ACUTE CORONARY SYNDROME
Acute coronary syndrome (ACS) is a broad
term for three types of coronary artery
disease that affect millions of people each
year. These potentially life-threatening
conditions occur when a blockage causes
blood flow to your heart to suddenly slow or
stop. The blockage is usually due to a blood
clot and can be sudden and complete. If a
clot forms due to a plaque rupture, a part of
the clot may break away and clog one of the
coronary arteries causing ACS.
TYPES OF HEART CONDITIONS
INCLUDED IN ACS
Acute coronary syndrome involves three
types of coronary artery disease that damage
or destroy heart tissue. The specific type
depends on:
Where blood flow to your heart is
blocked
How long the blockage last
The amount of damage it causes.
Types of ACS are:
 Unstable Angina: This involves
sudden, unexpected chest pain or
pressure, even while resting. It’s
a warning sign of a heart attack
and occurs when stable angina
worsens.
 Non-ST-elevation myocardial
infarction: An NSTEMI is a heart
attack that providers can detect
with a blood test but not with an
electrocardiogram (EKG). It
means your coronary arteries
aren’t fully blocked or were
blocked for a short amount of
time.
 ST-elevation Myocardial
Infarction: A STEMI a much
more severe heart attack that
providers can detect with blood
tests and EKG. It occurs when
blood flow to your heart is fully
blocked for a long time, affecting
a large part of your heart.
WHO ARE AT RISK?
 Males who are over 45 years old
 Menopausal woman
 Overweight/Obesity
 Cocaine Use
 Lack of physical activity
 Smoking
 Unhealthy diet
 Conditions such as COVID-19,
diabetes, family history of heart
disease
 High blood cholesterol
 High blood pressure
 Diabetes during pregnancy
REASONS FOR ICU ADMISSION
Indications for ICU admission that are
present in patients diagnosed with ACS
 Respiratory insufficiency
 Shock (cardiogenic)
 need for vasoppressors/inotopes in
the absence of shock
 hypotension without shock
 unstable arrythmia
 cardiac arrest
 need for ICU-restricted medications
 management of comorbidities
 Neurological emergencies
 Monitoring in the absence of other
indications
 The most common indication for
patients with ACS are respiratory
insufficiency, shock, vasoactive
therapy
PHYSICAL ASESSMENT:
 Assess blood pressure and heart
rate
 Assess distal peripheral pulses
and skin temperature
  Auscultate for an S3 gallop
 Assess the respiratory rate and
breath sounds
 Assess for the presence of
jugular venous distention and
peripheral edema
 Assess for signs of cyanosis
 Assess level of consciousness,
orientation and signs of
neurological deficit
 Assess for ST-segment changes
by obtaining an ECG
SIGNS AND SYMPTOMS:
1. Cardiovascular
Chest pain or discomfort not relieved
by rest or nitroglycerin; palpitations.
Heart sounds may include S3, S4,
and new onset of a murmur.
Increased jugular venous distention.
Blood pressure may be elevated
because of sympathetic stimulation
or decreased because of decreased
contractility, impending cardiogenic
shock, or medications.
Pulse deficit or irregular pulse
In addition to ST-segment and T-
wave changes, ECG may show
tachycardia, bradycardia, or other
dysrhythmias.
2. Respiratory
Shortness of breath, dyspnea,
tachypnea, and crackles
Pulmonary edema may be present
3. Gastrointestinal
Nausea, indigestion and vomiting.
4. Genitourinary
Decreased urinary output
5. Skin
Cool, clammy, diaphoretic, and pale
appearance
Dependent edema may also be
present
6. Neurologic
Anxiety, restlessness, and
lightheadedness; the same symptoms
may also herald cardiogenic shock.
Syncope, headache, visual
disturbances, altered speech, altered
motor function, and further changes
in level of consciousness
7. Psychological
Fear with feeling of impending
doom, or denial that anything is
wrong.
DIAGNOSTIC TESTS
 Electrocardiogram (ECG or
EKG).This quick test measures the
heart's electrical activity. Sensors
called electrodes are attached to the
chest and sometimes to the arms or
legs. Changes in the heartbeat may
mean the heart is not working
properly. Certain patterns in
electrical signals may show the
general location of a blockage. The
test may be repeated several times.
 Blood tests. Certain heart proteins
slowly leak into the blood after heart
damage from a heart attack. Blood
tests can be done to check for these
proteins.
