Nursing Management of ACS

ACS Learning Objectives

• Demonstrate in-depth understanding of ACS pathophysiology and clinical manifestations.
• Explain methods and techniques for conducting a comprehensive nursing history and focused physical assessment.
• Identify and analyze appropriate diagnostic tests and investigations for ACS diagnosis.
• Recognize clinical cues for patient deterioration.
• Develop a therapeutic plan of care using critical analysis of assessment findings and the clinical reasoning cycle for patients experiencing ACS.
• Outline collaborative management strategies for ACS patients in the acute care setting and the registered nurse's role.
• Examine various pharmacological agents used to treat health problems and the impact of polypharmacy on nursing care.

Nursing Management of Ischemic Chest Pain

• Minutes Mean Myocardium: Prompt assessment and action are crucial.
• Assessment and Positioning: Assess pain using PQRST (Provocation, Quality, Radiation, Severity, Timing), and vital signs.
• Oxygen and Access: Administer oxygen if required and establish IV access.
• 12-Lead ECG: Obtain an ECG immediately.
• Nitroglycerin and Pain Management: Administer Nitroglycerin (GTN) and morphine if needed. Aspirin also plays a key role.
• Escalation of Care: Prepare for potential angiogram and transfer to a coronary care unit if an ST-segment elevation (STE) is present.
• Cardiac Biomarkers: Monitor cardiac biomarkers (troponin).

ACS Treatment: Reperfusion

• STEMI: Primary percutaneous coronary intervention (PCI) is the gold standard. This includes angioplasty and stent placement, potentially with thrombectomy.

  • Goal: Open the blocked artery within 90 minutes of symptom onset.
  • Advantages of PCI: Effective in restoring blood flow to the heart.
  • Complications of PCI: Bleeding, stroke, allergic reaction, and damage to blood vessels.
  • Nursing Care: Pre- and post-angiogram care are crucial to ensure patient safety and monitoring.

• Thrombolytics: Considered when PCI is unavailable.

  • Not recommended: More than 12 hours after symptom onset.
  • Ideal Window: Ideally within 3 hours of symptom onset.
  • Contraindications: Specific medical conditions may preclude their use.

• Unstable Angina and NSTEMI:

  • Pain Management: Relieve pain using nitrates and morphine.
  • Antiplatelet Therapy: Use antiplatelet medications (e.g., aspirin, clopidogrel).
  • Anticoagulation: Administer anticoagulants (e.g., heparin, enoxaparin).
  • Angiography: Once the patient is stabilized, perform angiography.

Coronary Angiogram

• Diagnostic Tool: Angiogram visualizes coronary arteries to identify blockages.
• Procedure: Catheter with dye is inserted into a blood vessel, and images are captured.

Percutaneous Coronary Intervention (PCI)

• Minimally Invasive Procedure: PCI is used to open blocked coronary arteries.
• Technique: A balloon-tipped catheter is inserted into the blockage to dilate the artery, and a stent is usually placed to keep it open.

Coronary Artery Bypass Surgery (CABGS)

• Open-Heart Surgery: CABGS uses grafts (typically blood vessels from the leg or chest) to bypass blockages in the coronary arteries.
• Procedure: Performed under general anesthesia with a heart-lung machine supporting circulation.

Medications for Acute Coronary Syndrome

• Goal: Reduce oxygen demand and/or increase oxygen supply to the heart.
• Medication Categories:
  • Nitrates: Short- and long-acting nitrates, such as nitroglycerin (GTN), are used to reduce blood pressure and dilate blood vessels.
  • Morphine: Used to reduce pain and anxiety.
  • Antiplatelet Medications: Aspirin, clopidogrel, and other antiplatelet medications inhibit platelet aggregation, preventing blood clots.
  • Anticoagulants: Heparin, enoxaparin, and other anticoagulants prevent blood clots from forming in the blood vessels.
  • ACE Inhibitors: ACE inhibitors (e.g., enalapril, lisinopril) help lower blood pressure by preventing the formation of angiotensin II, a powerful vasoconstrictor.
  • Beta-Blockers: Beta-blockers (e.g., metoprolol, atenolol) slow down the heart rate and reduce the heart's workload.
  • Calcium-Channel Blockers: Calcium-channel blockers (e.g., diltiazem, amlodipine) relax blood vessels and improve blood flow.

