I.

INTRODUCTION

A heart beat signifies life, from the day it starts to beat in the womb, till it
stops, and where death conquers us. The heart beats not only to one tune but it
also responds to the tune of emotions and physical stress. As some of us may
have also experience moments of joy or sorrow and the heart may feel pain or
pleasure.

In medicine, an acute disease is a disease with a rapid onset or a short

course. The term “Acute” may often be confused by the general public to mean
“severe” however, this has a different meaning. Coronary, may refer to as “the
heart” or “relating to the heart”. While syndrome is defined as a set of signs and
symptoms that tend to occur together and which reflect the presence of a
particular disease or an increased chance of developing a particular disease.

According to the morbidity rate, taken from the records of the

Department of Health for region X, the occurrence of cardiovascular diseases
per 100,000 populations is 3,356. This data is taken from the 2001-2005, a 5
years average record. While the occurrence rate for cardiovascular disease for region X
by 2006 is recorded to be 4,373 per 100,000 populations.

Acute Coronary Syndrome is defined as a spectrum of conditions involving

chestdiscomfort or other symptoms caused by lack of oxygen to the heart muscle
(themyocardium). The unification of these manifestations of coronary artery disease under
asingle term reflects the understanding that these are caused by a similar pathophysiology
(sequence of pathologic events) characterized by erosion, fissuring, or rupture of a pre-existing
plaque, leading to thrombosis (clotting) within the coronary arteries and impaired blood supply
to the heart muscle.

1
II. REVIEW OF ANATOMY AND PHYSIOLOGY of the organs involved

CARDIOVASCULAR SYSTEM

HEART
For all its might, the cone-shaped heart
is a relatively small, roughly the same size as a
closed fist—about 12 cm (5 in) long, 9 cm (3.5
in) wide at its broadest point, and 6 cm (2.5 in)
thick. Its mass averages 250 g (8oz) in adult
females and 300 g (10oz) in adult males. The
heart rests on the diaphragm, near the midline
of the thoracic cavity. It lies in the mediastinum,
a mass of tissue that extends from the sternum
to the vertebral column between the lungs.
About two-thirds of the mass of the heart lies to
the left of the body’s midline. Visualize the heart as a cone lying on its side. The
pointed end of the heart is the apex, which is directed anteriorly, inferiorly, and to
the left. The broad portion of the heart opposite the apex is the base, which is
directed posteriorly, superiorly, and to the right.
In addition to the apex and the base, the heart has several surfaces and
borders9margins). The anterior surface is deep to the sternum and ribs. The
inferior surface is the part of the heart between the apex and the right border and
rests mostly on the diaphragm. The right border faces the right lung and extends
from the inferior surface to the base. The left border, also called the pulmonary
border, faces the left lung and extends from the base to the apex.
Layers and Coverings of the Heart
The heart is located between the lungs in the thoracic cavity and is
surrounded and protected by the pericardium (peri - _ around). The pericardium
consists of an outer, tough fibrous pericardium and an inner, delicate serous
pericardium. The fibrous pericardium attaches to the diaphragm and also to the
great vessels of the heart. Like all serous membranes, the serous pericardium is
a double membrane composed of an outer parietal layer and an inner visceral
layer. Between these two layers is the pericardial cavity filled with serous fluid.
The wall of the heart has three layers: the outer epicardium (epi - _ on, upon;
cardia _ heart), the middle myocardium (myo muscle), and the inner
endocardium (endo - _ within, inward). The epicardium is the visceral layer of the
pericardium. The majority of the heart is myocardium or cardiac muscle tissue.
The endocardium is a thin layer of endothelium deep to the myocardium that
lines the chambers of the heart and the valves.
Surface Structures of the Heart
The human heart has four chambers and is divided into right and left
sides. Each side has an upper chamber called an atrium and a lower chamber
called a ventricle. The two atria form the base of the heart and the tip of the left
ventricle forms the apex. Auricles (auricle _ little ear) are pouch-like extensions of
the atria with wrinkled edges. Shallow grooves called sulci (sulcus, singular)

