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Acute coronary syndromes result from a sudden blockage in a coronary artery.

This blockage causes unstable angina

or heart attack (myocardial infarction) depending on the location and amount of blockage. People who experience an acute coronary syndrome usually have chest pressure or ache, shortness of breath, and fatigue. y People who think they are experiencing an acute coronary syndrome should call for emergency help and then chew an aspirin tablet. Doctors use electrocardiography (ECG) and measure substances in the blood to determine whether a person is experiencing an acute coronary syndrome. Treatment varies depending on the type of syndrome but usually includes attempts to increase blood flow to affected areas of the heart.

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In the United States, more than 1.5 million people have a heart attack each year. About 400,000 to 500,000 of them die, half before they reach the hospital. Almost all of them have underlying coronary artery disease and about two thirds of them are men. Acute Coronary Syndrome Background: Initial diagnosis of acute coronary syndrome is based almost entirely on history, risk factors, and, to a lesser extent, ECG. The symptoms are due to myocardial ischemia, which has an underlying cause of an imbalance between supply and demand for myocardial oxygen. Pathophysiology: Myocardial ischemia most often develops as a result of reduced blood supply, due to atherosclerotic plaques, to a portion of the myocardium. The plaques initially allow sufficient blood flow to match myocardial demand. These areas of narrowing may become clinically significant and precipitate angina when myocardial demand increases. Angina that is reproduced by exercise, eating, and/or stress and is subsequently relieved with rest and without recent change in frequency or severity of activity necessary to produce symptoms is called chronic stable angina. Over time, the plaques may thicken and rupture, exposing a thrombogenic surface upon which platelets aggregate and thrombi form. The patient may note a change in symptoms of cardiac ischemia with a change in severity or of duration of symptoms. This condition is referred to as unstable angina. A less common cause of angina is dynamic obstruction, which may be caused by intense focal spasm of a segment of an epicardial artery (Prinzmetal angina). Two other causes include arterial inflammation and secondary unstable angina. Arterial inflammation may be caused by or related to infection. Secondary unstable angina occurs when the precipitating cause is extrinsic to the coronary arterial bed, such as fever, tachycardia, thyrotoxicosis, hypotension, anemia, or hypoxemia. Most patients who experience secondary unstable angina have chronic stable angina. Irrespective of the cause of unstable angina, the result of persistent ischemia is myocardial infarction (MI). Frequency: In the US: Estimates of frequency and prevalence of angina are of limited accuracy due to the variable nature of the disease and history-based diagnosis. Treatment modalities and variations in diagnostic criteria also affect prevalence. Internationally: In Britain, annual incidence of angina is estimated at 1.1 cases per 1000 males and 0.5 cases per 1000 females aged 31-70 years. In Sweden, chest pain of ischemic origin is thought to affect 5% of all males aged 50-57 years. In industrialized countries, annual incidence of unstable angina is approximately 6 cases per 10,000 people. Mortality/Morbidity: When the only treatment for angina was nitroglycerin and limitation of activity, studies of patients with newly diagnosed angina indicated 40% incidence of MI and 17% mortality within 3 months of onset. More recent studies show that prognosis of patients with stable angina pectoris is significantly better due to improvements in identification, risk stratification, and intervention. Clinical characteristics associated with a poor prognosis include advanced age, male sex, prior MI, diabetes, hypertension, and multiple-vessel or left-mainstem disease. Sex: Incidence is higher in males in those younger than 70 years. This is due to the cardioprotective effect of estrogen in females. At 15 years postmenopause, incidence of angina occurs with equal frequency in both sexes. Age:

Angina becomes progressively more common, as does the underlying cardiac disease responsible, with increasing age. In persons aged 40-70 years, angina is diagnosed more often in men than in women. In persons older than 70 years, men and women are affected equally. Acute coronary syndrome (ACS) is usually one of three diseases involving the coronary arteries: ST elevation myocardial infarction (30%),non ST elevation myocardial infarction (25%), or unstable angina (38%).[1] These types are named according to the appearance of the electrocardiogram (ECG/EKG) as non-ST segment elevation myocardial infarction (NSTEMI) and ST segment elevation myocardial infarction (STEMI).[2] There can be some variation as to which forms of MI are classified under acute coronary syndrome.[3] ACS should be distinguished from stable angina, which develops during exertion and resolves at rest. In contrast with stable angina, unstable angina occurs suddenly, often at rest or with minimal exertion, or at lesser degrees of exertion than the individual's previous angina ("crescendo angina"). New onset angina is also considered unstable angina, since it suggests a new problem in a coronary artery. Though ACS is usually associated with coronary thrombosis, it can also be associated with cocaine use.[4] Cardiac chest pain can also be precipitated by anemia, bradycardias(excessively slow heart rate) or tachycardias (excessively fast heart rate).

