Dx ¹^,²

ECG w/i 10min of arrival, then Q15-30min x1hr if not initially diagnositc
CXR / Chest CT to r/o thoracic aortic aneurysm / dissection, PE, pneumothorax, PNA, etc
Serial cTn ASAP then Q3-6hr
TIMI Risk Score for all NSTE-ACS (1pt for each below ³)
- ≥ 65yo
- Prior Coronary Stenosis ≥ 50%
- ST Depression ≥ 0.5mm
- ≥ 2 Anginal events w/i 24hrs
- ASA use w/i 7d
- (+) Cardiac Enzymes
- ≥ 3 CAD risk factors
  - Smoking
  - HTN
  - Dyslipidemia
  - DM
  - FHx of premature CAD or Sudden Cardiac Death
- GRACE Risk Score

STEMI Dx Criteria

ESC/ACC/AHA ⁴^,⁵
- ST Elevation in 2 anatomically contiguous leads ≥ 0.1mV at the J-point except V₂-V₃ (use the following in V₂-V₃
- Men ≥ 40: ≥ 0.2 mV
- Men < 40: ≥ 0.25 mV
- Women: ≥ 0.15 mV
- New horizontal / down-sloping ST-depression in 2 contiguous leads ≥ 0.05 mV
- T-wave Inversion in 2 contiguous leads ≥ 0.1 mV with prominent R waves or $\frac{R}{S} > 1$
- Definitively new LBBB
In the presence of existing LBBB consider Smith-Modified Sgarbossa Criteria [^smith2012-lbbb-stemi]
- ≥ 3 points ⇒ 98% Likelihood of MI
- ST-elevation ≥1 mm in a lead with upward QRS complex (concordant) - 5 points
- ST-depression ≥1 mm in lead V1, V2, or V3 - 3 points
- $\frac{\text{ST-change}}{\text{S-wave}} \le -0.25$ - 2 points
New LAFB and RBBB is concerning for LAD occlusion
ST-elevation with ST-depression in aVL is highly suspicious for STEMI
Local ST-depression in V₁-V₄ is suspicious for isolated posterior infarct
ST-elevation in aVL with depression in III is suspicious for high lateral MI
Subtle LAD occlusion vs EBR ⁶
- 0.052 x QTc - 0.151 x (QRS voltage in V2) - 0.268 x (R-wave amplitude in V4) + 1.062 x (ST-elevation 60ms after J-point in V3)
- ≥ 18.2 ⇒ 88.8% sensitive, 94.7% specific
- ≥ 17.75 ⇒ 90.2% sensitive, 90.6% specific

Infarction EKG Patterns ¹

Location	Electrocardiographic Findings	Artery
Anteroseptal	ST-segment elevations in V1, V2, and possibly, V3	LAD
Anterior	ST-segment elevations in V1, V2, V3, and V4	LAD
Anterolateral	ST-segment elevations in V1–V6, I, and aVL	LAD or LCX
Lateral	ST-segment elevations in I and aVL	LCX
Inferior	ST-segment elevations in II, III, and aVF	RCA or RCX (20%)
Inferolateral	ST-segment elevations in II, III, aVF, and V5 and V6	LCX or RCA or RCX
True posterior	Initial R waves in V1 and V2 > 0.04 s and R/S ratio ≥ 1	LCX
Right ventricular	ST-segment elevations in II, III, and aVF and ST elevation in right-side V4	RCA

Tx ¹^,⁴

Empiric ASA 325mg (chew & swallow) for all pts at risk for AMI w/o CIs
Nitrates
- Nitro 0.4mg SL Q5min x3 doses
- Nitro IV Start at 10 mcg/min, titrate to 10% reduction in MAP if normotensive, 30% reduction in MAP if hypertensive
- Avoid in RV infarction (d/t dependance on preload for maintaining CO)
- CI w/ PDE-5 Inhibitors w/i 24hr (48hr if Tadalafil)
Supplemental O2 PRN for O2Sat < 90%
Morphine 2-5mg IV Q5-15min PRN is the preferred method of pain control d/t vasodilatory properties

