Acute Coronary Syndromes

Chapter 12 Cardiovascular Disorders

Medical Surgical Nursing II
 Acute Coronary Syndromes
• Term describes array of clinical presentations
• Range from unstable angina to acute
myocardial infarction (MI)
 Angina
• Chest pain that occurs in response to
myocardial ischemia
• Causes spasm/blockage
• Symptoms in women often present differently
as we discussed
Anginal pain presentations
FIGURE 12-1 Common Sites for Anginal Pain. A, Upper part of chest. B,
Beneath sternum, radiating to neck and jaw. C, Beneath sternum, radiating
down left arm. D, Epigastric. E, Epigastric, radiating to neck, jaw, and arms. F,
Neck and jaw. G, Left shoulder. H, Intrascapular.
 Types of Angina
Stable
• Predictable
• Patient knows what causes
the pain and can tell a
provider if it is their usual
chest pain.
• Relieved with nitrates
prescribed, rest, relaxation,
or sometimes even activity
Unstable
• Unstable is a change in a
known pattern of chest pain
• Pain is more intense or has
added cardiac equivalents
not normally experienced
• Usually not relieved with
the usual amount of nitrates
Care of the Patient with Stable Angina

Eliminate chest pain Eliminate Chest pain

• A- Aspirin/Antianginal • Cholesterol/Cigarettes
medications • Monitor lipid profiles fasting
• B. Beta-blockers/blood • Lower LDL<100
pressure – ACEI’s goal bp • Increase HDL>40 in men
<140/90 if no other CAD
factors • Increase HDL>50 in women
• <130/80 if diabetes or • Increase fiber
chronic kidney disease is • Smoking cessation
present
Care of the Patient with Stable Angina

D – Diet and Diabetes Education and Exercise

• Low fat • Assess risk factors and
• Low calorie develop an individualized
teaching plan
• Keep fasting glucose 70 to • Exercise 30 to 60 minutes
100 mg/dl per day
• HbA1C <7% • Treat metabolic syndrome
BMI within Height and
weight
• Treat Depression
• Flu Shot yearly
Care of the patient with stable angina
• Summarize the differences between stable
and unstable angina based on symptoms?
• If a nurse caring for a patient say on the
medical floor has relief of chest pain/pressure
with the usual dose of nitrates or usual
method of pain reduction nursing action
indicated would be?
 Unstable Angina
• Stable to unstable –
• Medical Emergency
– Unstable angina is an indication of atherosclerotic
plaque instability.
– It is often a warning sign that precedes an acute
heart attack
– A patient with unstable angina needs to be
treated with interventional cardiac methods the
sooner the better
Other medications that are commonly
administered for Unstable Angina
• Aspirin
• Nitroglycerin
• LMWH – Lovenox
• Heparin Drip
• Intravenous antiplatlet agents
 Nursing Diagnosis Priority
• Acute pain r/t transmission and perception
ischemic impulses amb patients individualized
complaints.
– Myocardial Ischemia is the one diagnosis in which
relief of pain equals patient improvement from
the cellular level all the way to the psychological
level.
 Recognition of Myocardial Ischemia
Subjective
• Rate the discomfort – 0 to 10 scale
• Individualize the pain scale to the person’s
abilities
• Avoid the use of the word pain as patients
with myocardial ischemia do not feel like it is
pain
• Other descriptors are:
Objective Assessment of Myocardial
Ischemia

• Vitals
• Place the patient on a cardiac monitor
• Oxygen saturation
• Note skin color, temperature
• Peripheral pulse strength
• Mentation
• Overall tissue perfusion
12 Lead EKG

From initial
complaint to
EKG should
be less than
10 minutes
Why the 12 lead ECG
 Zones of Ischemia, Injury,
and Infarction

FIGURE 12-3 Zone of ischemia, zone of injury, and zone of infarction are shown through ECG waveforms
and reciprocal waveforms corresponding to each zone.
 ECG Changes

FIGURE 12-4 ECG Changes Indicative of Ischemia, Injury, and Infarction (Necrosis) of the Myocardium. A, Normal
ECG. B, Ischemia indicated by inversion of the T wave. C, Ischemia and current of injury indicated by T-wave inversion and ST-segment
elevation. The ST segment may be elevated above or depressed below the baseline, depending on whether the tracing is from a lead
facing toward or away from the infarcted area and depending on whether epicardial or endocardial injury occurs. Epicardial injury
causes STsegment elevation in leads facing the epicardium. D, Ischemia, injury, and myocardial necrosis. The Q wave indicates
necrosis of the myocardium.
 Correlations among Ventricular Surfaces,
Electrocardiographic Leads, and Coronary Arteries

Surface of Left Electrocardiographic Coronary Artery

Ventricle Leads Usually Involved
Inferior II, III, aVF Right coronary artery
Lateral V5-V6, I, aVL Left circumflex
Anterior V2-V4 Left anterior
descending
Anterior lateral V1-V6, I, aVL Left main coronary
artery
Septal V1-V2 Left anterior
descending
Posterior V1-V2 Left circumflex or right
coronary artery
(reciprocal changes)
FIGURE 12-6 Changes Seen on a 12-Lead ECG with An Anterior
Wall MI. A, Infarction location on the cardiac wall. B, ECG leads
with expected ST-segment elevation. C, A 12-lead ECG from a
patient experiencing left anterior wall MI. LAD, left anterior
descending artery.
FIGURE 12-6 Changes Seen on a 12-Lead ECG with An Lateral Wall MI.
A, Infarction location on the cardiac wall. B, ECG leads with expected
ST-segment elevation. C, A 12-lead ECG from a patient experiencing
lateral STEMI
FIGURE 12-8 Changes Seen on a 12-Lead ECG with an Inferior Wall MI. A, Infarction
location on cardiac wall. B, ECG leads with expected ST-segment elevation. C, A 12-lead
ECG from a patient experiencing inferior wall MI.