Compare conditions

Put any two — or three — conditions side by side, adult or pediatric, to spot the look-alike differences fast, row by row.

Acute Coronary Syndrome

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In one line

·A clot blocks a heart artery, and heart muscle starts dying because it cannot get oxygen.

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Normal physiology

·Coronary arteries deliver oxygen-rich blood to heart muscle. The heart uses more oxygen per ounce of tissue than almost any other organ because it beats nonstop, about one hundred thousand times a day. Even at rest, the heart pulls nearly all the oxygen out of the blood passing through. When the heart needs more oxygen during exercise or stress, the only way to get it is to widen the coronary arteries and push more blood through. Keep that picture in mind, because every abnormal finding in Acute Coronary Syndrome is a change from this normal state. When a coronary artery gets blocked by a cracked cholesterol patch and a clot, that is the upstream break we are tracing.

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What goes wrong

·One broken thing—a cholesterol plaque that cracks open and triggers a clot inside a coronary artery—explains all the clinical findings together.

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Hallmark signs

·Chest discomfort—pressure, squeezing, heaviness, or tightness
·Pain spreading to the left arm, jaw, neck, back, or upper belly
·Sweating (diaphoresis)
·Nausea or vomiting
·Shortness of breath (dyspnea)
·Lightheadedness or fainting (syncope)
·Feeling the heart race or beat irregularly (palpitations)
·Atypical presentation—just feeling tired, weak, or short of breath without any chest pain (especially in women, older adults, and people with diabetes)

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Red flags · escalate now

·ST-segment elevation on the EKG—this means a coronary artery is completely blocked (STEMI, ST-elevation heart attack (myocardial infarction)) and the patient needs the artery opened within 90 minutes with a balloon and stent (percutaneous coronary intervention, or PCI) or clot-busting medicine (fibrinolytic therapy)
·Cardiogenic shock—cool clammy skin, blood pressure very low, confusion, almost no urine output—means the heart is failing and cannot pump enough blood to keep the body alive
·New heart murmur heard on exam—suggests a papillary muscle tore (causing the mitral valve to leak, called acute mitral regurgitation) or a hole opened between the pumping chambers (ventricular septal defect, or VSD); both are life-threatening mechanical problems
·Ventricular arrhythmias on the monitor—ventricular a fast heart rate (tachycardia) (V-tach, fast dangerous rhythm from the lower chambers) or ventricular fibrillation (V-fib, heart just quivers and stops pumping)—can stop the heart and cause sudden cardiac arrest
·Right ventricular tissue death from blocked blood flow (infarction) signs—low blood pressure, neck veins bulging (elevated jugular venous pressure, or JVP), lungs clear on exam—needs IV fluids, NOT water pills (diuretics) or nitroglycerin, which will drop pressure even more

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Workup

·12-lead electrocardiogram (EKG or ECG)
·High-sensitivity troponin I or troponin T (blood test)
·Complete blood count (CBC)
·Basic metabolic panel (BMP) with creatinine and electrolytes—sodium, potassium, chloride, bicarbonate, glucose
·Chest X-ray (portable anterior-posterior view if the person is too unstable to stand)
·Transthoracic echocardiogram (bedside ultrasound of the heart)
·Coronary angiography (cardiac catheterization with dye injection)
·B-type natriuretic peptide (BNP) or N-terminal pro-BNP (NT-proBNP)

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Treatment

·Aspirin 162–325 mg chewed immediately (non-enteric-coated tablet)
·Second antiplatelet drug—ticagrelor 180 mg loading dose, prasugrel 60 mg loading dose, or clopidogrel 600 mg loading dose (dual antiplatelet therapy, called DAPT)
·Anticoagulation—unfractionated heparin IV bolus (60–70 units per kg body weight, max 5000 units) plus continuous infusion, or enoxaparin 1 mg per kg subcutaneous injection every 12 hours, or bivalirudin continuous infusion
·Urgent percutaneous coronary intervention (PCI)—door-to-balloon time under 90 minutes for STEMI, within 24 hours for high-risk NSTEMI (GRACE score >140, refractory starved blood flow (ischemia), hemodynamic instability, or life-threatening arrhythmia)
·Fibrinolytic therapy (alteplase, tenecteplase, or reteplase IV) if PCI cannot be performed within 120 minutes of first medical contact and symptom onset is within 12 hours
·Beta-blocker (metoprolol tartrate 25–50 mg by mouth every 6–12 hours, carvedilol, or bisoprolol) started within 24 hours if the person is hemodynamically stable
·High-intensity statin (atorvastatin 80 mg or rosuvastatin 40 mg by mouth once daily) started immediately in the hospital, regardless of baseline LDL cholesterol level
·ACE inhibitor (lisinopril starting at 2.5–5 mg daily and titrated up, enalapril, or ramipril) or ARB (losartan, valsartan) if ACE inhibitor causes intolerable cough—started within 24 hours if LVEF ≤40%, anterior wall MI, clinical heart failure, high blood pressure (hypertension), or diabetes

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NCLEX trap

·Start treatment the moment you suspect Acute Coronary Syndrome based on chest pain and EKG changes. Troponin takes 3 to 6 hours to rise after heart muscle starts dying, and every minute of delay kills more muscle. In Acute Coronary Syndrome, time is muscle—treat first, confirm later.
·Do NOT give nitroglycerin if the EKG shows an inferior (bottom-wall) heart attack and you suspect right-ventricle involvement. The right side of the heart needs higher blood pressure to push blood forward; nitroglycerin drops pressure and can cause the heart to stop pumping. Always check the EKG and blood pressure first.
·Pain relief does NOT rule out Acute Coronary Syndrome. A partly blocked artery can cause pain that comes and goes as the clot shifts or the artery squeezes tight (it spasms). You still need serial troponins (troponin checked at 0 and 3 hours, then again later), continuous EKG monitoring, and admission. Never diagnose or discharge based only on symptom relief.
·Up to half of patients with Acute Coronary Syndrome have a normal or near-normal EKG at first, especially in non-ST-elevation cases (when the blockage is partial and the EKG does not show the classic ST-segment lift). You must check troponin at 0 and 3 hours, observe the patient, and admit anyone with ongoing symptoms or risk factors. A normal EKG today does not mean the artery is not blocked.
·Acute Coronary Syndrome can strike anyone: young athletes with undiagnosed genetic lipid disorders (inherited high cholesterol), women taking birth control pills (which raise clotting risk), cocaine users (cocaine makes arteries spasm and clot), or people with hidden plaques. Age and appearance do not rule it out. Plaque can rupture in any artery at any age.
·Women, older adults, and people with diabetes often present with atypical symptoms: jaw or back pain, nausea, overwhelming fatigue, shortness of breath, or vague discomfort—no chest pressure at all. These presentations are still Acute Coronary Syndrome until proven otherwise. Missing atypical cases kills patients.

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