Acute coronary syndrome general overview

1. UNIVERSITY OF GONDAR
COLLEGE OF MEDICINE AND HEALTH SCIENCES
SCHOOL OF NURSING
DEPARTMENT OF EMERGENCY AND CRITICAL CARE
NURSING
Medical Emergency Seminar Presntation
Title: Acute Coronary Syndrome
Presenter:
April/2021

2. Presentation Outline
 Definition
 Types of ACS
 Epidemiology of ACS
 Risk factors
 Causes of ACS
 Pathophysiology
 Clinical manifestations
 Dx/investigations
 DDx
 Management
 Complications
8/9/2021
By: 1st Yr MSc EMCCN students 2

3. Objectives
After this presentation you will be able
to:
 List the causes/risk factors of ACS
 Describe the pathophysiology of ACS
 Discuss the clinical features of ACS
 Explain management modalities of ACS
 Describe the approach to a patient with ACS
 Manage a patient with ACS
 Dispose a patient with ACS
8/9/2021 By: 1st Yr MSc EMCCN students 3

4. Definition
 Ischemic heart disease/CAD is an imbalance in
myocardial oxygen demand and supply resulting
from insufficient blood flow almost always
caused by coronary atherosclerotic disease.
 IHD/CAD fall in to two subtypes:-
 1-Chronic coronary artery disease/stable
angina
Predictable and consistent pain on exertion(2-
5minutes).
2-ACS-Aute myocardial infarction/Unstable angina
Coronary vessel atherosclerotic obstruction with
acute superimposed thrombotic occlusion.
8/9/2021 By: 1st Yr MSc EMCCN students 4

5. Types of ACS
Unstable Angina-Symptoms of myocardial
ischemia but no elevation in cardiac enzymes,
with or without ECG changes indicative of
ischemia.
 It is considered to be present in the following
circumstances:
 Rest angina >20 minutes in duration
 New onset angina & no response to nitrates
 Increasing angina- more frequent or longer in
duration, severe or occurs with less exertion
than previous angina.
8/9/2021 By: 1st Yr MSc EMCCN students 5

6. Type Cont…
Acute Myocardial Infarction (STEMI and NSTEMI)
 The term ACS is clinically used because the initial
presentation, Pathophysiology and early
management of unstable angina, STEMI, and
NSTEMI are frequently similar.
 MI is necrosis of myocardium as a result of an
interruption of blood supply to the coronary artery.
 Myocardial cell death resulting from hypoxia.
WHO criteria for MI are:
 Clinical history (>20 minutes of chest discomfort
or equivalent symptoms consistent with
ischemia),
 EKG changes, and/or
 Elevated myocardial serum markers.
8/9/2021 By: 1st Yr MSc EMCCN students 6

7. Type Cont…
 NSTEMI: No ST elevation on ECG (other ECG
evidence of ischemia may be present), elevated
cardiac enzymes and symptoms of myocardial
ischemia.
 Results from ischemia that extends only to the
subendocardium.
 The distinction between Unstable angina and
NSTEMI is based entirely on cardiac enzymes.
The latter has elevation of troponin or creatine
kinase-MB (CK-MB). Both lack ST-segment
elevations.
8/9/2021 By: 1st Yr MSc EMCCN students 7

8. Type Cont…
STEMI: Significant ST elevation or new left
bundle branch block (LBBB) on ECG, elevated
cardiac enzymes (Troponin and/or CKMB) and
symptoms of myocardial ischemia(Transmural).
The sudden rupture of a plaque and the
subsequent thrombosis are responsible for ACS.
Transmural: shifted in the direction of the outer
(epicardial) layers.
 ST elevation >2 mm contiguous chest leads V1–
V6.
 ST elevation >1 mm contiguous limb leads I,
aVL, II, III, aVF, aVR.
 New LBBB.
8/9/2021 By: 1st Yr MSc EMCCN students 8

9. 8/9/2021 By: 1st Yr MSc EMCCN students 9

10. Type Cont…
8/9/2021 By: 1st Yr MSc EMCCN students 10

11. Type Cont…
8/9/2021 By: 1st Yr MSc EMCCN students 11

12. Type Cont…
8/9/2021 By: 1st Yr MSc EMCCN students 12

13. Epidemiology
 Globally, ischemic heart disease remains the
number one cause of mortality
 Race ( higher in African American )
 Sex- male >women
 IHD causes more deaths and disability and
incurs greater economic costs than any other
illness in the developed world.
8/9/2021 By: 1st Yr MSc EMCCN students 13

