Acute Coronary Syndrome Is a Medical Emergency
Pharmacists should identify barriers that may prevent patients from adhering to complicated regimens or receiving proper care.
Cardiovascular diseases affect millions of people globally each year, and many affected individuals must be treated both at onset and continuously after.
With cardiovascular diseases accounting for approximately one-third of all deaths worldwide—and approximately 7.5 million of those deaths due to ischemic heart disease—the entire health care team must manage patients diagnosed with cardiovascular-related conditions that lead to ischemic heart disease carefully to ensure long-term, relatively symptom—free survival.1,2
Acute coronary syndrome (ACS) is an umbrella term encompassing 3 common cardiovascular-related conditions that lead to ischemic heart disease2,3: non—ST-segment elevation myocardial infarction (NSTEMI), ST-segment elevation myocardial infarction (STEMI), and unstable angina.
All 3 conditions occur when plaque inside the coronary artery ruptures suddenly, decreasing cardiac blood flow (ischemia).2-4 When patients with stable angina experience changes from baseline or new symptoms, they enter unstable angina.3,4 Unstable angina is a medical emergency, as it may progress further to either NSTEMI or STEMI, more commonly called a heart attack.3-5
NSTEMI and STEMI present differently on an electrocardiogram (ECG), with the ST segment being either nonelevated or elevated, respectively.3 Electrical ECG changes may be absent with NSTEMI. Clinicians will need to look at other chemical markers, including cardiac troponin and other cardiac proteins.4,5 Generally, NSTEMI is a partial or small blockage typically associated with better outcomes than STEMI, which is a full blockage to an area of the heart.4
ACS EVENT AT THE PHARMACY: RECOGNIZE AND RESPOND
As accessible health care providers, pharmacists may find themselves face to face with a patient experiencing ACS signs and symptoms at some point in their careers. Knowing what to do is critical.
First, time is of the essence. Recognizing a patient experiencing an ACS event will expedite their arrival at the hospital and improve the likelihood of a better outcome.5,6 Common signs and symptoms of ACS occur abruptly and include angina (usually described as aching or pressure); diaphoresis; a feeling of impending doom; indigestion; nausea and vomiting; pain spreading from the chest to the arms, back, jaw, shoulder, and upper abdomen; and unexplained fatigue.4 First and foremost, call 911.
Of course, patients may not experience all these symptoms or may present with different symptoms, so it is important to gather the appropriate facts quickly to assist emergency medical technicians (EMT) and other medical professionals. Table 1 lists questions to ask in case the patient is unable to answer them when EMTs arrive.
Asking patients if they take a phosphodiesterase (PDE) inhibitor, such as sildenafil, and when they took the last dose is also prudent. Many times, patients may be embarrassed to admit taking an erectile dysfunction drug, but if taken with nitroglycerin, sildenafil and other PDE inhibitors can cause life-threatening hypotension. Asking the right questions and providing a detailed medication list to EMTs are crucial in treating these patients effectively and promptly.5
THE PHARMACIST'S ROLE IN POST-ACS CARE
ACS may be an abrupt event, but it typically requires lifelong treatment and monitoring to prevent further episodes.3,7,8 Chances are, the patient will see pharmacists more than other health care providers, which presents an opportunity to hold patients accountable for proper medication use following hospital discharge.8,9 Medication nonadherence is a major predictor of poor outcomes in patients who have experienced an ACS event.9 After a hospital stay for ACS, patients will often have prescriptions for new medications, summarized in table 22,5-12.
With a mixture of familiar and unfamiliar medications, patients post-ACS need counseling from all health care team members. Pharmacists should identify barriers that may prevent patients from adhering to complicated regimens or receiving proper care.9,12 A negative event, such as ACS, can open the door to talk to the patient about positive changes that may prevent future recurrences.8,9,12 Lifestyle management, proper medication use, and smoking cessation can define a patient’s future and are just a few important areas in which pharmacists can make a difference.
Canyon Hopkins is a PharmD candidate at the University of Connecticut School of Pharmacy in Storrs.
- Bueno H. Epidemiology of acute coronary syndromes. ESC CardioMed. 2018:1213- 1218. doi:10.1093/med/9780198784906.003.0305
- Reilly K. The pharmacist’s guide to acute coronary syndrome. US Pharmacist. February 19, 2020. Accessed November 15, 2020. https://www.uspharmacist.com/ article/the-pharmacists-guide-to-acute-coronary-syndrome
- CAD: acute coronary syndrome. Cleveland Clinic. Updated April 22, 2019. Accessed November 15, 2020. https://my.clevelandclinic.org/health/diseas- es/16713-cad-acute-coronary-syndrome
- Getting active after acute coronary syndrome. Mayo Clinic. January 9, 2019. Accessed November 15, 2020. https://www.mayoclinic.org/diseases-conditions/acute-coro- nary-syndrome/in-depth/getting-active-after-acute-coronary-syndrome/art-20207799
- Nestelberger T, Boeddinghaus J, Greenslade J, et al; APACE and ADAPT Investigators. Two-hour algorithm for rapid triage of suspected acute myocardial infarc- tion using a high-sensitivity cardiac troponin I assay. Clin Chem. 2019;65(11):1437- 1447. doi:10.1373/clinchem.2019.305193
- Roffi M, Patrono C, Collet J-P, et al; ESC Scientific Document Group. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J. 2016;37(3):267-315. doi:10.1093/eurheartj/ehv320
- Guedeney P, Aboyans V, Dalon F, et al. Epidemiology, treatment patterns and outcomes in patients with coronary or lower extremity artery disease in France. Arch Cardivasc Dis. 2019;112(11):670-679. doi:10.1016/j.acvd.2019.05.009
- Guedeney P, Collet J-P. Diagnosis and management of acute coronary syndrome: what is new and why? insight from the 2020 European Society of Cardiology Guidelines. J Clin Med. 2020;9(11):3474. doi:10.3390/jcm9113474
- Zidan A, Awaisu A, Kheir N, et al. Impact of a pharmacist-delivered discharge and follow-up intervention for patients with acute coronary syndromes in Qatar: a study protocol for a randomised controlled trial. BMJ Open. 2016;6(11):e012141. doi:10.1136/bmjopen-2016-012141
- Tarantini G, Mojoli M, Varbella F, et al; DUBIUS Investigators; Italian Society of Interventional Cardiology. Timing of oral P2Y12 inhibitor administration in non- ST elevation acute coronary syndrome. J Am Coll Cardiol. 2020;76(21):2450-2459. doi:1110.1016/j.jacc.2020.08.053
- Puymirat E, Simon T, Cayla G, et al; USIK, USIC 2000, and FAST-MI investiga- tors. Acute myocardial infarction: changes in patient characteristics, management, and 6-month outcomes over a period of 20 years in the FAST-MI program (French Registry of Acute ST-Elevation or Non-ST-Elevation Myocardial Infarction) 1995 to 2015. Circulation. 2017;136(20):1908-1919. doi:10.1161/CIRCULATIONAHA.117.030798
- Zwart B, Parker WAE, Storey RF. New antithrombotic drugs in acute coronary syndrome. J Clin Med. 2020;9(7):2059. doi:10.3390/jcm9072059