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. 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. 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). 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 Anyone with history of CAD, HTN, ESRD, DM Blood loss due to GI Bleed, surgery, trauma Blood loss due to GI Bleed, surgery, trauma Patients on dialysis with AV Fistulas ( ↑ myocardial O2 demands) Patients on dialysis with AV Fistulas ( ↑ myocardial O2 demands) Decreased O2 saturations (particularly in COPD) Decreased O2 saturations (particularly in COPD) Fever, hyperthyroidism, sustained tachycardia, prolonged hypotension, hypothermia, DIC, drug use (especially cocaine) 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 Musculoskeletal chest pain Pericarditis (can have acute ST changes) Pericarditis (can have acute ST changes) Aortic dissection Aortic dissection Central Nervous System Disease (may mimic MI by causing diffuse ST-T wave changes) Central Nervous System Disease (may mimic MI by causing diffuse ST-T wave changes) Pancreatitis/Cholecystitis Pancreatitis/Cholecystitis

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

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

7. 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 = 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 = II, III & aVF = Inferior Wall MI = Right Coronary Artery Right Coronary Artery blockage blockage

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

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

14. What part of the heart is affected ? I, aVL, V5 and V6 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 = I, aVL, V5 + V6 = Lateral Wall = Lateral Wall = Circumflex Artery Circumflex Artery Blockage 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 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 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 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 Unexplained tachycardia Tachypnea Tachypnea Sudden elevation in PA catheter #’s or ICP (unexplained) Sudden elevation in PA catheter #’s or ICP (unexplained) Nausea and/or diaphoresis that doesn’t make sense Nausea and/or diaphoresis that doesn’t make sense Pallor Pallor Symptoms of sudden heart failure (pulmonary edema/crackles) Symptoms of sudden heart failure (pulmonary edema/crackles) Unexplained restlessness/all of a sudden needs more sedation 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 After completing an EKG, look at each of the leads for ST segment changes Remember the three I’s: 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 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! Remember the symptoms that would prompt you to obtain an EKG!