Acute Coronary Syndrome (ACS) Clinical Presentation Report Analysis

This report provides a comprehensive analysis of Acute Coronary Syndrome (ACS), encompassing its definition, clinical manifestations, and underlying pathophysiology. The report begins with an introduction to ACS, differentiating between unstable angina, STEMI, and NSTEMI. It then delves into the primary survey assessment, including the patient's presenting symptoms, vital signs, and Glasgow Coma Scale (GCS). The report highlights the significance of elevated troponin levels in diagnosing ACS and discusses the pathophysiology of the condition, focusing on plaque rupture, thrombosis, and the resulting myocardial ischemia. It further explores nursing interventions, including assessment and evaluation, immediate responses, and patient education. The report also includes a case study of a patient named Margaret Law. The discussion covers assessment findings, interpretation of the data, and subsequent nursing management strategies. The report emphasizes the importance of early diagnosis, risk stratification, and prompt initiation of appropriate treatment modalities, including antiplatelet therapy, anticoagulation, and revascularization when indicated. The report concludes by underscoring the significance of individualized patient care and the need for continuous monitoring to improve patient outcomes.

Running head: Acute coronary syndrome (ACS)
Acute coronary syndrome (ACS)
Name of the Student
Name of the University
Author Note

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Acute coronary syndrome (ACS)
Introduction
Acute coronary syndrome (ACS) describes the spectrum of myocardial ischemic
disorders that involve unstable angina (UA), or ST-elevated myocardial infarction (STEMI) or
non-ST elevated myocardial infarction (STEMI). A detailed analysis of clinical characteristics,
such as electrocardiogram (ECG) findings and biochemical indicators of myocardial necrosis, is
used to identify and define ACS. The UA is characterized by the existence of biomarkers of
ischemic signs and improvements, if any, of ECGs. In the sense of acute myocardial ischemia,
myocardial infarction (MI) is used where there is indication of acute myocardial ischemia. The
pathophysiology that underlies ACS decreases blood supply to a portion of the heart that is
usually secondary to plaque rupture and thrombosis development. ACS may also be parallel to or
without atheroscleratic vasospasm (Smith et al., 2015). This results in reduced blood supply to a
part of the cardiac muscles, which contributes first to ischaemia and eventually to cardiac
infarction. The most ominous sign of the coronary artery disorder (CAD) is "Acute Coronary
Syndrome." The burden and influence of ACS are noteworthy. Cardiovascular disease is
currently the world's leading cause of death, although several deaths are attributed to CAD. As a
consequence, although CAD is commonly a significant public health problem in the nation, ACS
is especially troubling as both exist while at the same time have weak prognosis (Fuster &
Kovacic, 2014). Modern treatments will decrease the morbidity and mortality associated with
ACS in well-served populations in developed nations, but many individuals live in less
privileged circumstances of low- and middle-income countries tend to experience the effects of
this disorder. While advanced treatment can reduce ACS morbidity and mortality in well-served
populations residing in wealthy countries, many individuals living in poorer and middle-income
countries remain vulnerable to the harm done by the disease. ACS is a major factor to both

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morbidity and mortality in Australia. In fact the outcomes are worse than that in urban areas for
ACS citizens who reside in rural areas and are handled at rural hospitals (Nadel, Hewitt &
Horton, 2014). Despite this perspective, substantial improvement is being made in pathology
awareness; diagnosis and ACS care (Fuster & Kovacic, 2014).
Thus, this paper will discuss on the pathophysiology and clinical management of this
issue, Acute Coronary Syndrome, with the help of a case study, given.
Discussion:
Primary survey:
Primary survey helps in immediately identifying and treating life threatening conditions
of the patients. For patients with cardiac arrest, the sequencing is DRCAB for aligning it with the
contemporary clinical practice. The primary survey is therefore in the order DRCAB which
stands for Danger, Response, Circulation, Airway and Breathing. Thus, following the patient’s
arrival and admission, the primary responsibility of the nurses is to collect both subjective and
objective data by conducting necessary assessments required as per the clinical manifestations.
However, there are some common assessments that are needed to be performed for all patients,
such as measuring vital signs.
The symptoms that has been experiencing include chest pain, scoring about 7/10 since 2
hours. She reports that she was having reflux at 5 pm and she was not relieved after taking
Mylanta. Her chest pain was getting worse and she was having shortness of breath and sweat,
however she was cool to touch.
Her Glasgow Coma Scale (GCS) was measured first. The Glasgow Coma Scale (GCS) is
a neurological measure or scale intended to provide the initial as well as a subsequent

