1. Acute Coronary Syndromes
At the end of this self-study the participant will:
Describe the pathophysiology of Acute Coronary Syndromes
List signs and symptoms of:
Stable angina
Unstable angina
Acute myocardial infarction

2. What is ACS?
The term Acute Coronary Syndrome (ACS) includes a constellation of syndromes: chest pain, unstable angina, non ST elevation MI (Non-STEMI) and ST elevation MI (STEMI).
The American College of Cardiology (ACC) and American Heart Association (AHA) recommends that health care providers use the term ACS as a provisional diagnosis and once the diagnosis is made use the term that applies: Chest Pain Syndrome, Unstable Angina, Non-Q wave MI and Q-wave MI.
Mortality rates and the risk associated with ACS is the greatest during the first 30 days after presentation and stabilizes to a lower rate after 30 days, validating the importance of early diagnosis and treatment.1

3. ACS: Triad of I’s Ischemia vs. Injury vs. Infarction
All represent an oxygen supply problem:
Ischemia = reversible
Injury = acute period of both ischemia and infarction
Infarction = irreversible cell death

4. ACS Unstable angina (U/A)
a clinical syndrome usually resulting from disrupted atherosclerotic plaque, which subsequently results in an imbalance between myocardial oxygen supply and demand.
U/A and Non-STEMI are closely related in presentation.
ECG may show ST depression,
or be normal
Cardiac enzymes are normal
Ischemia is reversible

5. ACS Non-ST Elevation Myocardial Infarction (Non-STEMI)
Differs from unstable angina mostly due to severity of ischemia
Non-STEMI causes enough myocardial damage to release detectable cardiac markers indicating myocardial injury [Troponin I (TnI), Troponin T (TnT), and/ or Creatinine kinase( CK-MB)].1
ECG changes may occur
No sustained ST segment elevation.
Can limit the area of infarction through medical and nursing interventions

6. ACS ST Elevation Myocardial Infarction (STEMI)
a loss of cardiac myocytes as a result of prolonged ischemia due to a perfusion-dependent imbalance between supply and demand.
Myocardial ischemia does not cause immediate cell death but rather it occurs over a finite period of time. It can take at least 4 to 6 hours for complete necrosis of myocardial cells
This is dependent upon the presence of collateral blood flow into the ischemic zone or coronary artery occlusion.2
Examples of ST changes in STEMI

7. ECG changes that commonly occur with increasing levels of coronary artery occlusion
When a patient is admitted to the emergency department (ED) with ischemic type chest pain, it is difficult to assess if they are having an AMI or not. The 12-Lead electrocardiogram (ECG) is key to sending them down the correct treatment algorithm. This is based on whether the ECG has ST-segment elevation(STEMI), new LBBB, or presents with a non-ST-segment elevation (NSTEMI) pattern. The ECG determines which algorithm the patient is placed into and if a reperfusion strategy is offered.
There is no myocardial necrosis with UA. Myocardial necrosis does occur with NQMI and QMI, with the distinction between these two diagnoses placed on the development of electrocardiographic Q waves.
The amount of interference of blood supply-measured by the extent of coronary obstruction (by plaque & thrombus) and how developed the collateral circulation is ranges from nonexistent to significant or complete obstruction.
Clinical manifestations may be absent or present (UA/AMI/Sudden Death).
This slide visualizes open lumen with the beginning of plaque formation with progression to occlusive thrombus. It also demonstrates the common ECG changes that commonly occur with these lumen changes.
Clinical presentation and history, ECG analysis, and cardiac markers of necrosis are critical in diagnosis and risk stratification. Each of these important topics will be addressed.

8. 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.

9. Cardiac Risk Factors Factors That Can’t Be Changed
Factors that can be changed or controlled
Heredity
Gender
Age
Smoking
Hypertension
Hypercholsterolemia
Obesity
Physical Inactivity
Stress
Diabetes

10. History of Presenting Illness
The most important diagnostic information is the patient’s “story”
Current symptoms
Time of onset
Pain assessment
Past medical history / medications

11. “Typical” Signs and Symptoms of MI
Associated Signs and Symptoms of MI
“Typical” Signs and Symptoms of MI
Denial
Chest discomfort
Syncope/weakness
Cool/pale/diaphoretic
Dyspnea
Nausea/vomiting
Sense of impending doom
Chest discomfort:
Crushing, pressure, tightness
Sustained
Unrelieved or partially relieved by rest
Unrelieved or partially relieved by nitroglycerin
Pain may radiate to other areas

12. PQRST: Eliciting pain information
P: Placement/ provocation/ precipitating factors
Q: Quality
R: Radiation, relief and reproducibility
S: Severity (0-10 scale)
T: Time of onset

