Learning Objectives:

1
Acute Coronary Syndromes Cases

• Learning Objectives
• Definitions of the acute coronary syndromes
• Use of the Ischemic Chest Pain Algorithm
• The why (actions), when (indications), how
  (dose), and watch out (precautions) of
  medications to consider for patients with
  ischemic chest pain
• Morphine ---- Oxygen ---- Nitroglycerin
  ---- Aspirin
• Heparin ---- ?-Blockers ---- Primary PTCA
  ---- Thrombolytic agents
• ACE inhibitors
• ECG criteria for significant ST-segment changes
• Methods for measuring ST-segment elevation and
  depression
• Basic principles of anatomic localization of
  infarct, injury, and ischemia

2
Case 1

• You are an EMT-paramedic called to the home of a
  55-year-old man with a chief complaint of severe
  (10 of 10) substernal chest pain. Screening
  history reveals that he has pain radiating down
  his left arm and up into his jaw. He complains
  of nausea and a profound sense of impending doom.
  He is covered with small beads of sweat.

PE TEMP 37.2C HR 110 BP 150/100 RESP
12 Describe your immediate assessment.Describe
your immediate general treatment.
3
Box 2 Items of Immediate Assessment (

Check vital signs with automatic or standard BP
cuff.

Determine oxygen saturation.

Obtain IV access.

Obtain 12-lead ECG.

Obtain a brief, targeted history and perform a
physical examination use checklist (yes-no)
focus on eligibility for thrombolytic therapy.

Draw blood send for initial serum cardiac marker
levels once in ED.

Initiate electrolyte and coagulation studies.

4
Box 3 Items of Immediate General Treatment

• Oxygen at 4 L/min
• Aspirin 160 to 325 mg
• Nitroglycerin SL or spray
• Morphine IV (if pain is not relieved with
  nitroglycerin)

Review the Why (actions), When (indications), How
(dose), and Watch Out (precautions) of these
medications to consider in patients with ischemic
chest pain.
5
Medications Used in ACLS

• Why? (Actions)
• When? (Indications)
• How? (Dose)
• Watch Out! (Precautions)

6
Oxygen Used in Acute Coronary Syndromes

• Why?
• Increases supply of oxygen to ischemic tissue

• When?
• Always when AMI suspected

• How?
• Start with nasal cannula at 4 L/min
• Remember one word Oxygen-IV-monitor

• Watch Out!
• Very rarely COPD patients with hypoxic
  ventilatory drive

7
Nitroglycerin Used in Acute Coronary Syndromes

• Why? (Actions)
• Decreases pain of ischemia
• Increases venous dilation
• Decreases venous blood return to heart
• Decreases preload and oxygen consumption
• Dilates coronary arteries
• Increases cardiac collateral flow

8
Nitroglycerin Used in Acute Coronary Syndromes

• When? (Indications)
• Class I Over first 24 to 48 hours in patients
  with ST-segment elevation or depression
  complicated by any of the following
• Left ventricular failure (acute pulmonary edema
  or congestive heart failure)
• Elevated blood pressure (especially with signs of
  left ventricular failure)
• Large anterior infarction
• Persistent ischemia
• Suspected ischemic chest pain
• Unstable angina (change in angina pattern)
• Acute pulmonary edema (if BP 90 mm Hg systolic)

9
Nitroglycerin Used in Acute Coronary Syndromes

• How? (Dose)
• Sublingual 0.30 to 0.44 mg. Repeat every 5
  minutes.
• Spray inhaler Repeat every 5 minutes.
• IV infusion 10 to 20 ?g/min increase by 5 to 10
  ?g/min every 5 to 10 minutes.

10
Nitroglycerin Used in Acute Coronary Syndromes

• Watch Out! (Precautions)
• Use with extreme caution if systolic BP Hg.
• Use with extreme caution in right ventricular
  infarction.
• Suspect RV infarction in patients with inferior
  ST changes.
• Limit BP drop to 10 if patient is normotensive.
• Limit BP drop to 30 if patient is hypertensive.
• Watch for headache, drop in BP, syncope,
  tachycardia.
• Instruct patient to sit or lie down during
  administration of medication.

