Acute Coronary Syndrome (1) C.L.I.P.S. Definition: -Acute myocardial ischemia and/or infarct due to an abrupt reduction in coronary blood flow -Occurs when there is an imbalance of myocardial oxygen consumption and demand Epidemiology: -In the US, the mean age of ACS presentation is 68 with male to female ratio of 3:2 -Greater than 78,000 persons experience ACS in one year Presentation: -Pressure-type chest pain that typically occurs at rest or with minimal exertion lasting greater than or equal to 10 minutes -Frequently starts retrosternal and can radiate to either or both arms, neck, or jaw -Can also present with diaphoresis, dyspnea, nausea, abdominal pain, or syncope -Factors that increase risk are older age, male sex, positive family history of CAD, and presence of PAD, DM, renal insufficiency, prior MI, and prior coronary revascularization -Physical exam can be normal, can have S4, paradoxical splitting of S2, or new murmur of MR DDX: -Non-ischemic cardiovascular causes: aortic dissection, expanding AAA, pericarditis, PE -Non-cardiovascular causes: -Pulmonary: pneumonia, pleuritis, pneumothorax -GI: GERD, esophageal spasm, PUD, pancreatitis, biliary disease -MSK: costochondritis, cervical radiculopathy -Psychiatric disorders: anxiety -Other etiologies: sickle cell crisis, herpes zoster Types of ACS: -STEMI: chest pain with new ST-elevation (greater than or equal to 0.5mm) -NSTEMI: chest pain with no new ST-elevation but positive biomarkers (troponin) -Unstable Angina: chest pain with no new ST elevation and negative biomarkers STEMI: If candidate for reperfusion then needs FMC (first medical contact) within 90 mins. If FMC not PCI capable transfer to facility <120 mins. Updated 6/18 PVo

Acute Coronary Syndrome (2) C.L.I.P.S. Prognosis: Early Risk Stratification -12-lead EKG performed within 10 minutes of arrival at facility -If initial EKG not diagnostic but patient continues to remain symptomatic with high clinical suspicion then serial EKGs (15-30 minutes interval) -Serial cardiac troponin should be obtained and then 3-6hrs after onset of symptoms -Supplemental oxygen with O2 sat <90%, respiratory distress, or other high risk features of hypoxemia -Patient with continued ischemic pain should receive SL Nitroglycerin 0.4mg q5mins up to 3 doses -Reasonable to administer morphine sulfate for continued ischemic chest pain Suspect NSTE-ACS: Initiate DAPT and Anticoagulation Therapy 1. ASA (non-enteric coated, chewable aspirin, 162mg to 325mg) 2. P2Y12 inhibitor (Clopidogrel 300mg or 600mg loading dose or Ticagrelor 180mg loading dose) 3. Anticoagulation (UFH, Enoxaparin, or Fondaparinux) 4. Bivalrudin if undergoing early invasive therapy Discharge/Postcare: Class I Recommendations: -Oral beta-blocker should be initiate within the first 24hrs in patient w/o signs of HF, evidence of low-output state, increased risk for cardiogenic shock, or other contraindications to beta blockage -Can give nondihydropyridine CCB (verapamil or diltiazem) in patients with continuing ischemia and contraindications to beta blockers in absence of LV dysfunction, increased risk for cardiogenic shock, PR interval >0.24 secs, or 2nd/3rd degree AV block -High intensity statin should be initiated or continued in all patients with NSTE-ACS -ACE inhibitors should be started and continued indefinitely in all patients with LVEF <40 and in those with HTN, DM, or stable CKD -Maintenance dose of 81mg should be continued indefinitely -A P2Y12 inhibitor (clopidogrel 75mg daily or ticagrelor hen 90mg BID daily ) should be administered for up to 12 months If unable to transfer to PCI capable facility within 120 mins then administer fibrolytic within first 30 minutes; then transfer.