13. Women’s Issues Heart disease leading cause of death
Sharp rise in smoking-related illness
1/3 of adult women are sedentary
1 in 3 women are overweight
More nonfatal chronic conditions
Less available supports
Because many chronic conditions are disabling, middle-aged and older women are about 80% more likely than men to report difficulties in taking care of themselves.
Women's Issues:
Heart disease leading cause of death
Heart disease continues to be the leading cause of death with a key factor being the high death rate in the oldest age categories.
Sharp rise in smoking-related illness
Smoking is a significant factor leading to heart disease. Presently about 23% of women smoke. The report cites a tripling of the deaths related to lung cancer among women since 1970.
One-third of adult women are sedentary.
Sedentary lifestyle is one of the 5 controllable independent risk factors for heart disease. (Obesity was just added to the list.)
1 in 3 women are overweight.
Proportion of overweight women increased from 1 in 4 to 1 in 3 over the past decade.
More nonfatal chronic conditions which make them . . .
More likely to have problems taking care of themselves
Because many chronic conditions are disabling, middle-aged and older women are about 80% more likely than men to report difficulties in taking care of themselves.
Source:
U.S. Dept. Health and Human Services Special Profile of Women’s Health. 6/96 The U.S. Department of Health and Human Services published a Special Profiles of Women’s Health (Released 6/18/96):
U.S. Dept. Health & Human Services, Special Profile Women’s Health, 1996.

14. Cardiac Symptoms in the Elderly
AMI Statistics in the Elderly
Acute or progressive dyspnea
Extreme fatigue
Abdominal pain
Nausea & vomiting
Syncope
Congestive heart failure
Weakness/falls
Pain in other places (not chest)
Higher in-hospital mortality
Higher post-discharge mortality
Do not have larger infarcts
Cardiac Symptoms in the elderly
Instead of “classic” crushing chest pain, the elderly tend to experience symptoms such as acute/progressive dyspnea, extreme fatigue, abdominal pain, nausea/vomiting, syncope, CHF, weakness/falls, or pain in areas other than the chest.
As many as 40% of elderly present without chest pain.
These symptoms can easily obscure the correct diagnosis. An initial "non-diagnostic" 12-lead ECG could further lead a clinician toward a different diagnosis despite a positive cardiac history or the presence of multiple cardiac risk factors.
Source:
Nowak, KA, Nurse Practitioner, 1997: 22:
FTT Collaborative Group. Lancet. 1994;343:311.
White, HD, et al. Circulation. 1996;94:
Miller, TD,et al. Circulation. 1997; 96 (suppl): Abstract 149.
Nowak, KA. Nurse Pract :11-14.

15. Diabetes & Acute MI
Independent predictor of mortality (mechanism unknown)
Lowest mortality in patients who received fibrinolytics
Diabetic patients:
Were older and more often female
Had more anterior MIs and triple vessel CAD
Presented later and were treated later
Left ventricular function may differ from those w/o diabetes due to possible impaired left ventricular performance in non-MI zones
Diabetes and AMI: Results from GUSTO
Diabetes is an independent predictor of 30-day and 1-year AMI mortality (14.5% vs. 8.9%, p< 0.001). Mortality was highest among diabetic patients on insulin.
Lowest mortality in patients who received fibrinolytics
Diabetic patients were older, more often female, had more anterior infarcts, presented later, received fibrinolytic therapy later and had more triple vessel CAD.
Sources: Mak, KH, et al. JACC, Woodfield, SL, et al , JACC, 1996
More recent findings have:
Confirmed that DM remains an independent predictor for death or
new MI (although the mechanism is unknown)
Source: Strandberg, et al (2000) Longitudinal (2-5 yrs f/u) study of
suspected AMI pts treated with fibrinolysis
LV function may differ from non-DM:
Impaired LV performance in the non-infarct areas & metabolic derangement during AMI may account for the adverse outcomes
Must correct abnormalities for greater survival benefit
Source:
Mak, KL & Topol, TJ. JACC. 2000; 35: 563-8
Mak, KH, et al. JACC. 1997; 30:171.
Woodfield, SL, et al. JACC;1996; 29:35. Strandberg, LE, et al. J Int Med. 2000; 248:119
Mak, KL & Topol, TJ. JACC. 2000; 35: 563-8

16. Goal: Early Reperfusion Therapy
Defined as the initial strategy employed to restore blood flow to the occluded coronary artery by two standards of care
Fibrinolytic therapy
Primary percutaneous transluminal coronary angioplasty (PTCA)
Outcomes Dependent Upon:
Time to treatment
Early and full restoration of blood flow
The pathophysiology of AMI has been adequately covered. The next section will cover the importance of early reperfusion therapy.
When a patient presents with STEMI/new LBBB initiating reperfusion therapy quickly is critical. Reperfusion therapy is defined as the initial strategy employed to restore blood flow to the occluded coronary artery.
Currently, two forms of reperfusion therapies meet the standards of care listed in the ACC/AHA guidelines for care of the patient experiencing STEMI. Both fibrinolytic therapy for eligible patients and primary percutaneous transluminal coronary angioplasty (PTCA) are recommended forms of reperfusion therapy (Ryan T,et al. 1999).
Both forms of therapy are dependent on time to treatment issues and early and full restoration of blood flow.

17. Next: ACS Diagnostics