ACUTE CORONARY SYNDROME

Acute coronary syndrome is exactly what it says, a syndrome.  This syndrome encompasses a few different actual entities.  These include unstable angina, non-ST elevated myocardial infarction ( NSTEMI), and ST elevation myocardial infarction (STEMI).

Unstable Angina is a somewhat grey area.  It is a place somewhere between stable angina and an acute myocardial infarction.  This can include patients with angina at rest and patients with new onset angina.

The pathophysiology surrounding the acute coronary syndrome involves the disruption of plaque.  Fissuring or rupture of these plaques leads to the local generation of thrombin-fibrin.  This promotes platelet aggregation and the formation of a thrombus; unstable angina and NSTEMI are generally white, platelet-rich, and only partially occlusive thrombus.  STEMI’s, in contrast, involve a red, fibrin-rich, and more occlusive thrombus.

Diagnosis of unstable angina and NSTEMI’s have similar clinical presentations.  Cardiac marker ( CK, CK-MB, and Troponin ) are useful in the diagnosis of the NSTEMI.  An NSTEMI may have a normal EKG and thus obtaining cardiac markers are of the utmost importance.  You can find texts that go into more depth regarding the pathophysiology of acute coronary syndrome.

STEMI actually show an elevation of the ST segment on the 12 lead EKG.  This elevation can usually show what area of the heart has ischemia or has been damages.  The different areas of the heart that can be damaged are related to the coronary arteries that have been occluded.  Please refer to the page in this portion of the Intro to Critical Care Nursing, Coronary Care Unit,  learn about the different coronary arteries and the injury that can occur to the different areas of the heart with these being occluded.

Treatment of these patients, whether having a NSTEMI or a STEMI, in the Emergency Department usually include (if not contraindicated) the patient receiving aspirin, a beta-blocker, possible nitroglycerin sub-lingual and sometimes by IV drip.  These patients are also often started on a heparin drip until they can be taken to the cath lab for coronary catheterization where any interventions that are required may be done.  The American Heart Association has come up with guidelines and protocols for the treatment of patients presenting with acute coronary syndrome.  These guidelines have undoubtedly increased the favorable results of treatment of this disease.  See the page about Emergency Department Protocols.

Knowing the warning signs of a heart attack are very important.  They are important for the public at large; but particularly important for the RN to know so that she can educate patients for signs to watch for in the future.  Patient education is a very important aspect of the role of the nurse.  The following are typical signs of a heart attack:  chest discomfort, discomfort in other areas of the upper body, shortness of breath, the skin becoming moist, nausea, and lightheadedness.  Teach the patient that if any of these occur they should not drive themselves to the hospital, but call 9-1-1.

Calling 9-1-1 is very important as a heart attack is a potentially life threatening event.  An ambulance can bring life saving treatment which includes a defibrillator and medications, plus the knowledge to use these in the most effective manner.  You can access a page on this web site that will give you a brief overview of what is called ACLS (Advanced Cardiac Life Support).

Extensive studies have been to determine the risks associated for Coronary Heart Disease.  The American Heart Association has identified several risk factors for Coronary Heart Disease.  Some of these risks can be treated, or even done away with; and other risks cannot be modified.

Risk Factors that cannot be modified:

     Increasing Age

     Gender (Male)

     Heredity (Including Race)
 

Risk Factors that can be modified or treated:

     Smoking

     High Cholesterol

     High Blood Pressure

     Physical Inactivity

     Obesity

     Diabetes Mellitus
 

Other Factors that contribute to heart disease risk:

     Stress

     Alcohol

*The above information regarding risk factors for heart disease was obtained from the American Heart Association web site.