Acute coronary syndrome

INTRODUCTION

This clinical case reports on a 47-year-old patient Mr. Rahman, who sought medical care in the hospital due to severe chest pain, assessed as a 10 on the 0-10 pain scale. The major diagnostic hypothesis for this clinical case is acute coronary syndrome. 

Chest pain is the most common symptom for seeking emergency care and clinicians treat it as a major challenge, because of trouble in differentiating between non-emergency diagnosis and high mortality and morbidity, like acute coronary syndrome (ACS). 

Clinical examination, electrocardiogram, and myocardial necrosis markers are three basic parameters for the management in assessment of acute to severe chest pain. These parameters are required to be analyzed together while offering a safer approach to the patient, primarily in the case of ACS. 

Pathophysiology

About 15-20% of patients with severe chest pain are diagnosed with acute coronary syndrome, and this acts as a recurrent clinical manifestation (Canto et al., 2000). The characteristic presence of angina is the bigger determinant of an ischemic etiology in the clinical examination. Angina involves the compression sensation, burning, or difficulty in breathing in the precordial or any other region of the chest (Becker et al., 2002). This could radiate towards the neck, shoulder, and left arm. The pain enhances within minutes and includes symptoms of nausea and sweating. 

The Acute Coronary Syndrome can occur without obvious precipitating factors and can be asymptomatic (Birnbaum et al., 2002). It could be present as an ischemic equivalent, primarily in elder and diabetic patients suffering from autonomic dysfunction (dyspnea, syncope, and pre-syncope) (Landini et al., 2011). ACS findings indicate a worse prognosis because of mechanical complications or due to a huge area of myocardium at risk along with ventricular dysfunction (Kannel et al., 1987). 

In the diagnostic, prognostic, and therapeutic approach, the electrocardiogram is essential and must be obtained within ten minutes after the patient’s presentation with ongoing pain in the chest (Miniat et al., 1999). A serial ECG is indicated that enhances its sensitivity and assists in differentiating between acute and chronic alterations. 

Holistic assessment and immediate actions 

The patient reported in this clinical case had, at the admission ECG performed, changes consistent with ACS observed, suggesting the hypothesis of an acute coronary syndrome. The main hypothesis followed ACS care pathways. The clinical course of the patient is variable and may be acute and severe, resulting in death or sub-acute. 

The emergency care team assessed the patient and his blood sample was taken for analysis of cardiac markers. He was placed on a continuous cardiac monitor, where the full set of observations was taken to establish the ACS impact on his cardiac efficiency followed by a critical clinical assessment. 

A-E Assessment and Interventions

Clinical assessment declared clear airway and breathing, respirations 24 breaths per minute along with 97% of oxygen saturation. In circulatory analysis, the pulse came out to be 120 breaths per minute, which is regular. Blood pressure was observed as 180/90 and capillary refill as <2 seconds. With a disability alert, the blood glucose of the patients was measured as 6.8 mmol/L and body temperature as 36.5. 

The airways are patent if the patient can talk and be taken for a breathing assessment. If the patient is not in talking condition, he is observed for signs of airway compromise including cyanosis, see-saw breathing, use of accessory muscles, diminished breath sounds, and added sounds. 

In breathing, a normal respiratory rate is between 12-20 breaths per minute. ACS patients are tachypnoeic in order to enhance myocardial tissue oxygenation. The normal oxygen saturation range is 94-98% in healthy individuals whereas in patients with COPD, it ranges from 88-92% with a high risk of carbon dioxide retention (Landini et al., 2011). Cardiac failure and secondary pulmonary oedema can result in Hypoxaemia. If the patient has a low oxygen saturation range, then oxygen must be administered without delay involving a non-rebreathe mask with an oxygen flow rate of 15L. In the case of COPD, a venture mask should be used. If a patient is conscious, sit them upright that helps n oxygenation. 

In circulatory analysis, tachycardia is a common feature of ACS during pulse analysis. Bradycardia appears later resulting in cardiac arrest. Further, due to enhanced sympathetic activity and pain, patients might be hypertensive whereas hypotensive is a late sign, representing cardiac failure (Pope et al., 2000). In ACS treatment, morphine performs a dual function, both as a vasodilator and as an analgesic. Nitrates, aspirin, and clopidigrel improves blood flow. If pulmonary oedema is present, an intravenous diuretic like furosemide is useful as it increases diuresis. 

