Acute Coronary

Syndrome (ACS) and

Myocardial Infarction
(MI)
 ACUTE CORONARY
SYNDROME
Forms:
UNSTABLE Non-ST- ST-SEGMENT
ANGINA SEGMENT ELEVATION MI
▪ Reduced blood ELEVATION MI ▪ (+) ST segment
flow in a ▪ elevated elevation in 2
coronary artery cardiac contiguous
▪ angina/ biomarkers
preinfarction leads
▪ no definite ECG
angina evidence of
acute MI
 Definition of Terms
• Atherosclerosis – characterized by yellowish
plaques of cholesterol, other lipids, and cellular
debris in the inner layers of the walls of the arteries
• Plaque – a patch of atherosclerosis
• Atheroma – an accumulation of large amounts of
extracellular lipids and fibrous tissue localized into a
lipid core
 CORONARY ATHEROSCLEROSIS
- Abnormal accumulation of lipid, or fatty
substances and fibrous tissue in the lining
of the arterial blood vessel walls
Clinical Manifestations
• Chest pain
• Shortness of breath
• Indigestion
• Nausea
• Anxiety
Assessment and Diagnostic Findings

• Patient history
✔Description of presenting symptoms
✔ History of previous cardiac/ other illnesses
✔ Family history of heart disease

• Electrocardiogram (ECG) – obtained within 10 min

– T-wave inversion, ST-segment elevation and abnormal Q
wave
Normal ECG
Assessing for ACS and AMI
Cardiovascular
• Chest pain
• Increased jugular venous distention
• Increased BP
• Irregular pulse
• ECG changes
Respiratory
• Shortness of breath, dyspnea, tachypnea, crackles
Gastrointestinal
• Nausea, indigestion and vomiting
Skin
• Cool, clammy, diaphoretic and pale appearance

Neurologic
• Anxiety, restlessness and lightheadedness

Psychological
• Fear with feeling of impending doom
• Denial
a. Unstable Angina: The patient has clinical
manifestations of coronary ischemia, but
ECG and cardiac biomarkers show no
evidence of acute MI
b. STEMI: The patient has ECG evidence of
acute MI with characteristic changes; with
significant to the myocardium
c. NSTEMI: The patient has elevated cardiac
biomarkers but no definite evidence of
acute MI
• Echocardiogram – ventricular function
Laboratory tests
Cardiac biomarkers
– Troponin
3 isomers:
• Troponin C
• Troponin I specific for
• Troponin T cardiac muscle
– Creatine Kinase and its isoenzymes
• CK-MM, CK-MB, CK-BB
– Myoglobin
Cardiac Onset Peak Returns to
Biomarker Normal

Myoglobin 1-3 hrs 12 hrs 24 hrs

CK-MB 4-8 hrs 12-24 3-4 days

Troponin T or I 3-4 hrs 4-24 hrs 1-3 wks

Medical Management
Goal:
To minimize myocardial damage, preserve
myocardial function, and prevent
complications
A. Emergent Percutaneous
Coronary Intervention

B. Thrombolytics (Fibrinolytics)

C. Coronary artery bypass graft

While waiting:
1. Elevate head/ loosen tight clothing
2. Give O2
3. Gain IV access
4. Connect to heart monitor (or portable automatic external
defibrillators)

Within 10 min:
1. Admit to ER
2. Give aspirin
3. Place on ECG monitor
4. Draw blood samples of serum cardiac markers
A. Emergent Percutaneous Coronary
Intervention (PCI)

1. Percutaneous Transluminal Coronary

Angioplasty (PTCA)
2. Intracoronary stent Implantation
Percutaneous Transluminal Coronary
Angioplasty (PTCA)

