Acute Coronary Syndrome (ACS)

Question 1

Acute Coronary Syndrome (ACS) - Definition

Answer 1

Insufficient supply of blood to the heart, usually due to a blocked artery, causing cell and tissue death

Question 2

Goal of Care

Answer 2

Transport to hospital where the artery can be opened or kept open

Question 3

Myocardial Infarction (MI)

Answer 3

MY is usually caused by a clot in the coronary arteries that completely blocks blood flow beyond its location.

triggered by a rupture of plaque in the walls of a coronary artery and is defined as death of myocardial cells due to ischemia

MI can show up in two ways:
Acute, significant damage shows up on ECG w/ elevation of the ST segments “STEMI”
when there is only small amounts of damage, the ECG can be normal but cardiac enzymes will rise over 3-6 hours

Question 4

Unstable Angina

Answer 4

Unstable agina is a temporary insufficient blood supply w/o permanent damage
The pain of MI and UA are similar and both require urgent care

Question 5

Guiding Principles

Answer 5

pts w/ MI on ECG are losing muscle w/ each minute of delay to definitive treatment

Chest pain can also be the presentation of other life threatening conditions such as thoracic aortic dissection, pulmonary embolus, pericarditis. ruptured esophagus or other perforated viscus.

Treatment of choice for MI (STEMI + NSTEMI is angioplasty or thrombolysis

Question 6

Guiding Principles - Procedures

Answer 6

IV - if IV access is req’d - left arm is preferred.

O2 - should be titrated based on pulse oximetery aiming for SPO2 95% if the pt is not SOB or in shock
(pts SOB/in shock require high flow O2)

ASA helps to prevent re-occlusion but will not open the artery. It has been shown to reduce mortality and is one of the most important early treatments the pt can receive

Nitro - has not demonstrated an improvement in outcomes
relieve pain of angina but will not relieve pain of MI and may well worsen outcomes if it causes hypotension

Entonox - has been used for chest pain but has some cautions
Can cause rebound hypoxemia due to displacement of oxygen in the alveoli as nitrous diffuses out of the blood stream
It is vital to supplement any pt during and after NO2 use

Morphine - can be administered to STEMI pts who are in severe pain for analgesia
routine use of morphine for NSTEMI is not recommended however, as it is theorized to delay the absorption of oral antiplatelet agents

Question 7

Intervention Guidelines - EMR

Answer 7

• keep pt at rest
• position pt
• supp O2
• Platelet Aggregation Inhibition
  ASA 162mg PO
• Reduce pre-load and myocardial O2 demand
  Nitro w/ prescription
  0.4mg spray SL q3-5min if BP >90
  Nitro w/o prescription
  0.4mg spray SL q3-5min
  BP >100 and HR >50 <150
  mandatory consult w/ CliniCall

Question 8

Intervention Guidelines - PCP/ACP

Answer 8

PCP
all above plus
Symptom relief - nausea/vomiting IM or IV only
- Dimenhydrinate 25-50mg IV

ACP
all above 
12 lead ECG
Rapid hospital notification STEMU
Correct rhythm disturbance
- Symptomatic Bradycardia
- Symptomatic Narrow Complex Tachycardia
- Symptomatic Wide Complex Tachycardia

Symptom relief - pain and anxiety
- Morphine 2.5mg IV to effect
- Fentanyl 0.5-1.0mcg/kg IM/IV/IO
to a single max dose of 100mcg every 5mins PRN to max dose of 300mcg cumulative

Question 9

Further Care

Answer 9

• Fibrinolytic therapy/PCI
• IV Nitroglycerin
• Beta blockage
• Intra aortic balloon pump
• Surgical intervention