Education and Cardiac Rehabilitation

• Risk Factor Modification: Education on lifestyle changes to address risk factors for heart disease.
• Diet and Exercise: Dietary advice and guidance on physical activity to improve cardiovascular health.
• Medication Adherence: Importance of taking medications as prescribed and understanding their side effects.
• Angina Management: Teaching patients how to recognize and manage angina episodes.
• Resumption of Activity: Guidance on gradually resuming daily activities, including sexual activity, work, and driving.
• Cardiac Rehabilitation Program: Referral to a specialized cardiac rehabilitation program for comprehensive management and support.
• Follow-up Care: Providing a summary of care to the patient's primary care physician (PCP) and scheduling follow-up appointments.

Acute Myocardial Infarction (AMI) Complications

• Arrhythmias: Irregular heartbeats, potentially life-threatening.
• Cardiogenic Shock: The heart cannot pump enough blood to meet the body's needs.
• Heart Failure: Weakening of the heart muscle, leading to reduced pumping ability.
• Pericarditis: Inflammation of the sac surrounding the heart.
• Thromboembolism: Blood clots that break loose and travel through the circulatory system.
• Myocardial Rupture: A tear in the heart muscle.

Conduction System

• Essential for Electrical Impulses: The heart's conduction system is a network of specialized cells that transmit electrical impulses, coordinating heartbeat.
• Components: The system includes the sinoatrial node (SA node), the atrioventricular node (AV node), the bundle of His, and the Purkinje fibers.

Arrhythmias: Atrial Fibrillation (AFib)

• Most Common Heart Rhythm Disorder: AFib is characterized by a rapid and irregular heartbeat due to disorganized electrical activity in the atria.
• Prevalence: Most prevalent in the elderly.
• Life-Threatening Arrhythmias: Life-threatening arrhythmias, including ventricular tachycardia, ventricular fibrillation, asystole, and pulseless electrical activity, can lead to cardiac arrest.

Normal Sinus Rhythm

• Regular Rhythm: The heart beats at a normal rate of 60-100 beats per minute with a regular rhythm.
• Conduction Pattern: Electrical impulses follow the normal conduction pathway through the heart.

Atrial Fibrillation

• Chaotic Atrial Activity: AFib results from multiple ectopic foci firing in the atria, causing disorganized electrical activity.
• Abnormal P Waves: Fibrillatory waves (chaotic electrical activity) replace normal P waves on an ECG.

Risk Factors For Coronary Heart Disease

• Modifiable Risk Factors:
  • Hypertension (High Blood Pressure)
  • Smoking
  • Hypercholesterolemia (High Cholesterol)
  • Obesity
  • Sedentary Lifestyle
• Non-Modifiable Risk Factors:
  • Age
  • Ethnicity
  • Family History
  • Socioeconomic Status

Contributing Modifiable Risk Factors:

• Diabetes
• Metabolic Syndrome
• Illicit Substance Use
• Chronic Kidney Disease

Acute Coronary Syndrome (ACS)

• Spectrum of Conditions: ACS encompasses a range of conditions characterized by sudden and severe coronary ischemia (reduced blood flow to the heart).
• Categories:
  • Unstable Angina: Chest pain that occurs at rest or with minimal exertion.
  • Non-ST Elevation Myocardial Infarction (NSTEMI): Damage to the heart muscle with no ST-segment elevation on an ECG.
  • ST-Elevation Myocardial Infarction (STEMI): Damage to the heart muscle with ST-segment elevation on an ECG, indicating a complete blockage of a coronary artery.

Diagnosis of ACS

• Initial Assessment:

  • Clinical Presentation: History of chest pain, risk factors, and physical examination findings.
  • ECG: 12-lead ECG to evaluate for ST-segment changes.
  • Cardiac Serum Markers: Troponin levels are measured to detect heart muscle damage.

• Further Investigations:

  • Angiography: Visualizes coronary arteries for blockages.
  • Transthoracic Echocardiogram: Evaluates heart structure and function.
  • Exercise Stress Tests: Assess heart function during exercise.
  • Chest X-ray: Excludes other potential causes of chest pain.
  • Lipid Profile: Measures cholesterol levels.
  • Nuclear Imaging: Evaluates blood flow to the heart.

