Do you think that it might be ACS? How do you understand?

Coronary heart disease (CHD) is the leading reason behind death amongst adults within the United States, accounting for 1 in 5 deaths (CDC, 2023). In 2018, the American Heart Association reported that 28.1 million people within the United States have CHD, and it’s estimated that an American will experience a myocardial infarction (MI) roughly every 40 seconds (Benjamin et al., 2018). Acute coronary syndrome (ACS) refers to a spectrum of three critical diagnoses related to CHD: unstable angina (UA), non-ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI) (Amsterdam et al., 2014). ACS occurs when there may be a severe reduction in myocardial perfusion, resulting in ischemia and/or infarction. Given its high prevalence and powerful association with morbidity and mortality, ACS is a diagnosis that can’t be missed.

Symptoms of ACS (Amsterdam et al., 2014)

The most recognizable symptom of ACS is chest pain. However, chest pain is a typical symptom that will be related to most of the causes listed within the table below.

In ACS, chest pain is commonly described as a sense of pressure and should occur during rest or with minimal exertion. Ischemic chest pain may radiate down the arms, into the neck, or jaw, and is often related to sweating, shortness of breath, nausea, abdominal pain, or syncope. Importantly, new-onset or worsening exertional shortness of breath is essentially the most common analogue of angina pectoris and is usually the one symptom.

There are several key patient or disease characteristics that increase the suspicion that chest pain is resulting from ACS:

• Older age
• Male gender
• Positive family history of coronary artery disease
• Presence of peripheral vascular disease, diabetes, renal failure, previous myocardial infarction or previous coronary revascularization

While chest pain is essentially the most commonly reported symptom of ACS, nurses must also recognize atypical chest pain symptoms, which include epigastric pain, dyspepsia, stabbing or pleuritic pain, and worsening dyspnea within the absence of chest pain. An atypical clinical presentation is most typical in female patients, elderly patients (>75 years), and patients with diabetes, renal failure, and/or dementia.

Chest pain is characterised by several features typical of ischemia, including:

• Pleuritic pain (sharp or acute pain brought on by respiratory or coughing)
• Primary or sole location of discomfort in the center or lower abdomen
• Pain that happens with movement or palpation of the chest or arms
• Brief episodes of pain lasting just a few seconds or less
• Pain of maximum intensity at first
• Pain radiating to the lower limbs

Physical examination (Amsterdam et al., 2014)

The physical examination can provide many necessary clues to assist distinguish ACS from other diagnoses, and it can be crucial to look at the patient promptly but thoroughly. Many patients with ACS could have a traditional examination. Patients could have symptoms of heart failure, but it can be crucial to do not forget that heart failure symptoms can occur without ACS, and subsequently heart failure symptoms are nonspecific. Additional signs of ACS may include the presence of an S4 heart sound, paradoxical S2 splitting, or a brand new mitral regurgitation murmur resulting from papillary muscle dysfunction. The following examination findings should raise concerns for other conditions, as noted below:

• Pain on palpation –
• Pulsating Abdominal Mass –
• Back pain with unequal palpable pulse volume, a difference of 15 mm Hg or more in systolic blood pressure between each arms, or a murmur of aortic insufficiency –
• Pericardial friction friction –
• Paradoxical Pulse –
• Pleural friction rub –

Electrocardiogram (Amsterdam et al., 2014; Reeder, Awtry, and Mahler, 2018)

The ACC/AHA guidelines suggest that a 12-lead ECG (electrocardiogram) is essential to the decision-making process within the evaluation and treatment of patients presenting with symptoms suggestive of ACS and recommend that an ECG be obtained and interpreted inside 10 minutes of arrival within the emergency department/office. The initial ECG is commonly diagnostic in patients with ACS, so a traditional ECG doesn’t rule out ACS. ECGs ought to be repeated at 15- to 30-minute intervals if the initial study will not be diagnostic, especially if the patient stays symptomatic and/or there may be a high clinical suspicion of ACS. It is essential to do not forget that left ventricular hypertrophy, bundle branch blocks with repolarization abnormalities, and ventricular pacing may mask symptoms of ischemia/injury. ECG changes consistent with ischemia or injury in ACS may include ST-segment depression (particularly horizontal or downward), transient ST-segment elevation, or latest T-wave inversion. In STEMI, nurses may expect to see latest ST-segment elevation on the J point in two anatomically adjoining leads; nonetheless, within the early hours of myocardial infarction, the one abnormality could also be peaked, hyperacute T waves. In UA/NSTEMI, latest horizontal or downward ST-segment depression in two anatomically adjoining leads and/or T-wave inversion in two anatomically adjoining leads could also be observed.

Cardiac biomarkers (Amsterdam et al., 2014; Reeder, Awtry, & Mahler, 2024)

Serial serum biomarkers, namely troponin T and I, are sensitive and specific for acute myocardial injury and are essential to substantiate the diagnosis of myocardial infarction. High-sensitivity troponin is the popular test. They ought to be obtained as soon as possible in any patient at significant risk of ACS at presentation and repeated three to 6 hours later. Additional troponin levels at six hours could also be considered when there may be a moderate or high suspicion of ACS or when dynamic EGC changes are noted. By definition, patients with UA could have normal troponin levels, and in patients with ST-segment elevation myocardial infarction or non-ST-segment elevation myocardial infarction raised troponin level. Troponins could also be normal on the onset of an acute cardiac event and will not be elevated until 2 to 4 hours after the onset of symptoms in STEMI/NSTEM. Elevated troponin levels will be used to evaluate infarct size, diagnose reinfarction, and predict prognosis.

ACS is a typical, life-threatening condition that nurses often encounter. Early recognition of ACS is crucial for prompt treatment, which is essential to reducing the danger of mortality and subsequent cardiac events. Nurses play a key role in early recognition of ACS, in addition to in administering treatment and helping patients understand their condition and care.

Amsterdam, EA, Wenger, NK, Brindis, RG, Casey, DE, Ganatis, TG, and Holmes, DR (2014). 2014 AHA/ACC guidelines for the treatment of patients with non-ST-segment elevation acute coronary syndromes. Report of the American College of Cardiology/American Heart Association Practice Guidelines Task Force. Circulation 130, e344-e426.doi: 10.1161/CIR.0000000000000134

Benjamin, E. J., Virani, S. S., Callaway, C. W., Chamberlain, A. M., Chang, A. R., Cheng, S., …Munter, P. (2018). Heart Disease and Stroke Statistics 2018 Update: American Heart Association Report. Circulation, 137e67-e492.doi: 10.1161/CIR.0000000000000558

Centers for Disease Control and Prevention. (2023). Heart disease fact sheet. Retrieved from https://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_disease.htm

Reeder, GS, Awtry, E., and Mahler, SA (2024). Initial evaluation and treatment of suspected acute coronary syndrome (myocardial infarction, unstable angina) within the emergency department, Current. Retrieved May 15, 2024 from https://www.uptodate.com/contents/initial-evaluation-and-management-of-suspected-acute-coronary-syndrome-myocardial-infarction-unstable-angina-in-the-emergency-department