Acute coronary syndrome (ACS) is a potentially life-threatening condition that occurs when a blockage causes the blood flow to the heart to suddenly slow down or stop. The reduced blood flow does not result in cell death but will likely increase the risk of a heart attack.
ACS is a medical emergency that requires prompt recognition and intervention to reduce further damage and mortality. Coronary artery disease is the most common heart disease among the aging population and the leading cause of death in the U.S.
Signs and Symptoms of Acute Coronary Syndrome
Signs and symptoms of ACS typically present abruptly, and these may include:
- Chest pain or tightness – described as burning or crushing pain even while at rest.
- Radiating pain from the chest to the shoulder, arms, neck, back, or jaw.
- Feeling of indigestion, nausea, or vomiting.
- Shortness of breath and palpitations.
- Dizziness, lightheadedness, or decreased level of consciousness.
- Excessive sweating or diaphoresis.
- Fatigue or restlessness.
The signs and symptoms of ACS vary significantly depending on the location and severity of the blockage. Some patients such as those with diabetes, older or women may not have chest pain.
Types of Acute Coronary Syndrome
- Unstable angina. This is a sudden discomfort or chest tightness that often doesn’t have a pattern and usually gets worse. It usually happens during mild physical activity but can also happen even at rest or sleeping. It is caused by a clot or plaque in the coronary artery wherein the heart muscles can’t have enough oxygen which can cause a heart attack if left untreated.
- Non-ST-elevation myocardial infarction. This involves partial blockage of the coronary artery where the increased oxygen demand cannot be met causing myocyte necrosis. It can cause pressure-like substernal pain radiating to the neck, jaw, or arms that occurs with minimal exertion or even at rest. This can be detected by a blood test but not with an electrocardiogram (EKG).
- ST-elevation myocardial infarction. This is the most serious type of ACS with the greatest risk of serious complications and mortality. It is a complete thrombotic occlusion of a major coronary artery resulting in myocardial injury or necrosis. It can be described as squeezing pain at the center of the chest and can be detected by blood test and electrocardiogram (EKG).
Causes of Acute Coronary Syndrome
There are several causes of ACS with different severity, such as the following:
- Decreased oxygen supply. This can cause myocardial cell necrosis. This may eventually lead to heart muscle tissue damage causing unstable angina.
- Atherosclerosis. This is the most common cause which usually begins as plaque formation causing inflammation of the inner layer of the blood vessels. Continuous plaque builds up and sustaining an injury can cause the blood vessel to narrow which eventually limits blood flow. Rupture of an atherosclerotic plaque causes thrombus formation in the coronary artery which triggers a heart attack.
- Other causes. Rare causes of ACS are coronary artery embolism, coronary artery spasm, and spontaneous coronary artery dissection (SCAD).
Risk Factors to Acute Coronary Syndrome
Different risk factors can predispose a patient to acute coronary syndrome (ACS).
- Non-modifiable Risk Factors to ACS
- Male gender
- Aging increases risk significantly
- Familial history of heart disease, chest pain, or stroke
- Modifiable Risk Factors to ACS
- Obesity or weight gain
- Smoking history or frequent exposure to second-hand smoke
- Lack of physical activity or exercise
- Unhealthy or poor diet
- Drugs or cocaine use
- High blood pressure
- High blood cholesterol level
- Diabetes
- History of preeclampsia or gestational diabetes
Diagnosis of Acute Coronary Syndrome
- Blood test. Elevation of certain cardiac enzymes can detect cell death from damaged myocardial tissue. This is the initial diagnostic test used along with the signs and symptoms to make a primary diagnosis of acute coronary disease.
- Electrocardiogram (ECG). This procedure will determine the electrical impulses of the heart. Irregular and abnormal impulses suggest a myocardial problem and some patterns may show the location of the problem. ST-elevation and a new left bundle branch block will confirm acute coronary syndrome. A 12-lead ECG may also be used to reassess any changes in heart rhythm.
- Computerized tomography (CT) angiogram. This procedure uses specialized x-ray technology showing multiple images of the heart and provides a detailed view of blocked or narrowed coronary arteries.