Acute coronary syndrome is a term used for any condition brought on by sudden, reduced blood flow to the heart. Acute coronary syndrome can describe chest pain you feel during a heart attack, or chest pain you feel while you're at rest or doing light physical activity (unstable angina). Acute coronary syndrome is often diagnosed in an emergency room or hospital. Acute coronary syndrome is treatable if diagnosed quickly. Acute coronary syndrome treatments vary, depending on your signs, symptoms and overall health condition. Symptoms By Mayo Clinic staff Many acute coronary syndrome symptoms are the same as those of a heart attack. And if acute coronary syndrome isn't treated quickly, a heart attack will occur. It's important to take acute coronary syndrome symptoms very seriously. Get medical help right away if you have these signs and symptoms and think you're having a heart attack:

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Chest pain (angina) that feels like burning, pressure or tightness and lasts several minutes or longer Pain elsewhere in the body, such as the left upper arm or jaw (referred pain) Nausea Vomiting Shortness of breath (dyspnea) Sudden, heavy sweating (diaphoresis) If you're having a heart attack, the signs and symptoms may vary depending on your sex, age and whether you have an underlying medical condition, such as diabetes. Some unusual heart attack symptoms include:

Abdominal pain

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Pain similar to heartburn Clammy skin Lightheadedness, dizziness or fainting Unusual or unexplained fatigue Feeling restless or apprehensive When to see a doctor If you're having chest pain and you believe it's an emergency situation, seek medical help immediately. Whenever possible, get emergency medical assistance rather than driving yourself to the hospital. You could be having a heart attack. If you have recurring chest pain, talk to your doctor. It could be a form of angina, and your doctor can help you decide the best course of treatment. Causes By Mayo Clinic staff Acute coronary syndrome may develop slowly over time by the building up of plaques in the arteries in your heart. These plaques, made up of fatty deposits, cause the arteries to narrow and make it more difficult for blood to flow through them. This buildup of plaques is known as atherosclerosis. Eventually, this buildup means that your heart can't pump enough oxygen-rich blood to the rest of your body, causing chest pain (angina) or a heart attack. Another medical term closely related to acute coronary syndrome is coronary artery disease. Coronary artery disease refers to the damage to your heart arteries from atherosclerosis. If one of the plaques in your coronary arteries ruptures, it can cause a heart attack. In fact, many instances of coronary artery syndrome develop after a plaque ruptures. A blood clot will form on the site of the rupture, blocking the flow of blood through that artery. Risk factors By Mayo Clinic staff The risk factors for acute coronary syndrome are similar to those for other types of heart disease. Acute coronary syndrome risk factors include:

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Older age (older than 45 for men and older than 55 for women) High blood pressure High blood cholesterol Cigarette smoking Lack of physical activity Type 2 diabetes Family history of chest pain, heart disease or stroke lab How Does Cholesterol Cause Heart Disease? When there is too much cholesterol (a fat-like substance) in your blood, it builds up in the walls of your arteries. Over time, this buildup causes "hardening of the arteries" so that arteries become narrowed and blood flow to the heart is slowed down or blocked. The blood carries oxygen to the heart, and if enough blood and oxygen cannot reach your

