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Acute Coronary Syndromes

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Members of the Presentation

Mr. Herchand RaiMr. Ghaman DasMr. Rashid JokhioMr. Asif

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Objectives of the Presentation At the end of this presentation the participant will: Review anatomy and physiology of the heart. Describe Acute Coronary Syndromes List signs and symptoms of:

– Stable angina– Acute myocardial infarction

Define ischemia, Enlist causes and risk factors of ischemia

Discuss appropriate initial treatment and nursing care plan for ischemic heart disease

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Heart AnatomyHeart Anatomy Facts:

– The heart is about the size of a fist and weighs less than 1 pound

– The average bpm is 72– The average adult heart pumps about 6000-

7500 liters of blood per day through 60,000 miles of blood vessels each minute at rest.

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HeartHeart

Structure– Outer heart layer:

epicardium– Middle heart

layer: myocardium– Inner layer:

endocardium

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HeartHeartStructure (continued)

– Four hollow chambersTwo upper, atriaTwo lower, ventricles

– Divided by septum and valves

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HeartHeartFunction

– Right atrium receives deoxygenated blood

– Right ventricle pumps blood to lungs

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HeartHeartFunction (continued)

– Left atrium receives oxygenated blood

– Left ventricle pumps oxygenated blood to body

– AV valve closure: S1 heart sound

– Semilunar valve closure: S2 heart sound

– Coronary circulation

The coronary arteriesThe coronary arteries..

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Acute coronary syndrome Acute coronary syndrome (ACS) refers to a

spectrum of clinical presentations ranging from those for ST-segment elevation myocardial infarction (STEMI) to presentations found in non–ST-segment elevation myocardial infarction (NSTEMI) or in unstable angina. In terms of pathology, ACS is almost always associated with rupture of an atherosclerotic plaque and partial or complete thrombosis of the infarct-related artery.

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Acute coronary syndrome cont…

In some instances, however, stable coronary artery disease (CAD) may result in ACS in the absence of plaque rupture and thrombosis, when physiologic stress (eg, trauma, blood loss, anemia, infection, tachyarrhythmia) increases demands on the heart. The diagnosis of acute myocardial infarction in this setting requires a finding of the typical rise and fall of biochemical markers of myocardial necrosis in addition to at least 1 of the following:

– Ischemic symptoms– Development of pathologic Q waves– Ischemic ST-segment changes on electrocardiogram (ECG) or in the

setting of a coronary intervention

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Signs and Symptoms Overview Only 30-40% of all MI’s present with typical S & S’s. 60-70% exhibits less typical symptoms:

– Women exhibit less obvious symptoms than men– If over age 75, syncope is the main symptom– Diabetics express very non-specific symptoms– What if you are a diabetic female over the age of 75?

Cardiac risk factors must play an important role in deciding who receives a 12-lead ECG and who does not.

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Cardiac Risk Factors

Factors That Can’t Be Changed

Factors that can be changed or controlled

HeredityGender

Age

Smoking Hypertension

HypercholsterolemiaObesity

Physical InactivityStress

Diabetes

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Ischemic Heart DiseaseIschemic Heart Disease

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Definition" Ischaemia " refers to an insufficient amount

of  blood. The coronary arteries are the only source of  blood for the heart muscle. If this coronary arteries are blocked, the blood supply will reduce.

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Key ConceptsKey ConceptsIschemic heart disease (IHD): caused by

coronary atherosclerotic plaque formation which leads to imbalance between O2 supply & demand– results in myocardial ischemia

Chest pain: cardinal symptom of myocardial ischemia caused by coronary artery disease (CAD)

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Ischemic CycleIschemic CycleIschemia / infarction

chest pain

Diastolic Dysfunction Systolic Dysfunction

cardiac output

catecholamines

MVO2

wall tension

LV diastolic pressurepulmonarycongestionpO2

(heart rate, BP)

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High blood cholesterol High blood pressure Smoking Obesity Lack of physical activity

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Risk FactorsRisk FactorsUncontrollable

•Gender •Hereditary•Race•Age

Controllable•High blood pressure•High blood cholesterol•Smoking•Physical activity•Obesity•Diabetes•Stress and anger

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Myocardial InfarctionMyocardial Infarction Partial or total occlusion of one or more of the

coronary arteries due to an atheroma, thrombus or emboli resulting in cell death (infarction) of the heart muscle

When an MI occurs, there is usually involvement of 3 or 4 occluded coronary vessels

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MI, AtheromaMI, Atheroma When there is an atheroma, as mentioned before there

can be rupture resulting in thrombus formation because of the build up of platelets

When there is breakage of the thrombus there is emboli formation

An emboli can travel to the brain (cerebral infarct) can remain in the heart (myocardial infarct) or even travel to the extremities cutting off blood supply

As the area beneath the is disrupted atheroma hemorrhages, there can is increased risk of abscess formation and infection

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Complications of Complications of Myocardial InfarctionsMyocardial Infarctions

Infarction leading to inability of the heart to function properly leading to Heart Failure

Angina/Pain Cardiogenic shock Ventricular aneurysm and rupture Embolism Formation Arrhythmias Myocardial Infarctions can lead to

Ventricular Fibrillation (shockable!)

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Many people are able to manage coronary artery disease with lifestyle changes and medications.

Other people with severe coronary artery disease may need angioplasty or surgery.