2
externally mark the boundaries between the four heart chambers. Although a
considerable amount of external adipose tissue is present on the heart surface
for cushioning, most heart models do not show this. Cardiac muscle tissue that
composes the heart walls has its own blood supply and circulation, the coronary
(corona _ crown) circulation. Coronary blood vessels encompass the heart
similar to a crown and are found in sulci. On the anterior surface of the heart, the
right and left coronary arteries branch off the base of the ascending aorta just
superior to the aortic semilunar valve, and travel in the sulcus separating the atria
and ventricles. These small arteries are supplied with blood when the ventricles
are resting. When the ventricles contract, the cusps of the aortic valve open to
cover the openings to the coronary arteries.
A clinically important branch of the left coronary artery is the anterior
interventricular branch, also known as the left anterior descending (LAD) branch
that lies between the right and left ventricles and supplies both ventricles with
oxygen-rich blood. This coronary artery is commonly occluded which can result in
a myocardial infarct and, at times, death.
Great Vessels of the Heart
The great veins of the heart return blood to the atria and the great arteries
carry blood away from the ventricles. The superior vena cava, inferior vena cava,
and coronary sinus return oxygen-poor blood to the right atrium. The superior
vena cava returns blood from the head, neck, and arms; the inferior vena cava
returns blood from the body inferior to the heart. The coronary sinus is a smaller
vein that returns blood from the coronary circulation. Blood leaves the right
atrium to enter the right ventricle. From here, oxygen-poor blood passes out the
pulmonary trunk, the only vessel that removes blood from the right ventricle. This
large artery divides into the right and left pulmonary arteries that carry blood to
the lungs where it is oxygenated. Oxygen-rich blood returns to the left atrium
through two right and two left pulmonary veins. The blood then passes into the
left ventricle that pumps blood into the large aorta. The aorta distributes blood to
the systemic circulation. The aorta begins as a short ascending aorta, curves to
the left to form the aortic arch, descends posteriorly and continues as the
descending aorta.
Internal Structures of the Heart
The heart has four valves that control the one-way flow of blood: two
atrioventricular (AV) valves and two semilunar valves (semi- _ half; lunar _
moon).Blood passing between the right atrium and the right ventricle goes
through the right AV valve, the tricuspid valve (tri _ three; cusp _ flap). The left
AV valve, the bicuspid valve, is between the left atrium and the left ventricle. This
valve clinically is called the mitral valve (miter _ tall, liturgical headdress)
because the open valve resembles a bishop’s headdress. String-like cords called
chordae tendineae (tendinous strands) attach andsecure the cusps of the AV
valves to enlarged papillary muscles that project from theventricular walls.
Chordae tendinae allow the AV valves to close during ventricular contraction, but
prevent their cusps from getting pushed up into the atria. The twosemilunar
valves allow blood to flow from the ventricles to great arteries and exit the heart.
Blood in the right ventricle goes through the pulmonary (semilunar) valve to enter

3
the pulmonary trunk, a large artery. The aortic (semilunar) valve is located
between theleft ventricle and the aorta. These two semilunar valves are identical,
with each havingthree pockets that fill with blood, preventing blood from flowing
back into the ventricles.The two ventricles have a thick wall between them called
the interventricular septum.Between the two atria is a thinner interatrial septum.
Coronary Circulation
There are two major coronary arteries: the right and the left. These two
arteries branch out of the aorta immediately after the aortic valve. The right
coronary artery splits into the marginal branch, which feeds blood into the right
ventricle, and the posterior inter ventricular branch, which supplies the left
ventricle. The left coronary artery is notably larger than the right coronary artery
because it feeds the left heart, which, as a result of its more powerful
contractions, requires a more vigorous blood flow. The left coronary artery splits
into the anterior inter ventricular branch and a circumflex branch. The anterior
inter ventricular branch runs towards the apex of the heart, providing blood for
both of the ventricles and the ventricular septum. The circumflex branch, on the
other hand, follows the groove between the left atrium and the left ventricle,
providing blood supply to both of these chambers until it reaches and joins with
the right coronary artery in the posterior of the heart.
The coronary arteries are especially subject to blockage and narrowing
which can cause a depletion of blood to certain parts of the heart, possibly
causing a heart attack.
Blood Flow through the Heart
The function of the right side of the heart is to
collect de-oxygenated blood, in the right atrium, from
the body and pump it, via the right ventricle, into the
lungs (pulmonary circulation) so that carbon dioxide
can be dropped off and oxygen picked up (gas
exchange). This happens through the passive process
of diffusion. The left side (see left heart) collects
oxygenated blood from the lungs into the left atrium.
From the left atrium the blood moves to the left
ventricle which pumps it out to the body. On both
sides, the lower ventricles are thicker and stronger than the upper atria. The
muscle wall surrounding the left ventricle is thicker than the wall surrounding the
right ventricle due to the higher force needed to pump the blood through the
systemic circulation. Starting in the right atrium, the blood flows through the
tricuspid valve to the right ventricle. Here it is pumped out the pulmonary
semilunar valve and travels through the pulmonary artery to the lungs. From
there, blood flows back through the pulmonary vein to the left atrium. It then
travels through the mitral valve to the left ventricle, from where it is pumped
through the aortic semilunar valve to the aorta. The aorta forks, and the blood is
divided between major arteries which supply the upper and lower body. The
blood travels in the arteries to the smaller arterioles, then finally to the tiny
capillaries which feed each cell. The (relatively) deoxygenated blood then travels

