Nursing Practice Keywords: Acute coronary syndrome/

Myocardial infarction/Unstable angina

Review
Cardiology This article has been
double-blind peer reviewed

In this article...
● P athophysiology and risk factors for acute coronary syndrome
● Signs, symptoms, diagnosis and treatment of ACS
● Priorities in nursing care for patients with ACS

Diagnosis, management and nursing

care in acute coronary syndrome
Key points
Authors Selina Jarvis is research nurse and former Mary Seacole development scholar,

1 Acute coronary
syndrome is
a common
King’s College Hospital Foundation Trust; Selva Saman is consultant, Port Shepstone
Regional Hospital, Port Shepstone, South Africa.

and potentially Abstract Acute coronary syndrome refers to a range of potentially life-threatening
life-threatening conditions that affect the coronary artery blood supply to the heart, and is a common
condition associated presentation in patients with coronary heart disease. Understanding the diagnostic
with coronary approaches, as well as pharmacological and coronary interventions is crucial, given
heart disease the prevalence of ACS. This article discusses current evidence-based guidance in the

2 Primary
percutaneous
coronary intervention
management of ACS and the critical role of nurses.

Citation Jarvis S, Saman S (2017) Diagnosis, management and nursing care in acute
within 12 hours of coronary syndrome. Nursing Times; 113: 3, 31-35.
symptom onset is the

E
first-line treatment

3 Pharmacological
management in
the acute phase
very three minutes one person is
admitted to a UK hospital with
acute coronary syndrome (British
Treatment aims to ease symptoms,
improve coronary artery blood flow and
prevent complications. Immediate man-
focuses on pain Heart Foundation, 2017), a agement, combined with cardiac rehabili-
relief and prevention common and life-threatening condition tation and secondary prevention, can
of further clot associated with coronary heart disease. ACS improve patients’ outcomes and quality of
formation while (Box 1) refers to a range of conditions life. Nurses have a key role in:
minimising the risk affecting the blood supply to the heart mus- l F acilitating and administering prompt
of bleeding cles (myocardium); these include unstable treatment to patients;

4 After discharge
from hospital,
patients need
angina, non-ST segment elevation myocar-
dial infarction (NSTEMI) and ST segment
elevation myocardial infarction (STEMI).
l P

l P
 romoting the swift recognition of
deterioration;
 roviding holistic care and
secondary ACS can result from a sudden drop in psychosocial support;
prevention involving blood flow through the coronary arteries l E ncouraging patients to engage in
medications, cardiac supplying the different regions of the myo- healthy secondary-prevention
rehabilitation and cardium. This can compromise the myo- behaviours.
lifestyle changes cardium, leading to reversible ischaemia or

5 Nurses play a
crucial role in
delivering care and
a complete loss of blood supply, which in
turn leads to myocardial infarction and
ultimately myocardial cell death (necrosis).
psychological In-hospital mortality from ACS has
support at all fallen from 20% to around 5% over the past
stages of the 30 years, which may be due to better drug
patient journey therapies, prompt recognition and treat-
ment protocols (National Institute for
Health and Care Excellence, 2013a). Timely
management is crucial to reduce the risk
of mortality and further cardiac events.
Pathophysiology
Most ACS cases are caused by atheroscle-
rosis, which takes place in the coronary
arteries, often decades before a cardiac
event. The formation of an atherosclerotic
plaque begins with low-grade inflamma-
tion in the inner layer of blood vessels. The
endothelial cells lining blood vessels sus-
tain injury, change shape and become
increasingly permeable to fluid, lipids and
white blood cells. Circulating cholesterol

