ACUTE CORONARY SYNDROME Flashcards
MANAGEMENT: POSSIBLE ACS
INITIAL MANAGEMENT:
Place on Cardiac Monitor if active ischemia
IV Access
12 lead ECG within 10 min & compare to previous. Rule out STEMI vs. NSTEMI
Morphine: 2-4 mg IV, q5-30 min, max 10 mg/hr
Oxygen: As needed to keep 02 >95%
Nitroglycerin:
0.4 mg 1-2 sprays SL q5min x 3 (if SBP > 90)
OR
patch (0.4-0.8 mg/h)
OR
IV: 10 mcg / min
titrate to 10% reduction in MAP if normotensive, 30% reduction in MAP if hypertensive
C/I in HoTN, RV infarct, PDE5i
ASA:
ASA 160 mg - 325 mg chewed x 1, then 81 mg daily
C/i: Active bleeding, ASA allergy
INVESTIGATIONS:
ECG: Within 10 min. Review prehospital ECG and ECG on arrival, Compare to previous
-if ECG suggests occlusion MI; STEMI, STEMI Equivalent / STEMI -ve OMI -> STEMI Management
-if ECG suggests ischemia; ST depression, or T wave inversion, or ongoing symptoms -> serial ECG every 15 min, consider NSTEMI management
-If non diagnostic ECG but high clinical suspicion, reassess q15-30 min for ECG ischemia OR ongoing symptoms
-If non diagnostic ECG but LOW-MODERATE clinical suspicion -> serial troponin q 2 hr
Troponin
CBC
Cr
Serum Lytes
Mg
P04
Ca
Alb
CXR for cardiac silhouette size, pulmonary edema and aortic contour. Compare with previous.
REASSESSMENT: LOW-MODERATE ACS
-Order Repeat 2 hr Troponin & ECG
Calculate HEART SCORE
0-3 0.9%-1.7% MACE Discharge
4-6 12-16.6% MACE Admit
>/7 50-65% MACE Early Invasive
REASSESSMENT: LOW-MODERATE ACS
-2-3 hr Troponin / ECG
Calculate HEART Pathway
0-3 0.9%-1.7% MACE Discharge
4-6 12-16.6% MACE Admit
>/7 50-65% MACE Early Invasive
DISPOSITION:
HEART PATHWAY <4 - Discharge
HEART PATHWAY >/4 - Admit
FIRST LINE MANAGEMENT:
STEMI
STEMI EQUIVALENTS
NSTEMI with electrical / hemodynamic instability (acute pulmonary edema, shock, recurrent/refractory ventricular dysrhythmias, etc.)
NSTEMI with refractory ischemia (ongoing ischemic chest pain or refractory ECG findings of ischemia)
PCI if ischemic symptoms < 12 hr after onset, or 12-24 h if ongoing ischemia
PCI capable hospital: PCI within 60-90 min
Non-PCI hospital:
diagnosis to ballon time < 90 min
first medical contact to balloon time < 120 min
Give ASA, Antiplatelet loading dose, IV Heparin, Nitrates
ASA:
162 mg to 365 mg chewed x 1, then 81 mg daily
P2Y12 INHIBITOR::
give if ACS, withhold load dose if r/o ACS
Clopidogrel 600 mg loading dose x 1 then 75 mg daily for STEMI (PCI candidates)
OR
Ticagrelor 180 mg loading dose PO then 90 mg PO bid
ANTICOAGULANT
give no matter if ACS or r/o ACS
Heparin IV 60 U / kg bolus (max 4000 U) then 12 U / kg / hr, titrated to a partial thromboplastin time 1.5 - 2.5 x control
NITRATES
Nitroglycerin:
0.4 mg 1-2 sprays SL q5min x 3 (if SBP > 90)
OR
patch (0.4-0.8 mg/h)
OR
IV: 10 mcg / min
titrate to 10% reduction in MAP if normotensive, 30% reduction in MAP if hypertensive
C/I in HoTN, RV infarct, PDE5i
Consider Metorprolol 5 mg IV q 2 min x 3 as tolerated
C/i: systolic blood pressure (SBP) <120, heart rate >100 (strong sign of decreased stroke volume and impending cardiogenic shock), PR interval >240 ms, second- or third-degree atrioventricular (AV) block, or impending shock
SECOND LINE MANAGEMENT: FIBRINOLYTIC
Second Line: Fibrinolytic if door to balloon time > 120 min
Thrombolytic within 30 min of arrival
Give ASA, clopidogrel 300 mg, enoxaparin 1 mg / kg bid, fibrinolytic (if no contraindications)
ABSOLUTE C/I::
Any prior ICH
Known structural cerebral vascular lesion (eg, arteriovenous malformation)
Known malignant intracranial neoplasm (primary or metastatic)
Ischemic stroke within 3 mo
EXCEPT acute ischemic stroke within 4.5 h
Suspected aortic dissection
Active bleeding or bleeding diathesis (excluding menses)
Significant closed-head or facial trauma within 3 mo
Intracranial or intraspinal surgery within 2 mo
Severe uncontrolled hypertension (unresponsive to emergency therapy)
For streptokinase, prior treatment within the previous 6 mo
Tenecteplase (TNK-tPA):
Reconstitute a 50-mg vial in 10 mL sterile water (5 mg/mL)
Single weight-based bolus, IV push over 5 sec
<60 kg: 30 mg
60-69 kg: 35 mg
70-79 kg: 40 mg
80-89 kg: 45 mg
>90 kg: 50 mg
Alteplase (tPA):
90-min weight-based infusion
>67 kg: Infuse 15 mg IV over 1-2 min; then, 50 mg over 30 min; then, 35 mg over the next 60 min (ie, 100 mg over 1.5 h)
≤67 kg: Infuse 15 mg IV over 1-2 min; then, 0.75 mg/kg (max 50 mg) over 30 min; then, 0.5 mg/kg (max 35 mg) over 60 min
Post-thrombolytic care:
Transfer to PCI capable center within 6-24 hrs if reprofusion. Rescue PCI if no reprofusion.
