Acute Coronary Syndrome PDF
Acute Coronary Syndrome PDF
Acute Coronary Syndrome PDF
Acute coronary syndrome refers to a group of diseases in which blood flow to the
heart is decreases. Some examples include ST-elevation myocardial infarction, non-
ST elevation myocardial infarction, and unstable angina. This activity reviews the
evaluation and treatment of patients with acute coronary syndrome, and highlights
the role of the interprofessional team in caring for these patients.
OBJECTIVES:
• Identify risk factors for acute coronary syndrome.
• Identify how a patient with acute coronary syndrome might present, and
describe the evaluation that should be done.
• Describe the treatment of acute coronary syndrome.
• Describe the importance of well-coordinated interprofessional teamwork in
caring for patients with acute coronary syndrome.
DEFINITION:
Acute coronary syndrome (ACS) refers to a group of conditions that include ST-
elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction
(NSTEMI), and unstable angina. It is a type of coronary heart disease (CHD), which
is responsible for one-third of total deaths in people older than 35. Some forms of
CHD can be asymptomatic, but ACS is always symptomatic.
ETIOLOGY
ACS is a manifestation of CHD (coronary heart disease) and usually a result of
plaque disruption in coronary arteries (atherosclerosis). The common risk factors for
the disease are smoking, hypertension, diabetes, hyperlipidemia, male sex, physical
inactivity, family obesity, and poor nutritional practices. Cocaine abuse can also lead
to vasospasm. A family history of early myocardial infarction (55 years of age) is
also a high-risk factor.
PATHOPHYSIOLOGY
The underlying pathophysiology in ACS is decreased blood flow to part of heart
musculature which is usually secondary to plaque rupture and formation of
thrombus. Sometimes ACS can be secondary to vasospasm with or without
underlying atherosclerosis. The result is decreased blood flow to a part of heart
musculature resulting first in ischemia and then infarction of that part of the heart.
HISTORY AND PHYSICAL
The classic symptom of ACS is substernal chest pain, often described as crushing or
pressure-like feeling, radiating to the jaw and/or left arm. This classic presentation
is not seen always, and the presenting complaint can be very vague and subtle with
chief complaints often being difficulty breathing, lightheadedness, isolated jaw or
left arm pain, nausea, epigastric pain, diaphoresis, and weakness. Female gender,
patients with diabetes, and older age are all associated with ACS presenting with
vague symptoms. A high degree of suspicion is warranted in such cases.
In the physical exam, general distress and diaphoresis are often seen. Heart sounds
are frequently normal. At times, gallop and murmur can be heard. Lung exam is
normal, although at times crackles may be heard pointing toward associated
congestive heart failure (CHF). Bilateral leg edema may be present indicating CHF.
The rest of the systems are typically within normal limits unless co-pathologies are
present. The presence of abdominal tenderness to palpation should make the
provider consider other pathologies like pancreatitis and gastritis. The presence of
unequal pulses warrants consideration of aortic dissection. The presence of unilateral
leg swelling should warrant work-up for pulmonary emboli. Hence a thorough
physical exam is very important to rule out other life-threatening differentials.
EVALUATION /DIAGNOSIS
The first step of evaluation is an ECG, which helps differentiate between STEMI
and NSTEMI unstable angina. American Heart Association guidelines maintain that
any patient with complaints suspicious of ACS should get an ECG within 10 minutes
of arrival. Cath lab should be activated as soon as STEMI is confirmed in a
percutaneous coronary intervention (PCI) center. Cardiac enzymes especially
troponin, CK-MB/CK ratio is important in assessing the NSTEMI versus myocardial
ischemia without tissue destruction. A chest x-ray is useful in diagnosing causes
other than MI presenting with chest pain like pneumonia and pneumothorax. The
same applies for blood work like complete blood count (CBC), chemistry, liver
function test, and lipase which can help differentiate intraabdominal pathology
presenting with chest pain. Aortic dissection and pulmonary emboli should be kept
in differential and investigated when the situation warrants.
Acute coronary syndrome requires emergency medical care at a hospital. Tests are
done to check the heart and determine the cause. Some tests may be done while your
health care team asks you questions about your symptoms or medical history.
Other tests may be done to learn more about your condition and rule out other causes
of symptoms. The tests also may help determine treatment.
