initial management of acute coronary syndrome

Introduction

Assessment:

• vital signs
• oxygen saturation (pulse oximetry)
• IV access
• 12 lead ECG (within 10 minutes)
• history & physical
• markers of myocardial infarction
• electrolytes, PT/PTT
• chest X-ray within 30 minutes
• consider triage to facility capable of PCI for:
  • HR > 100/min AND SBP < 100 mm Hg
  • signs of pulmonary edema
  • signs of shock

Management

• aspirin 162-325 mg crushed, chewed, or PR, STAT & QD
• oxygen 4 L/min by nasal cannula
  • titrate as needed
  • duration 6 hours, unless otherwise indicated
• nitroglycerin except with suspected right ventricular MI
  • 0.4 mg SL every 5 minutes x 3
  • limit blood pressure drop
    • 10% of baseline in normotensive patients
    • 30% of baseline in hypertensive patients
    • keep systolic blood pressure (SBP) > 100 mm Hg
  • IV infusion for 24-48 hours if
    • acute MI with CHF
    • larger anterior wall MI
    • persistent ischemia
    • persistent hypertension
• morphine 2-4 mg IV every 5-15 minutes as needed, if pain not relieved by nitroglycerin
• beta-blocker for all patients without contraindications
  • if contraindicated, use diltiazem or verapamil
• add ACE inhibitor for patients with an anterior wall MI, LV dysfunction, heart failure, or diabetes mellitus
• in patients with heart failure, use loop diuretic rather than thiazide diuretic
• thrombolytic therapy if indicated (in hospital)
  • goal: door to thrombolytic therapy time < 30 minutes
• revascularization may be superior to thrombolytic therapy
  • percutaneous coronary intervention (PCI)
    • if PCI or transfer to PCU-capable facility can be facilitated within 2 hours of hospital arrival
• cycles of inflation & deflation of a blood pressure cuff enroute to hospital may salvage viable myocardium

More general terms

• protocol

Additional terms

• acute coronary syndrome; unstable angina (ACS)