 Echocardiogram. This test uses
sound waves to create pictures of the
beating heart. It shows how blood
flows through the heart and heart
valves. An echocardiogram can help
determine whether the heart is
pumping correctly.
Medical Management
 Myocardial perfusion
imaging. This test shows how well
blood flows through the heart
muscle. A tiny, safe amount of
radioactive substance is given by IV.
A specialized camera takes pictures
of the substance as it travels through
the heart. The test helps find areas of
poor blood flow or damage in the
heart.
 Computerized tomography (CT)
angiogram. This test looks at the
arteries that supply blood to the
heart. It uses a powerful X-ray
machine to create images of the
heart and its blood vessels.
 Clot busters help break up a blood
clot that's blocking an artery. These
drugs also are known as
thrombolytics.
 Nitroglycerin improves blood flow
by temporarily widening blood
vessels.
 Anti-platelet drugs help prevent
blood clots from forming. They
include aspirin, clopidogrel (Plavix)
and prasugrel (Effient).
 Beta blockers help relax the heart
muscle and slow the heart rate. They
decrease the demand on your heart
and lower blood pressure. Examples
include metoprolol (Lopressor,
Toprol-XL) and nadolol (Corgard).
  Angiotensin-converting enzyme
(ACE) inhibitors widen blood
vessels and improve blood flow.
This helps the heart to work better.
Examples include lisinopril (Zestril),
benazepril (Lotensin) and others.
 Angiotensin receptor blockers
(ARBs) help control blood pressure.
They include irbesartan (Avapro),
losartan (Cozaar) and others.
 Statins lower the amount of
cholesterol in the blood. They may
stabilize fatty deposits, making them
less likely to rupture and form a
blood clot. Statins include
atorvastatin (Lipitor), simvastatin
(Zocor, Flolipid) and others.
 Other cholesterol-lowering
medications such as ezetimibe
(Zetia).
Surgery and other procedures
Your health care provider may recommend
one of these treatments to restore blood flow
to the heart:
 Angioplasty and stenting. This
treatment uses a thin, flexible tube
and tiny balloon to open clogged
heart arteries. A surgeon inserts the
tube in a blood vessel, usually in the
groin or wrist, and guides it to the
narrowed heart artery. A wire with a
deflated balloon on the tip goes
through the tube. The balloon is
inflated, widening the artery. The
balloon is deflated and removed. A
small mesh tube is usually placed in
the artery to help keep it open. The
mesh tube also is called a stent.
 Coronary artery bypass
surgery. This major surgery
involves taking a healthy blood
vessel from the chest or leg area.
This piece of healthy tissue is called
a graft. A surgeon attaches the ends
of the graft below a blocked heart
artery. This creates a new path for
blood to flow to the heart.
Nursing Management
 Continuous cardiac monitoring
- Regular monitoring of ECG to
detect changes in heart rhythm or
ischemia.
 Oxygen therapy
- Administer oxygen to maintain
adequate oxygenation and reduce
myocardial workload.
 Pain management
- Administer analgesics to relieve
chest pain and reduce anxiety.
 Blood pressure management
- Monitor blood pressure to
decrease myocardial workload.
 Antiplatelet therapy
- Administer antiplatelet
medications to prevent further
clot formation.
 Intravenous access
- Establish and maintain IV access
for medications and fluids.
 Cardiac medication
- Administer medications such as
beta-blockers, nitroglycerin, and
antiarrhythmics as prescribed.
 Thrombolytic therapy
- Administer thrombolytic therapy
if indicated to dissolve clots.
 Fluid management
 - Monitor and manage fluid
balance to prevent fluid overload
or dehydration.
 Lab monitoring
- Regularly assess cardiac
biomarkers (troponin, CK-MB)
to evaluate heart muscle damage.
 Nutritional support
- Provide appropriate nutrition to
meet the patient’s energy needs
and promote healing.
 Rest and anxiety reduction
- Promote a calm environment to
reduce anxiety and myocardial
oxygen demand.
 Emotional support
- Offer emotional support and
education to reduce stress and
promote adherence to treatment.
 Prevent complications
- Monitor for complications like
heart failure, cardiogenic shock,
or arrhythmias.
 Patient education
- Educate the patient and family
about ACS, risk factors,
medications, and lifestyle
modifications for prevention.