Acute coronary syndromes

Acute coronary care is two skills glued together: recognize the ischemic emergency and prove you can assess perfusion and breath sounds well enough to catch the next failure early.

STEMI and unstable ischemic pain

Sudden crushing substernal pain, radiation to the arm or jaw, diaphoresis, and ST-segment elevation mean the coronary artery needs opening now. Support ABCs, keep the client on a monitor, establish IV access, and activate the reperfusion pathway (PCI when available). Adjuncts such as antiplatelet therapy, anticoagulation, and symptom drugs follow orders and allergies.

NSTEMI and unstable angina share the acute coronary syndrome umbrella without lasting ST elevation. Troponin rise marks myocardial injury in NSTEMI; unstable angina is ischemia without biomarker confirmation. Both still need urgent ECG, monitoring, and ordered anti-ischemic care. The clock is loudest for STEMI reperfusion, but “negative first troponin” does not clear a client who is still crushing with dynamic ECG changes. Serial enzymes and ECGs catch what a single draw misses.

• Stable angina teaching still matters between crises: know triggers, carry nitroglycerin, and rest at the first pain.
• After MI, watch for complications: dysrhythmias, heart failure, cardiogenic shock, and pericarditis-type pain patterns later in the course.
• MONA is a memory scaffold, not a blind checklist. Oxygen when hypoxic, aspirin unless contraindicated, nitro if BP allows, morphine only as ordered for refractory pain.

Nitroglycerin and the cath lab aftermath

Sublingual nitroglycerin

1. Sit or lie down before the dose (syncope risk).
2. Place under the tongue; allow to dissolve. Do not swallow like a tablet with water.
3. Repeat per the teaching plan if pain persists (commonly every 5 minutes up to 3 doses) and seek emergency care when pain does not resolve as instructed.
4. Hold the nitrate plan and escalate if blood pressure is already critically low, or if the client recently used a PDE-5 inhibitor for erectile dysfunction.

Thrombolytic / fibrinolytic therapy appears when PCI cannot be reached in time and the stem fits a STEMI reperfusion window. Bleeding risk, recent stroke/surgery exclusions, and neuro checks after the drug are the nursing watch list. Prefer PCI when the stem offers a ready cath lab; do not invent a lytic when the protocol says go to the lab.

Post cardiac catheterization (femoral)

Immediate priority is bleeding and limb ischemia at the access site: inspect the dressing and under the client, check distal pulses, color, temperature, and sensation, and enforce activity/bedrest limits. A soft blood pressure cuff on the same limb is not the win if the site is pouring.

When the infarct breaks the pump

Hours to a couple of days after a large MI, hypotension, tachycardia, cool clammy skin, crackles, and oliguria point to cardiogenic shock. Treat as pump failure with the ordered vasoactive and respiratory supports. Do not treat it like outpatient dehydration.

Cardiopulmonary assessment that the exam still asks

ACS stems still drop landmark, breath-sound, and perfusion items because opening a STEMI pathway is not enough. You also have to prove the pump and the airways are working before the next failure hides in plain sight.

Apical pulse for an adult is at the 5th intercostal space, left midclavicular line (mitral area). That is where you count rate and rhythm when the stem asks for the landmark, before digoxin-class drugs, or when peripheral pulses are weak. A radial-only count can miss an apical-radial gap and some dysrhythmias.

Capillary refill is a quick peripheral perfusion check. About 2 seconds or less is the usual adult expectation; several seconds means blood is not reaching the nail bed well. Pair it with color, temperature, and pulse quality. One number alone is not the whole story.

SpO2 for most adults on room air sits roughly 95 to 100%. Know the client's chronic baseline when COPD or longstanding hypoxemia is in the stem. Early hypoxia often shows as restlessness or agitation before late cyanosis, so do not wait for blue lips to act.

Crackles usually mean fluid in small airways or alveoli. After MI that can be the left ventricle failing into the lungs. Full heart-failure drug and diuresis teaching lives in Heart Failure and Drug Management. Here you need to hear the wet sound and escalate the pump picture.

Expiratory wheeze is narrowed lower airways. Stridor is upper-airway obstruction and an emergency. Treating stridor like ordinary wheeze is a classic miss. Foot pulses (dorsalis pedis, posterior tibial) plus color, temperature, and refill answer whether distal blood flow is intact after cath or when perfusion is in doubt. Broader arterial versus venous disease patterns live in Vascular Disorders and Anticoagulation.

Pericarditis after MI often hurts less when the client leans forward and may add a friction rub. That is different from ischemic crushing pain that demands reperfusion. Swallow safety and focused neuro exams belong in Stroke and Neuro Assessment when the stem turns on dysphagia or neuro deficits rather than cardiac landmarks.

Tamponade and endocarditis (look-alikes around the heart)

Tamponade is blood or fluid in the pericardial sac squeezing the heart so it cannot fill. The exam cluster is Beck’s triad: hypotension, jugular venous distention, and muffled heart sounds, often with pulsus paradoxus (systolic drop on inspiration) and clear lungs. That last point separates it from left-sided failure with crackles. This is obstructive shock. Fluids may buy filling pressure as a bridge; the fix is drainage (pericardiocentesis or return to the OR). Diuretics and nitroglycerin drop preload into an already empty ventricle. After cardiac surgery or trauma, sudden JVD plus a quiet heart is tamponade until proven otherwise. Tension pneumothorax and massive PE share the obstructive-shock family; those maps live in Shock and sepsis and Acute respiratory emergencies.

Infective endocarditis is infection of the valve surface. Fever, a new or changing murmur, and embolic skin or organ signs (Janeway spots, Osler nodes, splinter hemorrhages, stroke, splenic pain) are the cluster. Blood cultures before antibiotics when the timeline still allows, then prolonged IV therapy as ordered. Heart-failure signs mean the valve is failing mechanically, not that you should start with an ACE inhibitor lecture. The distractor that looks efficient is giving the first antibiotic before the culture on a stem that still has time, or calling tamponade “right-sided HF” and giving furosemide.

Valvular stenosis and regurgitation

A stenotic valve will not open; the chamber behind it works against a wall. Aortic stenosis is the exam favorite: syncope, angina, and heart-failure symptoms with a slow-rising pulse. Those clients live on preload. Sudden vasodilators or “dry them out” diuresis can drop cardiac output. Mitral stenosis (often after rheumatic fever) backs blood into the lungs: dyspnea, orthopnea, atrial fibrillation risk. A regurgitant valve leaks: the ventricle volume-loads. New severe regurgitation after endocarditis or papillary-muscle rupture post-MI is a surgical clock, not a teaching session on ACE inhibitors as the first move. Anticoagulation appears when AF or a mechanical valve is in the stem; dental prophylaxis teaching belongs with high-risk valves. Heart-failure drugs for chronic compensated valve disease live in Heart failure and drug management.

Discharge teaching after MI

Survival after the cath lab still depends on what the client does at home. Teach when to call emergency services for recurrent pain, how to use nitroglycerin, smoking cessation, cardiac diet (low saturated fat/sodium as ordered), medication adherence (dual antiplatelet therapy duration as prescribed), and graded activity or cardiac rehab referral. Sexual activity usually resumes when the client can climb about two flights without symptoms, per common teaching: do not invent exact week numbers if the stem gives a provider plan.

• Hold metformin around iodinated contrast as ordered to limit lactic acidosis risk.
• Report bleeding while on dual antiplatelet therapy; do not stop aspirin/P2Y12 agents without the cardiologist.
• Depression and denial after MI are common. Engage the support plan rather than shaming nonadherence alone.

Priority map