ACS
Acute Coronary Syndrome Overview
Instructors
Mary Resler DNP, MSN Ed., RN
Learning Objectives
Understand contributing factors to patients who have angina.
Understand treatment and education for patients who have angina.
Recognize early signs of symptoms of unstable angina.
Understand contributing factors for patients with non-ST elevated myocardial infarcts (NSTEMI) and ST elevated myocardial infarcts (STEMI).
Understand early diagnostics and treatments for patients having both STEMI and NSTEMI.
Acute Coronary Syndrome (ACS)
Definition: ACS is a condition that develops when ischemia is prolonged and not immediately reversible.
Types of ACS:
Unstable Angina: A condition marked by unpredictable chest pain due to decreased blood flow to the heart.
Myocardial Infarction (MI): Can be categorized into:
ST-Elevation Myocardial Infarction (STEMI): Characterized by the presence of ST-segment elevation on an ECG.
Non-ST-Elevation Myocardial Infarction (NSTEMI): Characterized by the absence of ST-segment elevation on an ECG.
Angina
Causes:
Obstruction of coronary blood flow due to:
Atherosclerosis
Coronary artery spasm
Conditions increasing myocardial oxygen consumption.
Types of Angina
Unstable Angina:
Occurs unpredictably.
Increase in occurrence, duration, and severity over time.
May not be relieved by nitroglycerin.
Variant Angina (Prinzmetal or Vasospastic Angina):
Occurs due to spasm of coronary arteries.
Preinfarction Angina:
Associated with acute coronary insufficiency.
Lasts longer than 15 minutes.
Can occur days to weeks prior to an MI.
Angina Assessment
Symptoms to assess:
Pain
Dyspnea
Pallor
Sweating
Palpitations and Tachycardia
Dizziness and Syncope
Hypertension
Digestive Disturbance
Diagnostic Studies for Angina
Electrocardiography (ECG): Helps in assessing heart activity.
Stress testing: Evaluates heart's function under stress.
Cardiac enzymes and Troponin levels: For identifying heart damage.
Cardiac Catheterization: An invasive procedure to visualize coronary arteries.
Interventions for Angina
Assess pain and vital signs continuously.
Administer oxygen as ordered to improve oxygen supply.
Elevate head of the bed (HOB) and remain with the patient for support.
Obtain a 12 lead ECG: Critical in diagnosing cardiac conditions.
Establish intravenous (IV) access for medication administration.
Administer nitroglycerin as ordered for relief of chest pain.
Anticipate antiplatelet therapy to reduce the risk of acute myocardial infarction (MI).
Myocardial Infarction
Types: STEMI and NSTEMI.
Myocardial Infarction Risk Factors
Key Risk Factors Include:
Atherosclerosis (hardening of the arteries).
Coronary Artery Disease (CAD).
Elevated Cholesterol Levels.
Smoking.
Hypertension.
Obesity.
Physical Inactivity.
Impaired Glucose Tolerance.
Stress.
Differentiation of ACS Types
Acute Coronary Syndrome categorizes patients based on:
Clinical history
ECG changes
Elevated Troponin levels
STEMI vs. NSTEMI
NSTEMI diagnosis involves:
Non-ST elevation on ECG or ST depression present.
Troponins elevate within 4 hours, but levels stop rising after 6 hours.
Treatment for NSTEMI includes:
Oxygen therapy
Aspirin administration
Nitrates for pain relief
Additional testing (stress tests, perfusion imaging, cardiac catheterization)
Anticoagulation therapy
Beta Blocker or ACE Inhibitors are commonly prescribed.
Thrombolytic therapy is not indicated for NSTEMI patients.
STEMI Diagnosis and Treatment
In STEMI, an occlusive thrombus causes ST-elevation in the ECG leads facing the area of infarction.
Areas affected may include the:
Left Anterior Descending (LAD) artery
Circumflex artery
Right coronary artery
An emergency situation occurs if the artery is not opened within 90 minutes of presentation.
Possible treatment methods include:
Percutaneous Coronary Intervention (PCI)
Thrombolytic therapy (fibrinolytic), which is used if PCI is unavailable.
STEMI Assessment Symptoms
Classic symptoms that may occur include:
Pain (assessed using the PQRST method)
Nausea and Vomiting
Diaphoresis (sweating)
Dyspnea (difficulty breathing)
Dysrhythmias
Feelings of fear or anxiety
Pallor, cyanosis, or cold extremities
Not all patients experience typical MI symptoms; women may have atypical symptoms.
STEMI Diagnostics
Important Labs Include:
Troponin level
Total CK level (Creatine Kinase)
CK-MB (Myocardial Band)
Elevated white blood cell (WBC) levels indicating inflammatory response 2–7 days after the event.
12 lead ECG for monitoring heart activity.
Cardiac Catheterization to assess coronary artery condition.
STEMI Interventions
Key interventions during STEMI include:
Continuous pain assessment.
Vital signs monitoring.
Obtain a 12 lead ECG quickly.
Administer oxygen to optimize oxygen delivery.
Establish IV access for efficient medication delivery.
Provide pain relief using nitroglycerin and/or morphine.
Administer aspirin therapy at a dose of 324 mg.
