Acute Coronary Syndrome

Acute Coronary Syndrome Definition: Acute Coronary Syndrome is myocardial ischemia or necrosis caused by reduced coronary blood flow and includes unstable angina, non-ST-elevation myocardial infarction (NSTEMI), and ST – elevation myocardial infarction (STEMI) Criteria for diagnosis Suspected coronary syndrome with pressure type angina at rest in retrosternal area confirmed by: o ECG:ST-elevation, ST-Segment depression, prominent T-wave inversion o ST -elevation at J point (in absence of LVH and LBBB): ≥ 2 mm in men and ≥ 1.5 mm in women leads V2-V3 or ≥ 1 mm in ≥ 2 contiguous chest leads or limb leads o Consider posterior chest wall leads (V7-V9) and right precordial leads (V3R and V4R) o Emergency coronary angiography (if highly suspicious for MI but ECG nondiagnostic) o Elevated Troponin Levels (do not delay reperfusion therapy) Clinical presentation (Subjective Information)  Pressure-type angina frequently in retrosternal area and usually occurring at rest or with minimal exertion  Dyspnea Typical presentation:  pain starts in retrosternal area and may radiate to one or both arms, neck, or jaw  occurs at rest or with minimal exertion  ≥ 10 minutes in duration  new-onset angina or angina with increased intensity  unrelieved within < 5 minutes of rest or nitroglycerin Atypical presentation:  pain in: o arm o shoulder o back o neck o jaw o epigastric

o ear Other symptoms may include:  new-onset or increased exertional dyspnea is most common  nausea  vomiting  diaphoresis  abdominal pain  syncope  unexplained fatigue  nocturnal angina Physical Exam Findings  signs of heart failure: o tachycardia o hypotension o bradycardia o conduction abnormalities o cyanosis o pallor o jugular vein distention  chest pain that is not elicited by palpation  S4  Paradoxical splitting S2  Mitral regurgitation murmur  Inspiratory rales or wheezes  Reduced peripheral pulses (PAD)  Peripheral edema (RVF)

 CXR Labs (if ACS suspected send to ED):  Cardiac biomarkers: o Troponin I or T at presentation, 3-6 hrs. after symptom onset, and beyond 6 hrs. if initial troponins negative o Fasting lipid profile o CBC o PT/INR/aPTT o CMP o BNP Pharmacotherapy Low-risk patients referred for outpatient testing:  provide instructions about activity level and follow-up with provider  daily aspirin  short-acting nitroglycerin  other appropriate medications (such as beta blockers) High risk patients referred to hospital (PCI capable):  Aspirin 162-325mg, continue indefinitely if tolerated (give prior to EMS arrival or in route to hospital, if available)  Nitroglycerin 0.3-0.4 mg SL q5min x 3  IV Nitroglycerin if persistent ischemia, HTN, or heart failure  Morphine if maximally tolerated anti-ischemic medications are ineffective  Based on risk stratification and revascularization approach antiplatelet and anticoagulation therapy recommendations are modified: o Anticoagulation (unfractionated heparin [UFH], enoxaparin, bivalirudin, or fondaparinux) o Antiplatelet therapy (Clopidrogel or Ticagrelor) for up to 12 months o IV glycoprotein IIb/IIIa inhibitors, (add in high-risk patients)  If STEMI and PCI cannot be done within first 120 minutes then administer fibrinolytics: o Tenecteplase (TNK-tPA) o Reteplase (rPA) o Alteplase (tPA)  Beta Blocker (start within 24 hours)  ACEi (HTN, Diabetes, LVEF < 40%, CKD) (start within 24 hours)  Oral long acting nondihydropyridine CCB (Verapamil, Diltiazem) if recurrent ischemic symptoms not relieved by nitrates or beta blockers

Other pharmacologic intervention aimed at controlling contributing factors:  Statins  Glucose control Lifestyle Modifications  Smoking cessation  Heart healthy diet  Stress management  Medication adherence  Activity/exercise modifications Anticipated Ancillary Support/Referrals (i.e PT, OT, CBT, , etc) / Tech integration (apps, devices, etc)  Referral to Cardiology if not already done: o Stress testing o Cardiac rehabilitation (home based vs supervised center) o Implantable Cardioverter Defibrillator  Psychosocial support  Education about activity resumption  Education about use of NTG/ when to seek care in ED/call 911 for unrelieved chest pain Guidelines (i.e. JNC 8, GOLD) 2007 ACC/AHA guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction Link 2011 ACCF/AHA focused update incorporated into the ACC/AHA 2007 Guidelines for the Management of Patients with Unstable Angina/Non-ST-Elevation Myocardial Infarction Link 2013 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction Link 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes Link 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients with Coronary Artery Disease Link

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Ganiats, T. G., Jneid, H., Lincoff, A. M., Peterson, E. D., Philippides, G. J., Theroux, P., Wenger, N. K., Zidar, J. P., Anderson, J. L., Adams, C. D., Antman, E. M., Bridges, C. R., Califf, R. M., … American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines (2011). 2011 ACCF/AHA focused update incorporated into the ACC/AHA 2007 Guidelines for the Management of Patients with Unstable Angina/Non-ST-Elevation Myocardial Infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines developed in collaboration with the American Academy of Family Physicians, Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons. Journal of the American College of Cardiology , 57 (19), e215– e367. https://doi.org/10.1016/j.jacc.2011.02.011