PHILIPPINE HEART ASSOCIATION

Council on CardioPulmonary Resuscitation

Acute Coronary Syndrome /

TITLE Infarction
Acute Myocardial
Algorithm
A Full Member of the

The Asian Representative of

 A.C.S.
• Most common proximate cause of sudden
cardiac death
• Chest pain
• ECG changes
• Cardiac markers
 A.C.S.
Treatment Objectives
• Reduce myocardial necrosis
• Prevent major adverse cardiac events
• Treat acute life-threatening complications
 ST Segment

•Isoelectric
•Normally
deviate bet. -0.5
& +1mm from the
baseline
INFARCT ISCHEMIA
 2015 UPDATED
RECOMMENDATIONS
• Pre-hospital 12-L ECG acquired early for patients with
possible ACS (Class I, LOE B)

• Pre-hospital notification of the receiving hospital (if

fibrinolysis is the likely reperfusion strategy) and/or pre
hospital activation of the catheterization laboratory
should occur for all patients with a recognized STEMI
on pre-hospital ECG (Class 1, LOE B)
 2015 UPDATED
RECOMMENDATIONS
• Implementation of 12-LECG diagnostic programs
(concurrent medically directed quality assurance)
(Class 1, LOE B)

• We recommend that computer-assisted ECG

interpretation may be used in conjunction with
physician or trained provider interpretation to recognize
STEMI (Class IIB, LOE C)
 2015 UPDATED
RECOMMENDATIONS
• hs-cTnI at 0 and 2 hours may be used in conjunction with clinical
risk stratification tools (TIMI score, HEART score) (Class IIa,
LOE B)

• Pre-hospital initiation of ADP inhibition/UFH in patients with

suspected STEMI intending to undergo PPCI may be
reasonable (Class IIb, LOE B)

• In STEMI patients presenting within 2 hours of symptom onset,

immediate fibrinolysis rather than PPCI may be considered
when the expected delay to primary PCI is >60mins
 2015 UPDATED
RECOMMENDATIONS
• In adult patients presenting with STEMI in the ED of a non-PCI
capable hospital, we recommend immediate transfer without
fibrinolysis to a PCI center instead of immediate fibrinolysis with
transfer only for ischemia-driven PCI (Class 1, LOE B)

• When fibrinolytic therapy is administered to a STEMI patient in a

non-PCI capable hospital, it may be reasonable to transport all
postfibrinolysis patients for early routine angiography on the first
3 to 6 hours and up to 24 hours rather than transport only when
they require ischemia guided angiography (Class II, LOE B)
 2015 UPDATED
RECOMMENDATIONS
TIMING OF REPERFUSION STRATEGY
2 HOURS- FIBRINOLYSIS > PCI
2-3 HOURS – FIBRINOLYSIS=PCI
3-12 HOURS – PCI > FIBRINOLYSIS
(> 6 hours fibrinolysis becomes significantly less
effective)

(Class IIb, LOE C)

 2015 UPDATED
RECOMMENDATIONS
• Coronary angiography should be performed
emergently (rather than later in the hospital stay or not
at all) for OHCA patients with suspected cardiac
etiology of arrest and ST elevation on ECG (Class 1,
LOE B)
• Emergency coronary angiography is reasonable for
select (eg, electrically or hemodynamically unstable)
adult patients who are comatose after OHCA of
suspected cardiac origin but without ST elevation on
ECG (Class IIa, LOE B) ???
 Case
• 55 y/o man
• Hypertensive,
diabetic, smoker
• High cholesterol
• Severe substernal
chest heaviness >
30 mins, “crushing”,
“squeezing”
 Question
• What do you do?
• A. assess vital signs
• B. insert IV line
• C. give oxygen per nasal cannula
• D. get a 12 lead ECG
Pre-Hospital Fibrinolytic
Checklist
STEMI
• Diagnosis?
• A. STEMI
• B. unstable angina
• C. NSTEMI
• D. noncardiac
chest pain
• Diagnosis?
• A. LBBB
• B. RBBB
• C. normal ECG
 ST-segment depression/
Dynamic T-wave inversion:
Strongly suspicious for
ischemia

•ST depression > 1mm

•Marked symmetrical T-wave
inversion in multiple precordial
leads
•Dynamic ST-T changes with
pain