Nursing Times March 2017 / Vol 113 Issue 3 31 www.nursingtimes.net

 Nursing Practice
Review
carriers, especially low-density lipopro-
tein (LDL), can enter the arterial wall and
undergo oxidation. White blood cells are
involved and transform into macrophages,
which engulf LDL; when they become lipid
laden they are referred to as foam cells.
These lipid-rich plaques contain inflam-
matory cells, cellular debris, smooth
muscle cells with cholesterol, and a fibrous
capsule. Over time they can progress and
cause luminal narrowing of the blood
vessel, thereby limiting blood flow.
ACS is usually triggered by the rupture of
an atherosclerotic plaque in the wall of a cor-
onary artery; this causes activation, adhe-
sion and aggregation of platelets and the
clotting systems, leading to the formation
of a thrombus. If the thrombus completely
occludes the coronary artery, the section of
the myocardium supplied by that artery is
starved of oxygen, leading to myocardial cell
necrosis, and typical ST elevation changes
are seen on an electrocardiogram (Fig 1). In
addition, cardiac enzymes are released from
damaged myocardial cells (troponin I and T,
creatinine kinase MB isoenzyme), which can
be measured in the blood.
Risk factors for ACS
ACS is more common in men, older people
and those with a family history of
ischaemic heart disease. Modifiable risk
factors include smoking, obesity, hyper-
tension, dyslipidaemia and poor diet. Life-
style changes such as smoking cessation,
weight loss, exercise, adherence to blood-
pressure drugs, tight glucose control in
patients with diabetes, and management of
dyslipidaemias can be useful in both pri-
mary and secondary prevention.
Signs and symptoms
Patients typically present with central
chest pain or tightness described as dull or
crushing; it can radiate to the jaw or down
the left arm and normally lasts for >15 min-
utes. Some patients, however, such as
those with diabetes, older people or
women, may not have chest pain.
Mnemonics, such as SOCRATES, can be
used to assess patients’ chest pain:
l S
 – site of pain;
l O
 – onset of pain;
l C
 – character of the pain;
l R
 – any radiation;
l A
 – associated factors;
l T
 – timing of the pain;
l E
 – exacerbating/alleviating factors; for
example, position or inspiration;
l S
 – severity of the pain using a rating
peter lamb
scale of 1-10 (10 being the worst pain).
Shortness of breath, palpitations,
Nursing Times March 2017 / Vol 113 Issue 3
Box 1. Universal definition of ACS
A rise in blood troponin level above the 99th percentile of the normal range and/or a
fall in troponin alongside one or more of the following criteria:
l Symptoms suggestive of cardiac ischaemia
l New electrocardiogram changes indicating new ischaemia (change to the ST
segment or T wave or new left bundle branch block)
l Development of a pathological Q wave in the ECG
l Imaging evidence of new loss of viable myocardium or new regional wall motion
abnormality (abnormal movement of heart muscle)
Sources: Adapted from NICE (2014) and Thygesen et al (2012)
coronary intervention (PCI). Often they will
Fig 1. STEMI changes in ACS
communicate with the cardiology team
Blocked before arrival, which will facilitate urgent
blood flow coronary reperfusion strategies (coronary
angioplasty with/without stents placed in
the affected coronary artery) once the
patient has arrived in hospital.
Primary PCI has become the first-line
treatment in patients with STEMI pre-
senting within 12 hours of onset of symp-
toms, provided it can be given within
120 minutes of the time in which throm-
Atheroma
bolysis could be given (NICE, 2013a). If pri-
mary PCI is not available or there is a delay,
thrombolysis may be performed (using
Atheroma lining
coronary artery drugs such as alteplase and reteplase) after
discussion with the on-call cardiologist –
Ischaemia if there are no major contraindications.
Infarction
If the ECG does not reveal an MI but car-
ACS = acute coronary syndrome. STEMI = ST
diac ischaemia is suspected, patients
segment elevation myocardial infarction should be admitted and have serial 12-lead
ECGs to assess any dynamic changes. If
there is myocardial damage, cardiac
syncope or autonomic symptoms such as enzymes (typically troponins T and I) are
sweating, nausea, tachycardia or vomiting raised, which can help confirm the diag-
may also occur (with or without chest nosis. NICE (2013b) advises that troponin
pain). Close attention to vital signs is crit- be included in the initial assessment on
ical as patients can deteriorate and become admission and a second sample be taken
haemodynamically unstable or develop 10-12 hours after symptoms began.
heart failure and arrhythmias. Increases or decreases of troponin above
or below the normal limit on the repeat test
Diagnosis and first investigations can confirm NSTEMI. A negative troponin
A thorough clinical history and physical and no ECG changes can support a decision
examination should be undertaken and to discharge patients who may have
supported by an ECG. This helps delineate unstable angina. These patients should
the treatment pathway and, in cases of receive follow-up in a rapid chest pain clinic