• A balloon-tipped catheter is used to open

the blocked coronary vessels to resolve
ischemia
• Purpose: To improve blood flow within a
coronary artery by copressing the
atheroma
• Can also be used to open blocked CABGs
Coronary Artery Stent
• Stent - a metal mesh that provides
structural support to a vessel at risk of
acute closure
• May or may not be coated with medications
• Medication -coated stents:
– Sirolimus (Rapamune)
– Paclitaxel (Taxol)
– Minimize the formation of thrombi or scar
tissue within the coronary artery lesion
Post-Procedure Care for PTCA
• Monitor for signs of bleeding
• GP IIb/IIIa agent (eptifebatide) several
hours following PCI
• Femoral sheaths removed after procedure
by using a vascular closure device (Angio-
Seal, VasoSeal)
Angio-Seal
 Post-Procedure Care for PTCA
• Hemostasis may also be achieved after
sheath removal by:
– Direct manual pressure
– Mechanical compression device (C-shaped
clamp)
– Pneumatic compression device (FemoStop)
FemoStop

C-shaped clamp
Post-Procedure Care for PTCA
• May return to the nursing unit with the
large peripheral access sheaths in place
(removed after blood studies)
• Remain flat on bed
• Keep the affected leg straight until the
sheaths are removed and for a few hours
afterwards
• Analgesics and sedation
• Back pain - reposition and heat application
• IV atropine
Post-Procedure Care for PTCA
• Unstable lesions and at high risk for abrupt
vessel closure
– restarted on heparin after sheath removal
– IV infusion of GP IIb/IIIa inhibitor
– Monitor closely
– May have delayed recovery period
• Hemostasis is achieved:
– A pressure dressing is applied
– Resume self-care
– Ambulate unassisted
B. Thrombolytics (Fibrinolytics)
• To dissolve the thrombus in a coronary artery
• Given within 30 min of presentation to the
hospital (door-to-needle time)
Indications:
• Chest pain lasting more than 20 min, unrelieved
by nitroglycerine
• ST-segment elevation in at least 2 leads that
face the same area of the heart
• Less than 6 hours from onset of pain
Thrombolytics
Absolute Contraindications:
• Active bleeding
• Known bleeding disorder
• History of hemorrhagic stroke
• History of intracranial vessel malformation
• Recent major surgery or trauma
• Uncontrolled hypertension
• Pregnancy
Thrombolytics
Agents:
• alteplase (Activase)
• reteplase (Retavase)
• tenecteplase (TNKase)
Thrombolytics
Nursing Considerations
• Minimize skin punctures
• Avoid IM injections
• Draw blood specimens when starting the IV line
• Start IV lines before thrombolytic therapy
• Avoid continual use of noninvasive blood pressure
cuff
• Monitor: acute dysrhythmias and hypotension
• Monitor for reperfusion: resolution of angina or
acute ST-segment changes
Thrombolytics
Nursing Considerations
• Check for bleeding:
– Decreased Hct and Hgb
– Decreased BP
– Increased HR
– Oozing or bulging at invasive procedure sites
– Back pain
– Muscle weakness
– Changes in level of consciousness
– Headache
Thrombolytics
• Major bleeding:
– discontinue thrombolytic therapy and
anticoagulants
– Apply direct pressure
– Notify primary provider
• Minor bleeding:
– Apply direct pressure if accessible and
appropriate
– Continue to monitor
C. Coronary Artery Bypass Graft
• A surgical procedure in which a blood vessel is grafted to
an occluded coronary artery so that blood can flow
beyond the occlusion
Indications:
• Alleviation of angina that cannot be controlled with
medication or PCI
• Treatment of left main coronary artery stenosis or
multivessel CAD
• Prevention of and treatment for MI, dysrhythmias, or HF
• Treatment for complications from an unsuccessful PCI
Coronary Artery Bypass Graft
Considerations for CABG:
• Coronary arteries to be bypassed must have at least
70% occlusion or at least 50% occlusion if in the left
main coronary artery
• The artery must be patent beyond the area of the
blockage
• Internal mammary artery should be used
• Commonly used vean: Saphenous vein (limited
patency; 5 to 10 may have atherosclerotic changes)
Traditional Coronary Artery Bypass Graft
1. Under general anesthesia
2. Median sternotomy and connected to
cardiopulmonary bypass (CPB) machine
3. Blood vessel is grafted, bypassing the obstruction
4. CPB is discontinued
5. Chest tubes and epicardial pacing wires are placed
6. Incision is closed
7. Admitted to critical care unit
Off-Pump Coronary Artery Bypass Graft (OPCAB)

