acute%20coronary%20syndromes%20w_out%20persistent%20st-segment%20elevation
ACUTE CORONARY SYNDROMES W/OUT PERSISTENT ST-SEGMENT ELEVATION
Acute coronary syndromes refer to any constellation of clinical symptoms compatible with acute myocardial ischemia which may be life-threatening.
It encompasses unstable angina, non-ST-segment elevation myocardial infarction (NSTEMI) and ST-segment elevation myocardial infarction (STEMI).
Unstable angina is the ischemic discomfort that presents without persistent ST-segment elevation on ECG and without the presence of cardiac markers in the blood.
Non-ST-segment elevation myocardial infarction is diagnosed if cardiac markers are positive with ST-segment depression or with nonspecific or normal ECGs.
The patient typically presents with ischemic-type chest pain that is severe and prolonged and may occur at rest or may be caused by less exertion than previous episodes.

Patient Education

Patient and Caregiver Education

  • Patient counseling tends to improve patient compliance and outcomes
  • Assess the functional capacity and the ability to carry out daily activities or work of the patient
  • Educate the patient and caregivers about unstable angina and cerebrovascular disease
    • Discuss the nature of the disease, drug regimens, lifestyle modifications and symptoms of angina
  • Before hospital discharge, provide instructions with respect to medication type, purpose, dose, frequency and side effects
  • Patient and caregivers should be instructed on what steps to take if anginal symptoms occur
    • Patient should be instructed to take sublingual nitrate and to seek emergency medical attention if 3 doses of nitrate fail to relieve pain
    • Explain to patient that if anginal symptoms change (eg pain more frequent, or occurs at rest, etc), they should contact their physician
  • Education should be a part of every patient encounter and should be tailored to the patient’s level of understanding
    • May be best to develop a plan with the patient and hold discussions over time so that patient is not overwhelmed by changing several behaviors all at one time (eg smoking, diet, exercise, etc)
  • Enlisting family members into the educational process to assist in achieving risk-factor modifications may be helpful
    • Eg cooking low-fat meals for the entire family or family exercise to further support the patient in changing risk behavior
    • Particularly important when screening of family members reveals common risk factors (eg hyperlipidemia, hypertension and obesity)
  • Inform schedule for follow-up after discharge
    • Low-risk medically treated patients and revascularized patients should return in 2-6 weeks
    • Higher risk patients should return within 2 weeks
    Annual influenza vaccination is recommended
  • Patient’s need for treatment of chronic musculoskeletal pain or discomfort should be assessed; pain relief should begin with Paracetamol, small doses of narcotics or nonacetylated salicylates
  • Antioxidant vitamins (eg vitamin E, C or beta-carotene) and folic acid with or without vitamins B6 and B12, should not be used for secondary prevention in UA/NSTEMI patients

Lifestyle Modification

Activity

  • Daily walking may be encouraged immediately after discharge
  • Exercise training can be started within 1-2 weeks after PCI or CABG to relieve ischemia
  • Discuss safety and timing of resumption of sexual activity
    • Usually 1-2 weeks for low-risk patients and 4 weeks for post-CABG
  • Give advice on resumption of driving (usually 1 week) if stressful driving conditions are avoided
  • Recommend timing of returning to work
  • Air travel may resume within 2 weeks of discharge, if patient travels with companion, carries sublingual GTN and takes airport transport to avoid rushing

Smoking Cessation

  • There are observational studies that show cigarette smoking increases the risk for CV disease events, insulin resistance and DM
    • Dose-dependent relationship exists between cigarettes smoked and CV risks
  • Primary goal is complete smoking cessation
  • Assess patient’s tobacco use and trongly urge patient and family to stop smoking
  • Identify which patients are willing to quit
    • Quit plan should be developed and pharmacological therapy (eg nicotine replacement, Bupropion, Varenicline), counseling and formal cessation programs should be provided, if needed
  • Aside from smoking cessation, avoidance of exposure to environmental smoke is also recommended
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