• Coronary angiogram. This test helps health care providers see
blockages in the heart arteries. A long, thin flexible tube called a catheter
is inserted in a blood vessel, usually in the groin or wrist. It's guided to
the heart. Dye flows through the catheter to arteries in the heart. A series
of X-rays show how the dye moves through the arteries. The catheter also
may be used for treatment.
• Echocardiogram. This test uses sound waves to create pictures of the
beating heart. It shows how blood flows through the heart and heart
valves. An echocardiogram can help determine whether the heart is
pumping correctly.
• Myocardial perfusion imaging. This test shows how well blood flows
through the heart muscle. A tiny, safe amount of radioactive substance is
given by IV. A specialized camera takes pictures of the substance as it
travels through the heart. The test helps find areas of poor blood flow or
damage in the heart.
• Computerized tomography (CT) angiogram. This test looks at the
arteries that supply blood to the heart. It uses a powerful X-ray machine
to create images of the heart and its blood vessels.
• Stress test. A stress test shows how well your heart works when you
exercise. It often involves walking on a treadmill or riding a stationary
bike while the heart is checked. If you can’t exercise, you might be given
medicine. This test is done only when you have no symptoms of acute
coronary syndrome or another life-threatening heart condition when you
are at rest. Other tests may be done during the stress test to see how well
the heart works.
RISK PREDICTION
Risk prediction Adults with NSTEMI or unstable angina should be assessed for
their risk of future adverse cardiovascular events using an established risk scoring
system that predicts six-month mortality (NICE, 2013b). This helps to plan clinical
management and decide on the best place of care (for example, coronary care or a
medical assessment unit). Several tools are available to stratify mortality risk in
ACS, including: l Global Registry of Acute Coronary Events score (GRACE;
Bit.ly/ Gamerscore) (Granger et al, 2003); l Thrombolysis in Myocardial Infarction
(TIMI) score (Antman et al, 2000).
TREATMENT / MANAGEMENT
The initial treatment for all ACS includes aspirin (300 mg) and heparin bolus and
intravenous (IV) heparin infusion if there are no contraindications to the
same. Antiplatelet therapy with ticagrelor or clopidogrel is also recommended. The
choice depends on local cardiologist preference. Ticagrelor is not given to the
patients receiving thrombolysis. Supportive measures like pain control with
morphine/ fentanyl and oxygen in case of hypoxia are provided as required.
Nitroglycerin sublingual or infusion can be used for pain relief as well. In cases of
inferior wall ischemia, nitroglycerine can cause severe hypotension and should be
used with extreme caution, if at all. Continuous cardiac monitoring for arrhythmia
is warranted. Further Treatment of ACS depends on whether it is a STEMI
/NSTEMI or unstable angina. The American Heart Association (AHA)
recommends an emergent catheterization and percutaneous intervention (PCI) for
STEMI with door to procedure start time of fewer than 90 minutes. A thrombolytic
(tenecteplase or other thrombolytic) is recommended if there is no PCI available
and the patient cannot be transferred to the catheterization lab in less than 120
minutes. AHA guideline dictates the door to needle (TNK/other thrombolytics)
time to be less than 30 minutes.
NSTEMI/Unstable Angina-Symptom control is tried along with the initial
treatment with aspirin, and heparin. If the patient continues to have pain, then
urgent catheterization is recommended. If symptoms are controlled effectively,
then a decision can be made for the timing of catheterization and other evaluation
techniques including myocardial perfusion study from case to case basis depending
on comorbidities. ACS always warrants admission and emergent cardiology
evaluation. Computerized tomography angiography might also be utilized for
further workup depending on availability and cardiologist preference.
Beta-blockers, statin, and ACE inhibitors should be initiated in all ACS cases as
quickly as possible unless contraindications exist. Cases not amenable to PCI are
taken for CABG (coronary artery bypass graft) or managed medically depending
upon comorbidities and patient choice.
SURGICAL TREATMENT
• Angioplasty and stenting. This treatment uses a thin, flexible tube and
tiny balloon to open clogged heart arteries. A surgeon inserts the tube in
a blood vessel, usually in the groin or wrist, and guides it to the
narrowed heart artery. A wire with a deflated balloon on the tip goes
through the tube. The balloon is inflated, widening the artery. The
balloon is deflated and removed. A small mesh tube is usually placed in
the artery to help keep it open. The mesh tube also is called a stent.
