SUSPECTED AND CONFIRMED ACUTE CORONARY SYNDROME (ACS) MANAGEMENT
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Chest Pain: Suspected and Confirmed Acute Coronary Syndrome (ACS) Management
Background
The acute coronary syndrome is a terminology used for a description of a variety of conditions. It is associated with the reduction of the flow of blood into the heart. A good example of this syndrome is the myocardial infarction. In this condition, the deaths of cells result in destruction and damage to the heart tissues. Even in a situation where the acute Coronary Syndrome does not result in the death of cells, the certain change in the heart rate and the reduction in the blood flow is risky because it is a significant sign of heart attack. After all, the heart is not able to function as expected.
It is caused by the deposition of fats, which is also known as plaques, in the coronary arteries’ walls, the blood vessels that carry oxygenated blood into the heart. The fat deposits rapture to form blood clots in the coronary arteries, blocking blood flow into the heart muscle and making the flow slow. The low supply of oxygen into the heart results in the death of heart cells and the muscles. The damage caused may be temporary or permanent, and even though the cells might survive, the condition might result in unstable angina.
The condition often results in severe chest pain, tightness around the chest region, and increased discomfort. On many occasions, the chest pain radiates to the left side of the shoulders or the jaw and is associated with profuse sweating, nausea, and shortness of breath. Besides, it is associated with three more manifestations, which are clinically tested and named according to how they appear in an electrocardiogram (ECG), non- ST-elevation myocardial infarction (NSTEMI), ST-elevation myocardial infarction (STEMI), and unstable angina. However, there is a variation in the types of myocardial infarctions that belong to the Acute coronary syndrome category.
On the other hand, Acute coronary syndrome should be differentiated from stable angina, which according to research and clinical tests, emerges during stress, and physical activity like exercise and can be controlled and stopped by resting.
Over the past decade, a significant change in the study of myocardial infarction (MI) shows a great decline in the condition’s occurrence, especially ST elevation (Hao et a. 2019). However, the study of acute coronary syndrome (ACS) did not show clear details on its progress from the past ten years. Although one study reports a decline in Acute Coronary Syndrome hospitalization cases, a patient is admitted into a hospital every three minutes ailing from it. Many reported acute coronary syndrome cases are patients diagnosed with other chest pain symptoms and are particularly women, aging patients, and those diagnosed with diabetes mellitus.
Current Practice
Morphine / Oxygen / Nitrates / Aspirin
Administer Oxygen therapy unless contraindicated to achieve a SaO2 of ≥ 94% or
- 88-92% in the process of chronic obstructive pulmonary disease (COPD), Type II Respiratory Failure [Level IV Or]
- As indicated by MO
The asymmetry of blood pressure may indicate aortic [Level IV].
Patients may prefer to sit up. In some instances, lying flat may provoke or worsen the pain—[Level IV].
MO to determine appropriate treatment, for example, emergency primary percutaneous Coronary Invention, thrombolytic therapy, and/ or medical management.
To relieve symptoms, limit myocardial damage, and reduce cardiac arrest risk—[Level IV].
Oxygen therapy should be prescribed at a dose to achieve normal or near-normal O2 saturation (92-98%). Oxygen therapy is commonly used in normoxic patients with ACS, although there is no benefit [Level I]. Hyperoxia is known to cause coronary blood flow [Level IV]. In the absence of hypoxia, the benefit of oxygen therapy is uncertain, and in some cases, oxygen therapy may be harmful [Level IV].
New Suggestion for Practice
- Administration of buccal glyceryl trinitrate (GTN) to relieve pain
- Infusion of GTN for patients with extreme pain
- Induction of Morphine in smaller doses until the pain is relieved.
- Avoid oxygen therapy, for it is harmful to the user’s health.
- Administration of non-platelet agents to bar clot formation, Aspirin is tagged along with P2Y12 for the same purpose.
- Induction of unfractionated heparin for patients with renal dysfunction.
Rationale
Patients experiencing extreme chest pain may need Sublingual or buccal glyceryl trinitrate (GTN) for pain relief. On the other hand, the patients’ experiencing intractable pain needs an infusion of the GTN. The GTN enhances venodilation and dilation of the coronary vessels. It can be administered to patients with ischaemic blood pressure if their blood pressure is greater than 90mmHg. However, this is not the case for the patients diagnosed with inferior MI because it can result in hemodynamic deterioration. The patients diagnosed with nitrate –refractory get opioids administration like morphine, administered in small doses until their pain is relieved.