STEMI ¹^,⁴

PCI Management

PCI w/i 90min if PCI at facility or w/i 120min for transfer if...
- <12hr from SSx onset
- <12h and CI to fibrinolytics regardless of time limits above
- Cardiogenic shock or acute HF regardless of SSx onset
- Potentially if SSx for 12-24hr
P2Y12 Inhibitor
- Clopidogrel 600mg load then 75mg PO QD x1yr
- Prasugrel 60mg load then 10mg PO QD x1yr (CI w/ prior stroke)
- Ticagrelor 180mg load then 90mg PO BID x1yr (ASA NTE 100mg w/ ticagrelor)
Anticoag
- UFH w/ GP IIb/IIIa: 50-70 U/kg bolus targeting aPTT 200-250s
- UFH w/o GP IIB/IIIA: 70-100 U/kg bolus targeting aPTT 250-350s
- Bivalirudin 0.75 mg/kg bolus then 1.75 mg/kg/hr
  - Reduce to 1 mg/kg/hr if CrCl < 30
  - Preferred over UFH w/ GP IIb/IIIa if high bleed risk
GP IIb/IIIa Inhibitors
- Only for select patients
- Abciximab 0.25 mg/kg IVB then 0.125 mcg/kg/min NTE 10 mcg/min
- Tirofiban 25 mcg/kg IVB then 0.15 mcg/kg/min
  - CrCl < 30: Reduce rate by 50%
- Eptifibatide 180 mcg/kg IVB then 2 mcg/kg/min then 180 mcg/kg IVB 10min after 1st IVB
  - CrCl < 50: Reduce rate by 50%
  - Avoid in pts on HD

Medical Management

Thrombolytics preferably w/i 30min, should be w/i 1-2hr of presentation if PCI not indicated from above (see dosing below)
- SSx < 12h
- Potentially if SSx for 12-24hr
- Check All CIs to thrombolytics closely
Clopidogrel
- ≤ 75yo: 300mg load then 75mg QD x14d-1yr
- > 75yo: 75mg QD x14d-1yr (no load)
Anticoag
- UFH
  - Target aPTT 1.5-2x ULN (⇒ 50-70s) x48hr or until revascularization
  - 60 U/kg IVB NTE 4000 U then
  - 12 U/kg/hr NTE 1000 U/hr initially titrated to above goal
- Enoxaparin
  - < 75yo: 30mg IV then 15min later 1 mg/kg SubQ Q12H NTE 100mg for the 1st 2 doses
  - ≥ 75yo: 0.75 mg/kg SubQ Q12H NTE 75mg for the 1st 2 doses
  - CrCl < 30: 1 mg/kg Q24H instead
  - For duration of stay NTE 8d or until revascularization (unless other indication arises)
- Fondaparinux
  - 2.5mg IVB then 2.5mg SubQ QD starting the next day
  - CI if CrCl < 30
  - For duration of stay NTE 8d or until revascularization (unless other indication arises)

NSTE-ACS ²

Choosing Strategies

Early Invasive w/i 2hr

Refractory Angina
Hemodynamic / Electrical Instability
Sustained VT / VF
SSx of HF or mitral regurgitation
Stable pts w/ increased risk of clinical events
Early-invasive (< 24hr) is better than delayed-invasive if intermediate-high risk

Ischemia Guided

Extensive co-morbidities significantly increasing the risk of catheterization
Acute chest-pain that has a low likelihood of being ACS who are (-) troponin, esp. in women
TIMI 0-1 or Grace < 109
Pt / clinician preference in pts w/o high-risk features

Early Invasive w/i 24hr

None of above but GRACE > 140
Changes in Troponin
New ST depression

Delayed Invasive (25-72hr)

None of above but DM
CrCl < 60
LVEF < 40%
PCI w/i 6mo
Prior CABG
GRACE 109-140 or TIMI ≥ 2
Early postinfarction angina

Ischemia Guided Strategy

P2Y12 Inhibitor
- Clopidogrel 600mg load then 75mg PO QD x1yr
- Ticagrelor 180mg load then 90mg PO BID x1yr (ASA NTE 100mg w/ ticagrelor, preferred)
Anticoag
- UFH 60 U/kg load NTE 4000 U then 12 U/kg/h NTE 1000 U/hr titrated to therapeutic aPTT x48hr or until PCI
- Enoxaparin 30mg mg/kg IV loading dose then 1 mg/kg Q12H w/ typical renal adjustments for duration of stay or until PCI
- Fondaparinux 2.5mg SubQ QD for duration of stay or until PCI

