This document outlines a presentation on acute coronary syndrome (ACS) given by nursing students. It defines ACS and its types, including unstable angina, NSTEMI, and STEMI. Risk factors, causes, pathophysiology, signs and symptoms, diagnosis, and management of ACS are discussed in detail. The goals of management are to increase blood flow to the heart, decrease oxygen demand, reduce chest pain, and prevent further damage. Pharmacological therapies and revascularization procedures are described for treating different ACS types. Potential complications are also reviewed.

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
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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
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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.
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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.
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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.
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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.
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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.
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10. Type Cont…
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11. Type Cont…
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12. Type Cont…
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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.
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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
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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)
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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.
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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
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18. Patho Cont…
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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…
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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.
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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.
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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.
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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
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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.
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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
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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.
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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
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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)
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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.
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32. Complications
 Arrythmia- the most common due to ischemia
 Congestive heart failure
 Pulmonary edema
 Cardiogenic shock.
 Pericarditis
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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.
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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.
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35. THANK YOU!!!
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36. 8/9/2021 By: 1st Yr MSc EMCCN students 36
THANK YOU!!!