4
to the venules, which coalesce into veins, then to the inferior and superior venae
cavae and finally back to the right atrium where the process began.
Blood Vessels
Blood circulates inside the blood vessels, which form a closed transport
system, the so-called vascular system. Like a system of roads, the vascular
system has its freeways, secondary roads, and alleys. As the heart beats, blood
is propelled into the large arteries leaving the heart. It then moves successively
smaller and smaller arteries and then into the arterioles, which feed the capillary
beds in the tissues. Capillary beds are drained by venules, which in turn empty
into the great veins (venae cavae) entering the heart. Thus arteries, which carry
blood away from the heart, and veins, which drain the tissues and return the
blood to the heart, are simply conducting vessels. Only the tiny hair-like
capillaries, which extend and branch through the tissue and connect the smallest
arteries (arterioles) to the smallest veins (venules), directly serve the needs of
the body cells. The capillaries are the side streets or alleys that intimately
intertwine among the body cells. It is only through their walls that exchanges
between the tissue cells and the blood can occur (Marieb, 2014).
Layers of Blood Vessel Walls
The walls of blood vessels have three coats, or tunics. The tunica intima
which lines the lumen or interior of the blood vessels, is a thin layer of
endothelium (squamous epithelial cells) resting on a basement membrane. Its
cells fit closely together and forma slick surface that decreases friction as blood
flows through the vessel lumen (Marieb, 2014).
The tunica media is the bulky middle coat. It is
mostly smooth muscle and elastic tissue. The smooth
muscle, which is controlled by the sympathetic
nervous system, is active in changing the diameter of
the vessels. As the vessel constrict or dilate, blood
pressure increases or decreases, respectively
(Marieb, 2014).
The tunica external is the outermost tunic; it is
composed largely of fibrous connective tissue. Its function is basically to support
and protect the vessels (Marieb, 2014).
The Microcirculation
The microcirculation is that portion of the
circulatory system for exchange of water, gases,
nutrients, and waste material. As such, it is the
most important part of the cardiovascular system
because it is where the exchange with tissues
takes place. Although the microcirculation is
considered as a closed system, its walls are much
more permeable than any other part of the
circulation.
Factors Affecting Flow of Blood
The flow of a fluid through a vessel is determined by the pressure
difference between the two ends of the vessel and also the resistance to flow.

5
 Pressure Difference
For any fluid to flow along a vessel there must be a pressure difference otherwise
the fluid will not move. In the cardiovascular system, the “pressure head” or force
is generated by the pumping of the heart and there is a continuous drop in
pressure from the left ventricle to the tissue and also from the tissue back to the
right atrium(Marieb, 2014).
 Resistance to Flow
Resistance is a measure of the ease with which a fluid flows through a
tube: the easier it is the less resistance to flow, and vice versa. In the circulatory
system, the resistance is usually described as vascular resistance or also known
as peripheral resistance. Resistance is essentially a measure of the friction
between the molecules of the fluid, and between the tube wall and the fluid. The
resistance depends on the viscosity of the fluid and the radius and length of the
tube(Marieb, 2014).
 Radius of the Tube
The smaller the radius of a vessel, the greater is the resistance to the
movement of particles. Small alterations in the size of the radius of the blood
vessels, particularly of the more peripheral vessels, can greatly influence the flow
of blood. Atheromatous changes in the walls of large and medium-sized arteries
cause narrowing of the lumen of the vessels and result in an increased vascular
resistance (Marieb, 2014).
 Length of the Tube
The longer the tube, the greater the resistance to the flow of liquid through it. A
longer vessel will require a greater pressure to force a given volume of liquid
through it than will a shorter vessel (Marieb, 2014).
 Viscosity of the Fluid
Viscosity is a measure of the intermolecular or internal friction within a fluid or in other
words, of the tendency of the fluid to resist flows. The greater the viscosity of the fluid, the
greater is the force required to move that liquid (Marieb, 2014).
Blood
Blood is a specialized bodily fluid (technically a tissue) that is composed of a liquid
called blood plasma and blood cells suspended within the plasma. The blood cells present in
blood are red blood cells (also called RBCs or erythrocytes), white blood cells (including both
leukocytes and lymphocytes) and platelets (also called thrombocytes). Plasma is
predominantly water containing dissolved proteins, salts and many other substances; and
makes up about 55% of blood by volume. Mammals have red blood, which is bright red when
oxygenated, due to hemoglobin. Some animals, such as the horse shoe crab use
hemocyanin to carry oxygen, instead of hemoglobin.
By far the most abundant cells in blood are red blood cells. These contain hemoglobin,
an iron-containing protein, which facilitates transportation of oxygen by reversibly binding to this
respiratory gas and greatly increasing its solubility in blood. In contrast, carbon dioxide is
almost entirely transported extracellularly dissolved in plasma as bicarbonate ion. White blood
cells help to resist infections and parasites, and platelets are important in the clotting of blood.
Blood is circulated around the body through blood vessels by the pumping action of
the heart. Arterial blood carries oxygen from inhaled air to the tissues of the

