PATIENT’S ILLNESS

A. Definition
Acute coronary syndrome is a term used for any condition brought on by
sudden, reduced blood flow to the heart.

An acute coronary syndrome (ACS) is a set of signs and symptoms

(syndrome) related to the heart. ACS is compatible with a diagnosis of myocardial
ischemia but it is not a characteristic of the diagnosis. Myocardial Ischemia is under
ACS.

The sub-types of acute coronary syndrome include 1) unstable angina and

two forms of 2) myocardial infarction in which heart muscle is damaged. These
types are named according to the appearance of the electrocardiogram (ECG) as
2a) non-ST segment elevation myocardial infarction (NSTEMI) and 2b) ST
segment elevation myocardial infarction (STEMI). There can be some
variation as to which forms of MI is classified under acute coronary syndrome.

ACS should be distinguished from stable angina, which develops during

exertion and resolves at rest. In contrast with stable angina, unstable angina occurs
suddenly, often at rest or with minimal exertion, or at lesser degrees of exertion
than the individual's previous angina.

Though ACS is usually associated with coronary thrombosis, it can also be

associated with cocaine use. Cardiac chest pain can also be precipitated by anemia,
bradycardias or tachycardias.
 Classification of acute coronary syndromes.

B. Predisposing/ Precipitating Factors

 PRECIPITATING FACTORS
The most common cause of acute coronary syndrome is coronary thrombosis on a
preexisting plaque.

These plaques, made up of fatty deposits, cause the arteries to narrow and make
it more difficult for blood to flow through them. This buildup of plaques is known
as atherosclerosis. Eventually, this buildup means that your heart can't pump
enough oxygen-rich blood to the rest of your body, causing chest pain or a heart
attack.

Another medical term closely related to acute coronary syndrome is coronary

artery disease. Coronary artery disease refers to the damage to your heart
arteries from atherosclerosis.

If one of the plaques in your coronary arteries ruptures, it can cause a heart
attack. In fact, many instances of coronary artery syndrome develop after a
plaque ruptures. A blood clot will form on the site of the rupture, blocking the flow
of blood through the artery.

 PREDISPOSING FACTORS
• Age
The incidence of acute coronary syndrome increases with age. Older patients
with acute coronary syndrome are most likely to present with atypical
symptoms. Many elderly patients with acute coronary syndrome do not receive
evidence-based therapies. This situation emphasizes the importance of
improving quality-of-care programs to reinforce the use of therapies among
elderly individuals. In persons older than 70 years, men and women are affected
about equally.

• Sex
In persons aged 40-70 years, ACS is diagnosed more often in men than in
women. This is due to the cardio protective effect of estrogen in females. At 15
years postmenopausal, the incidence of angina occurs with equal frequency in
both sexes.
Women are more likely than men to be older and to have more co morbid
conditions at the time of first presentation. Abnormal locations of pain, nausea,
vomiting, fatigue, dyspnea, and other atypical presentations are most common
in women.

Young women with acute coronary syndrome should be counseled regarding the
potential teratogenic effect of statins. Hormonal replacement therapy with
estrogen or progesterone) should be stopped in women who present with acute
coronary syndrome.

• Race and Ethnicity

African-Americans have the highest risk of heart disease, in part due to their
high rates of severe high blood pressure, as well as diabetes and obesity.

• Medical Conditions
Obesity and Metabolic Syndrome. Excess body fat, especially around the
waist, can increase the risk for heart disease. Obesity also increases the risk for
other conditions that are associated with heart disease. Obesity is particularly
hazardous when it is part of the metabolic syndrome, a pre-diabetic condition
that is significantly associated with heart disease. This syndrome is diagnosed
when three of the following are present:
• Abdominal obesity
• Low HDL cholesterol
• High triglyceride levels
• High blood pressure
• Insulin resistance

Unhealthy Cholesterol Levels. Low-density lipoprotein (LDL) cholesterol is the

"bad" cholesterol responsible for many heart problems. Triglycerides are another
type of lipid that can be bad for the heart.
High Blood Pressure. High blood pressure, or hypertension, has long been a
proven cause of coronary artery disease and heart problems.

Diabetes. Diabetes, especially for people whose blood sugar levels are not well
controlled, significantly increases the risk of developing heart disease. In fact,
heart disease and stroke are the leading causes of death in people with
diabetes. People with diabetes are also at risk for high blood pressure and
unhealthy cholesterol levels, blood clotting problems, kidney disease, and
impaired nerve function, all of which can damage the heart.

Vascular Diseases. Peripheral artery disease (PAD), aortic aneurysm, stroke,

and renal artery stenosis are vascular diseases that increase the risk for ACS.

• Lifestyle Factors

Smoking. Smoking is the most important risk factor for heart disease. Smoking
can cause elevated blood pressure, worsen lipids, and make platelets very
sticky, raising the risk of clots. Although heavy cigarette smokers are at greatest
risk, people who smoke as few as three cigarettes a day are at higher risk for
blood vessel abnormalities that endanger the heart. Regular exposure to passive
smoke also increases the risk of heart disease in nonsmokers.