14. Risk factors for ACS
 Modifiable risk factor
 Saturated fat diet/dyslipidemia- LDL>100,
HDL<40)
 Physical inactivity
 Tobacco and alcohol
 Over weight or obese
 Co-existing diseases- DM, HTN
 Non modifiable risk factors
 Family history
 Age over 65 years
 Sex-men higher risk
 Preexisting disease/ past history of chronic
8/9/2021 By: 1st Yr MSc EMCCN students 14

15. Causes of ACS
 The major cause of MI is coronary artery
occlusion by thrombosis or atheroma.
 Inflammation of the coronary arteries (rare)
 A stab wound to the heart
 A blood clot forming elsewhere in the body
 Complications from heart surgery
 Coronary artery Spasm( variant angina)
 congenital abnormalities (rare)
8/9/2021 By: 1st Yr MSc EMCCN students 15

16. Causes Cont…
 Decreased myocardial oxygen supply
a) Coronary artery occlusion- resulting from
atherosclerosis of coronary arteries, coronary
artery spasm, dissection, arteritis, and embolism.
b) Decreased coronary artery perfusion
pressure- as a result of hypotension, shock, or
aortic regurgitation.
 Increased myocardial oxygen demand can be
due to many causes- hypertension, hypertrophy,
aortic stenosis, tachycardia/tachyarrhythmia,
infection, surgery, thyrotoxicosis and emotional
or physical stress.
8/9/2021 By: 1st Yr MSc EMCCN students 16

17. Pathophysiology
Atherosclerotic
plaque
in
the
coronary
artery
Atherosclerotic
plaque
rupture/disrupted/become
unstable
Coagulation
cascade
activated/platelet
aggregation
Superimposed
thrombus
formation
Thrombus
acutely
occludes
the
artery
STEMI/ACS
8/9/2021 By: 1st Yr MSc EMCCN students
17

18. Patho Cont…
8/9/2021 By: 1st Yr MSc EMCCN students 18

19. Signs and symptoms of ACS
Symptoms
 Angina- pain of cardiac origin/chest pain due to
ischemia/imbalance between oxygen demand
and supply.
 Pain character and radiation -can be
described as pressure, squeezing, or fullness.
Burning and pleuritic pain may also be
consistent with ACS and may radiate to the
shoulder, arm, neck, jaw, abdomen.

20. Signs/symptoms Cont…
8/9/2021 By: 1st Yr MSc EMCCN students 20

21. Signs/symptoms Cont…
• Palpitation
•Anxiety and fear of impending death.
• fatigue
• nausea and vomiting
• shortness of breath
• cool extremities
-Vague symptoms in elderly, Pregnant or diabetic
patients (e.g., dizziness, syncope, confusion,
symptoms of peripheral emboli, or unexplained
hypotension) may represent silent ischemia.
8/9/2021 By: 1st Yr MSc EMCCN students 21

22. Signs/Symptoms Cont…
Signs
 Jugular venous distension
Cool, clammy skin and diaphoresis
Third heart sound(S3)
Apical Systolic Murmur (MR)
Rales-LVD/MR
hypotension or hypertension
• palpable precordial pulse
• muffled heart sounds.
8/9/2021 By: 1st Yr MSc EMCCN students 22

23. Diagnosis/investigation of ACS
History
History is the most sensitive tool for the detection
of ACS, and is a more powerful predictor for
cardiac ischemia than a normal or non-diagnostic
ECG.
A significant number of patients present with
atypical pain or no pain.
-ask about risk factors
Physical examination
 GA- Anxious and in considerable distress
 HR: Bradycardia to a rapid regular or irregular
tachycardia depending on degree of LV failure.
8/9/2021 By: 1st Yr MSc EMCCN students 23

24. Dx/Ix Cont…
 Fever: nonspecific response to tissue necrosis
 Tachypnea: -heart failure/results from anxiety
and pain
 Blood Pressure:↓ BP
 ≥50% of patients with inferior STEMI have
evidence of excess parasympathetic
stimulation, with hypotension, bradycardia
 LV dysfunction, hypovolemia
◦ ↑BP
 50% anterior STEMI show signs of
sympathetic excess and have HTN,
tachycardia, or both.
 Murmur(MR) 8/9/2021 By: 1st Yr MSc EMCCN students 24

25. Dx/Ix Cont…
ECG- Should be obtained immediately to identify STEMI.
Other ECG findings indicative of ischemia include ST
depression, T wave inversion.
Cardiac Biomarkers- When myocardial tissue is
damaged, enzymes leak into the vascular space and are
measured in the serum.
-Troponin (Tn)-cardiac specific gold standard elevated
with in 4-6 hours of injury and remain for 3-10 days.
-Differentiation is generally based on 3 sets of biomarkers
measured at 6-8 hours interval after patients presentation
to the ED. Continue measuring markers until peak is
reached or 3 sets of result are negative.
LDH: onset (24hrs) peak (48-72 hrs) return to normal (7-
10days)
Myoglobin- non-specific
8/9/2021 By: 1st Yr MSc EMCCN students 25