6
 body,andvenousblood carries carbon dioxide, a waste product of metabolism produced by
cells, from the tissues to the lungs to be exhaled.
Medical terms related to blood often begin with hemo- or hemato- (BE: haemo- and
haemato-) from the Greek word "αμα ἷ" for "blood." Anatomically and histologically, blood is
considered a specialized form of connective tissue, given its origin in the bones and the
presence of potential molecular fibers in the form of fibrinogen.
Constituents of human blood
Blood accounts for 7% of the human body weight, with an average density
of approximately 1060 kg/m³, very close to pure water's density of 1000 kg/m.
very close to pure water's density of 1000 kg/m 3. The average adult has a blood
volume of roughly 5 litres, composed of plasma and several kinds of cells
(occasionally called corpuscles); these formed elements of the blood are
erythrocytes (red blood cells), leukocytes (white blood cells) and
thrombocytes(platelets). By volume the red blood cells constitute about 45% of
whole blood, the plasma constitutes about 55%, and white cells constitute a
minute volume.
Cells
4.7 to 6.1 million (male), 4.2 to 5.4 million (female) erythrocytes: In
mammals, mature red blood cells lack a nucleus and organelles. They
contain the blood's hemoglobin and distribute oxygen. The red blood cells (together with
endothelial vessel cells and other cells) are also marked by glycoproteins that
define the different blood types. The proportion of blood occupied by red blood
cells is referred to as the he matocrit, and is normally about 45%. The combined surface
area of all the red cells in the human body would be roughly 2,000 times as great as the body's
exterior surface.
4,000-11,000 leukocytes:
White blood cells are part of the immune system; theydestroy and remove
old or aberrant cells and cellular debris, as well as attack infectiousagents
(pathogens) and foreign substances. The cancer of leukocytes is calledleukemia.
200,000-500,000 thrombocytes:
Platelets are responsible for blood clotting(coagulation). They
change fibrinogen into fibrin. This fibrin creates a mesh onto whichred blood cells
collect and clot, which then stops more blood from leaving the body andalso helps
to prevent bacteria from entering the body.
Plasma
About 55% of whole blood is blood plasma, a fluid that is the blood's liquid
medium, which by itself is straw-yellow in color. The blood plasma volume totals
of 2.7-3.0 litres in an average human. It is essentially an aqueous solution
containing 92%water, 8% blood plasma proteins, and trace amounts of other
materials. Plasma circulates dissolved nutrients, such as, glucose, amino acids
and fatty acids (dis solvedin the blood or bound to plasma proteins), and
removes waste products, such as, carbon dioxide, urea and lactir c acid.Other
important components include:
- Serum albumin
- Blood clotting factors (to facilitate coagulation)
- Immunoglobulins(antibodies)

