Acute Coronary Syndromes (MI-ST and Non ST, Unstable Angina ):

Definition/Etiology:

• Acute coronary syndrome (ACS): the suspicion or confirmed
  presence of acute myocardial ischemia caused by POOR
  PERFUSION
• Caused by clots, narrowed coronary arteries or vasospasms
  and damages the myocardium (heart muscle)
• Acute coronary syndrome may be further classified into the
  following categories:
  • Unstable angina
  • NSTEMI
  • STEMI

Pathophysiology:

• Unstable Angina
  • Partial Occlusion of coronary artery
  • “Traffic cones in the road”
  • No damage to myocardium
• NSTEMI
  • Partial occlusion of coronary artery
  • “One lane closed in the highway”
  • Damage to myocardium: inner layer only
• STEMI
  • Complete occlusion of coronary artery
  • “All lanes washed away – no road!”
  • Affects ALL layers of heart muscle

Noticing: Assessment & Recognizing Cues:

• Assessment
  • Pain (OLDCARTS or PQRST)
  • Heart monitor
    • Tachycardia, arrhythmias, waveform changes
  • Heart and Lungs sounds
    • symptoms of heart failure, murmurs
  • Frequent Vitals
• Subjective Cues
  • PAIN (including at rest
    • <20 MINS Unstable Angina/NSTEMI
    • >20 mins STEMI
  • SOB
  • DIZZY
  • Numbness
  • Anxiety
  • Nausea
  • Palpitations
  • Syncope
  • IMPENDING DOOM
• Objective Cues
  • Pallor
  • Vomiting
  • Syncope
  • Diaphoresis
  • Dyspnea

Interpreting: Analyzing & Planning:

• ECGS = ACS Type/Location
  • ECG Timing
    • ECG within 10 minutes of ED arrival.
    • Repeat every 15 minutes or so
• NSTEMI
  • ST Depression
  • T wave inversion
• STEMI
  • ST Elevation
  • Hyperacute T waves
• Priority Labs = Troponin
  • Troponin Timing ‘Drawn Serially”
    • Higher the troponin = worse the damage
    • Starts rising 3-6 hours after an MI
    • Peak 16 hours
    • Normal in 2 weeks
      • “Normal” = 0.04 ng/ml
  • Troponin determines ACS Type/Damage Extent
    • Unstable Angina = NEG Trop
    • NSTEMI = POS Trop
    • STEMI= POS Trop

Responding: Patient Interventions & Taking Action:

• Priority Pharmacological Interventions
  • Oxygen
    • If symptomatic
  • Nitrates
    • 0.4 mg SL Q 5 mins x 3
  • Aspirin
    • Platelets less sticky
  • Morphine
    • Dosing = low & slow
• Priority Non-Pharmacology
  • IV Access
  • Vitals
  • EKG results = intervention
    • Unstable Angina = Heparin gtt
    • NSTEMI = Heparin gtt → Cath Lab
    • STEMI = CATH LAB
• STEMI = Cath Lab
  • PCI (stent) in 90 mins
    • Clot Busters if not available (if not contraindicated)
  • GOAL = RESOLVE chest pain

Reflecting: Evaluating Patient Outcomes:

• Continued Monitoring
  • PCI?
    • Site monitoring
      • Radial vs Femoral
    • Retroperitoneal Bleed
      • Flank Pain, Hypotension, etc
    • Renal Panel
      • Procedure Dye
  • Vitals
    • Consider Hypotension if nitrates used
    • Reduction of pain = BETTER PERFUSION
      • Pain return? STENT CLOSED. EMERGENCY
  • Continuous bedside telemetry monitoring
    • ST Segment monitoring is vital
  • Troponin Levels Q 3-6 hours
    • The Lower the better
  • Continued IPharm
    • P2Y12 Inhibitors
      • Keep Stent open
    • Beta-Blockers
      • Start within 24 hours of PCI
    • STATINs
      • ↓ inflammation
    • ACE/ARBS
      • Prevents “remodeling”

Linchpins (Key Points):

• Consider Perfusion: Time = Tissue
  • MUST WATER GARDEN
• Notice: Signs of Ischemia
• Interpret: EKG within 10 minutes & Serial Troponin
• Respond: ONAM (NOT MONA) & STEMI = Cath Lab
• Reflect: NO PAIN = IMPROVED PERFUSION + WATCH ST segment monitoring