26. Dx/Ix Cont…
 Creatine kinase (CK) - is found in skeletal and
cardiac muscle. The CK-MB portion is a subunit of
CK and is more specific for myocardial tissue.
CKMB begins to increase 4–6 hours after infarction,
but is return to normal within 24–36 hours.
 lipid profile.
 Exercise Stress Testing- at least after 24HRs of
stabilization
Echocardiography- ventricular wall motion and LBBB
CXR- For cardiomegaly & pulmonary edema
A widened mediastinum (> 8 cm) causes concern for
an aortic dissection.
CT angiography-may be indicated in patients who are
suspected of having a PE or aortic dissection.
8/9/2021 By: 1st Yr MSc EMCCN students 26

27. DDx
 Pulmonary embolism causes sharp, pleuritic, or
dull chest pain with dyspnea and diaphoresis.
 Aortic dissection- ripping or tearing sensation
radiating to the interscapular area of the back.
 Tension pneumothorax. Patients usually present
with dyspnea accompanied by the signs or
symptoms of shock .
 Acute esophageal perforation/rupture- can
cause sharp pleuritic, poorly localized, constant,
and severe midline pain anywhere from the base of
the neck to the epigastrium associated with
systemic signs of infection and bleeding.
 Pneumonia is suggested by cough and fever with
or without pleuritic chest pain
8/9/2021 By: 1st Yr MSc EMCCN students 27

28. Management of ACS
Initial Approach/General management
1. Ensure adequate ABCs.
2. Vital signs monitoring
3. Supplemental O2- only when respiratory
distress/symptoms of hypoxemia present.
4. Cardiac monitoring & pulse oximetry.
8/9/2021 By: 1st Yr MSc EMCCN students 28

29. MGT Cont…
Goals of Management
 Increase blood flow(oxygen delivery to the
heart)
 Decrease oxygen consumption by the
heart
 Reduce chest pain
 Prevent further damage & future attack
8/9/2021 By: 1st Yr MSc EMCCN students 29

30. MGT Cont…
Pharmacological therapy
Unstable angina/NSTEMI—
Nitrates- sublingual NTG Q5 min, up to 3 minutes,
Iv NTG for persistent ischemia, HF or HTN.
Analgesics- morphine
β-blockers- metoprolol
Calcium channel blockers- nifedipine/amlodipine
when BB are C/I.
ACE inhibitors-Enalapril
Antiplatelet therapy- aspirin
ADP receptor inhibitors-clopidogrel
Anticoagulation- heparin, LMWH
Cholesterol Management- Statins(atorvastatin)
8/9/2021 By: 1st Yr MSc EMCCN students 30

31. MGT Cont…
STEMI—In addition to above therapy:-
Reperfusion therapy
 PCI-The artery is dilated using a PTCA balloon
catheter and stent placement.
 Fibrinolysis/thrombolysis-Streptokinase, tissue
plasminogen activator (tPA).
Revascularization Therapy
 Coronary artery bypass grafting(CABG)
native vessels (conduits) are harvested and
grafted into place to reroute blood flow past
diseased areas of the coronary arteries.
8/9/2021 By: 1st Yr MSc EMCCN students 31

32. Complications
 Arrythmia- the most common due to ischemia
 Congestive heart failure
 Pulmonary edema
 Cardiogenic shock.
 Pericarditis
8/9/2021 By: 1st Yr MSc EMCCN students 32

33. Disposition & Nursing Management
 Admission to Intensive Care Units (ICU)
 Oxygen support
 IV drug administration
 Monitor vital signs
 Monitor cardiac function
 Neurologic checks
 Determine cause and treat
 Diet and bowel: Decrease saturated fat & salt
diet.
◦ Small frequent feeding, diet rich in fiber / Stool
softeners
 Activity: bed rest for the first 12 h…sitting in a chair within
the first 24 h…day 3-ambulation TID.
8/9/2021 By: 1st Yr MSc EMCCN students 33

34. References
 Kaplan USMLE STEP 2 CK internal medicine
lecture notes, 2019.
 European society of cardiology(ESC), 2019.
 AHA/ACC Guidelines, for the management of
NSTE-ASC, 2016.
 Current medical diagnosis and treatment, 2015, 58th
edition.
 Tintinali's emergency medicine, 8th edition.
8/9/2021 By: 1st Yr MSc EMCCN students 34

35. THANK YOU!!!
35

36. 8/9/2021 By: 1st Yr MSc EMCCN students 36
THANK YOU!!!