ACS

chest discomfort—typically described as:

pressure, heaviness, tightness, or pain, often substernal and possibly radiating to the arms, neck, jaw, or back.
This discomfort is usually of sudden onset, may occur at rest or with minimal exertion, and lasts more than a few minutes.
Diaphoresis!

also look for other common features:

dyspnea, nausea, vomiting, palpitations, syncope, dizziness, unexplained fatigue, or epigastric discomfort
Physical findings may include signs of heart failure (e.g., pulmonary rales, S3 gallop), hypotension, tachycardia, or arrhythmias
Risk factors include:
- Personal history of atherosclerotic disease (e.g., prior MI, peripheral artery disease).
- Age.
- Smoking.
- Diabetes, hypertension.
- Radiation therapy.
- Sympathomimetic use (cocaine/methamphetamine).
- Vasculitis.
Likelihood ratio for pain attributes: (evidence)
- Radiation to arm(s) or shoulder(s): LR ~4.
- Worse with exertion: LR ~2.5
- Associated with diaphoresis: LR ~2.
- Sharp: LR ~0.3
- Positional: LR ~0.3
- Reproducible with palpation: LR ~0.3
- Pleuritic: LR ~0.2
- Caution: chest pain may be atypical in women, elderly, or patients with diabetes.

Initial:

Diagnostics:

EKG + hsTrop

	NSTE-ACS	STEMI
Electrocardiographic evidence of ischemia	New or presumed new and usually dynamic horizontal or down-sloping ST-segment depression ≥0.5 mm in ≥2 contiguous leads and/or T-wave inversion >1 mm in ≥2 contiguous leads with prominent R wave or R/S ratio >1 or transient ST-segment elevation.	New or presumed new ST-elevation of ≥1 mm in ≥2 anatomically contiguous leads (measured at the J-point) in all leads other than V2-V3 and ≥2 mm in men ≥40 y, ≥2.5 mm in men <40 y, and ≥1.5 mm in women regardless of age in leads V2-V3.*
Other observed electrocardiographic changes	Many patients with NSTE-ACS have either nonspecific ST-segment or T-wave changes or a normal ECG. The absence of electrocardiographic evidence of ischemia does not exclude ACS.	Posterior leads (V7-V9) should be obtained in patients with suspected left circumflex occlusion particularly in the setting of isolated ST-segment depression ≥0.5 mm in leads V1-V3.

Initial:

Morphine: Avoid if possible, inhibits P2Y12 activity
O2: if SpO2 <90%
Nitroglycerin .3mg every 5 min (max of 3)
- no PDE-4 (viagra, etc) w/in 24hrs, tadalfil w/in 48hrs,, caution if SBP <110, contraindicated in RV involvement (inferior MI)
Aspirin: 324mg chewed
P2Y12: yes, post-PCI (may delay CABG surgery)
Heparin Bolus + Drip:
- Initial therapy: Loading dose 60 IU/kg (max 4000 IU), with initial infusion 12 IU/kg per h (max 1000 IU/h) adjusted to therapeutic aPTT range of 60-80 s.
- To support PCI: In patients who have received prior anticoagulant therapy, additional UFH as needed to achieve an ACT 250-300 s.
- In patients who have not received prior anticoagulant therapy, 70-100 U/kg initial bolus to achieve target ACT of 250-300 s.
- With fibrinolytic therapy: Loading dose 60 IU/kg (maximum 4000 IU) with initial infusion 12 IU/kg per h (maximum 1000 IU/h) adjusted to therapeutic aPTT range.*

Within 24hrs:

PCI-capable Center: <90min door-to-balloon (correct terminology: FMC to device activation)
If able to transfer in time: <120min door-to-balloon

If unlikely to achieve PCI within 120 min:

Patients should be transferred to a PCI-capable hospital after initiation of fibrinolytic therapy for routine coronary angiography

Fibrinolytic Agent	Dose
Tenecteplase (TNK-tPA)	Single IV weight-based bolus*
Reteplase (rPA)	Two 10-unit IV boluses given 30 min apart (administered over 2 min)
Alteplase (tPA)	90-min weight-based infusion†
Consent

- Most important part of decision to use fibrinolytics

Fibrinolytic Contraindications
Absolute Contraindications
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†
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 therapy) (SBP >180 mm Hg or DBP >110 mm Hg)
Relative Contraindications
History of chronic, severe, poorly controlled hypertension
Significant hypertension on presentation (SBP >180 mm Hg or DBP >110 mm Hg)
History of prior ischemic stroke >3 mo
Dementia
Known intracranial pathology not covered in absolute contraindications
Traumatic or prolonged (>10 min) CPR
Major surgery (<3 wk)
Recent (within 2 to 4 wk) internal bleeding
Noncompressible vascular punctures
Pregnancy
Active peptic ulcer
Oral anticoagulant therapy

Quartz 5