Acute Coronary Syndrome

by Jo Anne Naylor RN, BSN CCU Educator

What is Acute Coronary Syndrome ? How can I look at an EKG and tell what part of the heart is affected ?

What do ICU RNs need to know ?

What is Acute Coronary Syndrome (ACS) ?

Acute Coronary Syndrome is when occlusion of one or more of the coronary arteries occurs, usually following plaque rupture, resulting in decreased oxygen supply to the heart muscle. ACS is the largest cause of death in U.S. Over 1 million people will have Myocardial Infarctions this year; almost half will be fatal. Majority of mortality associated with ST Elevation Myocardial Infarction (STEMI).

Who is at risk for ACS?

Anyone with history of CAD, HTN, ESRD, DM Blood loss due to GI Bleed, surgery, trauma Patients on dialysis with AV Fistulas ( myocardial O2 demands) Decreased O2 saturations (particularly in COPD) Fever, hyperthyroidism, sustained tachycardia, prolonged hypotension, hypothermia, DIC, drug use (especially cocaine)

Who is at risk for ACS?

Conditions that may mimic ACS include:

Musculoskeletal chest pain Pericarditis (can have acute ST changes) Aortic dissection Central Nervous System Disease (may mimic MI by causing diffuse ST-T wave changes) Pancreatitis/Cholecystitis

The Three Is

Ischemia= ST depression or T-wave inversion

Represents lack of oxygen to myocardial tissue

The Three Is

Injury = ST elevation -- represents prolonged

ischemia; significant when > 1 mm above the baseline of the segment in two or more leads

The Three Is

Infarct = Q wave represented by first

negative deflection after P wave; must be pathological to indicate MI

What part of the heart is affected ?

II, III, aVF =

Inferior Wall

I II III

aVR aVL aVF

V1 V2 V3

V4 V5 V6

Inferior Wall MI

Based on the EKG, which vessel in the heart is blocked?

II, III & aVF = Inferior Wall MI = Right Coronary Artery blockage

Which part of the heart is affected ? Leads V1, V2, V3, and V4 = Anterior Wall MI

aVR

V1

V4

II
III

aVL
aVF

V2
V3

V5
V6

Anterior Wall MI

Based on the EKG, which vessel in the heart is blocked?

V1 - V4 = Anterior Wall (Left Ventricle) = Left Anterior Descending Artery Blockage

What part of the heart is affected ?

I, aVL, V5 and V6

Lateral wall of left ventricle

I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

Lateral Wall MI

Based on the EKG, which vessel in the heart is blocked?

I, aVL, V5 + V6 = Lateral Wall = Circumflex Artery Blockage

What do ICU RNs need to know?

You should do a 12-Lead EKG when:

A patient who has CAD risk factors complains of Chest Pain

When you are analyzing your rhythm strip on the flowsheet, and you notice that it looks different from the previous shift; OR any arrhythmias or changes in rhythm If your patient who is intubated / sedated suddenly begins to have hemodynamic changes putting stress on the heart + lungs

What do ICU RNs need to know?

Unexplained tachycardia Tachypnea Sudden elevation in PA catheter #s or ICP (unexplained) Nausea and/or diaphoresis that doesnt make sense Pallor Symptoms of sudden heart failure (pulmonary edema/crackles) Unexplained restlessness/all of a sudden needs more sedation

Summary
After completing an EKG, look at each of the leads for ST segment changes Remember the three Is: Ischemia, Injury, and Infarct !! Identify the section of the heart (and vessel supplying it) affected by the blockage according to the groups of leads changing in the EKG Remember the symptoms that would prompt you to obtain an EKG!