• Subject Name : Nursing

Acute Coronary Syndrome

Table of Contents


Current published evidence.

Case Study 1: Acute Coronary Syndrome – Mr. Herz.

Case Study 2: Acute Myocardial Infarction Pediatric Case – Mika.



Introduction to Myocardial Infarction in Children

Collective terms to refer to the life-threatening conditions in the coronary artery are known as Acute Coronary Syndrome (ACS). It is caused due to reduced blood flow toward the heart muscles. A blockage in artery plaque or a corruptor inside the coronary artery leads to ACS. The blockage locations are described based on their types as well as the syndrome's severity, caused due to the rupture and blood flow’s blockage. Consequently, ACS includes ST-segment elevation on ECG (STEMI) and constitutes myocardial infarction without loss of cell. It includes myocardial infarction without ST-segment elevation on ECG (NSTEMI) along with myocardial ischemia. On the other hand, these refer to all emergency conditions or departmental cases requiring an immediate response. They are aimed to improve the heart’s blood flow by managing complications, with the ability to address future problems (Barry et al., 2016).

This paper discusses supplemental oxygen therapy administration as in the form of a patient’s management strategy. Using a compromised myocardium to study two patient’s case pieces of evidence as published in the appendices. Case study 1 (appendix I) is of a 68-year-old man (Mr Herz) presented at the emergency with crushing chest pain arriving within 40 minutes of pain. Case study 2 (appendix II) is an 11-year-old girl (Mika) with a severe retrosternal, radiating to the back in the emergency department. The discussion focuses on whether supplemental oxygen therapy’s administration is associated with a management strategy in both two cases should be changed or maintained.

Current Published Evidence

The physiologically cardiovascular system is a blood vessel’s network that elaborately supplies the human body with blood along with oxygen. To operate flawlessly this function must ensure adequate oxygen’s supply to the heart. The coronary arteries refer to the heart’s blood vessels instrumental in controlling oxygen’s amount passing in and out of the heart ensuring smooth flow of oxygen’s supply. Helps in not exceed the body’s oxygen demand and to perform at optimum physiological levels. These conditions balance oxygen’s supply and demand. 3 factors are there to maintain the heart's beat rate by controlling its contraction and expansion ability. It is also instrumental in controlling ventricular walls tension even in the presence of the body’s organ-based defense mechanism that possesses the capability to adapt to changing environments (Shin et al., 2017). These variables maintain optimal oxygen’s supply and demand to the heart with interferences that includes plaques like external factors leading to compromised vasculature. The patients during its occurrence develop acute coronary syndromes which are life-threatening (Bilici, Ture & Balik, 2018).

While the management and care facilities for the patients with acute suspected coronary syndrome using supplemental oxygen therapy has adopted as regular clinical practice since the late 1770s. It is when Joseph Priestley was in a view that oxygen potentially can benefit as well as cause medicinal harm. Later in 1890, these inferences were reinforced by Blodgett through a research report. This was instrumental in discovering that supplemental oxygen administration was used in the patient's benefit. For those who are suffering from respiratory-disease like pneumonia (Liu et al., 2019). A subsequent amount of research study on the discovering of additional illnesses to administer supplemental oxygen proves to be beneficial for the patients. Later it leads to discovery as well as a demonstration of a breakthrough in supplemental oxygen potential reliever in angina pectoris. The supplemental oxygen therapy’s administration was adopted universally as one clinical strategical routine in managing ACS (Brothers et al., 2017).

It refers to a common practice amongst the ACS patients as their emergency treatment’s part is provided in supplemental care and oxygen therapy. Physiological oxygen administration becomes the most logical action during acute coronary syndromes. These are associated with coronary artery blockage or rupture, meaning blood flow to the heart is restricted, leading to heart failure due to oxygen's lack (Kuzmiak-Glancy et al., 2018).

Manually supplying oxygen to the compromised myocardium through oxygen therapy is considered to be the first strategy in easing the situation. The strategy has been documented to help reduce the patient’s mortality rate. It is also instrumental in reducing patient’s pain by supplying oxygen to the vital cells. Consequently, it reduces or reverses the hypoxic effects (Giles et al., 2018).

