Acute Coronary Syndrome Immediate Management

Aka: Acute Coronary Syndrome Immediate Management, Myocardial Infarction Assessment, Ischemic Chest Pain Management, Immediate Myocardial Infarction Management, Immediate MI Management, Acute Chest Pain Approach

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II. History: Targeted Brief

  1. Duration of pain
  2. Prior Myocardial Infarction
  3. Cardiac Risk Factors
  4. Thrombolytic Contraindications

III. Exam: Targeted Brief

  1. Signs of right or left sided Heart Failure
  2. New murmur or pericardial rub
  3. Assess tissue perfusion, systemic Blood Pressure
  4. Asymmetry of peripheral pulses

IV. Diagnostics

  1. Electrocardiogram
    1. Obtain within 5-10 minutes of patient arrival (and repeat serially)
    2. See EKG in Acute MI
    3. See Evaluation: Electrocardiogram below
  2. Chest XRay
    1. Obtain within 30 minutes (typically portable)
  3. Echocardiogram (consider if no delay)
    1. See Echocardiogram in Acute MI
    2. See Echocardiogram for bedside technique
    3. Evaluate for additional emergent angiography indications
      1. Acute wall motion abnormality
      2. Ejection fraction <40%
    4. Evaluate Chest Pain differential diagnosis (e.g. Pericardial Effusion)

V. Labs

  1. Basic chemistry panel
  2. Complete Blood Count
  3. Troponin I

VI. Evaluation: Immediate Assessment

  1. ABC Management
  2. Mnemonic: IV-O2-Monitor
    1. Vitals with Oxygen Saturation
    2. Start Intravenous Access
    3. Cardiopulmonary monitor
  3. Consider Differential Diagnosis
    1. See Chest Pain

VII. Evaluation: Electrocardiogram (EKG)

  1. Precautions
    1. Evaluate the Electrocardiogram carefully (ischemic changes are commonly missed)
    2. Perform serial EKGs
      1. EKG is non-diagnostic in 11% of STEMI patients (and Troponin Is initially normal in 55% of cases)
      2. EKG is normal in 5-28% of Acute Coronary Syndrome patients
      3. EKG converts from non-diagnostic to STEMI in 33% by 30 min, 50% by 45 min, and 75% by 90 min
      4. Riley (2013) Am Heart J 165(1): 50-6 [PubMed]
  2. High Risk: Myocardial Infarction Protocol
    1. ST Elevation MI (Q-Wave MI)
    2. ST Elevation MI equivalent
      1. Posterior Myocardial Infarction
      2. New (or presumed new) Left Bundle Branch Block
        1. See High Risk Acute Coronary Syndrome Management for details
        2. Significant caveats to whether LBBB is a STEMI Equivalent
  3. Moderate Risk: Myocardial Ischemia Protocol
    1. Non-ST elevation MI (Non-Q-Wave MI)
    2. ST depression or dynamic T Wave inversion
    3. High Unstable Angina Risk
  4. Low Risk: Non-diagnostic Electrocardiogram Protocol
    1. Absent ST segment or T Wave changes on EKG
    2. Low Unstable Angina Risk