Clinical Manifestations of ACS

• Chest Pain: The most common symptom, described using PQRST:

  • Provocation: What triggers the pain?
  • Quality: Describe the feeling (e.g., crushing, tightness, burning).
  • Radiation: Does the pain spread (e.g., to the jaw, arm, back)?
  • Severity: How intense is the pain?
  • Timing: When did the pain start and how long does it last?

• Associated Symptoms:

  • Dyspnea (Shortness of Breath): May be caused by fluid buildup in the lungs.
  • Nausea and Vomiting: Can occur due to decreased blood flow to the heart.
  • Diaphoresis (Sweating): Caused by the body's stress response.
  • Decreased Exercise Tolerance: Difficulty with physical activity.
  • Dizziness: May occur due to decreased blood flow to the brain.
  • Palpitations: Rapid or irregular heartbeat.
  • Pallor: Pale skin.
  • Silent Ischemia: Some individuals experience ACS without typical chest pain symptoms.

ECG Interpretation

• ST Segment Elevation: Indicates a complete blockage of a coronary artery.
• ST Segment Depression: Indicates partial blockage of a coronary artery.
• T Wave Inversion: Can occur with ischemia or injury to the heart muscle.

Cardiac Biomarkers

• Troponin: A protein released from the heart muscle when it is damaged.
  • Rise: Occurs within 4-6 hours of injury or infarction.
  • Peak: Peaks at 10-24 hours.
  • Detectable: Remains detectable for up to 10-14 days.
• Creatine Kinase (CK): An enzyme found in the heart muscle.
  • CK-MB: Cardiac-specific isoenzyme.
  • Rise and Peak: Rises within 3-6 hours and peaks at 12-24 hours.
  • Return to Baseline: Returns to baseline within 12-48 hours.

Stable Angina, Unstable Angina, NSTEMI, STEMI

• Stable Angina: Chest pain that occurs predictably with exertion and resolves with rest or medication.
• Unstable Angina: Chest pain that occurs at rest or with minimal exertion, or is more severe, frequent, or prolonged than typical stable angina.
• NSTEMI: Myocardial infarction (heart attack) with no ST-segment elevation on the ECG.
• STEMI: Myocardial infarction with ST-segment elevation on the ECG.
• Differing Severity and Outcomes: Each of these conditions represents a different level of severity and has implications for treatment and prognosis.

Management of Acute Coronary Syndrome

• Collaborative Approach: A team of healthcare professionals works together to manage ACS.
• Key Interventions:
  • Pain Management: Medications such as nitrates, morphine, and aspirin are administered to relieve pain and prevent further damage to the heart.
  • Reperfusion Therapy: PCI or thrombolytic therapy is used to restore blood flow to the heart.
  • Monitoring Vital Signs: Cardiovascular parameters are closely monitored.
  • Electrolyte Management: Electrolyte imbalances are corrected.
  • Cardiac Rehabilitation: Patients are referred to cardiac rehabilitation programs to improve their overall health and reduce their risk of repeat events.
  • Lifestyle Modifications: Patients are educated about healthy lifestyle changes to reduce risk factors.
  • Medication Adherence: Patients are encouraged to take their prescribed medications as directed.

Additional Notes:

• Acute Coronary Syndromes are a group of conditions that involve a sudden blockage of blood flow to the heart.
• Prompt diagnosis and treatment are crucial in preventing serious consequences of ACS.
• This overview provides a foundational understanding of ACS, and further study is recommended for comprehensive knowledge.

Learning Objectives

• Understand the pathophysiology and clinical manifestations of Acute Coronary Syndrome (ACS)
• Describe the methods and techniques used to conduct a comprehensive nursing history and physical assessment for ACS
• Identify and analyze diagnostic tests and investigations appropriate to diagnose ACS
• Recognize the clinical cues for patient deterioration in ACS
• Develop a therapeutic plan of care for patients experiencing ACS through critical analysis of assessment findings and an understanding of the clinical reasoning cycle
• Outline collaborative management strategies for ACS patients in the acute care setting and the role of the registered nurse
• Examine pharmacological agents used to treat ACS and the impact of polypharmacy on nursing care

### Nursing Management of Ischemic Chest Pain

• Assess and position the patient
• Obtain a thorough patient history, including the PQRST of their pain and vital signs
• Administer oxygen if required and establish intravenous access
• Perform a 12-lead ECG to assess for ST elevation
• Administer nitroglycerin and/or morphine if needed, and aspirin as indicated
• Escalate care as necessary, including cardiac biomarkers, cardiac monitoring, and bed rest
• If ST elevation is present, prepare for angiogram and transfer to coronary care unit

