Start adjunctive treatments as indicated Nitroglycerin Heparin (UFH or LMWH) Consider: PO β-blockers

Clopidogrel Glycoprotein llb/llla inhibitor

Reperfusion goals: Door-to-balloon inflation (PCI)*** goal of 90 minutes Door-to-needle (fibrinolysis) goal of 30 minutes

Admit to monitored bed Assess risk status Continue ASA heparin, and other therapies as indicated

ACE inhibitor/ARB; HMG CoA reductase inhibitor (statin therapy) Not at high risk: cardiology to risk stratity

Abnormal diagnostic noninvasive imaging or physiologic testing?

If no evidence of ischemia or infarction by testing, can discharge with follow-up

Consider: Consider:

EMS assessment and care and hospital preparation*

* O’Connor RE, Brady W, Brooks SC, Diercks D, Egan J, Ghaemmaghami C, Menon V, O’Neil BJ, Travers AH, Yannopoulos D. “Part 10: acute coronary syndromes: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care”. Circulation. 2010;122(suppl 3):S787-S817. http://circ.ahajoumals.org/content/122/18_suppl_3/S787 **Afolabi BA, Novaro GM, Pinski SL, Fromkin KR, Bush HS. Use of the prehospital ECG improves door to balloon times in ST segment elevation myocardial infarction irrespective of time of day or day of week. Emerg Med J. 2007;24:588-591 *** O’Connor, RE AL, Ali, Brady , WJ, Ghaemmaghami CA, Menon V, Welsford M, Shuster M. Part 9: acute coronary syndromes: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015;132(suppl2):S483-S500

Syndromes Suggestive of Ischemia or Infarction

Check Vital Signs IV Access

Physical Exam

Activate Cardiac Cath Lab

Chest X-ray (<30 mins) 12–Lead ECG

If O2 sat<94% Start Oxygen

Aspirin 160–325 mg (If not already taken)

Activate Cardiac Cath Lab

Dynamic ECG changes consistent with ischemia

Clinical high-risk features

Troponin elevated

Develops 1 or more:

Concurrent ED assessment (<10 minutes)

Immediate ED general treatment

Acute Coronary Syndromes Algorithm

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