11
Morphine Sulfate Used in Acute Coronary Syndromes

• Why? (Actions)
• To reduce pain of ischemia
• To reduce anxiety
• To reduce extension of ischemia by reducing
  oxygen demands
• When?
• Continuing pain
• Evidence of vascular congestion (acute pulmonary
  edema)
• Systolic blood pressure 90 mm Hg
• No hypovolemia

12
Morphine Sulfate Used in Acute Coronary Syndromes

• How?
• 1 to 3 mg at frequent intervals (as often as
  every 5 minutes)
• Goal Eliminate pain
• Watch out for
• Drop in blood pressure, especially in
• Patients with volume depletion
• Patients with increased systemic resistance
• Patients with right ventricular infarction
• Depression of ventilation
• Nausea and vomiting (common)
• Bradycardia
• Itching and bronchospasm (uncommon)

13
Aspirin Used in Acute Coronary Syndromes

• Why? (Actions)
• Blocks formation of thromboxane A2 (thromboxane
  A2 causes platelets to aggregate and arteries to
  constrict).
• These actions will then
• Reduce overall mortality from AMI
• Reduce nonfatal reinfarction
• Reduce nonfatal stroke

14
Aspirin Used in Acute Coronary Syndromes

• When?
• As soon as possible!!
• Standard therapy for all patients with new pain
  suggestive of AMI
• Give within minutes of arrival
• How?
• 160 mg to 325 mg tablet taken as soon as possible
• Watch Out! (Precautions)
• Relatively contraindicated in patients with
  active ulcer disease or asthma.
• Contraindicated in patients with known
  hypersensitivity to aspirin.
• Higher doses interfere with prostacyclin
  production and limit positive benefits.

15
Box 5 Assess Initial 12-lead ECG
Assess initial 12-lead ECG
5
6
13
21
ST elevationor new or presumablynew BBB
stronglysuspicious for injury
ST depression orT-wave inversion ECG strongly
suspiciousfor ischemia
Nondiagnostic ECG absence of changesin ST
segmentor T waves
7
14

• Classify patients with acute ischemic chest pain
  into one of the three groups noted above within
  10 minutes of arrival.

16
Case 1 Conclusion

• This patient has become almost pain free (2 of
  10) soon after receiving oxygen, aspirin,
  nitroglycerin, and morphine. The heart rate has
  dropped to 90 beats/min BP 110/70 mm Hg. The
  12-lead ECG revealed acute anterior myocardial
  injury the patient is a candidate for
  thrombolytic therapy as the reperfusion strategy.
• The EMT-Ps have informed the receiving ED that a
  patient with acute injury changes on ECG is en
  route.
• Upon the patients arrival at the ED, the
  physicians rapidly initiate thrombolytic therapy
  infusion of the first bolus begins within 10
  minutes of the patients passing through the door.

17
Case 2
You are a physician on duty in the ED. A
63-year-old woman presents in the triage area
complaining of moderately severe substernal chest
pressure. The pain radiates to her left arm and
up into her neck. The woman had her husband drive
her to the ED after 5 hours of gradually
increasing pain. The pain is now 8 of 10. The
patient has high cholesterol, has smoked
cigarettes for 43 years, and has a father and an
uncle with heart problems.

• PE TEMP 36.9C HR 104 BP 145/98 RESP
  15
• Describe your immediate assessment.Describe your
  immediate general treatment.

18
Box 2 Items of Immediate Assessment (

• Check vital signs with automatic or standard BP
  cuff.
• Determine oxygen saturation.
• Obtain IV access.
• Obtain a 12-lead ECG.
• Obtain a brief, targeted history and perform a
  physical examination use checklist (yes-no)
  focus on eligibility for thrombolytic therapy.
• Draw blood send for initial serum cardiac marker
  levels once in ED.
• Initiate electrolyte and coagulation studies.

