ACS (ED, CDU, OBS) - Mededcoventry.com

What is ACS?Acute Coronary Syndromes are a group of conditionsrelated to Coronary Heart DiseaseThey vary from stable angina to myocardial infarctionCHDACSStable anginaSTEMINSTEMI+Unstable angina

What is ACS? Cont ...All types of ACS have a common aetiology in the formation ofthrombus on an inflamed and complicated plaque

Structure Of Thrombus In ACSThere are similar presentations with each type of ACS but treatmentand investigation with vary due to the type of plaque formationUA/NSTEMI:Partially-occlusive thrombus(primarily platelets)ST ↑ MI:occlusive thrombus(platelets, red blood cells, and fibrin)Intra-plaque thrombusPlaque coreIntra-plaque thrombus(platelet dominated)Plaque core(platelet dominated)SUDDENDEATH

ACS Presentation• About 600,000 patients per annum attend EmergencyDepartments in the UK with chest pain– Of these, 25% have ACS .– Symptoms on presentation include:•Discomfort/pain in the centre of the chestthat lasts for more than a few minutes orrecurs•Discomfort/pain radiating to other arease.g. arms/legs/ jaw/neck/back/stomach•Breathlessness•Tachycardia•Nausea or vomiting•Sweating and clamminess

Pain areas associated with MI/ACSUsual distribution of pain with myocardialischaemiaLess common sites of painwith myocardial ischaemiaRight sideJawEpigastriumBack

The ECG In ACSThe ECG in ACS is the vital component in determining how the chestpain is treated and then managedAn ECG should be performed within 10 minutes of the patients arrivalin ED or after the onset/reporting of an episode of chest painA pain free ECG should also be taken and on admission to a new wardareaEach ECG needs to be seen/reviewed as soon as its taken – Reviewsshould be undertaken by the on duty CNP / Doctor or if unavailable amember of CCU / Catheter LabNOTE – ECGs can change – just because the initial ECG is notdiagnostic DOES NOT mean that the repeat won’t be!!!!

ST Elevation Myocardial Infarction(Lateral / Posterior)

ST Elevation Myocardial Infarction(Anterior)

ST Elevation MyocardialInfarction (Inferior)

ST Depression

Dynamic T Wave Inversion

A Reminder as to theImportance of the RepeatECG

Initial / Presenting ECG

The Repeat ECG

Pharmacological Managementof ACS Initial Management of all ACS patients MONA Morphine Oxygen Nitrates Aspirin 300mg STEMI Patients (in Primary PCI) MONA plus Clopidogrel 600 mg

Pharmacolgical Management Cont ...Unstable Angina / NSTEMI MONA plus Clopidogrel 600mg Enoxoparin 1mg/kg BD ACE Inhibitor (eg Ramipril) Beta Blocker (eg Bisoprolol) GTN (PRN)In Patients with ongoing Chest pain expect an IV GTNinfusionIn Patients with ongoing chest pain and ECG changes alsoexpect Tirofiban and expedition to Catheter Lab andCoronary Care

Nursing ManagementTimely Pain management as prescribedCardiac MonitoringRegular (min 4hrly) observationHourly in ED or if on GTN infusionECGs when and ECG interpretation whenpatient in PainPOST pain releifon admission to ED/wardDailyOn DischargeBloods and Troponin Markers @ 6hrs / 12hrs post pain (as documentedby Drs or CNP)Report Ongoing pain to Doctors or CNPLimit Mobilsation – Do not let UA / Trop +ve patients mobilise freely(limit to bedside, bathroom, no showers UNLESS >24hrs pain free)

Any questions????