Early-Invasive Strategy

P2Y12 Inhibitor
- Clopidogrel 600mg load then 75mg PO QD x1yr
- Ticagrelor 180mg load then 90mg PO BID x1yr (ASA NTE 100mg w/ ticagrelor, preferred)
Anticoag
- UFH 60 U/kg load NTE 4000 U then 12 U/kg/h NTE 1000 U/hr titrated to therapeutic aPTT x48hr or until PCI
- Bivalirudin 0.1 mg/kg bolus then 0.25 mg/kg/hr
- Enoxaparin 30mg mg/kg IV loading dose then 1 mg/kg Q12H w/ typical renal adjustments for duration of stay or until PCI
- Fondaparinux 2.5mg SubQ QD for duration of stay or until PCI
GP IIb/IIIa Inhibitors (high-risk only)
- Only for select patients
- Tirofiban 12 mcg/kg IVB then 0.14 mcg/kg/min
  - CrCl < 30: Reduce rate and bolus by 50%
- Eptifibatide 180 mcg/kg IVB then 2 mcg/kg/min
  - CrCl < 50: Reduce rate by 50%
  - Avoid in pts on HD

Thrombolytic Dosing ⁷

tPA
- 15mg IVB over 1-2min then
- 0.75mg/kg IV over 30min NTE 50mg then
- 0.5 mg/kg IV over 1hr NTE 35mg
- Total dose NTE 100mg
- Wt to achieve max dose: 67kg
Reteplase 10 Units IV over 2min then 10 Units IV over 2min 30min later
Tenecteplase IV bolus over 5 seconds
- <60 kg: 30 mg
- ≥ 60 to <70 kg: 35 mg
- ≥ 70 to <80 kg: 40 mg
- ≥ 80 to <90 kg: 45 mg
- ≥ 90 kg: 50 mg

Thrombolytic CIs ⁴

Absolute CIs

Any prior ICH
Known structural cerebral vascular lesion (e.g., arteriovenous malformation)
Known malignant intracranial neoplasm (primary or metastatic)
Ischemic stroke within 3 mo
EXCEPT acute ischemic stroke within 4.5 h
Suspected aortic dissection
Active bleeding or bleeding diathesis (excluding menses)
Significant closed-head or facial trauma within 3 mo
Intracranial or intraspinal surgery within 2 mo
Severe uncontrolled hypertension (unresponsive to emergency therapy)
For streptokinase, prior treatment within the previous 6 mo

Relative CIs

History of chronic, severe, poorly controlled hypertension
Significant hypertension on presentation (SBP > 􏰁180 mm Hg or DBP > 􏰁110 mm Hg)
History of prior ischemic stroke > 􏰁3 mo
Dementia
Known intracranial pathology not covered in absolute contraindications
Traumatic or prolonged ( > 􏰁10 min) CPR
Major surgery ( < 􏰂3 wk)
Recent (within 2 to 4 wk) internal bleeding
Noncompressible vascular punctures
Pregnancy
Active peptic ulcer
Oral anticoagulant therapy

Post-ACS Chronic Therapies

Beta-blockers in pts w/o CIs
ACEIs / ARBs, esp in pts w/ LVEF < 40%
High-Intensity Statins
NTG SL PRN

References

Tintinalli JE, Stapczynski JS, Ma OJ, Cline D, Meckler GD, Yealy DM, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. Eight edition. New York: McGraw-Hill Education; 2016. ↩ ↩² ↩³ ↩⁴
Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes. Journal of the American College of Cardiology. 2014;64(24):e139-e228. doi:10.1016/j.jacc.2014.09.017 ↩ ↩²
DiPiro JT, ed. Pharmacotherapy: A Pathophysiologic Approach. Tenth edition. New York: McGraw-Hill Education; 2017. ↩
O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction. Journal of the American College of Cardiology. 2013;61(4):e78-e140. doi:10.1016/j.jacc.2012.11.019 ↩ ↩² ↩³ ↩⁴
Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD. Third Universal Definition of Myocardial Infarction. :16. ↩
Driver BE, Khalil A, Henry T, Kazmi F, Adil A, Smith SW. A new 4-variable formula to differentiate normal variant ST segment elevation in V2-V4 (early repolarization) from subtle left anterior descending coronary occlusion - Adding QRS amplitude of V2 improves the model. Journal of Electrocardiology. 2017;50(5):561-569. doi:10.1016/j.jelectrocard.2017.04.005 ↩
Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Available at: http://online.lexi.com. ↩

ACS

Dx 1,2

STEMI Dx Criteria

Tx 1,4

STEMI 1,4

PCI Management

Medical Management

NSTE-ACS 2

Choosing Strategies

Ischemia Guided Strategy

Early-Invasive Strategy

Thrombolytic Dosing 7

Thrombolytic CIs 4

Post-ACS Chronic Therapies

References

Dx ¹^,²

Tx ¹^,⁴

STEMI ¹^,⁴

NSTE-ACS ²

Thrombolytic Dosing ⁷

Thrombolytic CIs ⁴