Acute coronary Kingdom of Saudi Arabia

Ministry of Health
King Fahad Hofuf Hospital
syndrome Nursing Education

Presented by:
Nursing Education
Coordinator
Aqeel Jawad Almutlaq
 OUTLINES

 Definitions.  Location of the MI.

 Risk Factors of ACS.  Diagnostic Test.

 Signs And Symptoms.  Medical management.

 Complication of MI.  Nursing interventions.

 
Three systems have to work efficiently for the heart to pump Blood:

Circulatory system Conduction system Coronary system

 Definitions:
 The term Acute Coronary Syndrome covers a broad spectrum of clinical
situations including:

 Unstable Angina.
 Non ST -segment elevation myocardial infarction (NSTEMI).
 ST-segment elevation myocardial infarction (STEMI).
 Angina
It’s a partial occlusion of the Coronary Artery and it’s classified to:

 Stable Angina: is chest pain or discomfort that most often occurs with activity or
emotional stress.

 Unstable angina:  occurs randomly or unpredictably and is unrelated to any

obvious trigger such as physical exertion or emotional stress

 Variant Angina: is angina pectoris secondary to epicardial coronary artery spasm.

 Silent Ischemia
 Myocardial Infarction

It’s a total Occlusion of the Coronary Arteries.

 S-T elevation MI

 Non-ST elevation MI
 Transient ST-segment elevation
 ST-segment depression
 T-wave inversion MI
 Silent MI
Pathogenesis of Plaque Formation
 Risk Factors of ACS

Risk factors can be divided:

Modifiable risk factors.
Unmodifiable risk factors.
  Modifiable risk factors:

Elevated serum lipids Physical inactivity

Hypertension Diabetes mellitus

Smoking Stressful lifestyle

  Unmodifiable risk factors:

Age
Gender
Ethnicity
Genetic predisposition
 Signs And Symptoms

 Chest Pain – Radiate to the Neck,  Nausea, Vomiting

Jaw, Upper back, Elbow and Left  Dizziness

hand.  ECG Changes (T- wave

 Dyspnea inversion, ST depression,

 Excessive Sweating Elevation)

 Fatigue
 Complications of MI

 Dysrhthmias
 Heart failure / cardiogenic shock
 Hypertension
 Pericarditis
 Rupture of papillary muscles and ventricular
aneurysm
 Location of the MI

Left Coronary Artery : supplies

approximately 60-70% of the myocardium.

Left Anterior Descending (LAD):

Supplies 40% of the myocardium. Occlusion

may LVF Heart Block (interventricular septum)

Right Coronary Artery (RCA): Occlusion

may cause RVF & SA Dysfunction and

bradycardia
 Diagnostic Test

ECG
Continuous ECG monitoring ( usually in the CCU).
12 leads ECG and compared with previous ECG
ECG changes :
Angina: ECG may show T-wave inversions, ST segment depressions or
normal ECG.
MI: ST Elevation, Q wave MI
 Cardiac Enzymes Biochemical Markers

Trop I and Trop T ( Most sensitive) ( after 6 hrs).

Myoglobin (found in skeletal and cardiac muscle- released from ischemic muscle
occurs earlier than the release of CK.
CK and CK-MB : ↑ more rapidly than the troponins, but less sensitive and less specific
marker of myocyte damage.
 Protein First Detection Duration of Sensitivity for Specificity for
Detection Myocyte Myocyte
Necrosis Necrosis

Myoglobin 1.5-2 hours 8–12 hours +++ +

CK-MB 2–3 hours 1–2 days +++ +++
Troponin I 3–4 hours 7–10 days ++++ ++++
Troponin T 3–4 hours 7–14 days ++++ ++++
Creatine kinase 4–6 hours 2–3 days ++ ++
Aspartate 6–10 hours 3–5 days ++ +
aminotransferase
 Other medical investigations

 Exercise Treadmill Test: Detecting ECG changes while on exercise.

 Echocardiography: Evidence of LVF

 Thallium scanning: evidence of dead tissue (irreversible damage)

 Angiography (PCI): location of the occlusion(s)

 Aims of Medical Management

 Relief of pain (Opioids).

 Reduction in infarct size
 Stabilisation of haemodynamic (cardiac output, renal
function)
 Prevention of complications ( another MI, Arrhythmias,
LVF and AF)
 Patient education
 Reducing Infarct Size: (Reperfusion)

Pharmacological Reperfusion:
The earlier reperfusion therapy is initiated after the onset of symptoms, the smaller
the infarct size and the greater the survival benefit (i.e. door to needle time !).
Streptokinase, rt-plase.
 Pharmacological Treatment :
1) Antiplatelet (Aspirin & Clopedgril
2) IV Heparin (Anticoagulant)
3) Enoxparine (LMWH)
4) B-Blockers (i.e. Atenolo)
5) Nitrates (i.e. Isoket, GTN)
6) Ca Channels Blockers (i.e.
Amlpdipine & Felodipine)
Reduce clot formation
Anti-coagulant reduce clot
formation
 Myocardial O2 demand by
HR & Contractility
Vasodilation (venous return
(pre-load) & vasodilation of
coronary arteries, Coronary
perfusion
Peripheral Vasodilation, BP, &
some cause Coronary perfusion
 Non-Pharmacological Reperfusion:

 Percutaneous Transluminal Coronary Angioplasty (PTCA):

One or two vessels disease.

 Coronary Artery Bypass Graft (CABG):

o triple-vessel coronary artery disease
o or disease of the left main coronary
o artery.
 Nursing Priorities and Interventions

Morphine: Pain Relief Diamorphine 2.5 – 10 mgs IV

Oxygen : (high %) unless contraindicated
Nitrate : Vasodilators (check BP)
Aspirin : (unless contraindicated) but may also consider Heparin,
Clexane and Warfarin if needed.
 Nursing Priority (1): Chest Pain

1. Assess quality, duration, location of pain.

2. Administer IV morphine sulfate.

3. Provide a calm, quiet environment.

4. Administer analgesics appropriately for chest pain.

 Nursing Priority (2): Oxygenation/ ventilation

1. Assess respiratory rate, effort, and breath sounds q2–4h.

2. Obtain arterial blood gases per order.

3. Monitor arterial saturation by pulse oximeter.

4. Provide supplemental oxygen by nasal cannula or face

mask for the first 6 h, then as needed.

 Nursing Priority (3): Circulation / Perfusion

1. Monitor HR and BP q1–2h and PRN during acute failure phase.

2. Assist with pulmonary artery catheter insertion.

3. Maintain patent IV access.

4. Administer positive inotropic agents.

5. Evaluate effect of medications on BP, HR, & hemodynamic readings.

6. Prepare patient for intra-aortic balloon pump assist if necessary.

 Nursing Priority (4) : Dysrhythmia

1. Apical pulse is counted and heart sounds are assessed.

2. Close observations are maintained for the changes shown by ECG.

3. Antiarrhythmic drugs are administered by order of the physician,

4. Serum K+ levels are followed,

5. Effects of the antiarrhythmic drugs are observed,

6. Any changes over the ST segment of ECG is reported to the physician.

 Nursing Priorities (5): Psychosocial support

1. Provide explanations and stable reassurance in calm & caring manner.

2. Cautiously administer sedatives and monitor response.

3. Assess coping mechanism history.

4. Allow free expression of feelings.

5. Encourage patient/family participation in care.

6. Provide blocks of time for adequate rest and sleep.