Treatment for ACS - Reperfusion

• STEMI:
  • Primary Percutaneous Coronary Intervention (PCI):
    • Primary PCI within 90 minutes of symptom onset
    • Includes angioplasty, drug-eluting stent (DES) thrombectomy
    • May require coronary artery bypass graft surgery (CABGS)
  • Advantages:
    • Increased survival rates
    • Reduced risk of complications
  • Complications:
    • Bleeding
    • Stroke
    • Vessel dissection
    • Need for repeat interventions
  • Nursing care:
    • Pre-procedure: Provide education, assess and manage pain, administer medications, monitor vital signs
    • Post-procedure: Monitor vital signs, pain, bleeding, and complications, support emotional needs, provide education
• Thrombolytics:
  • Considered if PCI is not available
  • Ideally administered within 3 hours of symptom onset
  • Contraindicated after 12 hours of symptom onset
  • Nursing care:
    • Administer thrombolytic therapy as ordered
    • Monitor for bleeding complications
    • Provide education and support to the patient and family
• Unstable Angina/NSTEMI:
  • Relieve pain:
    • Nitrates
    • Morphine
  • Antiplatelet:
    • Aspirin
    • Clopidogrel
  • Anticoagulant:
    • Heparin
    • Enoxaparin
  • Angiography:
    • Once the patient is stabilized
    • Evaluate for coronary artery disease
    • Guide treatment decisions

Coronary Angiography

• Invasive procedure
• Uses contrast dye to visualize the coronary arteries
• Helps identify blockages and narrowing
• Guides treatment decisions

Percutaneous Coronary Intervention (PCI)

• Minimally invasive procedure
• Uses a catheter with a balloon to open blocked arteries
• Often followed by stent placement
• Alternative to coronary artery bypass graft surgery

Coronary Artery Bypass Graft Surgery (CABGS)

• Open heart surgery
• Uses healthy blood vessels from other areas of the body to bypass blocked arteries
• Allows blood to flow to the heart muscle
• Used for complex coronary artery disease

Medications for Acute Coronary Syndrome

• Goal:
  • Decrease oxygen demand
  • Increase oxygen supply
• Nitrates (short and long-acting):
  • Vasodilate coronary arteries
  • Reduce preload
  • Reduce myocardial oxygen demand
• Morphine:
  • Reduce pain
• Antiplatelet:
  • Aspirin
  • Clopidogrel
  • Prevent platelet aggregation
  • Reduce the risk of thrombus formation
• Anticoagulant:
  • Heparin
  • Enoxaparin
  • Prevent clot formation
• Angiotensin-converting enzyme (ACE) inhibitor:
  • Reduce blood pressure
  • Protect the heart from damage
• β-adrenergic blockers:
  • Decrease heart rate
  • Decrease blood pressure
  • Reduce myocardial oxygen demand
• Calcium-channel blockers:
  • Relax coronary arteries
  • Reduce blood pressure

Education and Cardiac Rehabilitation:

• Risk factors:
  • Discuss modifiable and non-modifiable risk factors
  • Encourage lifestyle modifications
• Diet and exercise:
  • Provide guidance on healthy dietary choices
  • Help establish an exercise program
• Medications:
  • Explain the purpose of medications
  • Encourage adherence to medication regimens
• Management of angina:
  • Teach patients about how to recognize and respond to angina
  • Encourage the use of nitroglycerin for symptom relief
• Resumption of activities:
  • Guide patients on the safe resumption of activities, such as sex, work, and driving
• Referral to cardiac rehab program:
  • Advise patients on the benefits of cardiac rehabilitation
• Summary to GP & follow-up appointment:
  • Provide a summary of the patient's hospital stay and treatment plan
  • Schedule follow-up appointments with the patient's primary care physician

Acute Myocardial Infarction: Complications

• Arrhythmias:
  • Ventricular tachycardia, ventricular fibrillation, atrial fibrillation, asystole, and pulseless electrical activity
• Heart failure:
  • The heart is unable to pump blood adequately
• Cardiogenic shock:
  • The heart is unable to pump enough blood to meet the body's needs
• Pericarditis:
  • Inflammation of the pericardium
• Myocardial rupture:
  • Tear in the heart muscle
• Ventricular aneurysm:
  • Bulge or weakened area in the ventricular wall
• Thromboembolism:
  • Blood clots that travel to other parts of the body
• Sudden cardiac death:
  • The heart suddenly stops beating

