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initial management of acute coronary syndrome

Assessment: 1) vital signs 2) oxygen saturation (pulse oximetry) 3) IV access 4) 12 lead ECG (within 10 minutes) 5) history & physical 6) markers of myocardial infarction 7) electrolytes, PT/PTT 8) chest X-ray within 30 minutes 9) consider triage to facility capable of PCI for: a) HR > 100/min AND SBP < 100 mm Hg b) signs of pulmonary edema c) signs of shock Management: 1) aspirin 162-325 mg crushed, chewed, or PR, STAT & QD 2) oxygen 4 L/min by nasal cannula a) titrate as needed b) duration 6 hours, unless otherwise indicated 3) nitroglycerin except with suspected right ventricular MI [3] a) 0.4 mg SL every 5 minutes x 3 b) limit blood pressure drop 1] 10% of baseline in normotensive patients 2] 30% of baseline in hypertensive patients 3] keep systolic blood pressure (SBP) > 100 mm Hg c) IV infusion for 24-48 hours if 1] acute MI with CHF 2] larger anterior wall MI 3] persistent ischemia 4] persistent hypertension 4) morphine 2-4 mg IV every 5-15 minutes as needed, if pain not relieved by nitroglycerin 5) beta-blocker for all patients without contraindications - if contraindicated, use diltiazem or verapamil [3] 6) add ACE inhibitor for patients with an anterior wall MI, LV dysfunction, heart failure, or diabetes mellitus [3] 7) in patients with heart failure, use loop diuretic rather than thiazide diuretic [3] 7) thrombolytic therapy if indicated (in hospital) - goal: door to thrombolytic therapy time < 30 minutes 8) 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 9) cycles of inflation & deflation of a blood pressure cuff enroute to hospital may salvage viable myocardium [2]

Related

acute coronary syndrome; unstable angina (ACS)

General

protocol

References

  1. ACLS - The Reference Texbook ACLS: Principles & Practice, Cummins RO et al (eds), American Heart Association, 2003 ISBN 0-87493-341-2
  2. Botker HE et al Remote ischaemic conditioning before hospital admission, as a complement to angioplasty, and effect on myocardial salvage in patients with acute myocardial infarction: A randomised trial. Lancet 2010 Feb 27; 375:727 PMID: 20189026 - Ovize M and Bonnefoy E Giving the ischaemic heart a shot in the arm. Lancet 2010 Feb 27; 375:699 PMID: 20189010
  3. Rosendorff C et al. Treatment of hypertension in patients with coronary artery disease: A scientific statement from the American Heart Association, American College of Cardiology, and American Society of Hypertension. J Am Coll Cardiol 2015 May 12; 65:1998 PMID: 25840655