VIII. Management: Immediate

  1. Aspirin
    1. Non-enteric coated Aspirin 324 mg orally
      1. Typically administered as four 81 mg chewable Aspirin
      2. Large, high quality study demonstrated 1 more patient survived for every 42 treated for STEMI (NNT=42)
      3. Number needed to harm: 167 (minor bleeding not requiring transfusion, and no increased Intracranial Hemorrhage)
      4. Newman in Herbert (2013) EM:Rap 14(1): 4
      5. (1988) Lancet 332(8607): 349-60 [PubMed]
    2. Aspirin sensitivity
      1. Aspirin Rash: Give Aspirin with Diphenhydramine (e.g. 12.5 mg IV)
      2. Aspirin Anaphylaxis or Angioedema: Give Clopidogrel (Plavix) 75 mg or Ticagrelor (Brilanta) 90 mg instead of Aspirin
      3. PUD History: Give Aspirin with H2 Blocker (e.g. Ranitidine)
  2. Nitroglycerin
    1. Nitroglycerin 0.4 mg sublingual (tablet or spray)
    2. Low threshold to switch to Nitroglycerin Drip
      1. Start if higher suspicion for Acute Coronary Syndrome
    3. Nitroglycerin paste 1 inch (consider starting with 1/2 inch)
      1. Eratic absorption limits use in Acute Coronary Syndrome
    4. Exercise caution
      1. Nitroglycerin is contraindicated in Aortic Stenosis, Pulmonary Hypertension, Hypotension, PDE5 Inhibitor
      2. Inferior Myocardial Infarction (risk of right sided Myocardial Infarction)
        1. Risk of severe, refractory Hypotension
        2. Obtain Right sided EKG to exclude right sided Myocardial Infarction
        3. Secure IV Access and hang IV crystalloid in case of Hypotension
  3. Oxygen (if indicated)
    1. Deliver by Nasal Cannula at 2-4 liters per minute if Hypoxia (Oxygen Saturation <90-92%)
    2. Empiric oxygen without Hypoxia may increase coronary vascular resistance
  4. Morphine Sulfate
    1. Part of Mnemonic: "MONA" greets all patients
    2. IV 2-5 mg every 5-30 min prn
    3. Pain not relieved with 3 Sublingual Nitroglycerins (AND Nitroglycerin Drip)
    4. Morphine is an adjunct only in Chest Pain control (Nitroglycerin is the primary medication)
      1. Worse outcomes when Morphine is used in place of Nitroglycerin

IX. Management: Approach

  1. Cardiology Consultation (immediately in high risk Acute Coronary Syndrome)
  2. Consider Acute Coronary Syndrome Adjunctive Therapy
  3. Risk stratify
    1. High Risk Acute Coronary Syndrome Management
    2. Moderate Risk Acute Coronary Syndrome Management
    3. Low Risk Acute Coronary Syndrome Management
  4. Indications to transfer to PCI Center (catheter lab)
    1. STEMI
    2. Unstable Angina or NSTEMI
      1. Elevated Troponin
      2. ST Depression
      3. Congestive Heart Failure (with ejection fraction <40%)
      4. Valvular regurgitation
      5. Hemodynamic instability
      6. Ventricular arrhythmia
      7. Recent intervention (PCI, CABG)
      8. High risk score (e.g. TIMI Score, GRACE Score)

X. References

  1. Orman and Mattu in Herbert (2017) EM:Rap 17(7): 6-7
  2. (2000) Circulation 102(suppl I):I172-203 [PubMed]

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Ontology: Myocardial Infarction (C0027051)

Definition (MEDLINEPLUS)

Each year over a million people in the U.S. have a heart attack. About half of them die. Many people have permanent heart damage or die because they don't get help immediately. It's important to know the symptoms of a heart attack and call 9-1-1 if someone is having them. Those symptoms include

  • Chest discomfort - pressure, squeezing, or pain
  • Shortness of breath
  • Discomfort in the upper body - arms, shoulder, neck, back
  • Nausea, vomiting, dizziness, lightheadedness, sweating

These symptoms can sometimes be different in women.

What exactly is a heart attack? Most heart attacks happen when a clot in the coronary artery blocks the supply of blood and oxygen to the heart. Often this leads to an irregular heartbeat - called an arrhythmia - that causes a severe decrease in the pumping function of the heart. A blockage that is not treated within a few hours causes the affected heart muscle to die.