• Standard median sternotomy incision

without CPB
• Beta-adrenergic blocker - used to slow
the HR
• A myocardial stabilization device is used
to hold the site still for anastomosis of the
bypass graft into the coronary artery
while the heart continues to beat
NURSING MANAGEMENT
I. Assessment
✔ Symptom must be evaluated with regard to
time, duration, and the factors that precipitate
the symptom and relieve it; compare with
previous symptoms
II. Nursing Diagnoses
• Acute pain related to increased myocardial oxygen
demand and decreased myocardial oxygen supply
• Risk for decreased cardiac tissue perfusion related
to reduced coronary blood flow
• Risk for imbalanced fluid volume
• Risk for ineffective peripheral tissue perfusion
related to decreased cardiac output from left
ventricular dysfunction
• Anxiety related to cardiac event and possible death
• Deficient knowledge about post-ACS self-care
III. Planning
1. Relief of pain or ischemic S/S
2. Prevention of myocardial damage
3. Maintenance of effective respiratory function
4. Maintenance or attainment of adequate tissue
perfusion
5. Reduced anxiety
6. Adherence to the self-care program
7. Early recognition of complications
IV. Interventions
1. Relieve pain (primary focus)
✔Administer aspirin (S/E: epigastric distress &
GI bleeding), beta-blocker, NTG, heparin
✔Administer morphine, oxygen via nasal
cannula @ 2-4 LPM to maintain O2 sat of
96%-100%
✔Physical rest with head and torso elevated
2. Improve respiratory function
✔Encourage deep breathing and change
position frequently
3. Promote adequate tissue perfusion
✔Bed or chair rest during the initial
phase until pt is pain-free and
hemodynamically stable
✔Check skin temperature and pulses
4. Reduce anxiety
✔ Develop a trusting and caring relationship
✔ Provide information
✔ Ensure a quiet environment
✔ Prevent interruptions in sleep
✔ Use a caring & appropriate touch
✔ Teach relaxation techniques
✔ Provide spiritual support
✔ Encourage to share concerns and fears
✔ Convey acceptance
✔ Music therapy, pet therapy
5. Diet: small easily digested meals (acute
phase)
6. Monitor and manage potential
complications
✔Monitor changes in cardiac rate and
rhythm, heart sounds, BP, chest pain,
respiratory status, urinary output, skin
color, temperature, sensorium, ECG
changes, and lab values
7. Promoting home and community-based care
• Identify pt’s priorities
• Provide education about heart-healthy living
• Facilitate involvement in cardiac rehabilitation
Cardiac Rehabilitation
- Targets risk reduction by means of education,
individual & group support & physical activity
Goals: To extend life & to improve quality of
life.
Phase I – begins with the diagnosis of
atherosclerosis
⮚Encourage physical activity
⮚Client and family education
⮚Provide counseling
Phase II – from discharge until 4-6 weeks or
up to 6 months
⮚Supervised, often ECG-monitored exercise
training
⮚Support and guidance related to
adherence to treatment program, lifestyle
modification
⮚Outpatient cardiac rehabilitation program
Phase III – focuses on maintaining
cardiovascular stability and long-term
conditioning
⮚Patient is already self-directed
V. Evaluation
✔Relief of angina
✔No signs or respiratory difficulties
✔Adequate tissue perfusion
✔Decreased anxiety
✔Adherence to a self-care program
✔Absence of complications
THE END!