19
Box 3 Items of Immediate General Treatment

• Oxygen at 4 L/min
• Aspirin 160 to 325 mg
• Nitroglycerin SL or spray
• Morphine IV (if pain is not relieved with
  nitroglycerin)

Review the Why? (actions), When? (indications),
How? (dose), and Watch Out! (precautions) of
these medications to considerfor patients with
ischemic chest pain.
20
Box 5 Assess Initial 12-lead ECG
Assess initial 12-lead ECG
5
6
13
21
ST elevationor new or presumablynew BBB
stronglysuspicious for injury
ST depression orT-wave inversion ECG strongly
suspiciousfor ischemia
Nondiagnostic ECG absence of changesin ST
segmentor T waves
7
14

• Classify patients with acute ischemic chest pain
  into one of the three groups noted above within
  10 minutes of arrival.

21
Box 7 Consider Adjunctive Treatments
Assess initial 12-lead ECG
5
6
ST elevation or new or presumably new BBB
strongly suspicious for injury
7

• Consider adjunctive treatments(as indicated no
  reperfusion delay)
• ?-Blockers IV
• Nitroglycerin IV
• Heparin IV (especially with TPA)
• ACE inhibitors

• Patients with acute ischemic chest pain and ST
  elevationConsider for adjunctive treatments.

22
?-Blockers Used in Acute Coronary Syndromes

• Why?
• Decrease automaticity and arrhythmias
• Reduce sinus node discharge
• Lower blood pressure
• Lower myocardial contractility
• Block catecholamine stimulation
• Reduce myocardial oxygen consumption
• Net effect reduces size of infarction

23
?-Blockers Used in Acute Coronary Syndromes

• When?
• Class I All patients with ST-segment elevation
  if treated within 12 hours of onset of infarction
  (without a contraindication to ?-blocker therapy)
• Patients with acute coronary syndrome with signs
  of excess sympathetic activity (eg, diaphoresis,
  elevated heart rate, blood pressure)
• Patients with acute coronary syndrome with
  refractory chest pain or tachycardias due to
  excessive sympathetic tone

24
?-Blockers Used in Acute Coronary Syndromes

• How?
• Metoprolol 5 mg IV push (slow) q 5 minutes to a
  totalof 15 mg or
• Esmolol 0.5 mg/kg loading dose over 1 minute,
  followed by continuous infusion of 0.05 mg/kg per
  minute or
• Propranolol 1 mg IV (slow) q 5 minutes to a
  total of 5 mg

25
?-Blockers Used in Acute Coronary Syndromes

• Watch Out!
• Contraindications to IV ??-blockers
• Congestive heart failure/pulmonary edema
• Bronchospasm or history of asthma
• Bradycardia (
• Hypotension (
• Signs of peripheral hypoperfusion
• PR interval 0.24 second
• Second- or third-degree block
• Severe COPD
• Severe peripheral vascular disease
• Insulin-dependent diabetes mellitus

26
Nitroglycerin Used in Acute Coronary Syndromes

• Why? (Actions)
• Decrease pain of ischemia
• Increases venous dilation
• Decreases venous blood return to heart
• Decreases preload and oxygen consumption
• Dilates coronary arteries
• Increases cardiac collateral flow

27
Nitroglycerin Used in Acute Coronary Syndromes

• When? (Indications)
• Class I Over the first 24 to 48 hours in
  patients with ST-segment elevation or
  depression complicated by any of the following
• Left ventricular failure (acute pulmonary edema
  or congestive heart failure)
• Elevated blood pressure (especially with signs of
  LV failure)
• Large anterior infarction
• Persistent ischemia
• Suspected ischemic chest pain
• Unstable angina (change in pattern)
• Acute pulmonary edema (if BP 90 mm Hg systolic)

28
Nitroglycerin Used in Acute Coronary Syndromes

• How? (Dose)
• SL 0.30 to 0.44 mg. Repeat q 5 minutes.
• Spray inhaler Repeat q 5 minutes.
• IV infusion 10 to 20 ?g/min increase by 5 to 10
  ?g/min q 5 to 10 minutes.

