Chest discomfort suggestive of ischemia

EMS assessment and care and hospital preparation:

• Monitor, support ABCs. Be Prepared to provide CPR and defibrillation
• Administer oxygen, aspirin, nitroglycerin, and morphine if needed
• If availabe, obtain 12-lead ECG; if ST-elevation:
• Notify receiving hospital with transmission or interpretation
• Begin fibrinolytic chechlist
• Notified hospital should mobilize hospital resources to respond to STEMI

Immediate ED assessment (<10 min) Immediate ED general treatment

- Check vital signs; evaluate oxygen saturation - Morphine IV if pain relieved by nitroglycerin
- Establish IV access - Oxygen at 4 L/min; maintain 0, sat > 90%
- Obtain/review 12-lead ECG - Nitrogycerin sublingual, spray, or IV
- Perform brief, targeted history, physical exam - Aspirin 160 to 325 mg (if not given by EMS)
- Review/complete fibrinolytic checklist; check
- Containdication (table 1)
- Obatain initial cardaic marker levels; initial electrolyte
and coagulation studies
- Obtain portable chest x-ray (< 30 min)

Review initial 12-lead ECG

ST elevation or new or ST-depression or dynamic T-wave inversion; Normal or nondiagnostik

presumably new LBBB; strongly strongly suspicious for ischemia changes in ST segement or T
suspicious for injury High-Risk Unstable Angina/ wave
Non-ST-Elevation MI (UA/NSTEMI Intermediate/Low-Risk UA
ST-Elevation MI (STEMI)*
Start adjunctive treatment as
indicated (see text for
contraindications)
Do not delay reperfusion
- Clopidogrel
- -adrenergic reseptor blockers
- Heparin (UFH or LMWH)
>12
hours
Time from onset of
symptoms < 12 hours?
<12 hours
Reperfusion strategy:
Therapy defined by patients and
center criteria (table 2)
- Be aware of reperfusion goals:
•Door-to-ballon inflation
(PCI) goal of 90 min
•Door-to-needle
(fibrinolysis) goal of 30 min
- Continue adjunctive therapies
and:
•ACE inhibitors/angiotensi
receptor blockers (ARB)
within 24 hours of symptom
anset
•HMG CoA reductase
Start adjunctive treatments as Develop high or
indicated (see text for Yes
intermediate risk
contraindications) criteria (tables 3,4)
•Clopidogrel
or
•Nitroglycerin
•B-adrenergic receptor blockers
troponin-positive
•Heparin (UFH or LMWH) No
•Glycoprotein IIb/IIIa inhibitor
Consider admission to ED
chest pain unit orto
monitored bed in ED
Admit to monitored bed
Assess risk status Follow:
• Serial cardiac marker
(including troponin)
• Repeat ECG/continous ST
High-risk patient : segment
•Refractory ischemic chest pain monitoring
•Recurrent/persistent ST deviation • Consider stress test
•Ventricular tachycardia
•Hemodynamic instability
•Signs of pump failure Yes
•Early invasive strategy, including Develop high or intermediate
catheterization and revascularization risk criteria or
for shock within 48 hours of an AMI troponin-positive
Continue ASA, heparin, and other
therapies as indicated No
•ACE inhibitor/ARB
•HMG CoA reductase inhibitor (statin If no evidence of ischemia or
therapy)
infarction can discharge with
Not at high risk: cardiology to risk-
stratify follow-up