heart, you may suffer chest pain. If the blood supply to a portion of the heart is completely cut off by a blockage, the result is a heart attack. High blood cholesterol itself does not cause symptoms, so many people are unaware that their cholesterol level is too high. It is important to find out what your cholesterol numbers are because lowering cholesterol levels that are too high lessens the risk for developing heart disease and reduces the chance of a heart attack or dying of heart disease, even if you already have it. Cholesterol lowering is important for everyone--younger, middle age, and older adults; women and men; and people with or without heart disease. LDL (bad) cholesterol--the main source of cholesterol buildup and blockage in the arteries high blood sodium level means you have hypernatremia and is almost always due todehydration without enough water intake. Symptoms include dry mucous membranes, thirst, agitation, restlessness, acting irrationally, and coma or convulsions if levels rise extremely high. In rare cases, hypernatremia may be due to increased salt intake without enough water, Cushing syndrome, or a condition caused by too little ADH, called diabetes insipidus. Sodium urine concentrations must be evaluated in association with blood levels. Concentrations may mirror blood levels or be the opposite. The body normally excretes excess sodium, so the concentration in the urine may be elevated because it is elevated in the blood. It may also be elevated in the urine when the body is losing too much sodium. In this case, the blood level would be normal to low. If blood sodium levels are low due to insufficient intake, then urine concentrations will also be low.

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Decreased urinary sodium levels may indicate dehydration, congestive heart failure, liver disease, or nephrotic syndrome. Increased urinary sodium levels may indicate diuretic use or Addison's disease.

Sodium levels are often evaluated in relation to other electrolytes and can be used to calculateanion gap in order to identify the cause of acidosis. A low hemoglobin count is a below-average concentration of the oxygen-carrying hemoglobin proteins in your blood. Hemoglobin (Hb or Hgb) is the main component of red blood cells. A low hemoglobin count is generally defined as less than 13.5 grams of hemoglobin per deciliter (135 grams per liter) of blood for men and less than 12 grams per deciliter (120 grams per liter) for women. In children, the definition varies with age and sex. The threshold differs slightly between medical practices. A low hemoglobin count is a common blood test result. In many cases, a low hemoglobin count is only slightly lower than normal, isn't considered significant and causes no symptoms. A low hemoglobin count can also be caused by an abnormality or disease. In these situations, a low hemoglobin count is referred to as anemia. Electrocardiogram (ECG) An electrocardiogram (ECG or EKG) measures and records the electrical activity of the heart. The waves measured by the ECG correspond to the contraction and relaxation pattern of the different parts of the heart. Specific waves seen on an ECG are named with letters as follows: The P wave is associated with the contractions of the atria (the two chambers in the heart that receive blood from outside). QRS. The QRS is a series of waves associated with ventricular contractions. (The ventricles are two major pumping chambers in the heart.) T and U. These waves follow the ventricular contractions. Click the icon to see an image of a normal sinus rhythm. Physicians will use a term called the P-Q or P-R interval, which is the time taken for an electrical impulse to travel from the atria to the ventricle. The most important wave patterns in diagnosing and determining treatment for a heart attack are called ST elevations and Q waves.