The patient’s consciousness level reduces in ACS with hypotension. Using the AVPU scale (alert, verbal, pain, unresponsive), the patient’s level of consciousness is measured. Treatment involves blood glucose and ketones measurement. If GCS is 8 or below, urgent expert help is recommended while maintaining the patient’s airway (Canto et al., 2000). 

Person-centered care plan

Person-centered care aims at establishing a partnership between patients and healthcare professionals in the care and treatment planning that emphasizes the capabilities and resources of the patient. It enhances general self-efficacy while improving both subjective and objective health outcomes. Various aspects of nursing care include knowledge and practice of patient management and quality of life. It is important to discover pain and symptom prevalence and its severity involving psychosocial outcomes like stress, anxiety, depression, burnout, and distress.

Other than this, social, spiritual, and practical aspects must be included in the patient-care plan. PCC interventions target patients, their families, friends, nurses, physiotherapists, and other healthcare professionals. Healthcare professionals including doctors, physiotherapists, dieticians, and nurses best manage physical and biological care. The family best administers psychological care. Moreover, friends play the best role in a social environment. 

Documentation is one of the three major cornerstones in the practical application of the person-centered approach. The Patient’s narrative is the first cornerstone that forms the basis of a partnership between the patient and healthcare professionals. Patients and healthcare professionals working together form the second cornerstone and create a personal healthcare plan. Medical tests and examinations form the basis of this plan. Documentation is the third cornerstone of the health plan. 

Health plan goals

Health plan goals can be divided into three categories including lifestyle changes, illness management, and relational activities at all three care levels. Lifestyle changes involve physical activities, weight loss, cessation of smoking, changes in diet, and reduced consumption of alcohol. Family plays a great role in managing lifestyle changes. 

Illness management goals involve decreased stress and decreased symptoms like pain and breathlessness. However, relational activity goals involve social life, leisure activities, professional paid work, and family life. Social life and leisure activities consist of trips, parties, recreational membership, quality time with children, and special events like a movie, and theater visits. Paid professional work involves a return to the workplace or changing the work situation. Family life includes household tasks, shopping, gardening, and renovation of a house. 

Personal resources and support needed for the attainment of the goal involve social support, family, and own resources. Own resources categorize as being motivated, self-knowledge from previous lifestyle, creativity, patience, and being settled and organized. Further, family and social support involve an involvement of spouse, children, and grandchildren in distinct ways, like changes in diet habits and leisure activities. 

Healthcare relayed support involves cardiac rehabilitation in the form of a hospital-based physical exercise program that includes periodic training sessions. Patients can use a web-based eHealth tool to track symptoms. Physiotherapists can help in physical training and support. A Dietitian can prescribe healthy diet. 

The person-centered care process accounts perspectives of both patients and professionals by focusing on disease, the personal capabilities of the patient, and goals. Listening to the narratives of the patient forms the starting point in personal-centered care plan. 

Conclusion

Acute coronary syndrome refers to any condition occurred due to sudden reduction or blockage of blood flow to the heart. It is most often caused by a rupture in plaque or the formation of clots in the arteries of the heart. Symptoms include heart attack-like chest pressure, pressure in the chest, or sudden stoppage in the heart

In this case analysis, we found the patient’s presentation quite challenging. The patient had severe chest pain upon which he was taken to the emergency department via ambulance. The major diagnostic hypothesis for this clinical case is an acute coronary syndrome. 

The emergency care team assessed the patient and his blood sample was taken for analysis of cardiac markers. He was placed on a continuous cardiac monitor, where the full set of observations was taken to establish the ACS impact on his cardiac efficiency followed by a critical clinical assessment. 

Furthermore, the above case study has depicted a few interventions based on the A-E approach along with personal-centered care plan to enhance the chances of recovery in case of acute coronary syndrome. 

References 

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• Birnbaum Y, Fishbein MC, Blanche C, Siegel RJ. Ventricular septal rupture after acute myocardial infarction. N Engl J Med. 2002;347(18):1426–1432. 

• Canto JG, Shlipak MG, Rogers WJ, et al. Prevalence, clinical characteristics, and mortality among patients with myocardial infarction presenting without chest pain. JAMA 2000;283:3223–9.

• Kannel WB, Cupples LA, D'Agostino RB. Sudden death risk in overt coronary heart disease: the Framingham Study. Am Heart J. 1987;113(3):799–804.

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Pope JH, Aufderheide TP, Ruthazer R, Woolard RH, Feldman JA, Beshansky JR, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med. 2000;342(16):1163–1170.