II. History: Targeted Brief
- Duration of pain
- Prior Myocardial Infarction
- Cardiac Risk Factors
- Thrombolytic Contraindications
III. Exam: Targeted Brief
- Signs of right or left sided Heart Failure
- New murmur or pericardial rub
- Assess tissue perfusion, systemic Blood Pressure
- Asymmetry of peripheral pulses
IV. Labs
- Basic chemistry panel
- Complete Blood Count
- Troponin I
V. Diagnostics
-
Electrocardiogram
- Obtain within 5-10 minutes of patient arrival (and repeat serially)
- See EKG in Acute MI
- See Evaluation: Electrocardiogram below
VI. Imaging
-
Chest XRay
- Obtain within 30 minutes (typically portable)
-
Echocardiogram (consider if no delay)
- See Echocardiogram in Acute MI
- See Echocardiogram for bedside technique
- Evaluate for additional emergent angiography indications
- Acute wall motion abnormality
- Ejection fraction <40%
- Evaluate Chest Pain differential diagnosis (e.g. Pericardial Effusion)
VII. Evaluation: Immediate Assessment
- ABC Management
- Mnemonic: IV-O2-Monitor
- Vitals with Oxygen Saturation
- Start Intravenous Access
- Cardiopulmonary monitor
- Consider Differential Diagnosis
- See Chest Pain
VIII. Evaluation: Electrocardiogram (EKG)
- Precautions
- Developing Q Waves does not modify the reperfusion strategy
- Evaluate the Electrocardiogram carefully (ischemic changes are commonly missed)
- Hyperacute T Waves precede ST Elevation
- More than 25-30% of NSTEMI patients have complete coronary Occlusion (benefit from emergent PCI)
- Perform serial EKGs
- EKG is non-diagnostic in 11% of STEMI patients (and Troponin Is initially normal in 55% of cases)
- EKG is normal in 5-28% of Acute Coronary Syndrome patients
- EKG converts from non-diagnostic to STEMI in 33% by 30 min, 50% by 45 min, and 75% by 90 min
- Riley (2013) Am Heart J 165(1): 50-6 [PubMed]
- Observe for right sided inferior MI
- Inferior STEMI or Posterior STEMI (V1-V2 ST Depression and right sided EKG with V4 ST Elevation)
- Avoid Nitroglycerin and infuse crystalloid to maintain adequate systolic Blood Pressure
- ST Elevation criteria in leads V1-V2 varies by age and gender
- Men age <40 years old
- V1-V2 ST Elevation >2.5 mm
- Accounts for Early Repolarization in young men
- Men age >40 years old
- V1-V2 ST Elevation >2 mm
- Women
- V1-V2 ST Elevation >1.5 mm
- Men age <40 years old
- Consider other high risk findings
- Biphasic or Deep T Wave Inversion in V2, V3 (Wellen's Syndrome)
- High risk for left anterior descending artery ischemia and Anterior Wall Myocardial Infarction
- Hyperacute T Waves with J Point Depression (De Winter T Waves)
- J Point depression with upsloping ST Segment AND
- Tall, prominent, hyperacute precordial T Waves
- Hyperacute T Waves also seen in Hyperkalemia, STEMI without J Point depression
- ST Depression >1 mm in 8 or more leads (esp I, II, V4-6) AND ST Elevation in aVR or V1
- Suggests multi-vessel ischemia or left main obstruction
- Biphasic or Deep T Wave Inversion in V2, V3 (Wellen's Syndrome)
- High Risk: Myocardial Infarction Protocol
- ST Elevation MI (Q-Wave MI)
- ST Elevation MI equivalent
- Posterior Myocardial Infarction (ST depression in V1, V2)
- Confirm with a right sided EKG and evaluate for ST Elevation in right-sided V4
- New (or presumed new) Left Bundle Branch Block
- See High Risk Acute Coronary Syndrome Management for details
- Significant caveats to whether LBBB is a STEMI Equivalent
- See Sgarbossa Criteria
- Posterior Myocardial Infarction (ST depression in V1, V2)
- Moderate Risk: Myocardial Ischemia Protocol
- Non-ST elevation MI (Non-Q-Wave MI)
- ST depression or dynamic T Wave Inversion
- High Unstable Angina Risk
