Acute Coronary Syndromes
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God Knows
God Knows
Pt is responsive at this time.

(Remember Door to Drug treatment [fibrinolysis] should be < 30 minutes and Door to Balloon [PCI=Percutaneous Coronary Intervention] should be < 90 minutes)

  I.  Patient is having symptoms suggestive of ischemia or infarction
     A. Common Symptoms

          1. Chest discomfort (many times patients describe as pressure and not pain)
              lasting longer than 15 to 20 minutes
          2. Discomfort in upper body
          3. Shortness of air
          4. Difficulty Breathing
          5. Sweating
          6. Nausea
          7. Dizziness

      B. Atypical symptoms may occur more commonly in the elderly, in
          women, and in diabetics.
          1. May have isolated sweating
          2. Nausea
          3. May or may not present with discomfort

II.  Immediate Assessment

     A. Obtain 12-lead ECG looking for ST elevation or a new Left Bundle
         Branch Block (LBBB)
         1. ST - Elevation II, III, AVF (Inferior Wall)
         2. ST - Elevation V1, V2 (Septal Wall)
         3. ST - Elevation V3, V4 (Anterior Wall)
         4. ST - Elevation I, V5, V6 (Lateral Wall)
         5. LBBB - Look at leads I, V1, and V6
             a. In a typical LBBB, lead I and V6 with have an upright QRS
                 complex
             b. And lead V1 will be inverted or have the QRS complex
                 pointing downward
             c. The QRS complex will be widened and may or may not have
                 the classic notch on the R wave.


    B. Place on "O2, IV, Monitor"
         1. Oxygen - should be provided if needed to maintain an O2 saturation > 90%.
         2. Establish IV access
         3. Place patient on a continuous heart monitor

     C.  Check vital signs including pain (please note that the provider
           needs to explain and teach a pain scale to the patient, 0-10, to
           include all discomfort). Many patients may deny chest pain but
           would describe discomfort or pressure.
      
     C.  Assess for a targeted cardiovascular history

    D.  Draw blood for cardiac marker levels (Troponin I or T),
           Electrolytes, CBC, & coagulation panel
   
    E.  Complete fibrinolytic checklist

     E.  Initial physical exam

     F.  Portable Chest X-Ray (< 30 minutes)
III.  Immediate General Treatment (MONA greats everyone at the door)

     M.O.N.A. 
   (Morphine, Oxygen, Nitroglycerin, Aspirin)
       A. Oxygen - should be given if
            1. O2 sats > 90%
            2. A patient having difficulty breathing
            3. A patient with signs of heart failure (i.e. ejection fraction < 40%, crackles
                heard in lung sounds)
       B. Aspirin - 160 - 325 mg non-enteric coated should be chewed or 300 mg
            suppository if patient has severe nausea
            1. Aspirin has been shown to reduce death
            2. Aspirin has been shown to reduce vascular events
            3. Contraindications for aspirin are allergy to aspirin or active gastrointestinal
                (GI) hemorrhage
            4. Aspirin has an anti-platelet effect by inhibiting thromboxane, preventing
                cyclooxgenase (COX) formation. This prevents platelets from aggregating
               for the life of the platelet (7-10 days).
            5. All other NSAIDs are contraindicated
        C. Nitroglycerin - 0.4 mg sublingual every 3-5 minutes times 3 is still advised
             for patients with ischemic discomfort
            1. It dilates the coronary arteries
            2. It reduces preload and can be a contraindication in inferior wall MIs or
                right ventricular damage.
            3. It lowers blood pressure and should be stopped if SBP < 90mmHg or
                > 30 mmHg drop in baseline (i.e. BP was 155/85, gave one
                Nitroglycerin, and rechecked BP was 100/40).
         D. Morphine is still recommended for use if Nitrates do not reduce pain in the
              patient with a STEMI (ST elevation MI), but is asked to use caution in
              patients with unstable angina and in non-STEMI patients because of
              adverse effects in studies