Thrombolytic therapy if PCI is not available.
Talk to the patient and family about the situation to offer emotional support and reassurance.
Immediate Actions during STEMI
During EMS Response (GET ON IT STAT):
EKG monitoring
Oxygen supplementation
Administer Nitroglycerin
Establish IV access
Administer Morphine or continued Nitroglycerin
Aspirin therapy to prevent further clotting after STEMI event.
Post-STEMI Medications
Medications may include:
ACE Inhibitors
Angiotensin Receptor Blockers (ARBs)
Sample ACE Inhibitors and ARBs
ACE Inhibitors Examples:
Benazepril (Lotensin)
Captopril
Enalapril (Vasotec)
Lisinopril (Prinivil, Zestril)
Ramipril (Altace)
Trandolapril (Mavik)
ARBs Examples:
Azilsartan (Edarbi)
Candesartan (Atacand)
Irbesartan (Avapro)
Losartan (Cozaar)
Telmisartan (Micardis)
Valsartan (Diovan)
Percutaneous Coronary Intervention (PCI)
An invasive procedure through cardiac catheterization.
Catheterization provides diagnostic information on:
Structure and performance of heart chambers
Coronary circulation performance.
Pre-Procedure Interventions for PCI
Obtain consent and assess for allergies (especially shellfish for contrast dye).
Ensure patient is NPO (nothing by mouth) for 6–8 hours prior to the procedure.
Document client’s height, weight, and baseline vitals.
Assess peripheral pulses to ensure quality.
Communicate with the patient regarding anesthetic use and possible sensations felt during the procedure.
Prepare and clean insertion site.
Ensure IV access is established, and assess medication use (e.g., metformin).
Thrombolytic Therapy
Indications for Thrombolytics:
Used when PCI is unavailable.
Most effective in STEMI cases.
Should be administered within 6 hours of symptom onset.
Ensure patients don’t have contraindications to treatment.
Establish three IV lines prior to administer therapy.
Common Thrombolytic Agents:
Alteplase (t-PA)
Reteplase (r-PA)
Streptokinase
Coronary Artery Stents
Purpose: Used during catheterization to improve vessel patency.
Procedure involves:
Inflation of a balloon catheter with the stent to open the artery.
Post-procedure care includes:
Antiplatelet therapy for several months.
Monitoring for acute thrombosis complications.
If stenting is not successful, Coronary Artery Bypass Grafting (CABG) may be needed.
Post-Procedure Interventions for PCI
Continuous monitoring of:
Vital signs
Cardiac rhythm
Assessing for chest pain.
Monitoring peripheral pulses, color, warmth, and sensation of extremity (the 5 P's).
Notify provider of any neurological deficits or extremity changes (e.g., numbness or cyanosis).
Encourage fluid intake if not contraindicated to facilitate kidney function.
Assess the insertion site for bleeding and adhere to hospital policy for managing such incidents.
Maintain the patient in a flat position for 4–6 hours as per provider's orders.
Complications of STEMI or NSTEMI
Possible complications include:
Dysrhythmias (e.g., AFIB, atrial flutter, V-tach)
Heart Failure
Pulmonary Edema
Cardiogenic Shock
Thrombophlebitis
Pericarditis
Mitral Valve Insufficiency
Post-infarction Angina
Ventricular Rupture
Dressler’s Syndrome
Coronary Artery Bypass Grafting (CABG)
Indications for CABG include:
Patients not responding to medical management or having severely occluded vessels.
Preoperative CABG Preparation
Educate: Expect sternal and donor site incisions after surgery.
Discuss the presence of an endotracheal tube and mechanical ventilation post-surgery.
Prepare the patient for postoperative pain management.
Teach splinting techniques and incentive spirometry use.
Encourage questions and addressing concerns to relieve anxiety.
Follow provider's orders regarding medication cessation prior to surgery.
Postoperative CABG Management
Monitor vital signs and various parameters including heart rate, rhythm, and urinary output.
Assess mediastinal chest tube drainage and ensure it does not exceed 100–150 mL/hr.
Monitor for signs of cardiac complications like tamponade.
Employ proper pain management techniques.
Cardiac Tamponade Post-CABG Assessment
Signs of cardiac tamponade include:
Pulsus paradoxus
Increased central venous pressure (CVP)
Jugular vein distention with clear lung sounds
Distant, muffled heart sounds
Decreased cardiac output
Narrowing pulse pressure
Interventions for Cardiac Tamponade
Administer IV fluids as indicated.
Utilize chest X-ray or echocardiogram to assess.
Potentially perform pericardiocentesis to drain excess fluid.
Consider surgical options (Pericardial window) if fluid accumulation recurs.
References
Hinkle, J. L., & Cheever, K. H. (2018). Brunner & Suddarth's Textbook of Medical-Surgical Nursing (14th ed.) Philadelphia, PA: Wolters Kluwer.
Silvestri, L., & Silvestri, A. (2020). Saunders Comprehensive Review for the NCLEX-RN Examination (8th ed.) St. Louis, MO: Elsevier.
Sole, M., Klein, D., & Moseley, M. (2017). Introduction to Critical Care Nursing (7th ed.). St. Louis, MO: Elsevier.