- Low Risk: Non-diagnostic Electrocardiogram Protocol
- Absent ST Segment or T Wave changes on EKG
- Low Unstable Angina Risk
IX. Management: Immediate
-
Aspirin
- Non-enteric coated Aspirin 324 mg orally
- Typically administered as four 81 mg chewable Aspirin
- Large, high quality study demonstrated 1 more patient survived for every 42 treated for STEMI (NNT=42)
- Number needed to harm: 167 (minor bleeding not requiring transfusion, and no increased Intracranial Hemorrhage)
- Newman in Herbert (2013) EM:Rap 14(1): 4
- (1988) Lancet 332(8607): 349-60 [PubMed]
-
Aspirin sensitivity
- Aspirin Rash: Give Aspirin with Diphenhydramine (e.g. 12.5 mg IV)
- Aspirin Anaphylaxis or Angioedema: Give Clopidogrel (Plavix) 75 mg or Ticagrelor (Brilanta) 90 mg instead of Aspirin
- PUD History: Give Aspirin with H2 Blocker (e.g. Ranitidine)
- Non-enteric coated Aspirin 324 mg orally
-
Nitroglycerin
- Nitroglycerin 0.4 mg sublingual (tablet or spray)
- Low threshold to switch to Nitroglycerin Drip
- Start if higher suspicion for Acute Coronary Syndrome
-
Nitroglycerin paste 1 inch (consider starting with 1/2 inch)
- Eratic absorption limits use in Acute Coronary Syndrome
-
Exercise caution
- Nitroglycerin is contraindicated in Aortic Stenosis, Pulmonary Hypertension, Hypotension, PDE5 Inhibitor
- Inferior Myocardial Infarction or posterior Myocardial Infarction (risk of right sided Myocardial Infarction)
- Risk of severe, refractory Hypotension
- Obtain Right sided EKG to exclude right sided Myocardial Infarction
- Secure IV Access and hang IV crystalloid in case of Hypotension
- Oxygen (if indicated)
- Deliver by Nasal Cannula at 2-4 liters per minute if Hypoxia (Oxygen Saturation <90-92%)
- Empiric oxygen without Hypoxia may increase coronary vascular resistance
-
Morphine Sulfate
- Part of Mnemonic: "MONA" greets all patients
- IV 2-5 mg every 5-30 min prn
- Pain not relieved with 3 Sublingual Nitroglycerins (AND Nitroglycerin Drip)
-
Morphine is an adjunct only in Chest Pain control (Nitroglycerin is the primary medication)
- Worse outcomes when Morphine is used in place of Nitroglycerin
X. Management: Approach
- Cardiology Consultation (immediately in high risk Acute Coronary Syndrome)
- Consider Acute Coronary Syndrome Adjunctive Therapy
- Risk stratify
- Indications to transfer to PCI Center (catheter lab)
- STEMI (emergent transfer)
- Unstable Angina or NSTEMI (See NSTE-ACS Protocol)
- Elevated Troponin
- New ST segment Depression
- Cardiogenic Shock
- Severe Left Ventricular Dysfunction or Acute Heart Failure
- Recurrent or persistent rest Angina despite intensive medical therapy
- New or worsening Mitral Regurgitation
- New Ventricular Septal Defect
- Hemodynamic instability
- Sustained Ventricular Arrhythmia
- Recent Percutaneous Coronary Intervention in last 6 months
- Prior Coronary Artery Bypass Graft
- High risk score (e.g. TIMI Score, GRACE Score)
XI. References
- Velasco, Lee, Chandra (2019) Crit Dec Emerg Med 33(1): 3-10
- Orman and Mattu in Herbert (2017) EM:Rap 17(7): 6-7
- Swaminathan and Mattu in Herbert (2018) 18(9): 11
- (2000) Circulation 102(suppl I):I172-203 [PubMed]
- Ibanez (2018) Eur Heart J 39(2): 119-77 +PMID:28886621 [PubMed]
Images: Related links to external sites (from Bing)
Related Studies
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
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, シンゾウホッサNOS, シンゾウホッサ, 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 |
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 |
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, キュウセイカンドウミャクショウコウグン |
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 |