Alcohol. Moderate alcohol consumption (one or two glasses a day) can help
boost HDL good cholesterol levels. Alcohol may also prevent blood clots and
inflammation. By contrast, heavy drinking harms the heart. In fact, heart disease
is the leading cause of death in alcoholics.

Diet. Diet plays an important role in the health of the heart, especially by
reducing dietary sources of Trans fats, saturated fats, and cholesterol and
restricting salt intake that contributes to high blood pressure.

Physical Inactivity. Exercise has a number of effects that benefit the heart and
circulation, including improving cholesterol levels and blood pressure and
 maintaining weight control. People who are sedentary are almost twice as likely
to suffer heart attacks as are people who exercise regularly.

• Medications

NSAIDs and COX-2 Inhibitors. All nonsteroidal anti-inflammatory drugs

(NSAIDs) carry heart risks. NSAIDs and COX-2 inhibitors may increase the risk for
death in patients who have experienced a heart attack. The risk is greatest at
higher dosages, but not necessarily for length of time.

The American Heart Association recommends that patients who have, or who are
at risk for, heart disease first try non-drug methods of pain relief (such as
physical therapy, exercise, weight loss to reduce stress on joints, and heat or
cold therapy). If these methods don't work, patients should take the lowest
possible dose of acetaminophen (Tylenol) or aspirin. COX-2 inhibitors, such as
celecoxib (Celebrex), should be the last resort.

• Family history of coronary heart disease

Other causes of NSTEMI acute coronary syndrome include the following:

• Cocaine or amphetamine use, which increases myocardial oxygen demand
and which may cause coronary vasospasm
• Inflammation and/or infection, which destroys the normal lining of the
heart changing it to fibrous tissues which are less mobile, less flexible and less
functional.

C. Signs and Symptoms

The cardinal sign of patients with acute coronary syndrome is chest pain
experienced as tightness around the chest and radiating to the left arm and the left
angle of the jaw due to a decreased blood flow to the heart.
 This may be associated with diaphoresis, nausea and vomiting, as well as
shortness of breath. In many cases, the sensation is "atypical", with pain
experienced in different ways or even being completely absent. Some may report
palpitations, anxiety or a sense of impending doom and a feeling of being acutely ill,
yet again, due to decreased blood flow to the heart hence, decreased in cardiac
output resulting to poor perfusion of the organs.

D. Health Promotion and Preventive Aspects of the Disease

• HEALTH PROMOTION and PREVENTION
Acute coronary syndrome often reflects a degree of damage to the coronaries by
atherosclerosis. Primary prevention of atherosclerosis is controlling the risk
factors: healthy eating, exercise, treatment for hypertension and diabetes,
avoiding smoking and controlling cholesterol levels; in patients with significant
risk factors, aspirin has been shown to reduce the risk of cardiovascular events.

o Don't smoke. If you smoke, the most important thing you can do to improve
your heart's health is to stop. Talk to your doctor if you're having trouble with
quitting.

o Eat a heart-healthy diet. Too much saturated fat and cholesterol in your
diet can narrow arteries to your heart. Follow the advice of your doctor and
dietitian on eating a heart-healthy diet that includes plenty of whole grains,
lean meat, low-fat dairy, and fruits and vegetables. Also, watch your salt and
fat intake. Eating too much salt and saturated or trans fats will increase your
blood pressure and cholesterol.

o Exercise regularly. Regular exercise helps improve heart muscle function

and keeps blood flowing through your arteries. It can also reduce your risk of
acute coronary syndrome by helping you to achieve and maintain a healthy
weight and control diabetes, elevated cholesterol and high blood pressure.
Exercise doesn't have to be vigorous. For example, walking 30 minutes a day,
five days a week can improve your health.
o Check your cholesterol. Have your blood cholesterol levels checked
regularly, through a blood test at your doctor's office. If your cholesterol
levels are undesirably high, your doctor can prescribe changes to your diet
and medications to help lower the numbers and protect your cardiovascular
health.

o Control your blood pressure. Have your blood pressure checked at least
every two years. Your doctor may recommend more frequent checks if you
have high blood pressure or a history of heart disease.

o Maintain a healthy weight. Excess weight strains your heart and can
contribute to high cholesterol, high blood pressure and diabetes. Losing
weight can lower your risk of acute coronary syndrome.

o Manage stress. To reduce your risk of a heart attack, reduce stress in your
day-to-day activities. Rethink workaholic habits and find healthy ways to
minimize or deal with stressful events in your life.

o Consume alcohol in moderation. Drinking more than one to two alcoholic

drinks a day raises blood pressure, so cut back on your drinking if necessary.
From a heart-healthy standpoint, one to two drinks daily is fine for men, and
women can have one alcoholic beverage a day. One drink is equivalent to 12
ounces (355 milliliters, or mL) of beer, 4 ounces (118 mL) of wine or 1.5
ounces (44 mL) of an 80-proof liquor.