MANAGEMENT: NSTEMI / UNSTABLE ANGINA
Maximum Medical Management = ASA + Anticoagulant + P2Y12 Inhibitor + IV Nitroglycerine as tolerated
ASA
162 mg - 365 mg chewed x 1, then 81 mg daily
P2Y12 INHIBITOR
give if ACS, withhold load dose if r/o ACS
Clopidogrel 300 mg PO for age < 75 and No loading dose required in patients > 75 years old receiving fibrinolytics
OR
Ticagrelor 180 mg loading dose PO then 90 mg PO bid
ANTICOAGULANT
give no matter if ACS or r/o ACS
Heparin IV 60 U / kg bolus (Max 5000 U) then 12 U / kg / hr (max 1000 U / hr)
OR
Enoxaparin 1 mg/kg sub q 12 hr (reduce dose to 1mg/kg sc OD if CrCl < 30) for the duration of hospitalization or until PCI is performed
Fondaparinux 2.5 mg sc; 2.5 mg IV with fibrinolysis
Do NOT use in AFib, prosthetic valves, CrCL < 30 or Cr > 265
NITRATES
Nitroglycerine
0.4 mg 1-2 sprays SL q5min x 3 (if SBP > 90)
OR
patch (0.4-0.8 mg/h)
OR
IV: 10 mcg / min, titrate to 10% reduction in MAP if normotensive, 30% reduction in MAP if hypertensive
C/I in HoTN, RV infarct, PDE5i
MORPHINE
2-5 mg IV, q5-15 min PRN, max 10 mg/hr
BETA BLOCKER
Initiate within 24 hrs
Metoprolol 50 mg P, then 5 mg IV q 5 min x 3 bid within 24 hrs, titrate to target HR 50-60
C/I if worsening CHF, HoTN, tachycardia, bradycardia, risk of cardiogenic shock, PR>0.24s, 2 or 3 degree AV block, severe asthma
DOCUMENTATION
Time of onset
Time of HPI
Substernal chest discomfort dull/ache/heaviness that might or might not radiate to the jaw, neck, shoulders or arms (LR +1.3)
Provoked by exertion (LR + 2.4) or emotional stress
Relieved within 5 min of rest or nitroglycerin
Pain similar to prior ischemia (2.2)
4 hightest predictors of ACS:
Chest pain with radiation (B > R > > L)
Chest pain with diaphoresis
Chest pain with vomiting
Chest pain that is worse with exertion
Radiates to right arm or shoulder (LR +4.7)
Radiates to both arms or shoulders left shoulder (LR +4.1)
Radiates to Left arm (LR +2.3)
Diaphoresis (LR +2.0)
Nausea / Vomiting (LR + 1.9)
Pain similar or worse than prior cardiac chest pain (LR +1.8)
Risk Factors for Non Classic ACS presentation:
Advanced Age
Female
Diabetes
Weak / fatigues / malaise
RISK FACTORS FOR ACS:
Age: M > 45, W > 55
Obesity
CARDIAC PMHx:
CAD (2.0)
Abnormal previous recent stress test (3.1)
Stents
Echo
Cardiologist Involvement
PAD (2.7)
FHx < 65
SoHx: Smoking
PHYSICAL EXAM
specificity >95%:
hypotension (systolic blood pressure [SBP] <100 mm Hg), tachycardia (heart rate >120 bpm)
tachypnea
rales on lung auscultation.
Time of Call to Cardiology
HEART Score
High-risk HEART score 7-10 (13.0)
DDx Cardiac Etiology for Elevated Cardiac Troponin
Cardiac Contusion
Cardiac Procedures
Aortic Dissection
Aortic Valve Disease
Hypertrophic Cardiomyopathy
Mycardial Infiltrative Disease
Apical Ballooning Syndrome
Arrhythmias
Inflammatory Cardiac Disease
Coronary Artery Vasculitis
Congestive Heart Failure
Coronary Vasospasm
Severe Hypertension
Acute MI
Thee Principle Presentations of Unstable Angina
ACS that does not have 1) at least one troponin greater than the 99th percentile and 2) an increase and/or decrease in troponin (defined for each assay).
Angina occuring at rest that is prolonged, usually > 20 min
New-onset angina that markedly limits ordanary physical activity, such as walking 1-2 blocks or climbing 1 flight of stairs or performing lighter activity
Previously diagnosed angina that becomes distinctly more frequent, has a longer duration, or is lower in threshold, limiting ability to walk 1-2 blocks or climb 1 flight of stairs or perform lighter activity.
NSTEMI PCI INDICATIONS
Early (within 48 hrs) invasive therapy for patients with recurrent angina / ischemia with or without symptoms of CHF, elevated troponins, new ST depression, high risk findings on non invasive testing, depressed LVF, hemodynamic instability, sustained ventricular tachycardia, PCIs within the last 6 months, prior coronacy bypass grafting