NIH: National Heart, Lung, and Blood Institute
Definition (NCI_FDA) Gross necrosis of the myocardium, as a result of interruption of the blood supply to the area, as in coronary thrombosis.
Definition (NCI_CTCAE) A disorder characterized by gross necrosis of the myocardium; this is due to an interruption of blood supply to the area.
Definition (NCI) Gross necrosis of the myocardium, as a result of interruption of the blood supply to the area, as in coronary thrombosis.
Definition (CSP) gross necrosis of the myocardium, as a result of interruption of the blood supply to the area.
Definition (MSH) NECROSIS of the MYOCARDIUM caused by an obstruction of the blood supply to the heart (CORONARY CIRCULATION).
Concepts Disease or Syndrome (T047)
MSH D009203
ICD10 I22 , I21
SnomedCT 66514008, 266288001, 155304006, 194796000, 233824008, 22298006
LNC LP98884-7, MTHU035551, LA14274-7, LA10558-7
English Myocardial Infarct, Infarctions, Myocardial, Myocardial Infarction, Myocardial Infarctions, Infarcts, Myocardial, Myocardial Infarcts, HEART ATTACK, Infarct, Myocardial, Infarction, Myocardial, MI, Myocardial infarction (MI), Attack heart (NOS), Infarct myocardial, cardiac infarction, Myocardial Infarction [Disease/Finding], attacking heart, heart attacks, attack hearts, infarctions myocardial, infarcts myocardial, myocardial infarctions, Infarction;heart, myocardial infarcts, Infarction;myocardial, AMI, attacks coronary, attacks hearts, coronary attack, disorder infarction myocardial, myocardial necrosis, syndrome myocardial infarction, heart attack, mies, Heart Attack, Attack - heart, Cardiac infarct, myocardial infarction, myocardial infarction (diagnosis), MI, MYOCARDIAL INFARCTION, MYOCARDIAL INFARCTION, MYOCARDIAL INFARCTION, (MI), INFARCTION (MI), MYOCARDIAL, -- Heart Attack, Cardiovascular Stroke, Cardiovascular Strokes, Stroke, Cardiovascular, Strokes, Cardiovascular, Myocardial infarct, Myocardial infarction, Heart attack, MI - Myocardial infarction, Cardiac infarction, Infarction of heart, Myocardial infarction (disorder), cardiac; infarction, infarction; myocardial, Cardiac infarction, NOS, Heart attack, NOS, Infarction of heart, NOS, Myocardial infarction, NOS, Heart Attacks, Infarctions (Myocardial), Myocardial infarction NOS, Attack coronary, heart infarction
German MYOKARDINFARKT, Koronarattacke, Herzanfall, MI, Herzanfall (NNB), HERZANFALL, Herzinfarkt, Myokardinfarkt
Dutch hartaanval, hartinfarct, hartaanval (NAO), MI, cardiaal; infarct, infarct; myocard, myocardinfarct, Hartinfarct, Infarct, myocard-, Myocardinfarct
French Crise coronaire, IM, Crise cardiaque SAI, Crise cardiaque, CRISE CARDIAQUE, INFARCTUS DU MYOCARDE, IDM (Infarctus Du Myocarde), Infarctus du myocarde, Infarctus myocardique
Italian MI, Attacco cardiaco, Attacco coronarico, Attacco cardiaco (NAS), Infarto del miocardio, Infarto miocardico
Portuguese Ataque coronário, Ataque do coração, Ataque cardíaco NE, EM, ATAQUE CARDIACO, ENFARTO DO MIOCARDIO, Enfarte do miocárdio, Infarto do Miocárdio
Spanish IM, Crisis coronaria, Ataque al corazón, Ataque al corazón (NEOM), Infarto miocárdico, ATAQUE CARDIACO, INFARTO DE MIOCARDIO, Infarto al Miocardio, ataque al corazón, infarto cardíaco, infarto de corazón, infarto de miocardio (trastorno), infarto de miocardio, Infarto de miocardio, Infarto del Miocardio
Japanese 心臓発作（ＮＯＳ）, 冠発作, 心臓発作, ｶﾝﾎｯｻ, ｼﾝｿﾞｳﾎｯｻNOS, ｼﾝｿﾞｳﾎｯｻ, ｼﾝｷﾝｺｳｿｸ, 冠状動脈梗塞, 心筋梗塞, 冠動脈梗塞, 心筋梗塞症
Swedish Hjärtinfarkt
Czech infarkt myokardu, Srdeční záchvat, Srdeční záchvat (NOS), IM, Koronární záchvat, Infarkt myokardu
Finnish Sydäninfarkti
Russian INFARKT MIOKARDA, ИНФАРКТ МИОКАРДА
Croatian SRČANI INFARKT
Polish Świeży zawał serca, Zawał serca świeży, Zawał mięśnia sercowego, Zawał serca
Hungarian Coronaria roham, Szívroham (k.m.n.), Szívroham, Infarctus myocardii, Szívizom infarctus, MI
Norwegian Hjerteinfarkt, Hjerteattakk, Myokardinfarkt
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Myocardial Ischemia (C0151744)

