Acute Coronary Syndrome Algorithm

1. Symptoms suggestive of ischemia or infarction. Perform an assessment of chest discomfort suggestive of ischemia or infarction
2. EMS assessment and care and hospital preparation. During the stabilization, triage, and transport of the patient to an appropriate facility, monitor and support airway, breathing, and circulation, providing CPR and defibrillation if needed. Administer aspirin, and provide oxygen if saturation levels are below 90%. Consider the use of nitrates and analgesics if indicated in the management of the patient’s condition.Obtain a 12-lead ECG and notify the hospital if ST elevation is identified. Notified hospital should mobilize hospital resources to respond to STEMI. Complete a fibrinolytic checklist if it’s indicated. Consider obtaining a 15-lead ECG if assessment of the patient and other diagnostic tools indicate the need for evaluation.
3. Concurrent ED assessment (<10 minutes) and immediate general treatment. Assessment and stabilization of the patient should occur within the first 10 minutes of arrival at the emergency department. Obtain and interpret a 12-lead ECG if that has not already been done. Assess the patient’s vitals and oxygen needs and establish an IV. Obtain a brief history, and perform a physical exam. Check for contraindications for fibrinolytic therapy if indicated, and obtain initial cardiac marker labs, coagulation studies, and electrolyte panel.If oxygen saturation is below 90%, start oxygen at 4 liters per minute. Administer 160 to 325 milligrams of aspirin to the patient if it has not already been given. Administer nitrates for chest pain if indicated. If the pain persists, consider the use of analgesics to manage the patient’s pain.Obtain and review a portable chest x-ray within 30 minutes of the patient’s arrival at the emergency department.
4. ECG interpretation. Classify the patient into one of three clinical groups: ST-elevation myocardial infarction, or STEMI; non-ST-elevation acute coronary syndrome; or low to intermediate risk acute coronary syndrome.
5. ST-elevation MI (STEMI). If ST elevation or new or presumably new lower bundle branch block is detected, begin treatment for STEMI. For EMS providers, activate a STEMI alert with the receiving hospital as soon as possible.
   • Start adjunctive therapies. Once STEMI has been determined, start adjunctive treatments if indicated, but do not delay reperfusion.
   • Time from onset of symptoms < 12 hours. If the time from onset of symptoms is 12 hours or less, proceed with reperfusion therapy. If the time from onset is greater than 12 hours, treat as a troponin elevated or high-risk patient.
   • Reperfusion goals. The door to balloon inflation goal for PCI is 90 minutes. The door to needle goal for fibrinolysis is 30 minutes.
6. High-risk non-ST-elevated ACS (NSTE-ACS). If ST depression or dynamic T-wave inversion is found, ischemia is highly suspected. Begin treatment for high-risk non-ST-elevated acute coronary syndrome.
   • Troponin elevated or high-risk patient. A troponin elevated or high-risk patient should be considered for early invasive strategy if they are experiencing refractory ischemic discomfort, recurrent ST deviation, unstable blood pressure, ventricular tachycardia, or signs of heart failure. Administer nitroglycerin and heparin as indicated.
7. Low- or intermedicate-risk ACS. If changes in the ST segment or T-wave are normal or nondiagnostic, begin treatment for low- or intermediate-risk acute coronary syndrome.
   • Consider admission to ED chest pain unit. For a patient with low- or intermediate-risk acute coronary syndrome, consider admission to an appropriate bed for further monitoring and possible intervention.

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