cardiovascular disorders
Overview of Acute Coronary Syndromes (ACS)
Treatment of Acute Coronary Syndromes
Prehospital care: Oxygen,aspirin, and nitrates and triage to an appropriate medical center Drug treatment: Antiplatelet drugs, antianginal drugs, anticoagulants, and in some cases other drugs Often, angiography to assess coronary artery anatomy Often, reperfusion therapy: Fibrinolytics, percutaneous coronary intervention or coronary artery bypass surgery Supportive care Post-discharge cardiac rehabilitation and chronic management of coronary artery disease Treatment, including Drugs for Acute Coronary Syndromes , is designed to relieve distress, interrupt thrombosis, reverse ischemia, limit infarct size, reduce cardiac workload, and prevent and treat complications. An acute coronary syndrome is a medical emergency; outcome is greatly influenced by rapid diagnosis and treatment. Treatment occurs simultaneously with diagnosis. Contributing disorders (eg, anemia, heart failure) are aggressively treated. Because the chest pain of myocardial infarction usually subsides within 12 to 24 hours, any chest pain that remains or recurs later is investigated. It may indicate such Complications of Acute Coronary Syndromes as recurrent ischemia, Oxygen Aspirin Nitrates Triage to appropriate medical center (325 mg), pain management with nitrates (see table Drugs for Coronary Artery Disease* ), early thrombolysis when indicated and possible, and triage to the appropriate hospital where primary PCI is available—can reduce risk of mortality and complications. attenuates activity of some P2Y12 receptor inhibitors and may contribute to worse patient outcomes ( Treatment references ). Early diagnostic data and response to treatment can help determine the need for and timing of Revascularization for Acute Coronary Syndromes when primary percutaneous coronary intervention is not possible. Drug therapy with antiplatelet drugs, anticoagulants, and other drugs based on reperfusion strategy Risk-stratify patient and choose a reperfusion strategy (fibrinolytics or cardiac angiography with PCI or CABG for patients with STEMI and cardiac angiography with PCI or CABG for patients with unstable angina or NSTEMI) On arrival to the emergency room, the patient's diagnosis is confirmed. Drug therapy and choice of revascularization depend on the type of acute coronary syndrome as well as the clinical picture (see figure Approach to acute coronary syndromes ). Choice of drug therapy is discussed in attenuates activity of some P2Y12 receptor inhibitors and may contribute to worse patient outcomes ( Treatment references ). † Complicated means that the hospital course was complicated by recurrent angina or infarction, heart failure, or sustained recurrent ventricular arrhythmias. Absence of any of these events is termed uncomplicated. ‡ Although some recent trials raise questions, CABG is still generally preferred to PCI for patients with the following: Left main or left main equivalent disease Left ventricular dysfunction Diabetes Also, lesions that are long or near bifurcation points are often not amenable to PCI. CABG = coronary artery bypass grafting; GP = glycoprotein; LDL = low density lipoprotein; NSTEMI = non-ST-segment elevation MI; MI = myocardial infarction; PCI = percutaneous intervention; STEMI = ST-segment elevation MI. When the diagnosis is unclear, bedside cardiac marker tests can help identify low-risk patients with a suspected ACS (eg, those with initially negative cardiac markers and nondiagnostic ECGs), who can be managed in 24-hour observation units or chest pain centers. Higher-risk patients should be admitted to a monitored inpatient unit or critical care unit (CCU). Several validated tools can help stratify risk. Thrombolysis in MI (TIMI) risk scores may be the most widely used. Patients with suspected NSTEMI and intermediate or high risk should be admitted to an inpatient care unit or CCU. Those with STEMI should be admitted to a CCU. Only heart rate and rhythm recorded by single-lead ECG are consistently useful for routine, continuous monitoring. However, some clinicians recommend routine multilead monitoring with continuous ST-segment recording to identify transient, recurrent ST-segment elevations or depressions. Such findings, even in patients without symptoms, suggest ischemia and identify higher-risk patients who may require more aggressive evaluation and treatment. Qualified nurses can interpret the ECG for arrhythmia and initiate protocols for its treatment. All staff members should know how to do CPR (cardiopulmonary resuscitation). The care unit should be a quiet, calm, restful area. Single rooms are preferred; privacy consistent with monitoring should be ensured. Usually, visitors and telephone calls are restricted to family members during the first few days. A wall clock, a calendar, and an outside window help orient the patient and prevent a sense of isolation, as can access to a radio, television, newspaper and/or digital devices. On day 1, patients without complications (eg, hemodynamic instability, ongoing ischemia), including those in whom reperfusion with fibrinolytics or PCI is successful, can sit in a chair, begin passive exercises, and use a commode. Walking to the bathroom and doing nonstressful paperwork are allowed shortly thereafter. Patients with successful, uncomplicated primary PCI for acute MI may be ambulated quickly and be safely discharged in 2 to 4 days. If reperfusion is not successful or complications are present, patients require longer bed rest, but they (particularly older patients) are mobilized as soon as possible. Prolonged bed rest results in rapid physical deconditioning, with development of Orthostatic Hypotension , decreased work capacity, increased heart rate during exertion, and increased risk of Anxiety, mood changes, and denial are common. A mild tranquilizer (usually a benzodiazepine) is often given, but many experts believe such drugs are rarely needed. Reactive depression is common by the 3rd day of illness and is almost universal at some time during recovery. After the acute phase of illness, the most important tasks are often management of depression, Cardiovascular Rehabilitation , and institution of long-term preventive programs. Overemphasis on bed rest, inactivity, and the seriousness of the disorder reinforces anxiety and depressive tendencies, so patients are encouraged to sit up, get out of bed, and engage in appropriate activities as soon as possible. The effects of the disorder, prognosis, and individualized rehabilitation program should be explained to the patient. Maintaining normal bowel function with stool softeners (eg,docusate) to prevent straining is important. Urinary retention is common among older patients, especially after several days of bed rest or ifatropinewas given. A catheter may be required but can usually be removed when the patient can stand or sit to void. Because smoking is prohibited, a hospital stay should be used to encourage Smoking Cessation . All caregivers should devote considerable effort to making smoking cessation permanent. Although acutely ill patients have little appetite, tasty food in modest amounts is good for morale. Patients are usually offered a soft diet of 1500 to 1800 kcal/day with sodium reduction to 2 to 3 g. Sodium reduction is not required after the first 2 or 3 days if there is no evidence of Heart Failure (HF) . Patients are given a diet low in cholesterol and saturated fats, which is used to teach healthy eating. For patients with Diabetes Mellitus (DM) and STEMI, intensive glucose control is no longer recommended; guidelines call for an 1.Meine TJ, Roe MT, Chen AY, et al: Association of intravenousmorphineuse and outcomes in acute coronary syndromes: results from the CRUSADE Quality Improvement Initiative.Am Heart149(6):1043-1049, 2005. doi: 10.1016/j.ahj.2005.02.010 2.Kubica J, Adamski P, Ostrowska M, et al:Morphinedelays and attenuatesticagrelorexposure and action in patients with myocardial infarction: the randomized, double-blind, placebo-controlled IMPRESSION trial.Eur Heart J37(3): 245–252, 2016. doi: 10.1093/eurheartj/ehv547 