- Echocardiogram. It is a type of ultrasound scan that uses sound waves to outline the cardiac muscles, valvular movement, and structure. An echocardiogram can reveal abnormalities in the walls of the heart being supplied by the blocked arteries.
- Myocardial perfusion imaging or nuclear stress test. This test uses a radioactive substance injected into the blood vessel to assess cardiac blood flow using imaging. This test can be used in conjunction with the cardiac stress test to assess myocardial motion abnormalities in response to stress and rest.
- Coronary angiogram. This is an invasive procedure that uses special contrast and x-ray imaging using a catheter inserted into the groin or arm to show the exact location of narrowed or blocked blood vessels. Always check for contraindications such as allergy to the contrast before proceeding with the procedure.
- Stress test or medication stress test. This test can only be done if there are no signs of a life-threatening heart condition. An electrocardiogram (EKG), echocardiogram, or myocardial perfusion imaging will be used simultaneously to monitor the heart while the test is ongoing. The patient will be asked to walk on a treadmill or ride a stationary bike while being monitored by an EKG to determine the heart’s ability to respond to stress.
Treatment for Acute Coronary Syndrome
The therapeutic management for ACS varies depending on the severity of myocardial damage and associated signs and symptoms. These may include:
- Pain management and medication. Prompt treatment of pain can also aid in the patient’s anxiety, decreasing further damage. Medications that can be used are:
- Nitroglycerin. Buccal or sublingual nitroglycerin provides immediate relief by promoting the dilation of blood vessels improving blood flow to the coronary arteries. Always check the blood pressure before giving this medication as this can cause hemodynamic deterioration in patients with <90mmHg systolic blood pressure.
- Anticoagulants or blood thinners. These medications prevent clot formation reducing the risk of further myocardial damage. This is commonly used in conjunction with antiplatelet therapy which has proven to reduce recurrent clot formation.
- Thrombolytics or fibrinolytics. These are primarily used for the first 12 hours of a heart attack to break down or dissolve clots that block the coronary artery to restore blood flow. These drugs are commonly used in patients with ST-elevation when timely angioplasty and stenting are unavailable.
- Antiplatelet drugs. These are used to prevent blood clots from forming after an atherosclerotic plaque rupture. These drugs can be used as dual therapy for both the non-ST segment and ST-segment elevation ACS.
- Beta-blockers. These decrease the workload of the heart by slowing the heart rate and controlling blood pressure. This drug should not be given to patients with hypotension, bradycardia, and heart failure.
- Angiotensin-converting enzyme (ACE) inhibitors. These drugs promote blood vessel dilation thereby improving blood flow and lowering blood pressure. They should be given within 24 hours of diagnosing ACS to reduce complications and heart failure.
- Statins. These drugs lower blood cholesterol level preventing plaque build-up. This is also given as home medication after an ACS as secondary prevention.
- Pain relievers. Small doses of pain relievers may be given in conjunction with other medications above to provide immediate relief.
- Supplemental oxygen. This must be given if the patient presents signs of hypoxia or heart failure.
- Surgical intervention. Restoration of blood flow to the heart is the main goal of patient care to prevent further damage and avoid another attack.
- Angioplasty and stenting. A catheter will be inserted into the narrowed or blocked part of the coronary artery, the balloon will be inflated compressing the plaques against the arterial wall, and a stent will be placed to keep the artery open.
- Coronary artery bypass surgery or coronary artery bypass graft (CABG). A graft will be taken from another part of the body and will be connected to create a new path around the blocked coronary artery.
Prevention of Acute Coronary Syndrome
Primary prevention is the key to preventing the emergence of ACS, while secondary prevention mainly focuses on the prevention of another attack. Below are ways to prevent an ACS:
- Eating a well-balanced diet, avoiding high cholesterol and processed foods. The patient may be referred to a registered dietitian about different diet options before engaging.
- Smoking cessation and avoidance of secondhand smoke. Nicotine is a vasoconstrictor that causes the narrowing of the blood vessels resulting in increased heart rate and blood pressure. The patient can be referred to smoking cessation programs and medications to help.
