Chapter 21 Marini Acute Coronary Syndromes

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CHAPTER 21 • Acute Coronary Syndromes

Symptoms of Infarction / Ischemia

EMS Assessment / Hospital Prep

• Monitor / Support ABCs; Prepare for CPR / Defibrillation • Deliver aspirin (morphine / oxygen / nitroglycerin if necessary) • Transport to PCI Capable facility if possible • Obtain 12-Lead ECG - If ST Elevation:

- Notify hospital; note first medical contact / onset time - Hospital staff should prepare for STEMI response - Use fibrinolytic checklist if considering prehospital fibrinolysis

Simultaneous ED Assessment (<10 min)

Immediate ED Treatment

• Check Vitals / O 2 Saturation • Brief targeted history / physical exam • Conduct fibrinolytic checklist / contraindications check • IV Access • Secure portable chest x-ray (<30 min) • Collect preliminary cardiac marker levels, coagulation and electrolyte studies

• Oxygen at 4 L/min (titrate) only if O 2 saturation <94, or respiratory disease • Aspirin : 160–325 mg • Nitroglycerin spray / sublingual • Morphine IV if nitroglycerin is ineffective

Interpret ECG

ST Depression / Dynamic T-wave Inversion; high potential for ischemia High risk unstable angina / non-ST-elevation MI (UA/STEMI)

ST-Elevation / New LBBB: high potential for injury ST-Elevation MI (STEMI)

Normal / Non-diagnostic changes in T-wave / ST Segment Low / Intermediate risk ACS

• Initiate adjunctive therapies • Don’t delay reperfusion

ED Chest Pain Unit Admission / Follow

High-Risk Patient / Elevated Troponin

Early invasive strategy if • Heart Failure Signs

• Continuous ST-segment / ECG monitoring • Serial cardiac numbers (troponin) • Noninvasive diagnostic test

• Ventricular Tachycardia • Hemodynamic Instability

>12 h

Symptoms Onset Time < 12 Hours?

• Refractory Ischemic Chest Discomfort • Persistent / Recurrent ST Deviation

< 12 h

YES

Exhibit(s) > 1: • Troponin Elevation

Initiate Adjunctive Treatments

• Heparin (UFH or LMWH) • Nitroglycerin • Consider: - Clopidogrel

• Clinical High-Risk Features • ECG Changes (consistent with ischemia)

Reperfusion Goals

Therapy based upon center / patient criteria • Fibrinolysis (Door-to-needle) Goal = 30 min • PCI (Door-to-balloon inflation) Goal = 90 min

- Glycoprotein IIb / IIa Inhibitor - PO b -blockers

NO

Physiologic Testing / Abnormal Diagnostic Noninvasive Imaging

YES

• Monitored bed admission • Continue heparin / ASA / other therapies • Determine risk status • Statin Therapy–HMG CoA reductase inhibitor • ACE Inhibitor / ARB • Cardiology to risk stratify (when not at high-risk

NO

Discharge (with follow-up) when no evidence of infarction / ischemia presents

FIGURE 21-5. Management of patients with chest pain presentation algorithm.

Initial Steps Patients with a chest pain history suggestive of AMI should be placed at bed rest, undergo immediate ECG testing, receive sufficient oxygen to assure normal

arterial saturation while avoiding hyperoxia, and have two peripheral intravenous catheters inserted, at which time blood samples should be drawn for elec- trolyte, hemoglobin, and CPK and troponin analyses.