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SYNDROME
Ischemic Chest Pain Algorithm
Chest pain
suggestive of ischemia
Immediate assessment (<10 minutes) Immediate general treatment EMS personnel can
perform immediate
Measure vital signs (automatic/standard BP cuff) Oxygen at 4 L/min
assessment and
Measure oxygen saturation Aspirin 160 to 325 mg treatment (MONA),
Obtain IV access Nitroglycerin SL or spray including initial 12-lead
Obtain 12-lead ECG (physician reviews) Morphine IV (if pain not relived with ECG and review for
Perform brief, targeted history and physical exam; nitroglycerin) fibrinolytic therapy
focus on eligibility for fibrinolytic therapy indications and
contraindications.
Obtain initial serum cardiac marker levels Memory aid: MONA greets all patients
Evaluate initial electrolyte and coagulation studies (Morphine, Oxygen, Nitroglycerin,
Request, review portable chest x-ray (<30 minutes) Aspirin)
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No Yes
Fibrinolytic therapy selected Primary PCI selected Perform cardiac Evidence
catheterization: of ishemia
Front-loaded alteplase or Door-to-ballon
anatomy suitable for Admit to CCU/ monitored bed or
inflation 90 30
Streptokinase or revascularization?
minutes Continue or start adjunctive infraction
APSAC or treatments as indicated
Experienced
Yes No
Reteplase or operators Serial cardiac markers
Discharge
Tenecteplase High-volume center Revascluraization Serial ECG
acceptable
Goal: door-to-drug <30 Cardiac surgical PCI Consider imaging study (2D
Arrange
minutes capabillity echocardiography or raionuclide)
CABG 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
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>90% of patients with ischemic- High-risk subgroup with increased Heterogeneous group: rapid
type chest pain and ST-segment mortality: assessment needed by
elevation will develop new Q waves
or positive serum markers for AMI. Persistent symptoms, recurrent Serial ECGs
ischemia
Patients with hyperacute T waves ST-segment monitoring
benefit when AMI diagnosis is Diffuse or widespread EG
abnormalities Serum cardiac markers
certain. Repeat ECG may be
helpful. Depressed LV function Further risk assessment helpful
Patients with ST depression in Congestive heart failure Perfusion radionuclide imaging
early precordial leads who have Stress echocardiography
posterior MI benefit when AMI Serum marker release: positive
diagnosis is certain troponin or CK-MB+