STEMI, decide whether the patient needs or in cardiology; their risk of adverse cardiac
urgent reperfusion. If ACS is suspected, events is 0.2% (Weinstock et al, 2015).
the emergency services should be called Fig 2 outlines the principles of ACS diag-
and, on arrival, paramedics should per- nosis and management.
form an immediate ECG. Many paramedics
are trained to recognise ECG changes seen Risk prediction
in STEMI, which include ST elevation of Adults with NSTEMI or unstable angina
≥1mm height in two adjacent chest leads, should be assessed for their risk of future
ST elevation of ≥2mm in two adjacent limb adverse cardiovascular events using an
leads, and new left bundle branch block. established risk scoring system that predicts
If STEMI is suspected, paramedics will six-month mortality (NICE, 2013b). This
aim to take patients directly to a ‘heart attack helps to plan clinical management and
centre’ that offers primary percutaneous decide on the best place of care (for example,
32 www.nursingtimes.net
 antiplatelet drugs is used. This drug class
Fig 2. Overview of ACS diagnosis and management
includes clopidogrel and the faster-acting
prasugrel and ticagrelor. Antiplatelet
ACS suspected
agents are associated with potentially life-
Symptom variation in women, older threatening bleeding. NICE recommends
people and people with diabetes using ticagrelor, as risk of bleeding is
lower than with the others (NICE, 2013a).
12-lead ECG The European Society of Cardiology rec-
Clinical assessment ommends ticagrelor with aspirin in
No ST elevation seen on ST elevation or LBBB patients with moderate-risk NSTEMI
ECG seen on ECG (Roffi et al, 2015). Many patients will have
to continue dual antiplatelet treatment for
Confirm these 12 months after an MI regardless of how it
+ve Troponin test -ve
are new ECG was managed.
changes
NSTEMI Unstable angina
Anticoagulation agents
STEMI Anticoagulation is used to prevent clot for-
Medical mation. Fondaparinux, an antithrombin
management: aim agent, reduces ischaemic events and
Discharge and Primary PCI or
for PCI within 72 improves long-term morbidity and mor-
arrange follow-up fibrinolysis if delay
hours in patients tality; 2.5mg should be given subcutane-
investigations
with a six-month ously once daily (Fifth Organization to
mortality rate ≥3% Assess Strategies in Acute Ischemic Syn-
dromes Investigators et al, 2006). It is asso-
ACS = acute coronary syndrome. ECG = electrocardiogram. LBBB = left bundle branch block. ciated with a reduced risk of major
NSTEMI = non-ST segment elevation myocardial infarction. PCI = percutaneous coronary
intervention. STEMI = ST segment elevation myocardial infarction.
bleeding compared with other anticoagu-
lants – bleeding risk being a concern with
most of them (NICE, 2013b).
coronary care or a medical assessment unit). There is some evidence that giving supple- In patients with renal dysfunction
Several tools are available to stratify mor- mental oxygen to patients with uncompli- (serum creatinine >256μmol/L), unfrac-
tality risk in ACS, including: cated MI can be harmful (Stub et al, 2015). tionated heparin is used. The decision to
l G lobal Registry of Acute Coronary give an anticoagulant, and which one,
Events score (GRACE; Bit.ly/ Antiplatelet agents revolves around whether and when the
GRACERiskScore) (Granger et al, 2003); Platelets play a pivotal role in clot formation patient is due to have PCI, as well as their
l T hrombolysis in Myocardial Infarction after an atherosclerotic plaque ruptures, so bleeding risk and cardiovascular risk score.
(TIMI) score (Antman et al, 2000). dual antiplatelet therapy is crucial in ACS
Table 1 compares GRACE and TIMI for management – both in NSTEMI and STEMI. Glycoprotein IIb/IIIa inhibitors (GPIs)
risk scoring in ACS. Aspirin is linked to reduced mortality GPIIb/IIIa receptor activation is the last
in ACS, with sustained effects at 10 years step in platelet aggregation when a clot is
Pharmacological management (Baigent et al, 1998), so it is standard prac- forming, so GPIs can be effective but,
Pain relief tice to give patients 300mg of non-enteric again, are linked to bleeding. NICE (2013b)
Patients presenting with chest pain may coated aspirin on presentation. Alongside recommends a GPI (for example, eptifiba-
need sublingual or buccal glyceryl trini- aspirin, the P2Y12 antagonist group of tide or tirofiban) be considered in patients:
trate (GTN) to relieve pain; those with
intractable pain may need a GTN infusion
(NICE, 2013a). GTN promotes venodilation Table 1. Risk scoring in ACS: GRACE versus TIMI
and dilatation of the coronary arteries. It TIMI GRACE
can be given to patients with ischaemic
History l Age l Hypertension l Age
chest pain provided their systolic blood
l Diabetes l Smoking
pressure is >90mmHg. It is contraindicated
l Dyslipidaemia l Family
in patients with an inferior MI or suspected
history l History of
right ventricular involvement, as it can
ischaemic heart disease
cause haemodynamic deterioration.
Some patients with nitrate-refractory Presentation l Severe angina l Heart rate l Systolic blood