7
- Various other proteins
- Various electrolytes (mainly sodium and chloride)
The termserumrefers to plasma from which the clotting proteins
have been removed.Most of the proteins remaining are albumin and
immunoglobulins.
The normal pH of human arterial blood is approximately 7.40 (normal
range is 7.35-7.45), a weak alkaline solution. Blood that has a pH
below 7.35 is too acidic, while blood pH above 7.45 is too alkaline.
Blood pH, arterial oxygen tension (PaO2), arterial carbon dioxide
tension (PaCO2) and HCO3 are carefully regulated by complex
systems of homeostasis, which influence the respiratory system and
the urinary system in the control the acid-base balance and respiration.
Plasma also circulates hormones transmitting their messages to
various tissues.
Color
Hemoglobin
Hemoglobin is the principal determinant of the color of blood in vertebrates. Each
molecule has four heme groups, and their interaction with various molecules alters theexact
color. In vertebrates and other hemoglobin-using creatures, arterial blood andcapillaryblood
are bright red as oxygen impacts a strong red color to the heme group. Deoxygenated blood is
a darker shade of red with a bluish hue; this is present in veins, and can be seen during blood
donation and when venous blood samples are taken. Blood in carbon monoxide poisoning is
bright red, because carbon monoxide causes the formation of carboxy hemoglobin. In cyanide
poisoning, the body cannot utilize oxygen, so the venous blood remains oxygenated,
increasing the redness. While hemoglobin containing blood is never blue, there are several
conditions and diseases where the color of the heme groups make the skin appear blue. If the
heme is oxidized, methemoglobin, which is more brownish and cannot transport oxygen, is
formed. In the rare condition sulfhemoglobinemia, arterial hemoglobin is partially oxygenated,
and appears dark-red with a bluish hue (cyanosis), but not quite as blueish as venous blood.
Veins in the skin appear blue for a variety of reasons only weakly dependent on the
color of the blood. Light scattering in the skin, and the visual processing of color play roles as
well.
Skinks in the genus.Prasinohaema have green blood due to a buildup of the waste
product biliverdin.
Hemocyanin
The blood of most molluscs, including cephalopods and gastropods, as well assome
arthropods such as horseshoe crabs contains the copper-containing proteinhemocyanin at
concentrations of about 50 grams per litre. Hemocyanin is colour less when deoxygenated
and dark blue when oxygenated. The blood in the circulation of these creatures, which
generally live in cold environments with low oxygen tensions, is grey-white to pale yellow, and
it turns dark blue when exposed to the oxygen in the air, as seen when they bleed. This is due
to change in color of hemocyanin when is it oxidized. Hemocyanin carries oxygen in
extracellular fluid, which is in contrast to the intracellular oxygen transport in mammals by
hemoglobin in RBCs.
Pancreatic Islets
8
 The pancreas, located close to the stomach in the abdominal cavity is a
mixed gland. Probably the best-hidden endocrine glands in the body are the
pancreatic islets, formerly called the islets of Langerhans. These little masses of
hormone-producing tissue are scattered among the enzyme-producing acinar
tissue of the pancreas. Two important hormones produced by the islet cells are
insulin and glucagons.
Glucagons act as an antagonist of insulin; that is, it helps to regulate blood
glucose levels but is a way opposite to that of insulin. Its release by the alpha
cells of the islets is stimulated by low blood levels of glucose. Its action is
basically hyperglycemic. Its primary target organ is the liver, which stimulates to
break down stored glycogen to glucose and to release glucose into the blood.
hypoglycemic
High levels of glucose in the blood stimulate the release of insulin from the
beta cells of the islets. Insulin acts on just about all body cells and increases their
ability to transport glucose across their plasma membranes. Once inside the
cells, glucose is oxidized for energy or converted to glycogen or fat for storage.
These activities are also speeded up by insulin. Since insulin sweeps the glucose
out of the blood, its effect is said to be hypoglycemic. As blood glucose levels fall,
the stimulus for insulin release ends (negative feedback control). Insulin is the
only hormone that decreases blood glucose levels. Insulin is absolutely
necessary for the use of glucose by the body cells. Without it, essentially no
glucose can get into the cells to be used.
Glucagons act as an antagonist of insulin;
that is, it helps to regulate blood glucose levels but
is a way opposite to that of insulin. Its release by
the alpha cells of the islets is stimulated by low
blood levels of glucose. Its action is basically
hyperglycemic. Its primary target organ is the liver,
which stimulates to break down stored glycogen to
glucose and to release glucose into the blood
(Marieb, 2014).
Insulin
The main function of the insulin is to participate in maintaining
homeostasis of blood glucose level and to promote other metabolic activities that
are anabolic. When absorbed nutrients, especially glucose, are in excess of
immediate needs insulin promotes storage. It reduces high blood nutrients by:
Acting on cell membranes and stimulating uptake and utilization of
glucose by muscles and connective tissue cells;
Increasing conversion of glucose to glycogen, especially in the liver and
skeletal muscles;
Accelerating uptake of amino acids by cells, and the synthesis of proteins;
Promoting synthesis of fatty acids and storage of fat in adipose tissue,
and; Preventing the breakdown of protein and fat and gluconeogenesis.
Glucagon
The effect of glucagon is increasing blood glucose levels by stimulating:
Conversion of glycogen to glucose (in the liver and skeletal muscle);

