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03.01 Acute Coronary Syndrome (ACS)

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Overview

Acute Coronory Syndrome includes the continuum of Unstable Angina, non-ST segment elevation myocardial ischemia (NSTEMI) and ST segment elevation myocardial ischemia (STEMI). The different syndromes refer to different levels of ischemia occuring and differing oxygen demands.

Nursing Points

General

  1. Chest Pain
    1. Unstable Angina
    2. NSTEMI
    3. STEMI

Assessment

  1. Presentation
    1. Differences between males and females
    2. OLDCARTS – P
      1. Onset
      2. Location
      3. Duration
      4. Characteristics
      5. Aggravating Factors
      6. Relieving Factors
      7. Treatment
      8. Severity
      9. Prior History
    3. Diagnostic tests
      1. 12-lead EKG
      2. Cardiac Enzymes

Therapeutic Management

  1. Old way –
    1. MONA
      1. Morphine
      2. Oxygen
      3. Nitroglycerin
      4. Aspirin
    2. New way –
      1. Holding Morphine, Nitro, or O2 for certain patients
        1. Morphine – yes for STEMI, caution with angina and NSTEMI
        2. Nitro – In STEMI, can cause drug induced hypotension and worsen ischemia
  2. Outcomes:
    1. Angina – Nitro and observation
    2. NSTEMI – Medication management – Beta Blockers, platelet aggregators (aspirin, Plavix)
    3. STEMI – Cath lab for Percutaneous coronary intervention (PCI).
      1. If unable to get to cath within 90-120 minutes, consider fibrinolytics

Nursing Concepts

  1. EKG Rythyms
  2. Perfussion
  3. Prioritization

Patient Education

Any chest pain should be investigated by a physician

Reference Links

Video Transcript

Greetings everyone and welcome to our lesson on Acute Coronary Syndrome.

So what do we consider Acute Coronary Syndrome. Well it refers to a triad of conditions, Unstable Angina, non-st segment elevation myocardial infarctions (NSTEMI)  and ST segment myocardial infarctions (STEMI). It is important to know the differences and the treatments for each.

Anyone of the 3 can present with chest pain. In unstable angina, the pain that the patient is feeling can be very unpredictable. It can happen at rest or during activity. It is intense and difficult to relieve. Usually, with these symptoms, the patient is seeking out treatment. 

With any of our chest pain patients, we are going to do 2 things… an EKG and cardiac enzymes. If we see ST depressions and the enzymes are positive, its probably an NSTEMI. If we see those ST elevations in 2 or more contiguous leads (meaning next to each other), we can assume they are having a STEMI..the big one, and the situation in many facilities that now calls for a CODE STEMI. 

So here we see an inferior wall STEMI. If you look here, we can see the elevations in leads II, III, and AVF. This is bad and needs to get to the cath lab.

So when it comes to presentation, there are some very common signs and symptoms, and some not so common. Traditionally, males present with the signs we know and love. Chest pain that radiates to the lower jaw and left arm, diaphoresis and an increasing anxiety level. Females, on the other hand, may not be as cut and dry. Many complain of not feeling well. They can present with nausea, abdominal pain, dizziness, diaphoresis and a host of other symptoms we may not attribute to cardiac in nature. Guys…when in don’t, never hesitate to grab an EKG. It is noninvasive and takes literally seconds to do. 
When it comes to assessing the presentation and history of what is happening to the patient, we like to use the acronym OLDCARTS-P:

Onset – when did the symptoms or chest pain start?

Location – Where are they having pain?

Duration – How long does the pain last? Does it come and go or is it constant?

Characteristics – What does it feel like? This is where we hear the elephant on my chest analogy.

Aggravating factors – Does anything make the pain worse?

Relieving Factors – does anything make it better?

Treatment – have you done anything to help the pain, any medications?

Severity – one to 10

Prior history – well…do they have any history of cardiac problems?

So when it comes to treating ACS, there is the way many of us learned, and that was with MONA… morphine, oxygen, nitro, and aspirin. Well what we realized is that this may not have been the best treatment for these patients so some new evidence-based practices are being instituted.

So with morphine…we still give it for STEMI as this will help the pain, obviously, but will also help to lower blood pressure a little. We found that with NSTEMI and Unstable angina, the use of morphine actually has an association with increased mortality. That being said, if we have given sublingual nitro, and the pain is unrelieved, then let’s give them some IV morphine. 

With IV Nitro, the American Heart Association actually does not recommend its routine use. There is a concern for drug-induced hypotension, decreased coronary perfusion and worsening myocardial ischemia. 

So what are the outcomes for these patients? Well with angina, usually its nitroglycerin to open the coronary vessels, relieve the pain and admit for observation, usually overnight.

With NSTEMI, we lean towards medication management. Beta-blockers to keep the pressure low and platelet aggregators like aspirin or plavix to prevent further buildup in the vessels.

In the case of STEMI, we need to get these patients to the Cath lab. They have a significant blockage that needs to be opened up with an invasive procedure. If we don’t have a cath lab or it would take too long to get them to one, we can consider using fibrinolytics. Yup….TPA for heart attacks. It’s used more than you would think. 

We have to be able to interpret our EKG’s  How can we identify a STEMI if we don’t know what we are looking for.

When it comes to ACS, perfusion is key and it’s important to know which situation we are dealing with in order to determine how severe the blockage is.

And, just like with most things in the ED, prioritization is key. Getting that EKH, getting that blood, know the steps to care for these patients.

A few key points. We need to get that EKG and determine what we are dealing with.

Determine what meds are needed and which are contraindicated.

Depending on which diagnosis your patient has may tell you how severe there coronary blockage is.

Many patients may state they have a feeling of impending doom. If a patient tells you they feel like they are going to die… do not take that lightly

And in the end, we have to determine if these patients are going to the cath lab or not. 

Thanks again for joining us and as always, HAPPY NURSING!

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