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measurement a reliable and accurate means to monitor a person's consciousness. The resultant
scores of a individual are calculated according to scale parameters, with a value between three
(indicating deep unconsciousness) and 14 (original scale) and 15 (more commonly used,
modified or revised).The GCS has been used to assess the degree of cognition of an individual
after a head injury, and now it is used as an device for emergency care by the nurses and doctor.
Her GCS was found to be 15/15 indicating a mild head injury. Her eyes were opening
when she heard a voice. She was speaking in short sentences using only words and she was
exhibiting abnormal flexion to painful stimuli (decorticate response). Thus, the above condition
indicates a moderate head injury which is the sing of danger according to the primary survey.
The patient was also found to have troponin T of 5900ng/L, which is much higher and thus, is at
a high risk of cardiac arrest. Troponin is a highly responsive and precise biomarker, branded as
the 'gold standards' for acute myocardial injury. Troponin elevation was reported after a variety
of non-coronary disorders, including lung embolism, pulmonary hypertension, sepsis and
persistent renal failure and non-traumatic brain injury such as SAH, IVH, acute stroke, and
Guillain Barre Syndrome. The increased risk of heart and brain problems, increased mortality,
and worse functional outcomes were correlated in these settings, especially in SAH. However,
neurogenic myocardial pathophysiological process is little known. The hypothesis is linked to a
systemic catecholamine rush powered by the central neuroendocrine axis that raises sympathetic
flow dramatically and stimulates the adrenal glands. Damages to the insular and the
hypothalamus can cause a dynamic process, involving an activation accompanied by autonomous
nervous system failure and an acute inflammative reaction.
Heart failure following traumatic brain injury (STBI) is frequently found, but the
significance is not known. Until now, the risk of cardiac failure after sTBI is not well

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Acute coronary syndrome (ACS)
understood. This is not known whether such heart-brain events influence the morbidity and
mortality of STBI patients, and whether cardiac disease may be a novel marker for the clinical
outcomes.
Then, the patient’s response to stimulus was measured using AVPU scale, which means
Alert, Verbally Responsive, Painfully Responsive and Unresponsive (Romanelli, & Farrell,
2019). She was found to be Verbally Responsive, She as opening in response to a verbal
stimulus.
Pathophysiology:
Acute Coronary Syndrome (ACS) refers to any disorder due to coronary artery
obstruction that decreases blood supply to the heart, including unstable angina and myocardial
infarction (MI). While not listed under ACS, stable angina is known as ischaemic heart disorder.
Temporary pain is induced by a persistent flow restricting lesion inside the coronary artery which
happens when the need for myocardial blood is elevated, for example through physical activity
or emotional stress. ST elevation of the myocardial infarction (STEMI) corresponds to an
elevation of the ST portion of the ECG patient that typically has cardiac biomarkers (i.e. elevated
troponin level) suggesting necrosis of the heart muscle (Santos-Gallego, Picatoste & Badimón,
2014). The approach for clinical treatment relies on early reperfusion medication either with
thrombolytic injection or with percutaneous coronary intervention (PCI). Non-ST section
elevation acute coronary syndrome (NSTEACS) applies to symptomatic patients whose first
ECG indicates no ST elevation. Risk stratification exists before a diagnosis of NSTEMI or
dysfunctional angina has been established. Such patients are stratified as medium, moderate or
severe risk in terms of adverse reaction. Non ST elevation myocardial infarction (NSTEMI)
applies to patients who have not had a ST elevation on their ECG, but subsequent cardiac