The oxygen therapy as a practice in the treatment of ACS should be done away with because patients diagnosed with acute chest pain and presumed to have Acute coronary syndrome do not require oxygen unless they exhibit heart failure symptoms. Administering supplementary oxygen to patients with uncomplicated MI is harmful.
The blood composition platelets play a vital role in clot formation after the atherosclerotic plaque rapture. Therefore, dual antiplatelet therapy is vital for the management of Acute Coronary Syndrome (McCarthy et al. 2017).
Aspirin is vital for mortality reduction in the ACS condition, with sustained effects at 10 years of age; hence it is a standard practice to administer 300mg of non-enteric coated aspirin o ACS patients (Barun & Kassop, 2020). The P2Y12 antagonist category of antiplatelet drugs should be administered alongside the aspirin: the P2Y12 drug class includesticagrelor, clopidogrel, and the speedy-acting prasugrel. Antiplatelet agents are risky because they are associated with life-threatening bleeding. Ticagrelor is highly recommended because the risk of bleeding to death is reduced than in antiplatelet agents. Also, ticagrelor with aspirin is recommendable for patients with moderate NSTEMI.
Anticoagulation is also vital for clot formation. Antithrombin agents reduce ischaemic actions and enhance long-term mortality and morbidity. 2.5mg is supposed to be administered once every day.
Unfractionated heparin is administered to patients with renal dysfunction. The decision o administer anticoagulant rotates around the range of time remaining for the patient to receive a dose of PCI and their possibility of excessive bleeding. The GPIIb/IIIa completes the final step of platelet aggregation to prevent clot formation and enhance GPI’s effectiveness.
The Nice, on the prevention of secondary MI, recommends the use of Ace inhibitors like lisinopril, ramipril, and enalapril as early as possible within the first 24 hours (Fujise & Tsujita, 2017). The Ace inhibitors lead to improved left ventricular ejection fraction to reduce the risk of heart failure. An acetylcholine inhibitor such as eplerenone should be begun in individuals who have had signs and symptoms of cardiac arrest with ACS; this is introduced a few days after Antihypertensive agents and has been shown to minimize morbidity following acute MI.
Opioids are important for prevention and treatment, directed at reducing lipid; the Norwegian omeprazole Persistence Trial and follow-up trials reported their positive impacts on mortality and morbidity by reducing the LDL cholesterol levels. Their intervention, nevertheless, may go beyond decreasing LDL and, therefore, can high-density lipoprotein insulin levels: (Cannon) confirmed high-dose simvastatin gains and indicated that patients with verified ACS undergo amlodipine 80 mg for secondary prevention if no contraindications were present.
High blood pressure is a significant heart risk factor relating to ACS’s risk. Better results are correlated with antipsychotic agents such as beta-blockers, angiotensin-converting enzyme (ACE) receptors, and androgen antagonists. Beta-blockers (e.g., metoprolol, bisoprolol, carvedilol) should be initiated as early as possible if hypotension, cardiac failure symptoms, bradycardia, or heart block are not present. The workload on the heart is decreased, ischemia is decreased, and the growth is limited to the artifact’s size.
References
Braun, M., & Kassop, D. (2020). Acute Coronary Syndrome: Management. FP essentials, 490, 20-28.
McCarthy, C. P., Steg, G., & Bhatt, D. L. (2017). The management of antiplatelet therapy in acute coronary syndrome patients with thrombocytopenia: a clinical conundrum. European heart journal, 38(47), 3488-3492.
Hao, Y., Liu, J., Liu, J., Yang, N., Smith Jr, S. C., Huo, Y., … & Zhou, M. (2019). Sex Differences in In-Hospital Management and Outcomes of Patients With Acute Coronary Syndrome: Findings From the CCC Project. Circulation, 139(15), 1776-1785.
Fujisue, K., & Tsujita, K. (2017). Current status of lipid management in acute coronary syndrome. Journal of Cardiology, 70(2), 101-106.