pain receive opioids, such as intravenous l Prior aspirin use (<7 days) pressure l Elevated creatinine
morphine, at small doses every few min- l Elevated cardiac markers l Heart failure l Cardiac arrest

utes until they are pain free. l ST-segment deviation l Elevated cardiac markers
l ST-segment deviation

Oxygen ACS = acute coronary syndrome. GRACE = Global Registry of Acute Coronary Events.
Patients with acute chest pain and pre- TIMI = Thrombolysis in Myocardial Infarction.
sumed ACS do not need oxygen unless Sources: Adapted from Granger et al (2003) and Antman et al (2000)
they present with hypoxia or heart failure.

Nursing Times March 2017 / Vol 113 Issue 3 33 www.nursingtimes.net

Nursing Practice
Review
Box 2. Discharge and
secondary prevention post MI
Diagnosis and arrangements for
follow-up
Include in every discharge summary:
l Confirmation of acute MI diagnosis
l Investigation results
l Future management plans
l Secondary prevention advice
Patients should be given a copy of their
discharge summary
Cardiac rehabilitation (CR)
Advise patients about CR and encourage
them to attend. CR consists of:
l Physical activity
l Travel and health advice
l Psychological and social support
l Advice on sexual activity
l Support with lifestyle changes
Cardiac risk factors and lifestyle changes
l Control blood pressure
l Reduce LDL cholesterol
l Maintain glycaemic control
l Stop smoking
l Maintain a healthy diet
l Take up appropriate physical activity
l Restrict alcohol use to safe levels
l Maintain a healthy weight
Drug therapy for secondary prevention
Offer all of the following drugs:
l ACE inhibitor
l Dual platelet therapy
l Beta-blocker
l Statin
Ensure the GP is aware of the timing of
drug titration and the need to monitor
renal function and blood pressure
ACE = angiotensin-converting enzyme. LDL =
low-density lipoprotein. MI = myocardial
infarction.
Source: Adapted from National Institute for
Health and Care Excellence (2015)
l W
 ith intermediate or high
cardiovascular mortality risk who are
due to undergo PCI within 72-96 hours;
l W
 ho have had PCI with difficult lesions
in the coronary arteries.
Antihypertensives and statins
Hypertension is a major cardiac risk factor
that contributes to ACS risk, and antihyper-
tensive drugs such as beta-blockers, angio-
tensin-converting enzyme (ACE) inhibitors
and aldosterone antagonists are associated
with improved outcomes. Beta-blockers
(for example, metoprolol, bisoprolol,
Nursing Times March 2017 / Vol 113 Issue 3
carvedilol) should be started as early as pos-
sible provided there is no hypotension,
signs of heart failure, bradycardia or heart
block. They reduce the workload on the
heart, decrease ischaemia and limit the
development and/or size of an infarct.
The NICE pathway on MI secondary pre-
vention (NICE, 2017) recommends that ACE
inhibitors (such as ramipril, lisinopril and
enalapril) are also started as early as pos-
sible – normally within 24 hours. Evidence
suggests they are associated with a reduced
incidence of major adverse cardiovascular
events when given within the first days of
ACS onset, and can lead to improvement in
left ventricular ejection fraction, thereby
reducing the risk of heart failure (Køber et
al, 1995). Patients who have had symptoms
or signs of heart failure with ACS can be
started on an aldosterone antagonist such
as eplerenone; this is initiated a few days
after ACE inhibitors and has been shown to
reduce morbidity and mortality after acute
MI (Pitt et al, 2003).
Statins, aimed at lowering cholesterol,
are crucial to secondary prevention; the
Scandinavian Simvastatin Survival Study
and follow-up studies confirmed their
beneficial effects on morbidity and mor-
