Republic of the Philippines

TARLAC STATE UNIVERSITY

COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Lucinda Campus, Brgy. Ungot, Tarlac City Philippines 2300

NCM 101B Health Assessment Lecture

Acute Coronary Syndrome

Dagohoy, Francis Josh (Leader)

Concepcion, Cazzandra
Enriquez, John Martelino
Guiao, Celine Angela
Group 4 (BSN 3-2)

Prof. Bianca Camille Mercado

HA Lec Professor
 Overview of the Disease

Acute coronary syndromes result from acute obstruction of a coronary artery. Consequences depend on
degree and location of obstruction and range from unstable angina to non–ST-segment elevation
myocardial infarction (NSTEMI), ST-segment elevation myocardial infarction (STEMI), and sudden
cardiac death. Symptoms are similar in each of these syndromes (except sudden death) and include chest
discomfort with or without dyspnea, nausea, and diaphoresis. Diagnosis is by ECG and the presence or
absence of serologic markers. Treatment is antiplatelet drugs, anticoagulants, nitrates, beta-blockers, and,
for STEMI, emergency reperfusion via fibrinolytic drugs, percutaneous intervention, or, occasionally,
coronary artery bypass graft surgery.

Classification of Acute Coronary Syndromes

Acute coronary syndromes include

 Unstable angina
 Non–ST-segment elevation myocardial infarction (NSTEMI)
 ST-segment elevation myocardial infarction (STEMI)

These syndromes all involve acute coronary ischemia and are distinguished based on symptoms, ECG
findings, and cardiac marker levels. It is helpful to distinguish the syndromes because prognosis and
treatment vary.

Unstable Angina
- (acute coronary insufficiency, preinfarction angina, intermediate syndrome)
- is defined as one or more of the following in patients whose cardiac biomarkers do not meet criteria for
myocardial infarction (MI):

 Rest angina that is prolonged (usually > 20 minutes)

 New-onset angina of at least class 3 severity in the Canadian Cardiovascular Society (CCS)
classification (see table Canadian Cardiovascular Society Classification System for Angina Pectoris )
 Increasing angina, ie, previously diagnosed angina that has become distinctly more frequent, more
severe, longer in duration, or lower in threshold (eg, increased by ≥ 1 CCS class or to at least CCS
class 3)

Acute coronary syndromes

- are caused by a blockage of a coronary artery. Consequences range from unstable angina to non–ST-
segment elevation myocardial infarction (NSTEMI), ST-segment elevation myocardial infarction
(STEMI), and sudden cardiac death, depending on the degree and location of obstruction.

Chest discomfort with or without dyspnea, nausea, and diaphoresis are common symptoms in each of
these illnesses (excluding sudden death). ECG and the presence or absence of serologic markers are used
to make the diagnosis. Antiplatelet medications, anticoagulants, nitrates, beta-blockers, and, in the case of
STEMI, immediate reperfusion using fibrinolytic medicines, percutaneous intervention, or, in rare cases,
surgery are used to treat the condition.
Non–ST-segment elevation MI (NSTEMI, subendocardial MI)
- is myocardial necrosis (evidenced by cardiac markers in blood; troponin I or troponin T and CK will be
elevated) without acute ST-segment elevation. ECG changes such as ST-segment depression, T-wave
inversion, or both may be present.

ST-segment elevation MI (STEMI, transmural MI)

- is myocardial necrosis with ECG changes showing ST-segment elevation that is not quickly reversed
by nitroglycerin or showing new left bundle branch block. Troponin I or troponin T and creatine kinase
(CK) are elevated.

Both types of MI may or may not produce Q waves on the ECG (Q wave MI, non-Q wave MI).

The most common cause of acute coronary syndromes is an acute thrombus in an atherosclerotic coronary
artery.

Rarer causes of acute coronary syndromes are:

 Coronary artery embolism

 Coronary spasm
 Coronary artery dissection

Coronary arterial embolism can occur in mitral stenosis , aortic stenosis , infective endocarditis ,
marantic endocarditis, or atrial fibrillation .

Signs and Symptoms of Acute Coronary Syndromes depend somewhat on the extent and location of
obstruction and are quite variable.

 Pressure, ripping, gas with the urge to eructate, indigestion, burning, aching, stabbing, and
sometimes acute needle-like pain are all symptoms of painful impulses from thoracic organs,
including the heart. Many patients claim they are only experiencing "discomfort" and deny they are
in agony. Except in the case of a severe infarction, determining the level of ischemia based on
symptoms alone is challenging.

Symptoms of ACS are similar to those of angina and are discussed in more detail in sections on unstable
angina and acute myocardial infarction.