29
Nitroglycerin Used in Acute Coronary Syndromes

• Watch Out! (Precautions)
• Use with extreme caution of systolic BP Hg.
• Use with extreme caution in right ventricular
  infarction.
• Suspect RV infarction in patients with inferior
  ST changes.
• Limit BP drop to 10 if patient is normotensive.
• Limit BP drop to 30 if patient is hypertensive.
• Watch for headache, drop in BP, syncope,
  tachycardia.
• Instruct patient to sit or lie down when taking
  medication.

30
Heparin Used in Acute Coronary Syndromes

• Why? (Actions)
• Prevents thrombus formation over ruptured plaque
  surface (unstable angina)
• Prevents recurrence of thrombosis after
  thrombolysis
• Maintains patency of infarct-related artery
• Prevents mural thrombus formation in patients
  with large infarctions

31
Heparin Used in Acute Coronary Syndromes

• When? (Indications)
• Patients receiving TPA and Retavase (Class IIa)
• Patients receiving PTCA or surgical
  revascularization (Class I)
• Patients with acute ST-segment depression and
  T-wave inversions
• Patients with nondiagnostic ECGs history
  indicates unstable angina
• Patients with hypokinetic areas confirmed by
  echocardiography

32
Heparin Used in Acute Coronary Syndromes

• How? (Dose)
• Initial bolus 80 IU/kg
• Continue at 18 IU/kg per hour
• Adjustments
• Adjust to maintain activated partial
  thromboplastin time (aPTT) 1.5 to 2.0 times
  control values.
• Target range for aPTT after first 24 hours is 60
  to 85 seconds (may vary with laboratory).
• Check aPTT at 6, 12, 18, and 24 hours.
• If aPTT is 60 seconds at 24 hours, repeat bolus
  with 20 IU/kg heparin increase infusion by 3
  IU/h recheck aPTT in 2 hours.

33
Heparin Used in Acute Coronary Syndromes

• Watch Out! (Precautions)
• Same contraindications as for thrombolytic
  therapy
• Active bleeding
• Recent intracranial, intraspinal, or eye surgery
• Severe hypertension
• Bleeding disorders
• Gastrointestinal bleeding
• Caution when used with nitroglycerin

34
ACE Inhibitors Used in Acute Coronary Syndromes

• Why? (Actions)
• Block (inhibit) conversion of angiotensin I to
  angiotension II(a potent vasoconstrictor)
• Decrease afterload (peripheral vascular
  resistance)
• Decrease preload (pulmonary vascular resistance)
• Improve cardiac output
• Improve LV dysfunction ? reduce mortality in
  post-AMI patients
• Prevent adverse LV remodeling ? delay progression
  of heart failure
• Decrease sudden death and recurrent AMI

35
ACE Inhibitors Used in Acute Coronary Syndromes

• When? (Indications)
• Class I RecommendationsPatients With Acute
  Coronary Syndrome
• With ST-segment elevation in two or more anterior
  precordial leads
• Who develop LV ejection fraction
• Who develop clinical signs of heart failure from
  systolic pump dysfunction

• Class IIa RecommendationsPatients With Acute
  Coronary Syndrome
• Any within first 24 hours, provided no
  hypotension is present
• With history of old MI and mildly impaired LV
  function(EF 40 to 50)

36
ACE Inhibitors Used in Acute Coronary Syndromes

• How? (Dose)
• Start with low-dose oral administration
• Increase steadily to achieve full dose within 24
  to 48 hours
• Enalapril
• Start with a single dose of 2.5 mg PO
• Titrate to 20 mg PO BID
• Captopril
• Start with a single dose of 6.25 mg PO
• Advance to 25 mg TID and then to 50 mg TID as
  tolerated
• Ramipril
• Start with a single dose of 2.5 mg PO
• Titrate to 5 mg PO BID as tolerated