Definition (MSHCZE) Onemocnění srdce charakterizované nedostatečným prokrvením – ischemií. Porušeno je zásobení kyslíkem (hypoxie) a živinami i odvádění zplodin látkové výměny (vzniká lokální acidóza, iontové změny). Podkladem je zúžení (popř. uzávěr) koronárních tepen obv. aterosklerózou (aterosklerotický plát, trombóza, spasmus). Hlavními projevy ICHS jsou zejména angina pectoris a infarkt myokardu. Označují se jako bolestivé (algické) formy. Dalšími projevy ICHS mohou být arytmie nebo srdeční selhání (ischemie zvyšuje elektrickou nestabilitu myokardu a má negativní působení na kontraktilitu). K vzniku ICHS přispívají faktory, které jsou rizikovými faktory aterosklerózy (zejm. hyperlipoproteinemie, hypertenze, diabetes, kouření, stres atd.). V diagnóze se uplatňuje EKG, zátěžové testy (ergometrie), klidová i zátěžová echokardiografie, thalliový scan, biochemické vyšetření u akutní ischemie (infarktu). Zúžení koronárních tepen se zjišťuje koronarografií. V léčbě se používají nitráty, betablokátory, antagonisté kalcia, antiagregační léčba aj. V řadě případů se provádějí zákroky přímo na věnčitých tepnách – na otevřeném srdci (bypass) nebo perkutánně katetrizací (PTCA, stent). (cit. Velký lékařský slovník online, 2012 http://lekarske.slovniky.cz/ )
Definition (NCI) A disorder of cardiac function caused by insufficient blood flow to the muscle tissue of the heart. The decreased blood flow may be due to narrowing of the coronary arteries, to obstruction by a thrombus, or less commonly, to diffuse narrowing of arterioles and other small vessels within the heart. Severe interruption of the blood supply to the myocardial tissue may result in necrosis of cardiac muscle (myocardial infarction).
Definition (CSP) blood deficiency in the myocardium caused by a constriction or obstruction of its blood vessels; frequently occurs in conjunction with hypoxia, which is reduction in oxygen supply.
Definition (MSH) A disorder of cardiac function caused by insufficient blood flow to the muscle tissue of the heart. The decreased blood flow may be due to narrowing of the coronary arteries (CORONARY ARTERY DISEASE), to obstruction by a thrombus (CORONARY THROMBOSIS), or less commonly, to diffuse narrowing of arterioles and other small vessels within the heart. Severe interruption of the blood supply to the myocardial tissue may result in necrosis of cardiac muscle (MYOCARDIAL INFARCTION).
Concepts Disease or Syndrome (T047)
MSH D017202
ICD9 410-414.99
ICD10 I20-I25.9 , I20-I25
SnomedCT 155303000, 41702007, 32598000, 155322009, 194795001, 195540001, 194878003, 271430002, 233822007, 2610009, 414545008, 414795007
LNC LP31567-8, MTHU024507
English Disease, Ischemic Heart, Diseases, Ischemic Heart, Heart Disease, Ischemic, Heart Diseases, Ischemic, Ischemic Heart Disease, Ischemic Heart Diseases, Ischemia, Myocardial, Myocardial Ischemia, MYOCARDIAL ISCHAEMIA, Ischemias, Myocardial, Myocardial Ischemias, MYOCARDIAL ISCHEMIA, Ischaemic heart disease NOS, Ischaemic heart diseases, Ischemic heart diseases, HEART DIS ISCHEMIC, ISCHEMIC HEART DIS, Cardiac ischaemia, myocardial ischemia (diagnosis), myocardial ischemia, IHD, Ischemia myocardial, Myocardial Ischemia [Disease/Finding], cardiac ischaemia, Disease;ischaemic heart, ihd, cardiac ischemia, myocardial ischaemia, myocardial