Chest discomfort suggestive

of Ischemia
Symptoms consistent with
ACS
EMS assessment and care and hospital preparation
- Monitor, support ABCs. Be prepare to provide COR and defibrillation
- Administer oxygen, aspirin, nitroglycerin, and morphine if need
- If available,, obtain 12 lead ECG; if ST-elevation:
o Notify receiving hospital with transmission or interpretation
o Begin fibrinolytic checklist
- Notified hospital should mobilized hospital resources to respond to NSTEMI
Immediate ED assessment (< 10 minutes)
- Check vital signs; evaluate oxygen saturation
- Establish IV access
- Obtain/view 12-lead ECG
- Perform brief, targeted history, physical exam
- Review/complete fibrinolytic checklist; check
contraindication
- Obtain initial cardiac marker levels, initial electrolytes and
coagulation studies
- Obtain portable chest x-ray (< 30 minutes)
Immediate ED general treatment
- Start oxygen at 4 L/min; maintain O2 sat > 90%
- Aspirin 160 325 mg (if not given by EMS)
- Nitroglycerin sublingual, spray, or IV
- Morphine IV if pain not relieved by
nitroglycerine

Review initial 12-lead ECG
ST elevation or new or
presumably new LBBB; strongly
suspicious for injury
ST-elevation MI (STEMI)
ST depression or dynamic T-wave inversion;
strongly suspicious for ischemia
High risk unstable angina/ non-ST-
elevation MI (UA/NSTEMI)
Normal or non-diagnostic change
in ST-segment or T-wave
Intermediate / low risk UA
Start adjunctive treatments as
Indicated (see text for contraindication)
Do not delay reperfusion
-adrenergic receptor
blockers
Clopidogrel
Heparin (UFH or LMWH)
Start adjunctive treatments as
Indicated (see text for contraindication)
Nitroglycerin
-adrenergic receptor
blockers
Clopidogrel
Heparin (UFH or LMWH)
Glycoprotein Iib/IIIa inhibitor
Develops high or
intermediate risk criteria
(Table)
OR
Troponin-positive?
Symptom onset
< 1 hour ago
PCI available with 1 hour?
1 3 houra ago
PCI available within 90 miniutes
3 -1 2 hours ago
PCI available within 90 minutes (onsite); or
2 hours (offsite, including transport time)?
YES NO YES NO YES NO
PCI Fibrinolysis
(unless contraindicated*)
PCI
Fibrinolysis
(unless contraindicated*)
PCI
Fibrinolysis
(unless contraindicated*)
Patients in whom fibrinolysis is contraindicated, or with ongoing symptoms
or instability, should be transferred for PCI
Continue adjunctive therapies and:
ACE inhibitor/angiotensin receptor blocker (ARB) within 24 hours of
symptom onset
HMG CoA reductase inhibitor (statin therapy)
Admit to monitored bed
Assess risk status (Table)
High-risk patient (Table)
Refractory ischemic chest pain
Recurrent/persistent ST deviation
Ventricular tachycardia
Hemodynamic instability
Signs of pump failure
Early invasive strategy, including
catheterization and revascularization for
shock within 48 hours of an AMI
Continue ASA, heparin, and other therapies as
indicated.
ACE inhibitor/ARB
HMG CoA reductase inhibitor (statin
therapy)
Not at high risk: cardiology to risk-stratify
Continue to monitor:
chest pain
serial ECG
cardiac markers
Re-evaluate and risk stratify
(+/- cardiology consult)

High-risk NSTEACS
Presentation with clinical features consistent
with ACS and any of:
Repetitive or prolonged (>10 minutes)
ongoing
chest pain/discomfort
Elevation of at least 1 cardiac biomarker
(troponin or CK-MB)
Persistent or dynamic ST depression 0.5
mm
or new T wave inversion 2 mm
Transient ST segment elevation (0.5 mm)
in more than 2 contiguous leads
Haemodynamic compromise: systolic
blood
pressure <90 mmHg, cool peripheries,
diaphoresis,
Killip class >1 and/or new onset mitral
regurgitation
Sustained ventricular tachycardia
Syncope
LV systolic dysfunction (LVEF <40%)
Prior PCI within 6 months or prior CABG
surgery
Presence of known diabetes (with typical
symptoms of ACS)
Chronic kidney disease estimated GFR
<60 mL/
min (with typical symptoms of ACS)
Intermediate-risk NSTEACS
Presentation with clinical features
consistent with
ACS and any of:
Chest pain or discomfort within past 48
hours that
occurred at rest, or was repetitive or
prolonged
(but currently resolved)
Age >65 years
Known CHD: Prior MI with LVEF 40%
or known
coronary lesion >50% stenosed
No high risk ECG changes (see above)
Two or more of: known hypertension,
family
history, active smoking or
hyperlipidaemia
Presence of known diabetes (with
atypical
symptoms of ACS)
Chronic kidney disease estimated
GFR <60 mL/min (with atypical
symptoms of ACS)
Prior aspirin use
AND NOT meeting the criteria for high-
risk NSTEACS

Low-risk NSTEACS
Presentation with clinical features consistent
with
ACS without intermediate or high risk features
e.g.:
Onset of anginal symptoms within the last
month; or
Worsening in severity or frequency of
angina; or
Lowering in anginal threshold

Admit to coronary
care or other high
dependency unit and
treat with aggressive
medical management

Refer for angiography

PCI or CABG

Medical therapy

Stress test
(e.g. exercise ECG)

Recurrent ischaemia
or elevated troponin
at follow up testing

Appropriate period
of observation

Discharge with urgent
cardiac follow-up
(on upgraded
medical therapy)

YES
NO
+ -
>12
hours