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Chest discomfort suggestive of ischemia

EMS assessment and care and hospital preparation:

• Monitor, support ABCs. Be Prepared to provide CPR and defibrillation
• Administer oxygen, aspirin, nitroglycerin, and morphine if needed
• If availabe, obtain 12-lead ECG; if ST-elevation:
• Notify receiving hospital with transmission or interpretation
• Begin fibrinolytic chechlist
• Notified hospital should mobilize hospital resources to respond to STEMI

Immediate ED assessment (<10 min) Immediate ED general treatment

- Check vital signs; evaluate oxygen saturation - Morphine IV if pain relieved by nitroglycerin
- Establish IV access - Oxygen at 4 L/min; maintain 0, sat > 90%
- Obtain/review 12-lead ECG - Nitrogycerin sublingual, spray, or IV
- Perform brief, targeted history, physical exam - Aspirin 160 to 325 mg (if not given by EMS)
- Review/complete fibrinolytic checklist; check
- Containdication (table 1)
- Obatain initial cardaic marker levels; initial electrolyte
and coagulation studies
- Obtain portable chest x-ray (< 30 min)

Review initial 12-lead ECG

ST elevation or new or ST-depression or dynamic T-wave inversion; Normal or nondiagnostik

presumably new LBBB; strongly strongly suspicious for ischemia changes in ST segement or T
suspicious for injury High-Risk Unstable Angina/ wave
Non-ST-Elevation MI (UA/NSTEMI Intermediate/Low-Risk UA
ST-Elevation MI (STEMI)*
Start adjunctive treatment as Start adjunctive treatments as Develop high or
indicated (see text for Yes
indicated (see text for intermediate risk
contraindications) contraindications) criteria (tables 3,4)
Do not delay reperfusion or
- Clopidogrel •B-adrenergic receptor blockers
- -adrenergic reseptor blockers •Heparin (UFH or LMWH) No
- Heparin (UFH or LMWH) •Glycoprotein IIb/IIIa inhibitor
Consider admission to ED
>12 chest pain unit orto
hours monitored bed in ED
Time from onset of Admit to monitored bed
Assess risk status Follow:
symptoms < 12 hours? • Serial cardiac marker
<12 hours (including troponin)
• Repeat ECG/continous ST
Reperfusion strategy: High-risk patient : segment
Therapy defined by patients and •Refractory ischemic chest pain monitoring
center criteria (table 2) •Recurrent/persistent ST deviation • Consider stress test
- Be aware of reperfusion goals: •Ventricular tachycardia
•Hemodynamic instability
•Door-to-ballon inflation
•Signs of pump failure Yes
(PCI) goal of 90 min •Early invasive strategy, including Develop high or intermediate
•Door-to-needle catheterization and revascularization risk criteria or
(fibrinolysis) goal of 30 min for shock within 48 hours of an AMI troponin-positive
- Continue adjunctive therapies Continue ASA, heparin, and other
and: therapies as indicated No
•ACE inhibitor/ARB
•ACE inhibitors/angiotensi
•HMG CoA reductase inhibitor (statin If no evidence of ischemia or
receptor blockers (ARB) therapy)
within 24 hours of symptom infarction can discharge with
Not at high risk: cardiology to risk-
anset stratify follow-up
•HMG CoA reductase