9
 Gluconeogenesis, the manufacture of glucose by the body from non-
carbohydrate materials.
Somatostatin
The effect of somatostatin (also produced by hypothalamus) is to inhibit
the secretion of both insulin and glucagons. It delays intestinal absorption of
glucose (Marieb, 2014).
Metabolism
Metabolism is a broad term referring to all chemical reactions that are
necessary to maintain life. In involves catabolism, in which substances are
broken down to simpler substances, and anabolism, in which larger molecules or
structures are built from smaller ones. During catabolism, energy is released and
captured to make ATP, the energy-rich molecule used to energize all cellular
activities, including catabolic reactions (Marieb, 2014).
Just as an oil furnace uses oil (its fuel) to produce heat, the cells of the
body use carbohydrates as their preferred fuel to produce cellular energy (ATP).
Glucose, also known as blood sugar, is the major breakdown product of
carbohydrate digestion. Glucose is also the major fuel used for making ATP in
most body cells. Basically, the carbon atoms released leave the cells as carbon
dioxide, and the hydrogen atoms removed (which contain energy-rich electrons)
are eventually combined with oxygen to form water. These oxygen-using events
are referred to collectively as cellular respiration.
The overall reaction is summed up simply as:
C6H12O6 + 6 O2 => 6 CO2 + 6 H20 + ATP (energy)

10
 III. PATHOPHYSIOLOGY

Predisposing Factors: Precipitating Factors:

 Age (Men: 45↑  Hypertension
Women: 55↑)  Overweight
 Genetic Factors  Hyperlipidemia
 Hx. of CVD  Stress DM type II

Endothelial lining of
the arteries are injured

Permeability of the vessel to Platelets, WBC, and Fibrin

lipoproteins ↑ converge at the injured site

Lipoprotein accumulated in
the intima of the arterial wall

T-Lymphocytes & monocytes (that

become macrophages) infiltrate the
area to ingest lipids and die

Formation of dead fatty core

Formation of fibrous cap over

dead fatty core (Plaque)

Plaque protrudes in lumen of the vessel

Narrowed blood vessel Plaque ruptures and
obstruct/impedes blood causes thrombus
flow formation (Platelet
aggregation + Fibrin)

Occlusion of an artery

↓myocardial perfusion/ ↓ blood

flow to the myocardium
UNSTABLE
ANGINA Myocardial ischemia

Partially Total ischemic cells

ischemic cells
Accumulation of Accumulation of No supply of
Inadequate supply waste products waste products O2 & nutrients
of O2 &nutrients
11
Noncontractile No ATP
 Anerobic ↓ ATP
 Inflammatory mediators Loss cell membrane
metabolism production
 Granulocyte activation integrity
 O2 - free radicals
Accumulation Hypocontractile
Cell rupture
of lactate

Inhibition of
glycolysis Inhibition of
ion pumps

Altered cell
membrane integrity

Altered cell
Myocyte death/necrosis
membrane integrity

Myocardial Infarction
(Endocardium, mild-endocardium, Unrelieved chest
full thickness myocardium) pain radiating to
(inferolateral and anterolateral wall) the left shoulder for
over a night; Sever
anxiety; SOB
Myocardial infarction
Heart muscle loses Disrupt conduction
optimal strength system of the heart
↓ Contractility
↓ Stroke Volume Arrhythmias
↓ Cardiac Output
Baroreceptor activation ↓ Tissue perfusion

Sympathetic nervous RAAS activation

system activation

↑ Action Vasoconstriction
potential
↑ Contraction ↑ Vascular ↑ Venous return
speed resistance ↑ Ventricular filling
↑ Contractility ↑ MAP ↑ Stroke Vol.
↑ BP
↑ Cardiac Output

BRAIN EYES HEART KIDNEY

 TIA  Blindness  CHF; Infarct extension;  Renal Failure
 Aneurysm Myocardial rupture; Ventricular
 Thrombosis hypertrophy; Ventricular
 Hemorrhage Anuerism; Arrhythmias; Angina; 12
Cardiogenic shock
IV. LABORATORY
Blood Chemistry

Test Normal Range Results Implications

Creatinine .7-1.2 1.3 mg/dl Myocardial Infraction
Na 137-145 132 mmol/L Hypernatremia
K 3.5-5.1 3.4 mmol/L Hypokalemia
ALT 9-52 3.0 u/L Liver functioning decrease
r/t drugs adverse effect
and gerontologic
consideration
CK-MB 0-18 7 u/L
Differential Count