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biomarkers are increased. Up to 50 percent of patients infected with NSTEMI have an ECG that
is normal or displays only mild changes. Unstable angina is an intensified angina syndrome with
or without ECG shifts. It is differentiated from NSTEMI by the lack of increased cardiac
biomarkers (Carbone et al., 2014).
The Acute coronary syndrome (ACS) is a condition or a set of symptoms that is
attributed to a reduction in coronary artery blood supply, which implies that most of the heart
muscle can't operate properly or dies. The most frequent sign is chest pain, which frequently
radiates to the left shoulder or angle of the neck, squeezing, core, often combined with nausea
often sweating. Some may have other signs besides chest discomfort, in particular women,
elderly patients and diabetes mellitus patients. Atherosclerosis, occurring and progressing
decades before this acute events, contributes to the fundamental pathophysiological pathways for
such syndromes (Mohan & Zacharias, 2019). The low-quality inflammatory intima (inner lining)
in moderate-sized arteries, aggravated by well-known risk factors such as obesity, elevated
cholesterol, smoking, diabetes, and genetics, may be described as atherosclerosis. This
progressive development, as used for coronary atherosclerosis, contributes to a substantial
thickening of the coronary artery internal layer, which can decrease the artery lumen to different
degrees over time. Acute atherosclerosis of myocardial infarction leading to acute myocardial
and abrupt cardiac failure has a preferred choice for proximal sections of the main coronary
arteries, particularly arterial forks which modify the function of the artery. Any or more sudden
events, associated with one of the two processes: one asymptomatic plaque degradation with
non-intraluminal thrombus formation or plaque hemorrhage, will interrupt this incremental
atherosclerotic growth (Ambrose & Singh 2015).

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Acute coronary syndrome (ACS)
Coronary atherosclerosis also causes several ACS events decades before heart attacks.
Atherosclerotic plaque formation starts on the inner layer of the blood vessel with low
inflammation. Blood vessels are lined with the cholesterol, fat and white blood cells that are
released from endothelial cells. Conveyors of cholesterol that penetrate the arterial wall and are
oxidized, particularly the low-density lipoprotein LDL. White blood cells are triggered and
converted into macrophages with LDL absorption known as foam cells as they are filled with
lipid. This extremely lipid plaques include a fibrous capsule, immune cells, bacterial spores,
smooth cholesterol and muscle tissue. They will develop over time to increase the light blood
supply and thereby restrict the flow of blood. ACS results from a splitting of the atherosclerotic
plaque coronary artery wall and allows the initiation of platelet aggregation (Eisen, Giugliano &
Braunwald, 2016).
Nursing interventions:
Assessment and evaluation-
Making the records transparent and detailed is essential to ensuring that the nurses caring
for ACS patients are mindful of the health condition, points of concern and care strategy of the
patients. The caring nurses must monitor radial or femoral entry sites for patients who have never
experienced a coronary angiometric disease to identify their symptoms. Effective coordination is
critical with the personnel of the cardiac catheterization lab and the cardiac care team. Patients
undergoing this medication need comprehensive details regarding the procedure, complications,
medications and IV fluids they have received and if anticoagulants or GPIs have been
administered and are more vulnerable to bleeding (McCune, McKavanagh & Menown, 2015).
The common priorities for ACS patients include haemodynamic control and careful
examination of vital signs. Fluid state analysis may include details on renal perfusion, since

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certain patients may suffer or cause heart failure. Capillary blood glucose rates may be tested
frequently in patients with diabetes; others could be given IV insulin if their blood glucose
reaches > 11mmol / L. Patients freshly diagnosed with diabetes will be assigned to a professional
nurse with diabetes. Regulation of symptoms is needed in order to gain pain relief with GTN or
morphine. A main aspect in nursing diagnosis is the simple identification of any cardiac
modifications in the serial ECG. Patients that are deemed to present a high risk should be
monitored if regular cardiac monitoring is necessary since arythmias can precede a cardiac arrest
are at risk. High risk patients should be diagnosed with serial ECGs in a patient screening
facility. ACS nurses may have a chance to monitor ECG, because ECG movements and
arrhythmia are indicators of a possible deterioration (Jarvis, 2017).
Immediate response-
This is important to realize that discomfort or pain aversion is a cause that the individual
has visited the therapeutic setting. It is important that the healthcare professionals develop their
confidence and have direct contact during their initial crucial phase of their presence in the
clinical environment. Patients may feel frightened and nervous at this time. Apart from natural
causes, fear raises the heart rhythm and thereby enhances the need for myocardial oxygen
(Boyette & Manna, 2019). Medical nurses will take their duty into consideration when assessing
patient treatment and act as advocates for the patient and create confidence. Patients of life-
threatening disorders, such as severe coronary syndrome, continue to be taken into account and
helped in making choices. Therapeutic teamwork is crucial and nurses are assured that they can
condemn treatments that might not be relatively good in consistency, if necessary (Ibanez et al.,
2018).
Pain relief

