Acute Coronary Syndrome (ACS)

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

  • Substernal chest pain
  • Pain exacerbated by exertion
  • Pain relieved with rest or nitroglycerin (or both)


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

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