37
ACE Inhibitors Used in Acute Coronary Syndromes

• Watch Out! (Precautions)
• Contraindicated
• In pregnancy (may cause fetal injury or death)
• If systolic BP
• If history of bilateral stenosis of renal
  arteries
• If known allergy to ACE inhibitors
• Avoid hypotension, especially in patients with
  volume depletion
• Not started in ED but sometime within the first
  24 hours
• After thrombolytic therapy has been completed
• After blood pressure has stabilized

38
Box 8 Time From Onset of Symptoms
12 hours
8
Time from onset of symptoms?
9
Select a reperfusion strategy
10

• How is onset of symptoms defined?
• Why the division between 12 hours?

39
ACLS Case 6
Box 9 Select a Reperfusion Strategy
9
Select a reperfusion strategy
10

• Thrombolytic therapy selected (no
  contraindications)
• Front-loaded alteplase or
• Streptokinase or
• ReteplaseGoal Door-to-drug

• Which reperfusion strategy should be selected,
  given the circumstances of this case?

11
Patients selectedfor PTCAor with
contraindicationsto thrombolytic therapy
Orequivalentalternative
12

• Primary PTCA selected. Goal
• Door-to-dilatation interval, or
• Arrival-in-cath lab interval

• American Heart Association, Inc.

Acute Coronary Syndromes Case 2
40
ACLS Case 6
Box 10 Thrombolytic Therapy Selected
9
Select a reperfusion strategy
10

• Thrombolytic therapy selected (no
  contraindications)
• Front-loaded alteplase or
• Streptokinase or
• ReteplaseGoal Door-to-drug

• Which of the three available agents do you
  select?
• What are the usual absolute and relative
  contraindications to thrombolytic therapy?

11
Patients selectedfor PTCAor with
contraindicationsto thrombolytic therapy
Orequivalentalternative
12

• Primary PTCA selected. Goal
• Door-to-dilatation interval, or
• Arrival-in-cath lab interval

• American Heart Association, Inc.

Acute Coronary Syndromes Case 2
41
Which Thrombolytic Agent to Select?

• Alteplase (TPA) Best for patients with acute
  coronary syndrome and
• Short times from onset of symptoms (minutes)
• Large infarctions (widespread ECG changes)
• Low risk of brain hemorrhage (hypertensive and
  elderly)
• Streptokinase Best for patients with acute
  coronary syndrome and
• Longer times from onset of symptoms
• Smaller areas of injury
• Greater risk of brain hemorrhage
• Reteplase Initial trials suggest equivalent to
  TPA
• Easy administration double dose, 30 minutes
  apart
• No infusion pump required
• Dosing not based on weight

42
Absolute Contraindications to Thrombolytic Therapy

• Previous hemorrhagic stroke at any time
• Other strokes or cerebrovascular events within 1
  year
• Known intracranial neoplasm
• Active internal bleeding (except menses)
• Suspected aortic dissection

43
Relative Contraindications to Thrombolytic Therapy

• Severe uncontrolled hypertension on arrival (BP
  180/110 mm Hg)
• History of chronic severe hypertension
• Intracerebral pathology (other than stroke)
• Current use of anticoagulants (INR 2 to 3)
• Known bleeding diathesis
• Recent trauma (2 to 4 weeks), including head
  trauma
• Prolonged (10 minutes) potentially traumatic CPR
• Major surgery
• Noncompressible vascular punctures
• Recent (2 to 4 weeks) internal bleeding
• For streptokinase prior exposure (especially 5
  days to 2 years)
• Pregnancy
• Active peptic ulcer

44
Box 8 Time From Onset of Symptoms 12 Hours
12 hours
8
Time from onset of symptoms?
9
Select a reperfusion strategy
10
What is the recommendation for patients with
significant STelevation who present with 12
hours of pain?
45
Case 2 Conclusion