• Coronary artery bypass surgery. This major surgery involves taking
a healthy blood vessel from the chest or leg area. This piece of healthy
tissue is called a graft. A surgeon attaches the ends of the graft below a
blocked heart artery. This creates a new path for blood to flow to the
heart.
DIFFERENTIAL DIAGNOSIS
• Acute pericarditis
• Anxiety disorders
• Aortic stenosis
• Asthma
• Dilated cardiomyopathy
• Emergent treatment of gastroenteritis
• Esophagitis
• Hypertensive emergencies in emergency medicine
• Myocardial infarction
• Myocarditis
NURSING CARE PRIORITIES
❖ ACUTE HOSPITAL ADMISSION
Keeping clear and comprehensive notes is crucial to ensure all nurses caring for
patients with ACS know the patients’ clinical status, areas of concerns and
management plan. Nurses caring for patients who recently had coronary
angiography should monitor radial or femoral access sites and be able to recognize
complications. Close communication with cardiac catheterization laboratory staff
and the coronary care unit is crucial. Nurses receiving these patients need clear
information about the type of procedure they had, any complications, medications
and IV fluids, and whether they have received anticoagulants or GPIs, which will
put them at greater risk of bleeding (Macdonald et al, 2016). General priorities for
patients with ACS are hemodynamic monitoring and close observation of vital signs.
A review of fluid status can provide information about renal perfusion, as some
patients may present with, or develop, heart failure. In patients with diabetes,
capillary blood glucose levels should be regularly checked; some may be put on IV
insulin if their blood glucose is >11mmol/L. Patients recently diagnosed with
diabetes should be referred to the diabetes specialist nurse. Symptom monitoring is
important to achieve pain relief with GTN or morphine. Swift recognition of any
cardiac changes on the serial ECGs is also a key aspect of nursing care. Patients
considered at high risk should be managed where continuous cardiac monitoring is
available as they are at risk of arrhythmias, which can precede a cardiac arrest.
Patients at intermediate risk may be managed in a medical assessment unit, where
they are likely to receive serial ECGs. Nurses caring for patients with ACS should
have ECG interpretation skills, as ECG changes or arrhythmias are signs of potential
deterioration.
Other elements of nursing care include ongoing management of IV cannulas, central
venous pressure lines, urinary catheters and wounds and dressings. Patients are
likely to be anxious and frightened. Nurses should be calm and reassuring, and
ensure pain and other symptoms are well controlled. They play a central role in
providing psychosocial support; when possible, they should give patients a chance
to speak about their experiences, address their concerns and relay these to the
multidisciplinary team.
❖ DISCHARGE AND SECONDARY PREVENTION IN MI PATIENTS
There are several things to consider when patients with a confirmed MI (either
NSTEMI or STEMI) are ready to be discharged home . Secondary prevention should
be at the heart of nurses’ strategies. Patients need to understand their condition and
be encouraged to make any lifestyle changes needed, which will be crucial to prevent
recurrence. They will be discharged with much information, but the priority is for
them to understand: l They have had an acute MI; l Results of any investigations; l
How their condition will be managed. Patients are likely to go home with several
drugs and many will need to take them for the rest of their lives. These drugs usually
comprise dual antiplatelet therapy, beta-blockers, statins and ACE inhibitors. Some
patients will also need aldosterone antagonists. Nurses must ensure patients: l
Understand the dosages and administration routes; l Know not to discontinue
treatment without medical advice. Where possible relatives should be involved in
discussions, as they can often help with lifestyle changes. Patients should receive
advice on travel and be made aware of the rules about driving after an MI. They
should also be advised to seek urgent medical assessment if any chest pain recurs.
Advice can be reinforced with written information, such as booklets from the British
Heart Foundation (bhf.org.uk), and patients can be signposted to support groups and
websites such as NHS Choices (nhs.uk) as appropriate (Scottish Intercollegiate
Guidelines Network, 2016). Nurses should address patients’ concerns and refer them
to cardiac nurses or dietitians for specialist advice, as well as the primary care team
for ongoing secondary prevention. They should also encourage them to attend a
cardiac rehabilitation programme; this is particularly so for hard-to-reach groups –
older people, women, some ethnic groups, people in rural areas, those of lower
socioeconomic status – in which attendance is lower than average.