Elevated ST Segments: Heart Attack. Elevated ST segments are strong indicators of a heart attack in patients with symptoms and other indicators. They suggest that an artery to the heart is blocked and that the full thickness of the heart muscle is damaged. When this finding coincides with a heart attack, the condition is sometimes referred to as either as a Q-wave myocardial infarction or a STEMI (ST-segment elevation myocardial infarction). ST-elevations are strong indicators for aggressive treatments (thrombolytic drugs or angioplasty) to reopen blood vessels. (ST segment elevations do not always mean the patient has a heart attack. Also some heart attack patients do not have elevated ST segments. Other factors are important in making a diagnosis.) Non-Elevated ST Segments: Angina and Acute Coronary Syndrome. A depressed or horizontal ST wave suggests some blockage and the presence of a heart disease, even if there is no angina present. It occurs in about half of patients with other signs of a heart event. This finding, however, is not very accurate, particularly in women, and can occur without heart problems. In such cases, laboratory tests are needed to determine the extent, if any, of heart damage. In general, one of the following conditions may be present: Stable Angina (blood test results or other tests show no serious problems and chest pain resolves). Most patients with angina can go home. (It should be noted that between 25% and 50% of people who suffer from angina or have silent ischemia have normal ECG readings.) Acute Coronary Syndrome (ACS). This includes severe and sudden heart conditions that require aggressive treatment but have not developed into a full-blown heart attack. ACS, refers to either unstable angina or NSTEMI (non ST-segment elevation myocardial infarction)--also referred to as non Q-wave myocardial infarction. Unstable angina is potentially serious and chest pain is persistent, but blood tests do not show markers for heart attack. With NSTEMI, the blood tests suggest a developing heart attack, but most likely, injury in the arteries is less serious than with a full-blown heart attack. Acute coronary syndrome Introduction An acute coronary syndrome occurs when a sudden blockage in a coronary artery greatly reduces or cuts off the blood supply to an area of the heart muscle (myocardium). The lack of blood supply to any tissue is termed ischemia. If the supply is greatly reduced or cut off for more than a few minutes, heart tissue dies. A heart attack, also termed myocardial infarction (MI), death of heart tissue from ischemia. A blood clot is the most common cause of a blocked coronary artery. Usually, the artery is already partially narrowed by atheromas. An atheroma may rupture or tear, which releases substances that make platelets stickier, encouraging clots to form. Types of Acute Coronary Syndromes - or heart attacks Unstable angina: is a new symptom or a change from stable angina. The angina may occur more frequently, occur more easily at rest, feel more severe, or last longer. Unstable angina is an acute coronary syndrome and should be treated as a medical emergency. Non-ST segment elevation myocardial infarction (NSTEMI): This heart attack, or MI, does not cause changes on an electrocardiogram (ECG). In NSTEMI, the blockage may be partial or temporary, and so the extent of the damage relatively minimal. ST segment elevation myocardial infarction (STEMI): This heart attack, or MI, is caused by a prolonged period of blocked blood supply. It affects a large area of the heart muscle. Sign and Symptoms The cardinal sign of decreased blood flow to the heart is chest pain experienced as tightness around the chest and radiating to the left arm and the left angle of the jaw. This may be associated with diaphoresis (sweating), nausea and vomiting, as well as shortness of breath. In many cases, the sensation is "atypical", with pain experienced in different ways or even being completely absent (which is more likely in female patients and those with diabetes). Some may report palpitations, anxiety or a sense of impending doom and a feeling of being acutely ill. People with presumed ACS are typically treated with aspirin, nitroglycerin, and if the chest discomfort persists morphine. Prognosis Most people who survive for a few days after a heart attack can expect a full recovery, but about 10% die within a year. Most deaths occur in the first 3 or 4 months, typically in people who continue to have angina, abnormal heart rhythms originating in the ventricles (ventricular arrhythmias), and heart failure. The

prognosis is worse if the heart has enlarged after a heart attack than if heart size remains normal. Older people are more likely to die after a heart attack and to have complications, such as heart failure. National Statistics: A conservative estimate for the number of having ACS in the Hospital in 2006 is 733,000. Of these, an estimated 401,000 are female and 332,000 are male. The data found a 9.6 percent death rate for women versus a 5.3 percent death rate for men in the 30 days after an acute coronary syndrome, which includes events such as heart attack or unstable angina. International Statistics: In the US, about 1.5 million ACS occur annually, ACS results in death for 400,000 to 500,000 people, with about half dying before they reach the hospital. OBJECTIVES General Objectives: Acquired deeper knowledge and understanding of the development of acute coronary syndrome, discuss management and treatment and provide better nursing care. Specific Objectives: To be able to understand the causes of the disease. To describe the development, pathophysiology, medical-surgical management, and nursing care for the patient with Acute Coronary Syndrome. To be able to design and implement a Nursing Care Plan for the patient. To provide information and heath teachings for the progress of patient. To perform nursing procedures and nursing considerations for a patient. To establish therapeutic relationship with the patient and his family. To help the patient cope with his condition

Coronary Circulation The heart muscle, like every other organ or tissue in your body, needs oxygen-rich blood to survive. Blood is supplied to the heart by its own vascular system, called coronary circulation. The aorta (the main blood supplier to the body) branches off into two main coronary blood vessels (also called arteries). These coronary arteries branch off into smaller arteries, which supply oxygen-rich blood to the entire heart muscle. The right coronary artery supplies blood mainly to the right side of the heart. The right side of the heart is smaller because it pumps blood only to the lungs. The left coronary artery, which branches into the left anterior descending artery and the circumflex artery, supplies blood to the left side of the heart. The left side of the heart is larger and more muscular because it pumps blood to the rest of the body.