Acute Coronary Syndrome (ACS)

Angina (Typical = 3/3 symptoms, Atypical = 2/3)

Management

Non-ST-Elevation ACS (includes Unstable Angina and NSTEMI)

Calculate a TIMI (Thrombolysis in Myocardial Infarction) Score
- Helps to guide early-invasive (coronary angiogram within 24-48 hours) vs. ischemia-driven (medical management with angiogram if patients have recurring symptoms and/or positive stress test)
Pharmacologic Management
- Aspirin 81mg x4 load followed by 81mg daily
- Second antiplatelet agent (at Cardiology’s discretion)
  - Clopidogrel 300-600mg load followed by 75mg daily
  - Ticagrelor 180mg load followed by 90mg BID
    - Note that self-limiting shortness of breath may be an observed side effect
  - Prasugrel 60mg load followed by 10mg daily
- Heparin continuous infusion
- Nitroglycerin administration
  - Sublingual vs PO isosorbide mononitrate (once daily dosing) vs PO isosorbide dinitrate (q8hours dosing) vs IV continuous nitroglycerin
    - Contraindicated in right-sided MI (as these patients are preload-dependent and nitroglycerin will decrease preload) or in a patient using sildenafil or tadalafil
- Beta-Blocker
  - Metoprolol, carvedilol, or bisoprolol (decrease mortality), typically initiated within 24 hours
    - Contraindications: Bradycardia, heart failure signs/symptoms, severe asthma
- ACE-Inhibitor/Angiotensin-Receptor Blocker
  - Typically lisinopril or losartan initiated within 24 hours if blood pressure allows to prevent cardiac remodeling
- Statin
  - Typically Atorvastatin 40-80mg daily

ST-Elevation Myocardial Infarction

ST-elevation Equivalents
- Hyperacute T-waves, De Winter Syndrome, Wellen’s Sign A and B, “Shark fin”
Pharmacologically managed the same as Unstable Angina or an NSTEMI
Coronary Angiogram: Standard of care: door-to-balloon time less than 90 minutes
- Bare Metal Stent: Must be on dual-antiplatelet therapy (DAPT) for 1 month to prevent in-stent thrombosis. Higher risk of in-stent stenosis than drug-eluting stents.
- Drug-Eluting Stent (usually everolimus-eluting): Prevents in-stent stenosis but must be on DAPT for at least 6-12 months to prevent in-stent thrombosis
Thrombolysis
- Fibrinolytics indicated if there is no access to a catheterization lab
  - Requirements:
    1. Symptomatic
    2. Symptomatic for <12 hours
    3. Persistent ST-elevations > 1 mm in 2 concurrent leads
  - Contraindications: Many, but mostly summarized to any increased risk of bleeding (low platelets, brain metastases, history of aortic aneurysms, history of large GI bleeds, recent surgeries, etc.)
  - After fibrinolysis, transfer to center with cardiac catheterization capabilities

Coronary Artery Bypass Graft (CABG) indications

3-vessel disease
2-vessel disease including proximal left anterior descending artery (or if diabetic)
Left main artery disease