- Exercising daily and having an active lifestyle. Always ask the patient’s primary care provider about the safe exercises to begin and gradually increase the patient’s activities based on the patient’s body’s response.
- Maintaining a healthy weight. Staying in shape can improve the physical condition and decrease cardiac workload.
- Limiting alcohol intake. Recommended alcohol intake is one drink per day only as it can cause an increase in blood pressure.
- Promoting a stress-free environment. There are healthy ways that a nurse can teach the patient to deal with stressful situations and events. Psychological support is also important to help the patient cope with the current changes in their body.
- Having periodic checks up and blood tests to monitor the patient’s health. Always follow the prescribed treatment plan to reduce the risk of another attack. Take medications as prescribed to control blood pressure and cholesterol level to normal.
- Cardiac rehabilitation. This is a guided program to improve the patient’s quality of life by training the patient to regain strength and reduce health risks. The program is designed based on the patient’s condition and needs primarily focusing on exercise training, lifestyle modification, and emotional support.
Acute Coronary Syndrome Nursing Diagnosis
Nursing Care Plan for Acute Coronary Syndrome 1
Nursing Diagnosis: Acute Pain Related to Tissue Ischemia as evidenced by 92% oxygen saturation.
Desired Outcome: The patient will be able to establish and maintain an efficient breathing pattern using a non-pharmacological regimen maintaining normal oxygen saturation and avoiding presenting signs and symptoms of hypoxia.
| Acute Coronary Syndrome Nursing Interventions | Rationale |
| Assess and document the patient’s vital signs to establish baseline data, noting verbal and non-verbal cues such as the patient’s breathing pattern, signs of hypoxia, and decreased level of consciousness. | Pain can cause alteration in the patient’s breathing pattern with associated anxiety. Decreasing oxygen levels in the body can cause ineffective tissue perfusion resulting in chest pain and lightheadedness. |
| Administer supplemental oxygen as ordered and discontinue if oxygen saturation is above the target range. | Establishing a normal breathing pattern is the top priority. Supplemental oxygen will provide fast relief and effective tissue perfusion. |
| Instruct the patient to do deep breathing exercises, relaxation techniques, and diversional activities. | Calming the patient can reduce the anxiety level and decrease the pain. Diversional activities can help prevent further anxiety attacks. |
| Place the patient in a comfortable position, elevating the head of the bed while supporting it with a pillow. | Elevating the head of the bed can support the patient’s weight achieving maximum lung expansion. |
| Provide reassurance and information regarding the patient’s care. | Informing the patient about his/her condition and treatment plan facilitates trust and compliance. |
Nursing Care Plan for Acute Coronary Syndrome 2
Risk for Decreased Cardiac Output
Nursing Diagnosis: Risk for Decreased Cardiac Output related to Changes in Heart Rate and Rhythm.
Desired Outcome: The patient will be able to maintain stable cardiac output as evidenced by a normal heart rate without dysrhythmias.
| Acute Coronary Syndrome Nursing Interventions | Rationale |
| Monitor the patient’s vital signs every 4 hours, assess via auscultation of the heart sound, and attach an electrocardiograph (ECG). | Regular checking of vital signs can help detect sudden changes in heart rhythm, detecting arrhythmias on EKG in advance. |
| Assist and observe the patient’s response to activity including facial grimaces and chest movement while breathing. | Gradually resume the patient’s daily activities taking notes on the patient’s response to avoid overexertion. |
| Instruct the patient to have small meals of heart-healthy food. | Large meals increase myocardial workload and a properly balanced diet prevents high blood pressure and high cholesterol levels. |
| Instruct the patient on the proper medication administration and compliance. | Adherence to regular medication will help regulate blood flow reducing the risk of another attack. |
| Encourage lifestyle modification starting with exercise, maintaining a healthy weight, limiting alcohol consumption, and smoking cessation. | Living a healthy lifestyle will improve a patient’s quality of life and reduce the chances of having another attack in the future. |
| Educate the patient about signs and symptoms, the importance of medications, lifestyle modification, and follow-up consultation. | Proper education increases patients’ compliance with the treatment regimen improving their quality of life. |
Nursing Care Plan for Acute Coronary Syndrome 3
Nursing Diagnosis: Activity Intolerance related to decreasing oxygen supply to the heart as evidenced by generalized weakness, changes in skin color, and shortness of breath upon exertion.