• This patient received the following medications
• Prehospital oxygen, aspirin, nitroglycerin SL,
  and morphine
• Adjunctive in ED ?-blocker, nitroglycerin IV,
  heparin
• Reperfusion strategy alteplase (front-loaded
  or accelerated)
• The combination of prehospital and adjunctive
  medications rendered the woman virtually pain
  free (2 of 10) with a BP of 105/70 mm Hg HR 75
  beats/min.
• Within 25 minutes of the patients arrival in
  the ED, accelerated infusion of alteplase was
  started. The patient experienced several minutes
  of PVCs, approximately 5 to 10 per minute,
  during the half-hour of alteplase infusion.
  CK-MB levels drawn in the field and initially in
  the ED were moderately elevated by 12 hours
  they had returned to normal.
• The patient was started on enalapril soon after
  admission to the CCU. She experienced an
  uneventful hospital course and was discharged on
  metoprolol and enalapril.

46
Case 3

• You are a physician on duty in the ED. Your next
  patient is a60-year-old woman with a long
  history of hypertension treated with a diuretic
  and a calcium channel blocker. She has
  experienced 2 hours of gradually increasing
  substernal chest pain. The pain seems to radiate
  to her back and her left arm. She grades the
  pain as 4 of 10 at onset, increasing to 7 of 10
  over the past 45 minutes. She complains of
  weakness and slight nausea, but she is not short
  of breath.

PE TEMP 37.2C HR 55 BP 90/60 in both
arms RESP 14 Describe your immediate
assessment.Describe your immediate general
treatment.
47
Box 2 Items of Immediate Assessment (

• Check vital signs with automatic or standard BP
  cuff
• Determine oxygen saturation
• Obtain IV access
• Obtain 12-lead ECG (ECG tech on standing orders)
• Obtain a brief, targeted history and physical
  examination use checklist (yes-no) focus on
  eligibility for thrombolytic therapy.
• Draw blood send for initial serum cardiac marker
  levels once in ED
• Initiate electrolyte and coagulation studies

48
Box 3 Items of Immediate General Treatment

• Oxygen at 4 L/min
• Aspirin 160 to 325 mg
• Nitroglycerin SL or spray
• Morphine IV (if pain is not relieved with
  nitroglycerin)

MONA greets all patients
49
Morphine Sulfate Used in Acute Coronary Syndromes

• How?
• 1 to 3 mg at frequent intervals (as often as
  every 5 minutes)
• Goal Eliminate pain
• Watch Out!
• Drop in blood pressure, especially with
• Patients with volume depletion
• Patients with increased systemic resistance
• Patients with RV infarction
• Depression of ventilation
• Nausea and vomiting (common)
• Bradycardia
• Itching and bronchospasm (uncommon)

50
Nitroglycerin Used in Acute Coronary Syndromes

• Watch Out! (Precautions)
• Use with extreme caution if systolic BP Hg
• Use with extreme caution in RV infarction
• Suspect RV infarction in patients with inferior
  ST changes
• Limit BP drop to 10 if patient is normotensive
• Limit BP drop to 30 if patient is hypertensive
• Watch for headache, drop in BP, syncope,
  tachycardia
• Instruct patient to sit or lie down when taking
  medication

51
Box 5 Assess Initial 12-lead ECG
Assess initial 12-lead ECG
5
6
13
21
ST elevationor new or presumablynew BBB
stronglysuspicious for injury
ST depression orT-wave inversion ECG strongly
suspiciousfor ischemia
Nondiagnostic ECG absence of changesin ST
segmentor T waves
7
14

• Classify patients with acute ischemic chest pain
  into one of the three groups noted above within
  10 minutes of arrival.

52
Major Findings of Right Ventricular Infarction

• Hypotension (of varying degrees)
• Clear lung fields
• Elevated jugular venous distention
• Kussmauls sign (jugular venous distention
  paradoxically increases with inspiration)
• ST-segment elevation in leads II, III, aVF
• BP dependent on RV filling pressures

53
Box 7 Consider Adjunctive Treatments
Assess initial 12-lead ECG
5
6
ST elevation or new or presumably new BBB
strongly suspicious for injury
7

• Consider adjunctive treatments(as indicated no
  reperfusion delay)
• ?-Blockers IV
• Nitroglycerin IV
• Heparin IV (especially with TPA)
• ACE inhibitors

• Patients with acute ischemic chest pain and ST
  elevationConsider for adjunctive treatments.

