Acute Coronary Syndrome

Definition/Etiology:

Acute Coronary Syndrome
Chest pain caused by decreased oxygen supply to the heart (myocardial ischemia)

Acronyms:
ACS – acute coronary syndrome
AMI – acute myocardial infarction = heart attack
N-STEMI – non-ST elevation myocardial infarction
STEMI – ST elevation myocardial infarction
SOB – shortness of breath
MONA – morphine, oxygen, nitroglycerin, aspirin

Pathophysiology:

Acute Coronary Syndrome
(How, why)

Word Play:
Acute coronary syndrome (ACS) – think coronary artery
Coronary artery – blood supply of heart muscle
Syndrome = symptoms

Four stages:

SUNS
Short, Unrelieved, Not okay, Severe
Stable angina, Unstable angina, N-STEMI, STEMI

Highway – on the way to an important test
Stable angina – cone in the middle of the road
Unstable angina – lane closure
N-STEMI – accident intermittent closure
STEMI – highway closed (bypass – see alternate route)

Clinical Presentation:

Stable angina – chest pain upon exertion, short lived, relieved by rest or meds

Unstable angina – chest pain occurs at any time, unrelieved by rest or meds, negative troponin, maybe ST depression

ST depression = ischemia (not enough oxygen)

N-STEMI – AMI ischemic chest pain, intermittent coronary occlusion/blockage, no ST elevation (maybe ST depression), positive troponin, admission pt not okay

STEMI – AMI, obstructed coronary artery with thrombosis, ST elevation, positive troponin, immediate intervention = severe and life threatening

AMI

Chest pain or discomfort (burning, crushing, tightness, pressure, and aching)

Radiation – arm, neck, jawline, back, or shoulder

Other – nausea/vomiting, “indigestion,” SOB, diaphoresis, dizziness, syncope, palpitations, tachycardia, bradycardia

Collaborative Management:

• 12-lead ECG
• Treat chest discomfort
• Continuous monitoring
• Cardiac enzymes – troponin, CK-MB
• Chest x-ray and labs
• Pharm management – MONA
• STEMI
  • Reperfusion! Reperfusion! Reperfusion!
  • Gold standard – PCI <90 minutes
  • Fibrinolytics – “who’ya gunna call; clot busters”
  • Post – beta-blockers, ace inhibitors, ARB if no ACE inhibitors

Evaluation | Patient Monitoring | Education:

Keep on monitor. Frequent BPs. Enough IVs in case of arrest? Watch out for changes (EKG, LOC, etc.). SAFETY – even in ER.

Linchpins: (Key Points)

Decreased oxygen supply

SUNS
Short, Unrelieved, Not okay, Severe
Stable angina, Unstable angina, N-STEMI, STEMI

Highway – on the way to an important test

Stable angina – cone in the middle of the road
Unstable angina – lane closure
N-STEMI – accident intermittent closure
STEMI – highway closed (bypass – see alternate route)