Diagnosis and Treatment of Chest Pain and Acute Coronary Syndrome (ACS). Emergency Intervention Algorithm.

[See ST Elevation MI algorithm (Annotation #42)]

[See Non-Cardiac Causes algorithm]

[See Special Work-Up algorithm]

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Source: Institute for Clinical Systems Improvement (ICSI). Diagnosis and treatment of chest pain and acute coronary syndrome (ACS). Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2006 Oct. 76 p. Diagnosis and Treatment of Chest Pain and Acute Coronary Syndrome (ACS) Emergency Intervention Algorithm Indications and Relative Contraindications for Thrombolysis: Indications 1. ST in greater than or equal to 2 contiguous leads; greater than or equal to 1mm in limb leads, or Chest pain symptoms suggesting serious illness. Call 911. *greater than or equal to 2 mm in precordial leads, or *new or presumably new LBBB; ST segment depression of greater than or equal to 2 mm in V1V2 (true posterior infarction), and Ambulance transport to emergency department. A 2. Anginal chest pain greater than 30 minutes but less than 12 hours unrelieved with NTG SL. Absolute Contraindications 1. Previous hemorrhagic stroke at any time; other strokes or cerebrovascular events within one year. 2. Known intracranial neoplasm. Immediate assessment with cardiac monitoring *Oxygen. *Chewable ASA 324 mg. *Call for ECG and physician. *Start IV. *Draw cardiac markers. *Portable chest x-ray. A 3. Active internal bleeding (does not include menses). 4. Suspected aortic dissection. Relative Contraindications 1. Severe uncontrolled hypertension on presentation (greater than 180/110 mmHg). Vital signs compromised? A Initiate ACLS protocols. A 2. History of prior cerebrovascular accident or known intracerebral pathology not covered in above absolute contraindications. 3. Current use of anticoagulants in therapeutic doses (INR greater than or equal to 2.0-3.0); known bleeding diathesis. 4. Recent trauma (including head trauma) within 2-4 weeks. Symptoms suggest possibility of ACS? A ECG positive for ST-segment elevation? A Early Therapy: *Heparin/LMWH. *NTG. *Beta blocker. *Clopidogrel. *2b3a inhibitors. *Cardiology consult. A See ST Elevation MI algorithm (Annotation #42) Non-cardiovascular chest pain. A 5. Major surgery in past 3-6 months. 6. Noncompressible vascular punctures. 7. Recent internal bleeding. 8. For streptokinase/anistreplase: prior exposure (especially within 5 days - 2 years) or prior allergic reaction. 9. Pregnancy. 10. Active peptic ulcer. 11. History of chronic hypertension. Chest pain not related to CAD, but indicative of other serious diagnosis? A See Non-Cardiac Causes algorithm Risk Assessment (ACC/AHA criteria). A See Special Work-Up algorithm High risk. A Intermediate risk. A Low risk. A Early Therapy: *Heparin/LMWH. *NTG. *Beta blocker. *Clopidogrel. *2b3a inhibitors. *Cardiology consult. A Early Therapy: *Heparin/LMWH. *NTG. *Beta blocker. *Clopidogrel. *2b3a inhibitors. *Cardiology consult. A Discharge to outpatient management. A Admit Admit to CPU or monitored bed *Measure cardiac markers for 6 hours. A Perform cath within 24-48 hours. A Patient has positive: *markers? *ECG changes? *Treadmill stress test? *Unstable dysrhythmias? A A = Annotation All copyrights are reserved by the Institute for Clinical Systems Improvement, Inc.