54
Box 8 Time From Onset of Symptoms
12 hours
8
Time from onset of symptoms?
9
Select a reperfusion strategy
10
55
ACLS Case 6
Box 9 Select a Reperfusion Strategy
9
Select a reperfusion strategy
10

• Thrombolytic therapy selected (no
  contraindications)
• Front-loaded alteplase or
• Streptokinase or
• ReteplaseGoal Door-to-drug

• Which reperfusion strategy should be selected,
  given the circumstances of this case?

11
Patients selectedfor PTCAor with
contraindicationsto thrombolytic therapy
Orequivalentalternative
12

• Primary PTCA selected. Goal
• Door-to-dilatation interval, or
• Arrival-in-cath lab interval

• American Heart Association, Inc.

Acute Coronary Syndromes Case 3
56
ACLS Case 6
Box 11 Patients Selected for Primary PTCA or
With Contra-indications to Thrombolytic Therapy
9
Select a reperfusion strategy
10

• Thrombolytic therapy selected (no
  contraindications)
• Front-loaded alteplase or
• Streptokinase or
• ReteplaseGoal Door-to-drug

11
Patients selectedfor PTCAor with
contraindicationsto thrombolytic therapy
Orequivalentalternative
12

• Primary PTCA selected. Goal
• Door-to-dilatation interval, or
• Arrival-in-cath lab interval

• American Heart Association, Inc.

Acute Coronary Syndromes Case 3
57
ACLS Case 6
Box 12 Primary PTCA Selected
9
Select a reperfusion strategy
10

• Thrombolytic therapy selected (no
  contraindications)
• Front-loaded alteplase or
• Streptokinase or
• ReteplaseGoal Door-to-drug

What are the conditions a catheterization
laboratory must meet before primary PTCA can be
considered an equivalent alternative to
thrombolytic therapy?
11
Patients selectedfor PTCAor with
contraindicationsto thrombolytic therapy
Orequivalentalternative
12

• Primary PTCA selected. Goal
• Door-to-dilatation interval, or
• Arrival-in-cath lab interval

• American Heart Association, Inc.

Acute Coronary Syndromes Case 3
58
Equivalency Requirements
For primary PTCA to be the equivalent
ofthrombolytic therapy

• ED door-to-cath lab time
• Dilatation time (ED to balloon inflation) minutes
• Operators must be skilled (75 procedures
  performed per year).
• Centers must be high volume (200 procedures
  performed per year).
• Operators and centers must average high flow
  rates and low complication rates.

59
Case 4
You are a physician on duty in the ED when you
hear the following account from the triage nurse

• A 75-year-old woman was being evaluated in the
  rheumatology clinic when she developed gradual
  onset of substernal chest pressure, some nausea,
  and slight diaphoresis.
• She was transferred to the ED for further
  evaluation. No vital signs were noted, and no
  medications were given in the clinic.
• On initial interview she describes the pain as a
  squeezing, pushing pressure just under my
  breastbone. She grades it 6 of 10.

PE TEMP 36.8C HR 90 BP 140/90 RESP
15 Describe your immediate assessment.Describe
your immediate general treatment.
60
Box 2 Items of Immediate Assessment (

• Check vital signs with automatic or standard BP
  cuff.
• Determine oxygen saturation.
• Obtain IV access.
• Obtain 12-lead ECG (ECG tech on standing orders).
• Obtain a brief, targeted history and perform a
  physical examination.
• Draw blood for initial serum cardiac marker
  levels.
• Initiate electrolyte and coagulation studies.