On the other hand, this refers to patients with a lack or reduction of oxygen. In other types of acute coronary syndrome, such as ST-segment elevation of myocardial infarctions, myocardial perfusion is not associated with reduced oxygen saturation, thus, no oxygen therapy is added to these patient's types. The effects of air, as well as oxygen surrounding myocardial infarction, dubbed air vs oxygen in myocardial infarction (AVOID) tests. It was found that myocardial infarction patients tend to have an early loss of myocardium as a result of oxygen management and that patients are more likely to have more recurrent myocardial infarction with more severity. If these patients continue any surgical therapy procedure, the access formed during oxygen therapy may lead to loss of recovery. Oxygen therapy increases the resistance of the blood vessels, resulting in a decrease in the heart's blood flow. The creation of excess oxygen’s environment a platform for the reactive oxygen species formation causes DNA, proteins, RNA, as well as in the end failure of the heart (Cabello et al., 2016).

Case Study 1: Acute Coronary Syndrome – Mr. Herz

The presented patient, Mr Herz, mentioned in Appendix I of Case Study 1 is a 68year-old male with known heart disease history in addition to it he also has hypercholesterolemia with a minor PTCA procedure for removing a blockage in the coronary artery 12 months ago. The Emergency Department while assessing their vital signs indicates an above-normal Capillary oxygen saturation peripheral in the system with SpO2 99% (Kiel et al., 2017).

On the other hand, the emergency team elects and administers the supplemental oxygen through face mask therapy at six liters/minute. The oxygen therapy cannot be used with patients who do not possess oxygen deficiency in the bloodstream, this leads to the change in ANZCOR Guidelines. While managing the ACS as per newly written guidelines supplemental oxygen therapy needs to be administered to the patients who possess 94% or lower oxygen saturation deficiencies in the bloodstream (Brown et al., 2018). The primary symptom with all ACS types represents sharp pressure-like chest pain followed by breath shortness. The pain radiates through the neck affecting the patients’ body's sides making it hard to diagnose the ACS type. The reasons associated with this relates to the guidelines aimed to help healthcare providers in making the best systematic interventional decisions to manage these emergency conditions (Chaudhry & Rehman, 2018).

ACS’s ANZCOR guidelines in context to oxygen therapy run toward ACS hypoxemic patients with reduced oxygen saturation that goes below 94 percent with SpO2 less than 94%. Treatment of Mr. Herz’s involved PTCA procedure used to unblock or re-establish blood flow in the coronary artery. It is done through the insertion of 2 stents made up of bare-metals. The patient was put on oxygen therapy during the patient’s return to the care. Going further it is considered to be possible that the oxygen was referred to the original cause associated with the aspect of reperfusion damage. Considerably these had resulted in symptom’s reoccurrence associated with the witnessing of the initial presentation (English & Marshall, 2020). It is based on the above-mentioned explanations and the administration process associated with oxygen therapy. It is further in the form of a management strategy associated with Mr. Herz and that is what is in need to be stopped. The guidelines are a summary outline with all evidential conditions and the best possible management strategy placed in accordance with Level IV ANZCOR Guidelines 14.2 (nzec.org.nz, 2016). Strategies to manage Acute Coronary Syndrome, with three basic relief therapies are symptomatically available to patients with chest pains and are suspected to have ACS (Zheng et al., 2020).

Case Study 2: Acute Myocardial Infarction Pediatric Case – Mika

Even though ACS is commonly associated with elderly adults can now be also witnessed in the children. This is instrumental in presenting a slightly different approach. It is in context to the healthcare professionals associated with the terms associated with management. The reason behind this is that there are a number of non-prescribed guidelines related to the process of diagnostic both in terms of electrocardiography/echocardiography or those associated with a particular children’s enzyme. In addition to it, the children’s cardiovascular structures are considered to be still developing at a fast rate and are in their premature stages. It is therefore are already instrumental in presenting an ever-changing environment for the child. As the child tends to advance in his/her age (Chew et al., 2016).

In context to the common pediatric manifestations of myocardial infarction are in the form of compromised left coronary artery arrhythmias arising from the pulmonary artery (ALCAPA) and Kawasaki disease. The reason, finding a regular electrocardiographic diagnosis for ischemia becomes a challenge. Acute coronary syndromes prevalent in children are not often manifested because of inherited congenital heart disease from their family members although some do not. Additional cause in context to the coronary artery abnormalities possibly will be the result of a surgical procedure, congenital pneumothorax disease, or vasculitis that can lead to ischemia or infarction (Loscalzo, 2017).

