Management of Patient with Acute Coronary Syndrome

A) Initial management:

  1. Person with prolonged cardiac pain: Deep, visceral, heavy, squeezing, crushing, typically radiating to arms, lower jaw, abdomen, back but above umbilicus
  2. Call 102, come to nearby hospital
  3. Duty doctor: suspect ACS
  4. Do 12 lead ECG (1st investigation to be done)

B) Further management is based on ECG results:

1. No ST Elevation (Unstable angina, NSTEMI):

  • ECG changes: ST deviation and T wave inversion (in 30-50% cases only)
  • Open IV line, Bedrest, Give oxygen, Attach monitors
  • Give aspirin, morphine (if pain), Sublingual nitroglycerin, Beta blockers
  • Send for cardiac biomarkers (within normal range in unstable angina and elevated in NSTEMI)
  • Fibrinolytics are not indicated. Unfractioned heparin (Anti-thrombotic) and Metoprolol (Beta blocker) must be given.
  • Stress test performed to classify patient as high or low risk. Low risk patient can undergo invasive procedures later while the high risk patient requires invasive procedures within 4 hours.

Invasive procedures: Go for PCI if single vessel involved and CABG if >3 vessels involved

heart

2. ST Elevation (STEMI):

  • ECG changes: ST elevation atleast 2 mm in chest leads and 1 mm in limb lead in atleast 2 adjacent leads
  • Open IV line, Give oxygen, Attack monitor
  • Give aspiring (160-325 mg), morphine, sublingual nitroglycerin (don’t use if patient is using viagra), Beta blcokers
  • Decide for reperfusion strategies: Fibrinolytics or PCI (Percutaneous Coronary Intervention)
  • If the patient can be taken to nearby PCI facilitated centre, don’t go for fibrinolytics but the door-to-balloon time should be <90 min

PCI is better when:

  • Diagnosis is in doubt
  • Cardiogenic shock is present
  • Bleeding risk is increased
  • Symptoms have been present for atleast 2-3 hours when the clot is more mature and less likely to be dissolved by fibrinolytics

Contraindication to fibrinolytics

a. Absolute:

  • History of cerebrovascular hemorrhage
  • Non-hemorrhagic stroke within past year
  • Severe hypertension (>180/>110 mmHg)
  • Suspicion of aortic dissection
  • Suspicion of active internal bleeding

b. Relative:

  • Current use of anticoagulants
  • Recent (<2 weeks) surgical or invasive procedures
  • Prolonged (>10 min) CPR
  • Known bleeding diasthesis
  • If the patient can’t be taken to PCI facilitated center, check for fibrinolytic contraindications and door-to-needle time should be <30 min.
  • If available tenecteplase/reteplase; if not streptokinase but risk of allergy to streptokinase is present.
  • Give antithrombotic: If available – unfractioned heparin and if not – LMW heparin
  • Give P2Y12P inhibitor – Clopidogrel
  • Give Beta blocker – Metoprolol
  • Give ACE inhibitors
  • Check monitor from beginning for any Premature ventricular beat which can be sign of reperfusion but get alert as it can change to VF. Don’t give lidocaine to prevent VF because it increases death from STEMI if Beta blocker is already given.
  • Charge defibrillator
  • If VF occur: Start CPR immediately while Defibrillator being charged
  • Give 3 shock (200, 260 and 300 J – monphasic)
  • If VF is persistent: Give 1 mg iv epinephrine and then shock (continue the therapy of drug, shock and CPR in between)
  • Regular follow up for Post-MI complication management

Note:

  1. Cardiac biomarkers suck as cardiac specific troponin I, cardiac specific troponin T, CK-MB need to be waited for management of STEMI but can be evaluated later.
  2. Door-to-needle time: Time from patient at door of hospital to initiation of fibrinolytic therapy
  3. Door-to-balloon time: Time from patient at door of hospital to PCI being started
  4. Troponin I and Troponin T: Onset after 4-8 hrs and remain elevated for 7-10 days
  5. CK-MB: Onset after 4-8 hrs and remain elevated for 48-72 hrs

Article by:

Rajendra Prasad Shah (2nd Batch, KISTMCTH)

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