• TREATMENT and MEDICATIONS

The goals of treatment are to preserve patency of the coronary artery, augment
blood flow through stenotic lesions, and reduce myocardial oxygen demand.
All patients should receive antiplatelet agents, and patients with evidence of
ongoing ischemia should receive aggressive medical intervention until signs of
ischemia, as determined by symptoms and ECG, resolve.

Medications
It's likely that your doctor will recommend medications that can relieve chest
pain and improve flow through the heart. These could include:
o Aspirin. Aspirin decreases blood clotting, helping to keep blood
flowing through narrowed heart arteries. Aspirin is one of the first
things you may be given in the emergency room for suspected acute
coronary syndrome. You may be asked to chew the aspirin, so it's
absorbed into your bloodstream more quickly. If your doctor diagnoses
your symptoms as acute coronary syndrome, he or she may
recommend daily aspirin therapy.

o Nitroglycerin. This medication for treating chest pain and angina

temporarily widens narrowed blood vessels, improving blood flow to
and from your heart.

o Thrombolytics. These drugs, also called clotbusters, help dissolve a

blood clot that's blocking blood flow to your heart. If you're having a
heart attack, the earlier you receive a thrombolytic drug after a heart
attack, the greater the chance you will survive and lessen the damage
to your heart.

o Beta blockers. These drugs help relax your heart muscle, slow your
heart rate and decrease your blood pressure, which decreases the
demand on your heart. These medications can increase blood flow
through your heart, decreasing chest pain and the potential for
damage to your heart during a heart attack.

o Angiotensin-converting enzyme (ACE) inhibitors and

angiotensin receptor blockers (ARBs). These drugs allow blood to
 flow from your heart more easily. Your doctor may prescribe ACE
inhibitors or ARBs if you've had a moderate to severe heart attack that
has reduced your heart's pumping capacity. These drugs also lower
blood pressure and may prevent a second heart attack.

Surgery and other procedures

If medications aren't enough to restore blood flow through your heart, your
doctor may recommend one of these procedures:

o Angioplasty and stenting. In this procedure, your doctor inserts a

long, thin tube (catheter) into the blocked or narrowed part of your
artery. A wire with a deflated balloon is passed through the catheter to
the narrowed area. The balloon is then inflated, compressing the
deposits against your artery walls. A mesh tube (stent) is usually left in
the artery to help keep the artery open. Angioplasty may also be done
with laser technology.

o Coronary bypass surgery. This procedure creates an alternative

route for blood to go around a blocked coronary artery. The blocked
portion of the artery in your heart is removed, and an artery from
another part of your body, such as your leg, replaces the removed
portion.

• DETECTION
Laboratory Studies
o Electrocardiography
In the setting of acute chest pain, the electrocardiogram is the
investigation that most reliably distinguishes between various causes. If
this indicates acute heart damage (elevation in the ST segment),
treatment for a heart attack in the form of angioplasty or thrombolysis is
indicated immediately. In the absence of such changes, it is not possible
to immediately distinguish between unstable angina and NSTEMI.
o Measurement of cardiac enzyme levels
 Measurement of CK-MB levels
Elevation of CK is an indication of damage to muscle. It is therefore
indicative of Myocardial Infarction. Since it has a short duration, it
cannot be used for late diagnosis of acute MI but can be used to
suggest infarct extension if levels rise again.

 Measurement of troponin levels

The most sensitive and specific test for myocardial damage.
Because it has increased specificity compared with CK-MB, troponin
is a superior marker for myocardial injury.

Troponin is released during MI from the cytosolic pool of the

myocytes. Its subsequent release is prolonged with degradation of
actin and myosin filaments

 Measurement of myoglobin levels

Myoglobin is used less than the other markers. Myoglobin is the
primary oxygen-carrying pigment of muscle tissue. It is high when
muscle tissue is damaged but it lacks specificity. It has the
advantage of responding very rapidly, rising and falling earlier than
CK-MB or troponin.

o CBC determination
The CBC helps in ruling out anemia as a secondary cause of acute
coronary syndrome.

o Basic metabolic panel

Close monitoring of potassium and magnesium levels is important in
patients with acute coronary syndrome because low levels may
 predispose them to ventricular arrhythmias. Routine measurement of
serum potassium levels and prompt correction are recommended.

o New biomarkers
Levels of brain natriuretic peptide (BNP) and N-terminal pro-BNP (NT-pro-
BNP) are elevated in acute MI and provide predictive information for risk
stratification across the spectrum of acute coronary syndrome.

Imaging Studies
o Chest radiography
Chest radiography helps in assessing cardiomegaly and pulmonary
edema. A chest radiograph may also assist in diagnosing concomitant
disease as a precipitating cause of acute coronary syndrome.

o Myocardial perfusion imaging

Myocardial perfusion is a valuable method for triaging patients with chest
pain in the emergency department.

o Cardiac angiography
Cardiac catheterization helps in defining the patient's coronary anatomy
and the extent of the disease.