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Acute coronary syndrome (ACS)
Sublingual or buccal glyceryl trinitrate (GTN) may be required in those with thoracic
pain to alleviate pain; GTN injection may be required for those with intractable pain. GTN
facilitates coronary artery venodilation and development. Patients of ischaemic chest pain should
be treated, if they have > 90mmHg of systemic blood pressure. In patients suffering from a lower
MI or suspected right ventricular implication it is contraindicated as this can cause
haemodynamic deterioration (de Alencar Neto, 2018).
Oxygen therapy:
Oxygen can be avoided when oxygen saturation falls over 94 percent or 88-92 percent in
patients with possible acute coronary syndrome at COPD risk of hypercapnic respiratory failure.
Patients with severe chest pain and suspected ACS will not need oxygen until hypoxia or heart
failure is present. The application of extra oxygen may result in vasoconstriction. In patients with
an acute coronary syndrome this may lead to further occlusion of weakened coronary arteries.
The oxygen saturation of the patient was 94% which means she must be given with oxygen
therapy (Cabello et al., 2016).
Antiplatelet agents
Platelets are of vital significance in clot development after atherosclerotic plaque breaks,
so concurrent antiplatelet treatment – both in NSTEMI so STEMI is critical for ACS control.
Aspirin is correlated with decreased ACS mortality, with a cumulative 10 year impact and
patients are most usually treated with 300 mg of non-enteric coated aspirin. The antagonistic
P2Y12 antiplatelet group is used in combination with aspirin (Switaj, Christensen & Brewer,
2017).
Anticoagulation agents

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Acute coronary syndrome (ACS)
Clot forming is avoided by anticoagulation. Antithrombin agent Fondaparinux prevents
ischaemic incidents and increases long-term illness and mortality; 2,5 mg will be delivered once
daily subcutaneously. It is associated in comparison to other anticoagulants with a reduced risk
of major bleeding – most bleeding risks are a concern (Onwordi, Gamal & Zaman, 2018).
Other nursing interventions
Patients would potentially go home with many drugs and others may continue to carry
them for the rest of their lives. These medications usually include double platelet treatment, beta
blockers, statins and ACE inhibitors. Aldosterone antagonists are often needed in certain
patients. Nurses will insure that patients have the knowledge about the dose and the path of
administration; realize not to discontinue medication without professional advice. Families can
engage in discussions whenever possible as they also will assist in lifestyle changes.
Patients may be encouraged to obtain immediate medical treatment if there is any
recurrence of chest discomfort. Information can be reinforced by written material, such as
booklets. Nurses must discuss the needs of patients and recommend them attend cardiac nurses
or dietitians for professional advice, as well as to the primary care staff (Jarvis, 2017).
Psychosocial support-
Patients are expected to be nervous and afraid. Nurses should remain compassionate and
encouraging, and ensuring that discomfort and other effects are well managed. They have a key
role in delivering psychosocial support; when appropriate, they will allow patients the ability to
express their perspectives, answer their questions and communicate them with the
multidisciplinary team (Hill, Evans & Forbat, 2015).

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Acute coronary syndrome (ACS)
Conclusion:
ACS is a potentially life-threatening disease that impacts millions of people per year.
Facing decreasing hospitalization levels for Myocardial Infarction, the diagnosis and prevention
of ACS continues to be a significant public health issue. In the last few years, research has lead
to an increased view of the pathophysiology of ACS, and advances have been made in the
therapeutic treatment of this disorder. The presentation of the individual, here, is rather difficult.
The patient had extreme chest pain and mild GCS. Her CXR and ECG had become non-
diagnostic. Atypical cases of acute coronary syndrome are documented occurrences where there
is no chest discomfort. Some major risk factors have been reported such as older age, female
gender and comorbidities (diabetes and hypertension) are evident in the patient. . Initial ACS
evaluation will involve risk stratification, adequate pharmacological intervention, anticoagulation
and effective adjuvant medication, and the determination to adopt an early intrusive or traditional
care approach. Long-term treatment of the ACS case would meet evidence-based guidelines and
be personalized to each individual in order to get an improved outcome.

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