Test Normal Range Results Implications

Segmenters 55-65 % 46 Suggest anemia
Lymphocytes 25-35 % 53 Anemia
Eosinophils 1-3 % 01 Reduced in Stress
Hematology

Test Normal Range Result Implications

HCT 35-50 % 29.4 Iron Deficiency
Anemia
HGB 11-16.5 g/dl 9.8 Iron Deficiency
Anemia
RBC 3.8 – 5.80 10/mm
WBC 5-10 10/mm 9,100
Platelet Count 140,000-440,000 333,000
Chest x-ray Report

Examination Desired: CCXR Port

 Haziness seen in the left base
 Heart I magnified
 Aorta is calcified
 Spurs seen at the margins of the thoracic spine.

Impression:
 Probable left basal Pneumonia
 Atherosclerotic Aorta
 Thoracic Spondylosis

Fasting Blood Sugar Lipid Profile

13
 Test Normal Range Results Implications
Glucose 74-106 132 mg/dL Hyperglycemia
Uric Acid 2.5-6.2 8.4 mg/dL Hyperuricemia
Cholesterol 0-200 187 mg/L Hypercholesterolemia
Triglycerides 0-150 60 mg/dL Atherosclerosis
Direct HGL 40-60 38 mg/dL
LDL 60-180 137 mg/dL
VDRL 25-50 12 mg/dL
ALT 8-52 27 U/L
Troponin T (Quantitative)
2.0ng/ml

Interpretation of Results Rationale

< 0.03 ng/ml
Between 0.03 ng/ml & 0.1 ng/ml
Between 0.1 ng/ml % 3.0 ng/ml
>2.0 ng/ml
Electrocardiograph tracing
Low cardiac risk
Medium cardiac risk (possible Myocardial
Damage)
High Risk (Myocardial Damage Detected)
Massive Myocardial damage has been
detected

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ECG Findings (Possible)

Rhythm Sinus Axis +39

Rate: Atrial 93bpm Ventricular 93bpm Position
P.R. 0.20 sec QRS 0.1 sec QT 0.44 sec QT Ratio

ECG Diagnosis
-Sinus Rhythm
-Inferolateral and anterior wall ischemia

ECG Findings

Rhythm Sinus
Axis +10
Rate: Ventricular
93bpm Position
P.R. 0.20 sec QRS 0.08
sec QT 0.44 sec

ECG Diagnosis
-Sinus Rhythm
-Inferolateral and anterior wall
ischemia
-Left ventricular hypertrophy
by voltage criteria

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V. PHARMACOLOGIC STUDY

Medication Action Side-Effects Dosage Nursing Intervention

Generic Name: Inhibits CNS-dizziness, asthenia, N/A >Monitor patients who are also
Losartan Potassium vasoconstrictive and fatigue, headache, insomia. taking diuretics
aldosterone- CV- edema, ,chest pain. for symptomatic hypotension.
Brand Name: Cosaa secreting action of EENT-nasal congestion, >Monitor BP.
angiotensin II by sinusitis, pharyngitis, sinus >Assess patients renal
Classification: blocking angiotensin disorder. function>>Tell patient to avoid
Angiotensin receptor II receptor on the GI-Abdominal pain, nausea, salt substitutes.
blockers (ARBs surface of vascular diarrhea, dyspepsia. -Give medication on time.
smooth muscle and Musculoskeletal-muscle cramps, -Explain the side-effects of
other tissue cells myalgia, back or leg pain. medication to patient.
Respiratory-cough, upper
respiratory infection

Medication Action Side-effects Dosage Nursing Intervention

Generic Name Combines reversibly Nausea, vomiting, diarrhea, 50 mg -Verify Doctor’s Order
Metropolol Succinate mainly with beta- shortness of breathing, PO -Know the MOA of medication
Trade Name adrenergic receptors decreased WBC,platelet, BID -Give the medication on time
Lopressor to block the response hct, rash, fever -Explain the side-effects to the
to sympathetic nerve patient
Classification: impulses, circulating -Instruct patient to call
Antihypertensive catecholamines, or attention of nurse for any
adrenergic drugs. abnormalities.