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Management of Ischemic Heart Management of Ischemic Heart DiseaseDisease::

Pharmaceuticals:– Beta Blockers

Act either selectively or non-selectively on Beta receptors:– Beta 1 cardiac muscle increase rate and contraction– Beta 2 dilates bronchial smooth muscle

– Ca++ Channel Blockers Acts on vasculature blocking Ca++ and causing vasodilation

– Nitrates Vasculature vasodilation

– Anti-Hypercholesterolemia HMG CoA Reductase Inhibitors reduction in “manmade”

cholesterol thus helping to reduce atheroma formation– Antiplatelet Medication:

Clopidogrel (Plavix) Aspirin

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Surgical TreatmentSurgical Treatment

1) Stenting2) Angioplasty (balloon)3) Bypass surgery

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Management of Ischemic Heart Management of Ischemic Heart Disease:Disease:

Lifestyle:– Diet– Exercise Preventive treatment• Low fat, low cholesterol diet• Cessation of smoking• Red wine (in moderation)

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Nursing AssessmentNursing Assessment

1. Gather information about all facets of the client’s activities, especially those that precede and precipitate attacks of anginal pain.

2. Assess the risk factors in the client’s history and modifications possible to reduce risk.

3. If chest discomfort is present at the time of the interview, further collection of data is delayed until pain and dysrhythmias are resolved.

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Nursing Assessment cont…Nursing Assessment cont…

4. A complete physical assessment is performed to identify the presence of chest, epigastric, jaw, back, or arm discomfort which is then rated on a subjective scale of 1 to 10 in intensity. The client is questioned regarding nausea, vomiting, diaphoresis, dizziness, weakness, palpitations, and SOB.

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Nursing DiagnosisNursing Diagnosis 1. Pain related to myocardial ischemia.

2. Altered tissue perfusion: related to imbalance

3. between myocardial oxygen supply and demand.

4. Anxiety related to fear of death and knowledge deficit

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Nursing Plan and InterventionsNursing Plan and Interventions Goals

1. Prevention of pain.

2. Improved tissue perfusion as evidenced by absence of chest pain and absence of dysrhythmias.

3. Reduction of anxiety and increased knowledge of disease process.

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Nursing InterventionsNursing Interventions 1. The nurse must teach the client the link between

symptoms and activity and the need to avoid activities known to cause angina, such as sudden exertion, exposure to cold, and emotional excitement.

2. Medications used in the treatment of angina include nitrates, beta-blockers, calcium channel blockers, and platelet antiaggregants. Administer cardiac medication as prescribed and be alert for adverse side effects, particularly their effect on blood pressure. Teach the client the symptoms to be aware of and what measures to take.

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Nursing Interventions cont…Nursing Interventions cont…3. Encourage the client to remain on bed rest in order to

decrease cardiac workload and oxygen consumption.

4. Administer oxygen therapy as prescribed.

5. Evaluate vital signs hourly to determine the hemodynamic effect of the drugs and the client’s tissue perfusion.

6. Nursing care should be planned so that minimal time is spent away from the bedside due to the high level of client anxiety, as well as the unstable condition of the patient.

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Nursing InterventionsNursing Interventions7. Clients with unstable angina are at high risk for myocardial

infarction (MI) and sudden death. The nurse watches for development of heart failure and dysrhythmias.

8. Relieving pain is the top priority for the client with an acute MI, and medication therapy is administered to accomplish this goal.

9. Maintain patent IV for administration of fluids and vasodilators and anticoagulant therapy (Nitroglycerin and heparin). They relieve pain and they aid in minimizing permanent injury to the myocardium.10. Prepare for possible emergency heart catheterization or CABG.

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Nursing Interventions cont…Nursing Interventions cont…11. Whether CABG is planned as an elective procedure or

performed on an emergency basis, the nurse should try to alleviate the client’s and the family’s anxiety and assist them in understanding the need for this life-saving procedure.

12. The nurse describes the postoperative course, emphasizing the close monitoring and use of sophisticated equipment. The client is encourage to tell the nurse about any discomfort post-op.

13. Encourage the client and family members to verbalize their fears and concerns.

14. Teach the client the nature of the illness and the facts needed to reorganize living habits in order to reduce the frequency and severity of anginal attacks, delay the progress of the disease, and avoid other complications.

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EvaluationEvaluation 1. Verbalizes relief of chest pain.

2. No signs of respiratory difficulties.

3. Modifies lifestyle in order to prevent future attacks.

4. Demonstrates increased knowledge of disease process and reduction in anxiety.

5. Absence of complications.

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References Steven R. Bruhl MD, MS (2010). Acute Coronary Syndrome retrieved from

file:///C:/Documents%20and%20Settings/kamla/My%20Documents/Downloads/ACS_PPT_FINAL_6-14-10%20(6).ppt on dated 8-4-2015.

Joy Borrero, RN, MSN. Angina PectorisAcute Coronary retrieved from Syndromehttp://www.mccc.edu/nursing/documents/cardiac1.ppt on dated 6-4-2015.

KELVIN NGUYEN. Acute Coronary Syndrome retrieved from http://www.medicine.uci.edu/residency/powerpoint/acs.ppt on dated: 5-4-2015.

Steven R. Bruhl MD, MS. Acute Coronary Syndrome. retrieved from http://www.utoledo.edu/med/depts/medicine/residency/Didactics/pdf/ACS_PPT_FINAL_6-14-10.ppt on dated: 5-4-2015.

Robert Smith. (2003). Acute Coronary Syndromes retrieved from file:///C:/Documents%20and%20Settings/kamla/My%20Documents/Downloads/studentpresentation08-04-03%20(2).ppt 7-4-2015.