tality by lowering LDL cholesterol levels
(Pederson et al, 2000). However, their
action may go beyond lowering LDL and
raising high-density lipoprotein choles-
terol: Cannon et al (2004) confirmed bene-
fits of high-dose atorvastatin and NICE
(2013b) recommends that patients with
confirmed ACS receive atorvastatin 80mg
for secondary prevention, provided there
are no contraindications.
Coronary reperfusion strategies
STEMI
Patients who present with STEMI within
12 hours of symptom onset should receive
emergency reperfusion within two hours to
restore the coronary arterial flow and sal-
vage the myocardium (NICE, 2013a). PCI is
usually performed through the radial artery,
although the femoral artery is used in 10-15%
of cases (Macdonald et al, 2016). In the Myo-
cardial Ischaemia National Audit Project
(2014), 92% of eligible patients in England,
87% in Wales and 95% in Belfast received PCI
within 90 minutes of arrival in hospital.
Lagerqvist et al (2006) showed a signifi-
cant reduction in death and MI at five years
in patients who received combined anti-
coagulation and primary PCI. PCI is superior
to thrombolytics, which are reserved for
when PCI is not possible. The overarching
aim is for patients to have follow-up with
coronary stenting within 6-24 hours.
34
NSTEMI
All patients with NSTEMI should receive
antiplatelet and anticoagulation therapy.
Definitive coronary reperfusion strategies
are also required – NICE strongly recom-
mends that GRACE or TIMI are used to
determine the level of risk. Patients at
intermediate or high risk should be offered
coronary angiography, followed by PCI if
needed, within 72 hours of admission.
Patients with NSTEMI or unstable angina
who are clinically unstable should have
angiography (followed by PCI if indicated)
within 24 hours of becoming clinically
unstable (NICE, 2014).
Nursing care priorities
Acute hospital admission
Keeping clear and comprehensive notes is
crucial to ensure all nurses caring for
patients with ACS know the patients’ clin-
ical status, areas of concerns and manage-
ment plan. Nurses caring for patients who
recently had coronary angiography should
monitor radial or femoral access sites and
be able to recognise complications. Close
communication with cardiac catheterisa-
tion laboratory staff and the coronary care
unit is crucial. Nurses receiving these
patients need clear information about the
type of procedure they had, any complica-
tions, medications and IV fluids, and
whether they have received anticoagulants
or GPIs, which will put them at greater risk
of bleeding (Macdonald et al, 2016).
General priorities for patients with ACS
are haemodynamic monitoring and close
observation of vital signs. A review of fluid
status can provide information about renal
perfusion, as some patients may present
with, or develop, heart failure. In patients
with diabetes, capillary blood glucose
levels should be regularly checked; some
may be put on IV insulin if their blood glu-
cose is >11mmol/L. Patients recently diag-
nosed with diabetes should be referred to
the diabetes specialist nurse.
Symptom monitoring is important to
achieve pain relief with GTN or morphine.
Swift recognition of any cardiac changes
on the serial ECGs is also a key aspect of
nursing care. Patients considered at high
risk should be managed where continuous
cardiac monitoring is available as they are
at risk of arrhythmias, which can precede a
cardiac arrest. Patients at intermediate
risk may be managed in a medical assess-
ment unit, where they are likely to receive
serial ECGs. Nurses caring for patients
with ACS should have ECG interpretation
skills, as ECG changes or arrhythmias are
signs of potential deterioration.
www.nursingtimes.net

