What is Acute Coronary Syndrome?

In order for you to be a functional ACLS healthcare provider, you must have the basic knowledge and skills to recognize and treat patients with acute coronary syndrome, or ACS for short.

In this lesson, along with the next lesson, you'll be learning how to assess and treat the ACS patient following the latest recommendations and guidelines. And at the end of the lesson, we'll provide you with a brief Word on the goals of therapy for patients with acute coronary syndromes, along with EMS and hospital-based components.

An initial 12 lead ECG is used as part of the identification process for all ACS cases. The three ECG categories for ACS include the following:

1. ST-segment elevation, which suggests an acute myocardial infarction (or AMI).
2. ST-segment depression, which suggests ischemia
3. Nondiagnostic or normal ECG

STEMI (ST-Elevation Myocardial Infarction) will be the focus of this section as it is the most time-sensitive for reperfusion therapies and can also limit the amount and extent of the myocardial damage.

Although 12 lead ECG interpretation is beyond the scope of this ACLS provider course, some practitioners who are already ACLS certified will have already been trained in the interpretation and reading of 12 lead ECGs.

For those particular healthcare providers, this ACS case summarizes identification and treatment of STEMI patients.

Reperfusion may involve the use of coronary angiography with a balloon, angioplasty, and angioplasty with a stent, also known as PCI –percutaneous coronary intervention.

When PCI is used as the initial reperfusion treatment for STEMI, it's referred to as a primary PCI. Treatments other than primary PCI include, but are not limited to:

• Oxygen
• Aspirin or ASA
• Nitroglycerin sublingual tablet or spray
• Fibrinolytic therapies
• Heparin – UHF (Unfractionated Heparin)
• Heparin – LWMH (Low Molecular Weight Heparin)

A Word About the Primary Goals of Therapy for Patients with Acute Coronary Syndromes

The primary goals of therapy for patients with acute coronary syndromes (ACS) are to:

1. Reduce the amount of myocardial necrosis that can occur in patients with acute myocardial infarction (AMI), thus preserving left ventricular function, preventing heart failure, and limiting other cardiovascular complications.
2. Prevent major adverse cardiac events, such as death, nonfatal myocardial infarction, and the need for urgent revascularization.
3. Treat acute, life-threatening complications of ACS, such as ventricular fibrillation (VFib), pulseless ventricular tachycardia (pVT), unstable tachycardias, symptomatic bradycardias, pulmonary edema, cardiogenic shock, and mechanical complications of acute myocardial infarction.

Prompt diagnosis and treatment offers the greatest potential benefit for myocardial salvage. Therefore, it is imperative that all healthcare providers are able to recognize patients with potential acute coronary syndromes in order to initiate evaluation, appropriate treatment, and management as quickly and effectively as possible.

EMS Components

EMS components include:

• Prehospital ECGs
• The notification of the receiving facility of a patient with possible ST-segment elevation myocardial infarction (also known as a “STEMI alert")
• The activation of the cardiac catheterization team to shorten the reperfusion time
• Continuous review and quality improvement

Hospital-Based Components

Hospital-based components include:

• ED Protocols
  • Activation of the cardiac catheterization laboratory
  • Admission to the coronary ICU
  • Quality assurance, real time feedback, and healthcare provider education
• Emergency Physician
  • Empowered to select the most appropriate reperfusion strategy
  • Empowered to activate the cardiac catheterization team as indicated
• Hospital Leadership
  • Must be involved in the process and committed to support rapid access to STEMI reperfusion therapy