The diagnostic procedure in context to acute coronary syndromes in kids involves consultation and testing with various tests to reach the bottom of the symptoms presented with amnesia, laboratory tests as well as imaging in the Department of Myocardial Management. Gathering data such as previous surgery, the presence of coronary heart disease known as hypertrophic cardiomyopathy, or previous transpositions from the caregiver to the patient is crucial in assessing the situation. Proceed to determine the PR partition in ECG (Stub et al., 2015).

Presented Case Study 2 (Appendix II) is an eleven year old girl with a history of bronchial asthma with acute inception of chest pain that presents to ED that spreads to the back. The healthcare user experiences mild breathe shortness with acute retrosternal pressure-like chest pain. Its most important symptom indicate a normal lung with normal cardiac performance which is without any murmurs or clicking. The results of the electrocardiogram test indicate a heavy presence of ST-segmentation by augmentation of its vectors to the right (AVR). This confirmed that the healthcare user was suffering from an acute pediatric myocardial infarction which was probably due to bronchial asthma (Obokata et al., 2018). In view of the fact that there are no pediatrician-specific guidelines for the management, treatment and care of acute coronary syndromes, existing guidelines for adults are applied in this case. Healthcare user with ST-segment elevated MIs oxygen therapy should not be administered with complementary oxygen but should be exposed to ambient air as mentioned in ANZCOR guidelines 14.2 (2016). In this case, the management as well as treatment methods and strategies employed in the case of Mika must be maintained (Docherty, 2018).

Conclusion on Myocardial Infarction in Children

It will be good to conclude that the management as well as the care associated with acute coronary syndrome tends to have undergone a number of metamorphoses. It is due to the fact that since the time of its inception in the early 17th century, the practical use associated with supplemental oxygen therapy has started in the form of a primary care practice in favor of the patients over many years. After remaining neglected as a treatment to treat diseases of this nature in the latter part it was used successfully. On the other hand, recent research works are instrumental in showing that this particular strategy used to treat patients may not be safe for all forms associated with the treatment of ACS (Guensch et al., 2019). With a considerable amount of beneficial qualities in regards to the patients, it is still suspected as in the form of an ACS associated with hypoxemia. It is carried out by raising the levels of oxygen to a compromised myocardium as well as subsequently leads in the reduction of the infarct's size. The contextual supplemental oxygen is instrumental in adding no any number of beneficial value in regards to the patients with ST-segment elevated MI. It is true that a number of studies as discussed in context to this paper have indicated that it is considered to be harmful to the patients without oxygen deficiency. Hence the ANZCOR Guidelines were rewritten in 2016 indicating a fact that oxygen therapy can only be implemented with oxygen saturation deficiencies that is lower than 94%.

References for Myocardial Infarction in Children

Barry, J. S., Rozance, P. J., Brown, L. D., Anthony, R. V., Thornburg, K. L., & Hay Jr, W. W. (2016). Increased fetal myocardial sensitivity to insulin-stimulated glucose metabolism during ovine fetal growth restriction. Experimental biology and medicine241(8), 839-847.

Bilici, M., Ture, M., &Balik, H. (2018). Myocardial Infarction in Children. In Myocardial Infarction. IntechOpen.

Brothers, J. A., Frommelt, M. A., Jaquiss, R. D., Myerburg, R. J., Fraser, C. D., &Tweddell, J. S. (2017). Expert consensus guidelines: anomalous aortic origin of a coronary artery. The Journal of thoracic and cardiovascular surgery, 153(6), 1440-1457.

Brown, A. J., Ha, F. J., Michail, M., & West, N. E. (2018). Prehospital Diagnosis and Management of Acute Myocardial Infarction. In Primary Angioplasty (pp. 15-29). Springer, Singapore.

Cabello, J. B., Burls, A., Emparanza, J. I., Bayliss, S. E., & Quinn, T. (2016). Oxygen therapy for acute myocardial infarction. Cochrane Database of Systematic Reviews, (12).

Chaudhry, R., & Rehman, A. (2018). Physiology, Cardiovascular. In StatPearls [Internet]. StatPearls Publishing.

