
6. COMPLICATIONS

The complications of acute coronary syndromes depend on how much of the heart muscle is
damaged, which is a direct result of where a coronary artery was blocked and how long this
artery was blocked. If the blockage affects a large amount of heart muscle, the heart will not
pump effectively. If the blockage shuts off blood flow to the electrical system of the heart, the
heart rhythm may be affected. Complications are as follows:

 Pumping problems.
 Rhythm problems
 Pericarditis
 Myocardial rupture
 Ventricular aneurysm
 Blood clots