ACUTE CORONARY

SYNDROME

Ischemic Chest Pain Algorithm

Chest pain
suggestive of ischemia
Immediate assessment (<10 minutes)
Measure vital signs (automatic/standard BP cuff)
Measure oxygen saturation
Obtain IV access
Obtain 12-lead ECG (physician reviews)
Perform brief, targeted history and physical exam;
focus on eligibility for fibrinolytic therapy
Obtain initial serum cardiac marker levels
Evaluate initial electrolyte and coagulation studies
Request, review portable chest x-ray (<30 minutes)

Immediate general treatment

Oxygen at 4 L/min
Aspirin 160 to 325 mg
Nitroglycerin SL or spray
Morphine IV (if pain not relived with
nitroglycerin)
Memory aid: MONA greets all patients
(Morphine, Oxygen, Nitroglycerin,
Aspirin)

EMS personnel can

perform immediate
assessment and
treatment (MONA),
including initial 12-lead
ECG and review for
fibrinolytic therapy
indications and
contraindications.

Assess initial 12-lead ECG

ST elevation or new or
presumably new LBBB:
strongly suspicion for injury

ST depression or dynamic T-wave

inversion: strongly suspicious for
lachemia

Nondiagnostic ECG: absence of

change in ST segment or T
waves

ST-elevation AMI

High-risk unstable angina/ non-ST

elevation AMI

Intermediate/low-risk unstable
angina

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Start adjunctive treatments

Start adjunctive treatments

(as indicated: no reperfusion delay)

(as indicated: no contraindications)

-Adrenoceptor blockers IV

Heparin (UFH/LMWH)

Nitroglycerin IV

Aspirin 160 to 325 mg qd

Heparin IV

Glycoprotein IIb/IIIa receptor

inhibitors

ACE inhibitors (after 6 hours or

when stable)

Meets criteria for unstable

Yes

or new-onset angina?
Or
Troponin positive?

Nitroglycerin IV

No

-Adrenergic receptor blockers

Time from onset of symptoms

>12 hours

Admit to ED chest pain

unit

Assess clinical status

<12 hours
Select a reperfusion
strategy based on local
resources:
Angiography
PCI (angioplasty stent)
Cardiothoracic surgery
backup

Or to monitored bed
if signs of cardiogenic shock
or contraindications to
fibrinolytics, PCI is treatment
of choice (Class I) if available

High-risk patient: defined

by

If PCI is not available, use

fibrinolystics (if no
contraindications)

Recurrent ischemia

Persistent symptoms
Depressed LV function
Widespread ECG changes
Prior AMI, PCI, CABG

Clinically
stable

In ED follow
serial cardiac markers
(including troponin)
Repeat ECG/continuos
ST monitoring
Consider imaging
study (2D
echocardiogharphy or
radionuclide)

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No
Fibrinolytic therapy selected

Primary PCI selected

Front-loaded alteplase or

Door-to-ballon
inflation 90 30
minutes

Streptokinase or
APSAC or

Perform cardiac
catheterization:
anatomy suitable for
revascularization?

Yes

Admit to CCU/ monitored bed

Continue or start adjunctive
treatments as indicated

Reteplase or

Experienced
operators

Tenecteplase

High-volume center

Revascluraization

Serial ECG

Goal: door-to-drug <30

minutes

Cardiac surgical
capabillity

PCI

Consider imaging study (2D

echocardiography or raionuclide)

Yes

CABG

Serial cardiac markers

Evidence
of ishemia
or
infraction
No
Discharge
acceptable
Arrange
follow-up

This algorithm provides general guidelines that may not apply to all patients. Carefully consider proper indications and contraindications.

The Acute Coronary Syndromes

Assess the initial ECG
The 12-lead ECG is central to triage of ACS in the Emergency
Department
Classify patients as being in 1 of 3 syndromes within 10 minutes of
arrival

ST-segment elevation or
new LBBB

ST elevation 1 mm in 2 or
more contiguous leads
New or presumably new
LBBB (BBB obscuring STsegment analysis)

ST-segment depression/
dynamic T-wave Inversion:
strongly suspicious for
ischemia

Nondiagnostic or normal
ECG

ST depression >1 mm

ST depression 0.5 to 1.0 mm

Marked symmetrical T-wave

inversion in multiple precordial leads

T-wave inversion or flattening

in leads with dominant R waves

Dynamic ST-T changes with pain

Normal ECG

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 >90% of patients with ischemictype chest pain and ST-segment

elevation will develop new Q waves
or positive serum markers for AMI.
Patients with hyperacute T waves
benefit when AMI diagnosis is
certain. Repeat ECG may be
helpful.

High-risk subgroup with increased

mortality:

Heterogeneous group: rapid

assessment needed by

Persistent symptoms, recurrent

ischemia

Serial ECGs

Diffuse or widespread EG
abnormalities

ST-segment monitoring
Serum cardiac markers

Depressed LV function

Further risk assessment helpful

Patients with ST depression in

early precordial leads who have
posterior MI benefit when AMI
diagnosis is certain

Congestive heart failure

Perfusion radionuclide imaging

Serum marker release: positive

troponin or CK-MB+

Stress echocardiography

Reperfusion therapy

Antithrombin therapy with

heparin

Aspirin
Heparin (if using fibrinspecific lytics)
-Blockers
Nitrates as indicated

Antiplatelet therapy with

aspirin
Glycoprotein Iib/Iia Inhibitors
-Blockers
Nitrates

Aspirin
Other therapy as
appropite
Patients with positive
serum markers, ECG
changes, or functional
study: manage as high
risk

SELESAI