Desired Outcome: The patient will be able to gain an adequate energy level and perform desired activities with minimal help and supervision.
| Acute Coronary Syndrome Nursing Interventions | Rationale |
| Encourage rest periods. | Decrease myocardial workload and increased oxygen distribution in the body. |
| Assess the patient’s fatigue level (mild, moderate, or severe), physical appearance, and response to activity. | Provides baseline data about the triggers to avoid and activities to do in moderation. |
| Instruct proper breathing exercises and relaxation techniques. | To allow an adequate exchange of oxygen in the body while at rest. |
| Evaluate the patient’s activities of daily living. | This will help in planning the activities that the patient can tolerate. |
| Educate the patient about the gradual resumption of activities and exercise as tolerated. | Lifestyle modification is one of the most effective treatments for acute coronary syndrome. |
Nursing Care Plan for Acute Coronary Syndrome 4
Nursing Diagnosis: Anxiety related to change in health condition as evidenced by expression of concern about the current and future health restrictions.
Desired Outcome: The patient will be able to verbalize awareness of anxiety and identify effective coping strategies and support systems available.
| Acute Coronary Syndrome Nursing Interventions | Rationale |
| Acknowledge the patient’s perception of the current condition. | Understanding patients’ feelings and concerns can help in the assessment of their knowledge about the condition. |
| Assess the patient’s anxiety level. Observe verbal and non-verbal cues of anxiety. | This allows the patient to express their feelings and concern about the condition and restrictions. |
| Observe verbal and non-verbal cues of anxiety. Note for signs of depression or hopelessness. | Recognizing verbal and non-verbal cues of anxiety can help identify the proper emotional support needed by the patient. |
| Encourage expression of feelings, concerns, and fears. | Verbal expression of feelings can help in gauging a patient’s knowledge about the situation to properly address each concern appropriately. |
| Instruct the patient on proper breathing exercises, relaxation techniques, and diversional activities. | This can help the patient control their emotion, reducing anxiety and allowing relaxation. |
| Encourage the patient to do simple exercises and activities as tolerated. | Gradual resumption of activities may help the patient gain a sense of independence and increase the energy level. |
| Provide rest periods in between activities and encourage a complete rest at night. | This will help the patient regain strength and energy allowing the body to heal rapidly. |
| Ask for the patient’s consent and willingness before referring the patient to a psychologist. | This will ensure proper treatment and coping strategies that can effectively help the patient. |
Nursing Care Plan for Acute Coronary Syndrome 5
Nursing Diagnosis: Deficient Knowledge related to lack of information regarding the medical condition as evidenced by frequent questions and clarification.
Desired Outcome: The patient will be able to fully understand his/her condition and express full compliance to the treatment regimen.
| Acute Coronary Syndrome Nursing Interventions | Rationale |
| Assess the patient’s level of understanding and knowledge. | This will help identify misinformation and select the proper approach to teaching the patient. |
| Assess the patient’s willingness to learn and beliefs that may block the learning process. | Knowing the patient’s cognitive and behavioral status will be a great help to better understand the patient. Open-mindedness promotes good outcomes and better understanding. |
| Educate the patient about his/her medical condition, procedures to be done, and the treatment plan in terms that the patient can understand. | Detailed information will help the patient in accepting his/her condition and promote cooperation. Avoid using medical terms as this may cause confusion and further questions from the patient and significant others. |
| Provide information using visualization materials such as videos or structure models. | This will provide a clear and detailed picture of the patient’s condition without confusing the patient. |
| Ask the patient to repeat the information given. | To check if the patient fully understands the information that they have been given. |
| Encourage the patient to report any concerns or problems that may arise before, during, or after the treatment. | Building trust is important, as it promotes cooperation and compliance with the treatment plan. |
Nursing References
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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