ischemia/hypoxia, Ischemic heart diseases (I20-I25), Ischaemic heart disease (disorder), Ischemic heart disease NOS (disorder), Myocardial ischaemia (disorder), Ischaemia myocardial, Ischaemic heart disease NOS (disorder), ischemic heart disease, ischemic heart disease (diagnosis), ISCHEMIC HEART DISEASE, DISEASE, ISCHEMIC HEART, HEART DISEASE, ISCHEMIC, ischemia; heart, ischemia; myocardial, myocardium; ischemic, Ischemic heart disease, NOS, Ischaemic heart disease, NOS, Myocardial ischemia, NOS, Ischemic heart disease, IHD - Ischaemic heart disease, IHD - Ischemic heart disease, Ischaemic heart disease, Myocardial ischaemia, Myocardial ischemia, Cardiac ischemia, Ischemic heart disease (disorder), Myocardial ischemia (disorder), Ischemic heart disease NOS, Disease;ischemic heart, ischaemic heart disease
Portuguese ISQUEMIA MIOCARDICA, Isquemia cardíaca, Isquemia do miocárdio, Cardiopatia isquémica, Cardiopatia Isquêmica, Isquemia miocárdica, Doença Isquêmica do Coração, Isquemia Miocárdica
Spanish ISQUEMIA MIOCARDICA, ECI, Isquemia miocárdica, Enfermedad isquémica cardiaca, Isquemia cardiaca, Cardiopatía isquémica, cardiopatía isquémica, SAI (trastorno), Ischaemic heart disease NOS, cardiopatía isquémica, SAI, cardiopatía isquémica (concepto no activo), Ischemic heart disease NOS, enfermedad cardíaca isquémica, SAI, Isquemia de miocardio, cardiopatía isquémica (trastorno), cardiopatía isquémica, enfermedad cardíaca isquémica, enfermedad isquémica del corazón, isquemia miocárdica (trastorno), isquemia miocárdica, Cardiopatía Isquémica, Isquemia Miocárdica
Dutch hartischemie, IHD, ischemische hartziekte, ischemie myocard, ischemische hartaandoening, ischemie; hart, ischemie; myocard, myocard; ischemie, myocardischemie, Hartziekte, ischemische, Ischemie, myocard-, Ischemische hartziekte, Myocardischemie
French Ischémie cardiaque, Maladie cardiaque ischémique, IC, Cardiopathie ischémique, ISCHEMIE DU MYOCARDE, Ischémie myocardique, Ischémie du myocarde
German Myokardischaemie, ischaemische Herzkrankheit, IHD, kardiale Ischaemie, MYOKARDIALE ISCHAEMIE, myokardiale Ischaemie, Herzkrankheit, ischämische, Herzmuskelischämie, Ischämie, Myokard-, Ischämische Herzkrankheit, Myokardischämie
Italian Cardiopatia ischemica, Ischemia cardiaca, Ischemia miocardica
Japanese 心虚血, ｼﾝｷｮｹﾂ, ｷｮｹﾂｾｲｼﾝｼｯｶﾝ, ｼﾝｷﾝｷｮｹﾂ, 心筋虚血, 虚血-心筋, 虚血性心疾患, 心疾患-虚血性, 心臓疾患-虚血性, 虚血性心臓疾患
Swedish Myokardischemi
Finnish Sydänlihaksen iskemia
Russian ISHEMICHESKAIA BOLEZN' SERDTSA, SERDTSA ISHEMICHESKAIA BOLEZN', ISHEMIIA MIOKARDA, MIOKARDA ISHEMIIA, MIOKARDIAL'NAIA ISHEMIIA, ИШЕМИЧЕСКАЯ БОЛЕЗНЬ СЕРДЦА, ИШЕМИЯ МИОКАРДА, МИОКАРДА ИШЕМИЯ, МИОКАРДИАЛЬНАЯ ИШЕМИЯ, СЕРДЦА ИШЕМИЧЕСКАЯ БОЛЕЗНЬ
Czech Ischemie myokardu, Myokardiální ischemie, Ischemická choroba srdeční, Srdeční ischemie, ischémie myokardu, myokard - ischémie, ICHS, ischemická choroba srdeční
Croatian MIOKARD, ISHEMIJA
Polish Niedokrwienie mięśnia sercowego, Choroba niedokrwienna serca
Hungarian Cardialis ischaemia, Szív ischaemia, Szív ischaemiás betegsége, myocardialis ischaemia, Ischaemiás szívbetegség, Szívizom ischaemiája, Szívizom ischaemia, ISzB
Norwegian Ischemisk hjertesykdom, Myokardiskemi, Myokardischemi, Iskemisk hjertesykdom
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Acute Coronary Syndrome (C0948089)