AMI Algorithm
Absolute Contraindications to Beta
blocker Therapy

 Severe LV failure and pulmonary edema

 Bradycardia (heart rate <60 bpm)

 Hypotension (SBP < 100 mm Hg)

 Signs of poor peripheral perfusion

 Second or third-degree heart block

 UA / NSTEMI
UA/NSTEMI

•In general treat these patients Antithrombin (Heparin) plus

with both Antiplatelet (aspirin)
Antithrombin (heparin) and
an
Antiplatelet agent (aspirin) High Risk Criteria
•ST depression > 1 mm
•Persistent symptom, recurrent
ischemia
•Diffuse or widespread ECG
•Modify this treatment if abnormalities
patient meets criteria for
high risk •Depressed LV function
•Congestive Heart failure
•Serum marker release:
positive troponin or CK-MB+
 UA/ NSTEMI

Recommendations for Initial Management & Therapy

Patients who meet high risk Antithrombin (heparin) plus

criteria benefit from treatment
with Antiplatelet (aspirin)
•Aspirin Plus
•GP IIb/IIIa inhibitors &
Glycoprotein IIb/IIIa
unfractionated heparin or
•LMWH inhibitors

All patients without

B - blockers
contraindications should receive
 UA/NSTEMI

Recommendations for Initial Management & Therapy

Patient who suffer recurrent

angina should also receive Nitrates

As a third agent to use for

refractory angina or in patients Calcium Channel
with a contraindication to Blockers
B-blockers
 Start Adjunctive treatments
•Heparin (UFH/LMWH)
UA/NSTEMI
•ASA
•Glycoprotein IIb/IIIa
High risk
receptor inhibitors
•B-blockers

Assess clinical status Clinically stable

High risk patients:

•Persistent symptoms
•Recurrent ischemia
•Depressed LV fxn
•Prior AMI, PCI, CABG
Admit to CCU/ Monitored Bed
No •Adjunctive treatment
Perform Cardiac Cath
•Serial serum markers
•Serial ECG
Revascularization •Consider imaging study (2D
•PCI echo or radionuclide)
•CABG

AMI Algorithm
 Assess the Initial ECG

12L ECG is central to Triage of ACS in the ER

Classify patients as being 1 0f 3 syndromes within 10 minutes of arrival

ST-segment elevation ST-segment depression/ •Non-diagnostic

ECG
Or new LBBB Dynamic T-wave inversion: •ST
•ST depression
depression 0.5-1mm
0.5-1mm
•T
•T wave
wave inversion
inversion or
or
High risk unstable angina/
flattening
flattening in
in leads
leads with
with
non-STEMI dominant
dominant R R waves
waves
•Intermediate/ low
risk unstable
angina

AMI Algorithm
 Develops high
Start Adjunctive treatments •Non-diagnostic
or intermediate
•NTG ECG
risk criteria
•Heparin (UFH/LMWH) or troponin •Intermediate/
•Clopidogrel Yes positive low risk
•Glycoprotein IIb/IIIa unstable angina
receptor inhibitors No
•B-blockers Admit to ED chest pain unit or to
monitored bed
•Serial serum markers
Assess clinical status
•Repeat ECG/ continuous ST
monitoring
Clinically stable •Consider stress test

Admit to CCU/ Monitored Bed Yes

Evidence of ischemia/ infarction
•Adjunctive treatment
•Serial serum markers No
•Serial ECG Discharge Acceptable
•Consider imaging study (2D •Arrange follow-up
each or radionuclide)
AMI Algorithm
 Recap
• ACS  assess chest pain character and
timing
• Assess risk for CAD
• 12 L ECG to differentiate STEMI/NSTEMI/UA
• Initial treatment in ER
• Adjunctive treatment
• Select Reperfusion strategy
• Indication/availability of invasive strategies
 Summary of key issues and
major changes
• Pre-hospital ECG acquisition and interpretation
• Choosing a reperfusion strategy when pre-
hospital fibrinolysis is available
• Choosing a reperfusion strategy at a non-PCI
capable hospital
• Troponin to identify patients who can be safely
discharged from the ER department
• Interventions that may or may not be of benefit if
given before hospital arrival
The PHA Council on Cardiopulmonary Resuscitation