ACUTE CORONARY SYNDROME

SYMPTOMS may include: Substernal chest, jaw, arm or neck pain or discomfort (pain may or may not radiate), generalized weakness, sweating, lightheaded, N/V, shortness of breath, hypo/hypertension, pulmonary edema, IVD, cool / clammy skin, S3, S4, new onset LBBB

12-Lead EKG within 10 minutes of arrival: If not diagnostic, continue serial EKG Q15-30min for first hour

STABILIZE / Support ABC’s
Oxygen (O₂ Sal <90%, resp distress, risk)
Continuous EKG Monitor—treatment arrhythmias, Vital Signs, IV Access, Brief History & complete fibrinolytic checklist, Draw Labs (cardiac biomarkers, CBC, electrolytes, renal, coagulation studies, CRP, etc.), Chest X-Ray

End

Reperfusion Strategy

Percutaneous coronary intervention (PCI) with reperfusion— 90 minutes of STEMI diagnosis optimal
If PCI >120 minutes or PCI not available, consider fibrinolytics, give within 10 minites of diagnosis, transfer to PCI center

Suspected ongoing ischemia, consider angiography with 2 hours of assessment

UNSTABLE ANGINA
ST Segment / T Wave normal or undiagnostic

NSTEMI (Non-ST-segment elevation MI)
ST segment depression and/or T-Wave inversion—Elevated Cardiac Biomarkers

STEMI (ST-segment elevation MI)
ST elevation / LBBB or RBBB & Ischemic symptoms—Elevated Cardiac Biomarkers

Medication Management / Invasive Intervention(s)

Antithrombotic, pain relieving measures, other support medications such as: Nitrates Opioids, Anxiolytics, Aspirin, Beta Blockers, Calcium Channel Blockers, Statins
Anticoagulant: Unfractionated Heparin (Heparin)
P2Y (12) Platelet inhibitors: Brilinta
Platelet Aggregation Inhibitors: Plavix Effient
GP IIb/IIIa (glycoprotein) Antagonist Platelet Aggregation Inhibitors: Reopro, Integrillin, Aggrastat
LMWHS—Fragmin, Lovenox
Selective Factors Xa Inhibitor Anticoagulant: Xarello, Arixtra
Fibrinolytics (Thrombolytic): TNKase, Activase
Cardiogenic Shock—Pressor / inotropic agents such as dopamine, dobutamine, etc,
Intra-aortic pump for LV dysfunction / Emergent PCI prep and postprocedure care