Acute Coronary Syndrome (Assessment and Plan)

Author: William J Gibson MD, PhD

Patient presents with XX hour history of [substernal] chest pain that radiates to [jaw/arm], associated with [diaphoresis, shortness of breath]. EKG on admission showing XX. Troponin on admission XX and subsequently trended to XX XX hours later. [Most likely type 1 MI given abrupt onset, ST-segment elevation OR History suggests type 1 MI given high concern for supply demand mismatch. Differential includes coronary dynamic/non-occlusive obstruction (including vasospasm, microvascular ischemia, Takutsubo cardiomyopathy), non-plaque associated thromboembolism (Afib, cardioversion, PFO), coronary dissection, vascular steal, vasculitis.

Dx:

- Serial EKG (Q30 mins initially), if STEMI

- Serial troponins (admission, 2H and 6H) if concern ACS rapidly evolving, 3x Q6H for rule-out

Tx:

- Treat any secondary causes of myocardial ischemia (eg AF w RVR, anemia, hypoxemia (only if O2sat <92%), infection)

Initial therapy:

- Anticoagulation/Anti-platelet: ASA (325), Heparin drip (goal PTTT 60-80),

- Pain: sublingual nitro PRN,

Post-stenting:

- if stented will give clopidogrel 75mg PO QD (30 days of BMS, 1 year for DES)