IV.  Assessment of 12 Lead ECG-Center of the Decision Pathway
       Place into 1 of the 3 categories:  A, B, or C below

       A.  ST segment elevation or new or presumably new Bundle
            Branch Block or strongly suspicious for injury - STEMI
            1. Clopidogrel 300-600 mg loading dose is recommended. It
                blocks platelet aggregation different from aspirin in ages < 75 years old.
                            Ages > or = to 75, the dosage has not been studied.
            2. Beta Adrenergic Blockers - still recommended but use with
                causing to prevent cardiogenic shock - Hold if HR < 60 bpm
                Hold if SBP < 100 mmHg. ACLS has backed off of the IV
                use in the ED, but still recommends the PO use within first 24
                hours
            3. Heparins (looking more like low molecular weight heparin -
                LMWH, enoxaparin, may provide anticoagulation without as
                much increase risk of bleeding as unfractionated heparin
            4. ACE-I Angiotensin Converting Enzyme Inhibitor -
                recommended for use in first 24 hours - again watch for low
                BP as these will reduce the BP
            5. Statins - reduce inflammation and are recommended in the first
                24 hours unless contraindicated
            6. Maintain Potassium levels > 4 mEq/L and
                Magnesium > 2 mEq/L
 
       B. ST segment depression or dynamic T-wave inversion, high
           risk unstable angina or non-ST elevation MI (UA/NSTEMI)
        
            1.  Strongly suspicious for ischemia
           2.  Troponin elevated or high risk patient
           3.  Consider PCI-percutaneous coronary intervention - heart
                catherization if:
                a. Unable to relieve chest discomfort
                b. Continual ST deviation
                c. Hemodynamic instability
                d. Signs of heart failure
            4.  Treatments
                 a. Nitroglycerin
                 b. Heparin (UFH or LMWH)
                 c. PO Beta Blockers
                 d. Clopidogrel
                 e.  Consider Glycoprotein IIb/IIIa inhibitor
            5.  Admit to monitored bed and assess risk status, continue
                 Aspirin, heparin, ACE-I, Statin therapy


       C.  Normal or Nondiagnostic changes in ST segment or T wave

            1.  Consider admission to ED chest pain unit or to appropriate bed
                and follow:
                a. Serial cardiac markers (including troponin)
                b. Repeat ECG/continuous ST-segment monitoring
                c. Consider non-invasive diagnostic test
           2.  Check for developing 1 or more:
                a. Clinical high risk features
                b. Dynamic ECG changes consistent with ischemia
                c. Troponin elevated
            3.  If yes, go to B and treat
            4.  If no, is the diagnostic imaging or physiologic testing abnormal
            5.  If yes, go to B and admit to monitored bed
            6.  If no evidence of ischemia consider discharging


  V.  General guidelines for all < 12 hour time frame from onset of
       symptoms
       Consider a reperfusion strategy:

       A.  Thrombolytics (or commonly know as clot busters)

             1.  Within 3 to 6 hrs is best, some studies suggest within 12 hours
             2.  Absolute Contraindications in:
                 any prior intracranial hemorrhage,
                 arterial-venous malformations, known malignant brain cancer,
                 acute ischemic stroke within 3 months (if someone has had an
                 ischemic stroke within 3 hours of symptom onset - it is NOT
                 contraindicated), suspected aortic dissection, active bleeding,
                 significant closed head trauma or facial trauma within 3
                 months
             3.  Relative Contraindications:
                  SBP > 185 mmHg or DBP > 110 mmHg, Pregnancy,
                  Traumatic or prolonged CPR (> 10 min) or major surgery
                  < 3 weeks, active peptic ulcer, current use of anticoagulants,
                  recent bleeding (< 2-4 weeks), noncompressible vascular
                  punctures, history of prior ischemic stroke > 3 months or
                  dementia
             NOTE:  General Information for drugs does not preclude
              your institutions policies and procedures.  Read and follow
              them.
            There are several new thrombolytics on the market now, these are
            some of the older ones.
             3.  TPA  short acting within 2-6 hrs, expensive:  15 mg IV bolus,
                  then 0.75mg/kg over next 30 minutes (not greater than 50mg),
                  then 0.50mg/kg over next 60 minutes (not greater than 35mg),
                  start your Heparin protocol with the TPA
             4.  Streptokinase  longer acting, less expensive, watch for pts
                  with strep throat or received this product in the past may be
                  contraindicated:  1.5 million IU over 1 hour, start Heparin
                  protocol after Streptokinase is finished
             5.  Reteplase:  10 units IV plus a 10 unit IV bolus over 2 minutes,
                  30 minutes apart. 

       B.  PCI (heart cath) with CABG (open heart surgery) as back up

VI.  General  guidelines for all > 12 hours
      
       A.  Assess symptoms and treat

       B.  If high risk (1, 2, or 3), then PTCA, PTI (stent) or CABG
            1.  symptoms continue despite M.O.N.A. tx and others stated
                 above
            2.  depressed left ventricular fx
            3.  ECG changes

       C.  If stable, monitor serial ECGs and cardiac markers (CPK,
            CK-MB, and Troponin I)