Acute Coronary Syndrome

1. Acute Coronary Syndrome 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 ?

2. 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).

3. 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)

4. 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

5. The Three I’s • Ischemia=ST depression or T-wave inversion Represents lack of oxygen to myocardial tissue

6. The Three I’s • Injury = ST elevation -- represents prolonged ischemia; significant when > 1 mm above the baseline of the segment in two or more leads

7. The Three I’s • Infarct = Q wave— represented by first negative deflection after P wave; must be pathological to indicate MI

8. What part of the heart is affected ? • II, III, aVF = Inferior Wall I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

9. Inferior Wall MI

10. Based on the EKG, which vessel in the heart is blocked? • II, III & aVF = Inferior Wall MI = Right Coronary Artery blockage

11. I II III aVR aVL aVF V1 V2 V3 V4 V5 V6 Which part of the heart is affected ? • Leads V1, V2, V3, and V4 = • Anterior Wall MI

12. Anterior Wall MI

13. Based on the EKG, which vessel in the heart is blocked? • V1 - V4 = Anterior Wall (Left Ventricle) = Left Anterior Descending Artery Blockage

14. 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

15. Lateral Wall MI

16. Based on the EKG, which vessel in the heart is blocked? • I, aVL, V5 + V6 = Lateral Wall = Circumflex Artery Blockage

17. 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

18. What do ICU RNs need to know? • Unexplained tachycardia • Tachypnea • Sudden elevation in PA catheter #’s or ICP (unexplained) • Nausea and/or diaphoresis that doesn’t make sense • Pallor • Symptoms of sudden heart failure (pulmonary edema/crackles) • Unexplained restlessness/all of a sudden needs more sedation

19. Summary • After completing an EKG, look at each of the leads for ST segment changes • Remember the three I’s: 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!