Acute Coronary Syndromes

• Identification of patients with ST Elevation MI (STEMI) in order to facilitate early reperfusion
• Relief of chest pain
• Treatment of life-threatening complications including VF, VT and unstable tachyarrhythmias.
• Prevention of major adverse cardiac events (MACE)

ACS Sequence

1. Recognition of symptoms of myocardial infarction (MI)
   1. Chest pain or pressure
   2. Radiation of pain to the jaw, shoulder, or arms
   3. Lightheadedness, sweating, nausea or vomiting
   4. Sudden shortness of breath
2. Activation of EMS system
   1. Provide CPR (if necessary) while supporting the ABCs.
   2. Administer aspirin if the patient is not allergic and does not have a recent history of GI bleeding.
   3. Give the patient a nitroglycerin tablet every 3 to 5 minutes for ongoing pain AND if permitted by protocol.
   4. Administer oxygen for an oxygen saturation <94% or if the patient appears to be short of breath.
   5. Obtain and transmit a 12 lead ECG if possible; notify the hospital if there is any ST elevation.
   6. If pain is not controlled by nitroglycerin, give morphine (by protocol or order).
3. Emergency Department (ED) Assessment and treatment
   1. Perform a 12 lead ECG if one has not been done.
   2. Establish an IV if not done by EMS
   3. Give aspirin, nitroglycerin and morphine according to protocol or order; monitor for hypotension.
   4. Continually monitor vital signs and oxygen saturation; if oxygen saturation is <94%, start oxygen at 2-4 L/minute and titrate.
   5. Perform a brief assessment.
   6. Complete the fibrinolytic checklist
   7. Send baseline lab work.
   8. Obtain portable chest x-ray.
4. Interpret the ECG.
5. Classify the ECG in one of three categories and provide treatment based on the category:
   1. ST elevation MI (STEMI)
      1. If the time from the onset of symptoms is more than 12 hours, follow the NSTEMI sequence
      2. If the time from onset of symptoms is less than 12 hours, follow the facility protocol for reperfusion therapy. If PCI cannot be done within 90 minutes, consider use of fibrinolytic therapy for reperfusion. If PCI can be done within 90 minutes, fibrinolytics should not be given. Minimize delays to definitive reperfusion therapy.
      3. Additional therapies including heparin, beta blockers and ACE inhibitors may be started if these therapies do not delay reperfusion treatment.
   2. Non ST elevation MI (NSTEMI)
      1. If troponin is elevated and patient has persistent ST depression, hemodynamic instability, ventricular tachycardia, or congestive heart failure, consider invasive strategies.
      2. Adjunctive therapies including heparin, beta blockers and ACE inhibitors may be started.
      3. Admit to a monitored bed.
      4. Consider statin therapy.
   3. Normal or non-diagnostic ECG – Patient with a normal ECG are at low risk for ACS
      1. Consider admission for serial troponin evaluation
      2. If the Troponin is elevated indicating ischemia, follow the NSTEMI sequence.
      3. If there are no abnormal tests during the hospitalization, discharge the patient with instructions for follow up.