Conduction System

• Normal Sinus Rhythm:
  • Sinus node fires 60 - 100 beats/minute
  • Follows a normal conduction pattern
• Atrial Fibrillation:
  • Most common arrhythmia
  • Most prevalent in elderly patients
  • Disorganization of atrial electrical activity due to multiple ectopic foci
  • P waves replaced by chaotic, fibrillatory waves
  • May cause stroke, heart failure, and other complications

Risk Factors of Coronary Heart Disease

• Modifiable:
  • Hypertension
  • Smoking
  • Hypercholesterolemia
  • Obesity
  • Sedentary lifestyle
  • Diabetes
  • Metabolic syndrome
  • Illicit substance use
  • Chronic kidney disease
• Non-modifiable:
  • Age (greater than 45 for men and greater than 55 for women)
  • Ethnicity and socioeconomic status
  • Family history

Acute Coronary Syndrome (ACS)

• Includes unstable angina, non-ST elevation myocardial infarction (NSTEMI), and ST elevation myocardial infarction (STEMI)
• Characterized by acute coronary ischemia, which can lead to myocardial damage

Diagnosis of ACS

• Initial:
  • Clinical presentation: History, risk factors
  • 12-lead ECG
  • Cardiac serum markers: Troponin
• Investigative:
  • Angiography
  • Transthoracic echocardiogram
  • Exercise stress tests
  • Chest X-ray
  • Lipid profile
  • Nuclear imaging

Clinical Manifestations of ACS

• Chest Pain:
  • Precipitating factors
  • Quality (tightness, pressure, crushing)
  • Radiation (arms, jaw, back)
  • Severity
  • Timing (onset, duration)
• Associated symptoms:
  • Dyspnea
  • Nausea
  • Diaphoresis
  • Decreased exercise tolerance
  • Dizziness
  • Palpitations
  • Paleness
• Silent ischemia:
  • Myocardial ischemia without chest pain
  • Can occur in certain individuals, such as those with diabetes

ECG Findings in ACS

• ST Elevation Myocardial Infarction (STEMI):
  • ST segment elevation in at least two contiguous leads
  • Indicative of complete coronary artery occlusion and active myocardial damage
• Non-ST Elevation Myocardial Infarction (NSTEMI):
  • ST segment depression or T wave inversion
  • May be associated with partial occlusion or unstable angina
• Unstable Angina:
  • ECG changes may be non-specific or even normal
  • Indicates coronary ischemia without substantial myocardial injury

Cardiac Biomarkers

• Troponin:
  • Myocardial muscle protein
  • Rises within 4-6 hours of injury/infarction
  • Peaks at 10-24 hours
  • Detected for up to 10-14 days
  • Highly specific for myocardial damage
• Creatine kinase (CK):
  • CK-MB is cardiac-specific
  • Rises in 3-6 hours
  • Peaks in 12-24 hours
  • Returns to baseline within 12-48 hours

Stable Angina, Unstable Angina, NSTEMI, STEMI:

• Stable Angina:
  • Transient chest pain that is predictable and relieved by rest or nitroglycerin
  • Typically caused by a stable atherosclerotic plaque
• Unstable Angina:
  • New onset chest pain, or a change in the pattern of existing angina
  • Often occurs at rest or with less exertion
  • Suggests plaque rupture or erosion, leading to thrombus formation
• Non-ST Elevation Myocardial Infarction (NSTEMI):
  • Partial occlusion of a coronary artery
  • Myocardial injury occurs but not as extensive as in STEMI
• ST Elevation Myocardial Infarction (STEMI):
  • Complete occlusion of a coronary artery
  • Significant myocardial damage occurs
  • Requires prompt reperfusion therapy to minimize damage

Test your knowledge on the nursing management of acute coronary syndrome (ACS) with this comprehensive quiz. Understand the pathophysiology, assessment techniques, diagnostic tests, and collaborative management strategies for patients experiencing ischemic chest pain. Enhance your critical analysis skills in developing effective therapeutic plans for patient care.