Other elements of nursing care include
ongoing management of IV cannulas, cen-
tral venous pressure lines, urinary cathe-
ters and wounds and dressings.
Patients are likely to be anxious and
frightened. Nurses should be calm and
reassuring, and ensure pain and other
symptoms are well controlled. They play a
central role in providing psychosocial sup-
port; when possible, they should give
patients a chance to speak about their
experiences, address their concerns and
relay these to the multidisciplinary team.
Discharge and secondary prevention
in MI patients
There are several things to consider when
patients with a confirmed MI (either
NSTEMI or STEMI) are ready to be dis-
charged home (Box 2). Secondary preven-
tion should be at the heart of nurses’ strate-
gies. Patients need to understand their
condition and be encouraged to make any
lifestyle changes needed, which will be cru-
cial to prevent recurrence. They will be dis-
charged with much information, but the
priority is for them to understand:
l They have had an acute MI;
l Results of any investigations;
l How their condition will be managed.
Patients are likely to go home with sev-
eral drugs and many will need to take them
for the rest of their lives. These drugs usu-
ally comprise dual antiplatelet therapy,
beta-blockers, statins and ACE inhibitors.
Some patients will also need aldosterone
antagonists. Nurses must ensure patients:
l U nderstand the dosages and
administration routes;
l K now not to discontinue treatment
without medical advice.
Where possible relatives should be
involved in discussions, as they can often
help with lifestyle changes. Patients should
receive advice on travel and be made aware
of the rules about driving after an MI. They
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should also be advised to seek urgent med-
ical assessment if any chest pain recurs.
Advice can be reinforced with written
information, such as booklets from the
British Heart Foundation (bhf.org.uk), and
patients can be signposted to support
groups and websites such as NHS Choices
(nhs.uk) as appropriate (Scottish Intercol-
legiate Guidelines Network, 2016).
Nurses should address patients’ concerns
and refer them to cardiac nurses or dietitians
for specialist advice, as well as the primary
care team for ongoing secondary prevention.
They should also encourage them to attend a
cardiac rehabilitation programme; this is
particularly so for hard-to-reach groups –
older people, women, some ethnic groups,
people in rural areas, those of lower socioec-
onomic status – in which attendance is lower
than average (NICE, 2015; Dalal et al, 2015).
Specialist nurses
The development of chest pain specialist
and ACS specialist nurse roles has
improved care for ACS patients, particu-
larly those with NSTEMI. These nurses can
perform acute triage assessments and facil-
itate early access to specialist services and
cardiologists. Studies are starting to show
that nurse-led early triage can help identify
patients early, facilitating rapid interven-
tion (O’Neill et al, 2014; Alfakih et al, 2009).
Conclusion
ACS is a common, life-threatening condi-
tion and, in our ageing population, its
incidence is likely to rise. Nurses have a
crucial role in the clinical management of
patients with ACS, by helping them under-
stand their condition and care, and pro-
moting secondary prevention. NT
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l Barriers to attending cardiac
rehabilitation
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