Definition (MSH) An episode of MYOCARDIAL ISCHEMIA that generally lasts longer than a transient anginal episode that ultimately may lead to MYOCARDIAL INFARCTION.
Definition (NCI_CTCAE) A disorder characterized by signs and symptoms related to acute ischemia of the myocardium secondary to coronary artery disease. The clinical presentation covers a spectrum of heart diseases from unstable angina to myocardial infarction.
Definition (NCI) Signs and symptoms related to acute ischemia of the myocardium secondary to coronary artery disease. The clinical presentation covers a spectrum of heart diseases from unstable angina to myocardial infarction.
Concepts Disease or Syndrome (T047)
MSH D054058
SnomedCT 393587009, 394659003
Japanese 急性冠動脈症候群, ｷｭｳｾｲｶﾝﾄﾞｳﾐｬｸｼｮｳｺｳｸﾞﾝ
English Coronary Syndromes, Acute, Syndromes, Acute Coronary, Acute Coronary Syndromes, Acute Coronary Syndrome, Syndrome, Acute Coronary, Coronary Syndrome, Acute, Acute Coronary Syndrome [Disease/Finding], acute coronary syndromes, syndrome acute coronary, acute coronary syndrome (diagnosis), acute coronary syndrome, Acute coronary syndrome, Acute coronary syndrome (disorder), ACS - Acute coronary syndrome
Portuguese Síndrome Coronariana Aguda, Síndrome coronário agudo
Spanish Síndrome Coronario Agudo, síndrome coronario agudo (trastorno), síndrome coronario agudo, Síndrome coronario agudo
Finnish Akuutti sepelvaltimo-oireyhtymä
German Akutes Koronarsyndrom, akutes Koronarsyndrom
Italian Sindrome coronarica acuta
Russian KORONARNYI SINDROM OSTRYI, КОРОНАРНЫЙ СИНДРОМ ОСТРЫЙ
Swedish Akut koronarsyndrom
Czech Akutní koronární syndrom, akutní koronární syndrom
French Syndrome coronaire aigu, SCA (Syndrome Coronarien Aigu), Syndrome coronarien aigu
Polish Zespół wieńcowy ostry
Hungarian Acut coronaria syndroma
Norwegian Akutt koronarsyndrom, Koronarsyndrom, akutt, AKS
Dutch acuut coronairsyndroom
Derived from the NIH UMLS (Unified Medical Language System)

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