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 Medication Action Side-effects Dosage Nursing Intervention
Generic Name: Atorvastatin competitively Headache, flatulence, N/A -Verify Doctor’s Order
Atorvastatin inhibits HMG-CoA diarrhoea, nausea, -Know the MOA of
reductase, the enzyme that vomiting, anorexia, medication
Brand Name: catalysestheconversion of xerostomia, -Give the medication on
Lipitor HMG-CoA to mevalonic acid. angioedema,myalgia, time
This results in the induction rash/pruritus, alopecia, -Explain the side-effects to
Classification: of the LDLreceptors, leading allergy, infection, chest the patient
Dyslipidaemic Agent to lowered LDL-cholesterol pain -Instruct patient to call
concentration. attention of nurse for any
abnormalities.

Medication Action Side-effects Dosage Nursing Intervention

Clopidogrel inhibits platelet
aggregation by
irreversibly inhibiting the
Classification: binding of ATP to
Antiplatelet platelet receptors
agents; Reduction
Platelet of atherosclerotic
Aggregation events(MI, stroke,
inhibitors vascular death) in
patients at risk for such
events including recent
MI, acute coronary
syndrome (unstable
angina/non-Q-wave MI),
stroke, or peripheral
vascular disease.
CNS:
Depression, Dizziness, Fatigue,
Headache.
EENT: Epistaxis.
Resp:Cough, Dyspnea.
CV:Chest Pain,
Edema,Hypertension.
GI:GI Bleeding, Abdominal Pain,
Diarrhea,Dyspepsia, Gastritis.
Derm:Pruritus, Purpura,Rash.
Hemat: Bleeding, Neutropenia,
Thrombotic Thrombocytopenic
Purpura.
Metab:Hypercholesterolemia.
MS:Arthralgia, Back Pain.
Misc:Fever,
HypersensitivityReactions
N/A Assessment
-Assess patient for symptoms of
stroke, peripheral vascular
disease, or MI periodically
during therapy.
-Monitor patient for signs of
thrombotic thrombocyticpurpura
(thrombocytopenia,
microangiopathic hemolytic
anemia, neurologic findings,
renal dysfunction, fever).
-May rarely occur, even after
short exposure(<2 wk). -
Requires prompt treatment.
Implementation
-Discontinue clopidogrel 5-7
days before planned surgical

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procedures.
PO:
-Administer once daily without
regard to food.
Patient/Family Teaching
-Instruct patient to take
medication exactly as directed.
Take missed doses as soon as
possible unless almost time for
next dose; do not double doses.
-Advise patient to notify
health care professional
promptly if fever, chills, sore
throat, or unusual bleeding or
bruising occurs. Advise
patient to notify health care
professional of medication
regimen prior to treatment or
surgery

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VI. BIBLIOGRAPHY

Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2017). Brunner
&Suddarth’s textbook of medical-surgical nursing 13th edition. C&E
bookstore; Davao City.
Karch, A. M. (2012).Lippincott’s nursing drug guide nurses pocket guide 12th
edition. C&E bookstore; Davao City.
Marieb, E. N. (2014). Essentials of Human Anatomy & Physiology 10th
edition.C&E book store; Davao City.

Links:
 https://www.scribd.com/doc/238916284/Atorvastatin-Drug-Study
 https://www.scribd.com/doc/307814195/DRUG-STUDY-Metoprolol
 https://www.scribd.com/doc/163856584/Clopidogrel-Drug-Study
 https://www.drugs.com/losartan.html
 https://www.mayoclinic.org/diseases-conditions/acute-coronary-
syndrome/diagnosis-treatment/drc-20352140
 https://www.google.com.ph/search?source=hp&ei=TbVeXI2LHci88QWP9
onoDg&q=%E2%80%A2%09Myocardial+perfusion+imaging+%28MPI%29
&btnK=Google+Search&oq=%E2%80%A2%09Myocardial+perfusion+ima
ging+%28MPI%29&gs_l=psy-
ab.3..0i22i30l3.1900.1900..2356...0.0..0.157.285.0j2......0....2j1..gws-
wiz.....0.F2IynbHieBI
 https://www.mayoclinic.org/diseases-conditions/acute-coronary-
syndrome/diagnosis-treatment/drc-20352140
 https://www.google.com.ph/search?ei=ULVeXKnUNoaF8gWNwLmIBg&q=
Myocardial+perfusion+imaging+%28MPI%29++normal+result&oq=Myocar
dial+perfusion+imaging+%28MPI%29++normal+result&gs_l=psy-
ab.3..33i21.2516.11841..12225...0.0..0.193.2352.0j17......0....1..gws-
wiz.......0i71j0i7i30j0j0i30j0i22i30j33i160j33i22i29i30.SG7X6lVcUdc

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