61
Box 3 Items of Immediate General Treatment

• Oxygen at 4 L/min
• Aspirin 160 to 325 mg
• Nitroglycerin SL or spray
• Morphine IV (if pain is not relieved with
  nitroglycerin)

MONA greets all patients
62
Box 5 Assess Initial 12-lead ECG
Assess initial 12-lead ECG
5
6
13
21
ST elevationor new or presumablynew BBB
stronglysuspicious for injury
ST depression orT-wave inversion ECG strongly
suspiciousfor ischemia
Nondiagnostic ECG absence of changesin ST
segmentor T waves
7
14

• Classify patients with acute ischemic chest pain
  into one of the three groups noted above within
  10 minutes of arrival.

63
ACLS Case 6
Box 14 Consider Adjunctive Treatments
5
Assess initial 12-lead ECG
13
ST depression or T-waveinversion ECG
stronglysuspicious for ischemia
What are the indications for heparin IV,
nitroglycerin IV, and ?-blockers in patients
with ischemic chest pain and ST-segment
depression or T-wave inversions?
14

• Consider adjunctive treatments     (as
  indicated no contraindications)
• Heparin IV
• Nitroglycerin IV
• ?-Blockers IV

15
Assess clinical status

• American Heart Association, Inc.

Acute Coronary Syndromes Case 4
64
Adjunctive AgentsAcute ST-Segment Depression or
T-Wave Inversions
ACLS Case 6

• Heparin IV
• Recommended
• Heparin IV should be given on the assumption of
  unstable angina (if there are no
  contraindications)
• Nitroglycerin IV
• Recommended
• If pain is not controlled with up to 3
  nitroglycerin tablets SL or metered sprays
• If pain recurs after initial abatement
• If blood pressure is elevated after giving
  ?-blockers
• If signs of CHF develop
• Relative contraindications
• Hypotension (systolic BP
• Inferior ECG changes (suspected RV infarction)

• American Heart Association, Inc.

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65
Adjunctive AgentsAcute ST-Segment Depression or
T-Wave Inversions
ACLS Case 6

• ??-Adrenoceptor Blocking Agents (??-Blockers)
• Recommended
• Patients with continuing or recurrent ischemic
  pain
• Patients with tachyarrhythmias with rapid
  ventricular response
• Relative contraindications
• Heart rate
• Moderate or severe LV failure
• Signs of peripheral hypoperfusion
• Second- or third-degree block
• Severe COPD
• History of asthma
• Insulin-dependent diabetes mellitus

• American Heart Association, Inc.

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66
ACLS Case 6
Box 15 Assess Clinical StatusBox 16 High-Risk
Patient
15
Assess clinical status
16
19

• High-risk patient                   
• Persistent symptoms
• Recurrent ischemia
• Depressed LV function
• Widespread ECG changes
• Prior AMI, PTCA, CABG

Clinicallystable
What are the major clinical or history
assessments that categorize a patient as high
risk?

• American Heart Association, Inc.

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67
ACLS Case 6
Box 19 Clinically StableBox 20 Admit to
CCU/Monitored Bed
16
19

• High-risk patient                   
• Persistent symptoms
• Recurrent ischemia
• Depressed LV function
• Widespread ECG changes
• Prior AMI, PTCA, CABG

Clinicallystable
16

• Admit to CCU/monitored bed
• Continue or start adjunctive   treatments, as
  indicated
• Serial serum markers
• Serial/continuous ECGs
• Consider imaging study   (2D echocardiography
    or radionuclide)

• American Heart Association, Inc.

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68
Case 4 Conclusion

• This patient has received oxygen, nitroglycerin,
  morphine, and aspirin.
• Heparin was not started because of
  guaiac-positive rectal exam.
• By the time an admission bed becomes available,
  the patient is completely pain free. She is
  admitted to a telemetry bed.
• Her initial serum markers are normal. However,
  she develops moderate elevations in CPK-MB and
  myoglobin over the next 24 hours.
• ST-segment depression resolves over 24 hours. No
  repeat pain occurs. Her discharge 12-lead ECG is
  nonspecific, without Q waves.
• Her discharge diagnosis is nonQ-wave infarction.