Chew, D. P., Scott, I. A., Cullen, L., French, J. K., Briffa, T. G., Tideman, P. A., ... & Aylward, P. E. (2016). National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the management of acute coronary syndromes 2016. Medical Journal of Australia, 205(3), 128-133.

Docherty, A. B. (2018). Myocardial injury in critically ill patients with co-existing cardiovascular disease (Doctoral dissertation, University of Edinburgh).

English, S. W., & Marshall, J. C. (2020). Oxygen Delivery and Utilization: A Mathematical Artifact or a Target for Personalized Medicine?. Critical Care Medicine48(2), 271-272.

Giles, A. V., Sun, J., Femnou, A. N., Kuzmiak-Glancy, S., Taylor, J. L., Covian, R., ... & Balaban, R. S. (2018). Energetics and Metabolism: Paradoxical arteriole constriction compromises cytosolic and mitochondrial oxygen delivery in the isolated saline-perfused heart. American Journal of Physiology-Heart and Circulatory Physiology315(6), H1791.

Guensch, D. P., Fischer, K., Jung, C., Hurni, S., Winkler, B. M., Jung, B., ... & Eberle, B. (2019). Relationship between myocardial oxygenation and blood pressure: Experimental validation using oxygenation-sensitive cardiovascular magnetic resonance. PloS one14(1), e0210098.

Kiel, A. M., Goodwill, A. G., Noblet, J. N., Barnard, A. L., Sassoon, D. J., & Tune, J. D. (2017). Regulation of myocardial oxygen delivery in response to graded reductions in hematocrit: role of K+ channels. Basic research in cardiology112(6), 65.

Kuzmiak-Glancy, S., Covian, R., Femnou, A. N., Glancy, B., Jaimes III, R., Wengrowski, A. M., ... & Kay, M. W. (2018). Cardiac performance is limited by oxygen delivery to the mitochondria in the crystalloid-perfused working heart. American Journal of Physiology-Heart and Circulatory Physiology314(4), H704-H715.

Liu, Z., Barber, C., Gupta, A., Wan, L., Won, Y. W., Furenlid, L. R., ... & Unger, E. C. (2019). Imaging assessment of cardioprotection mediated by a dodecafluoropentane oxygen-carrier administered during myocardial infarction. Nuclear medicine and biology70, 67-77.

Loscalzo, J. (2017). Is oxygen therapy beneficial in acute myocardial infarction? Simple question, complicated mechanism, simple answer. N Engl J Med, 377(13), 1286-1287.

nzec.org.nz (2016), ANZCOR Guideline 11.6.1 – Targeted Oxygen Therapy in Adult Advanced Life Support, from: https://www.nzrc.org.nz/assets/Guidelines/Adult-ALS/ANZCOR-Guideline-11.6.1-Targeted-Oxygen-Therapy-Jan2.pdf [Retrieved On: 8th September 2020]

Obokata, M., Reddy, Y. N., Melenovsky, V., Kane, G. C., Olson, T. P., Jarolim, P., & Borlaug, B. A. (2018). Myocardial injury and cardiac reserve in patients with heart failure and preserved ejection fraction. Journal of the American College of Cardiology72(1), 29-40.

Shin, B., Cowan, D. B., Emani, S. M., Pedro, J., & McCully, J. D. (2017). Mitochondrial transplantation in myocardial ischemia and reperfusion injury. In Mitochondrial Dynamics in Cardiovascular Medicine (pp. 595-619). Springer, Cham.

Stub, D., Smith, K., Bernard, S., Nehme, Z., Stephenson, M., Bray, J., ... & Meredith, I. (2015). Air versus oxygen in myocardial infarction (AVOID) trial sub-study: time-dependent effect of oxygen administration on the myocardial injury. Heart, Lung and Circulation, 24, S374.

Zheng, M. L., He, S. R., Liu, Y. M., & Chen, L. (2020). Measurement of inotropy and systemic oxygen delivery in term, low-and very-low-birth-weight neonates using the Ultrasonic Cardiac Output Monitor (USCOM). Journal of Perinatal Medicine48(3), 289-295.

Remember, at the center of any academic work, lies clarity and evidence. Should you need further assistance, do look up to our Nursing Assignment Help

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