Complications

After the acute event, many complications can occur. They usually involve

 Electrical dysfunction (eg, conduction defects , arrhythmias )

 Myocardial dysfunction (eg, heart failure , interventricular septum or free wall rupture, ventricular
aneurysm, pseudoaneurysm, mural thrombus formation, cardiogenic shock )
 Valvular dysfunction (typically mitral regurgitation )

Diagnosis of Acute Coronary Syndromes

 Serial ECGs
 Serial cardiac markers
 Immediate coronary angiography for patients with STEMI or complications (eg, persistent chest
pain, hypotension, markedly elevated cardiac markers, unstable arrhythmias)
 Delayed angiography (24 to 48 hours) for patients with NSTEMI or unstable angina without
complications noted above

Acute coronary syndromes should be considered in men > 30 years and women > 40 years (younger in
patients with diabetes) whose main symptom is chest pain or discomfort. Pain must be differentiated from
the pain of pneumonia, pulmonary embolism , pericarditis , rib fracture , costochondral separation,
esophageal spasm , acute aortic dissection , renal calculus , splenic infarction, or various abdominal
disorders. In patients with previously diagnosed hiatus hernia, peptic ulcer, or a gallbladder disorder, the
clinician must be wary of attributing new symptoms to these disorders. (For approach to diagnosis, see
also Chest Pain.)

Brief Anatomy and Physiology

Coronary arteries supply blood to the heart muscle. Like all other tissues in the body, the heart muscle
needs oxygen-rich blood to function. Also, oxygen-depleted blood must be carried away. The coronary
arteries wrap around the outside of the heart. Small branches dive into the heart muscle to bring it blood.

What are the different coronary arteries?

The 2 main coronary arteries are the left main and right coronary arteries.

Left main coronary artery (LMCA)

- The left main coronary artery supplies blood to the left side of the heart muscle (the left ventricle
and left atrium).
-
A completely blocked coronary artery will cause a heart attack. The classic signs and symptoms
of a heart attack include crushing pressure in your chest and pain in your shoulder or arm,
sometimes with shortness of breath and sweating.
- The left main coronary artery is called the Widowmaker. So why is it called like
that?
- The left main coronary artery carries fresh blood into the heart so that the heart
gets the oxygen it needs to pump properly. If it's blocked, the heart can stop
very fast — which is why this type of heart attack is called a “widowmaker.”

- The left main coronary divides into branches:

1. The left anterior descending artery branches off the left coronary artery and supplies blood to the
front of the left side of the heart.

2. The circumflex artery branches off the left coronary artery and encircles the heart muscle. This
artery supplies blood to the outer side and back of the heart.

Right coronary artery (RCA)

- The right coronary artery supplies blood to the right ventricle, the right atrium, and the SA
(sinoatrial) and AV (atrioventricular) nodes, which regulate the heart rhythm. The right coronary
artery divides into smaller branches, including the right posterior descending artery and the acute
 marginal artery. Together with the left anterior descending artery, the right coronary artery helps
supply blood to the middle or septum of the heart.
- How important is the right coronary artery?
- The heart needs oxygen in the blood to function. The right coronary artery
specifically provides blood to the right atrium, heart ventricles, and the cells
in the right atrial wall, which are called the sinoatrial node. Injuries to the arteries,
or a poorly functioning artery, can cause a heart attack.
-

Why are the coronary arteries important?

Since coronary arteries deliver blood to the heart muscle, any coronary artery disorder or disease can have
serious implications by reducing the flow of oxygen and nutrients to the heart muscle. This can lead to a
heart attack and possibly death. Atherosclerosis (a buildup of plaque in the inner lining of an artery
causing it to narrow or become blocked) is the most common cause of heart disease.

Simplified Pathophysiology

Chest pain at rest

Non-cardiac chest pain Acute coronary syndrome

ST segment elevation Non ST segment elevation

Biomarkers positive Biomarkers negative

STEMI

NSTEMI Unstable angina

 Treatment/Management

Medications

1. Thrombolytics
2. Nitroglycerin
3. Antiplatelet drugs
4. Beta blockers
5. Angiotensin-converting enzyme inhibitors
6. Angiotensin receptor blockers
7. Statins

Surgery and other procedure

1. Angioplasty and stenting

- In this procedure, your doctor inserts a long, tiny tube (catheter) into the blocked or narrowed part of
your artery. A wire with a deflated balloon is passed through the catheter to the narrowed area. The
balloon is then inflated, opening the artery by compressing the plaque deposits against your artery walls.
A mesh tube (stent) is usually left in the artery to help keep the artery open.

2. Coronary bypass surgery

- With this procedure, a surgeon takes a piece of blood vessel (graft) from another part of your body and
creates a new route for blood that goes around (bypasses) a blocked coronary artery.

Nursing Responsibilities/Considerations

● Assess for chest pain not relieved by rest or medications.

● Monitor vital signs, especially the blood pressure and pulse rate.
● Assess for presence of shortness of breath, dyspnea, tachypnea, and crackles.
● Assess for nausea and vomiting.
● Assess for decreased urinary output.
● Assess for the history of illnesses.
● Perform a precise and complete physical assessment to detect complications and changes in the
patient’s status.
● Assess IV sites frequently.