Management of Acute Coronary Syndrome

Immediate Actions

The American College of Cardiology and European Heart Society recommend immediate admission to a coronary care unit or chest pain unit with continuous cardiac monitoring, 12-lead ECG, aspirin administration, and urgent risk stratification to determine if this represents acute coronary syndrome versus alternative causes of myocardial injury 1, 2
Obtain a 12-lead ECG immediately to assess for ST-segment elevation, ST-segment depression ≥1mm, or other ischemic changes that would indicate STEMI versus NSTE-ACS 1, 2
Administer aspirin (loading dose) immediately if acute coronary syndrome is suspected and no contraindications exist 3, 4
Establish continuous cardiac monitoring with defibrillator patches available if ongoing ischemia is present 2
Assess vital signs including blood pressure, heart rate, oxygen saturation, and respiratory status 2, 3

The European Heart Society recommends evaluating for pulmonary embolism, pericarditis, aortic dissection, and pneumothorax in patients with pleuritic chest pain 2, 3, 4
Pulmonary embolism should be considered and evaluated with D-dimer and CT pulmonary angiography if clinical suspicion exists 3, 4
Pericarditis should be evaluated with diffuse ST elevation, PR depression on ECG, and consider echocardiography 2
Aortic dissection should be assessed for blood pressure differential between arms, widened mediastinum on chest X-ray, and consider CT angiography if suspected 2, 3

If ST-segment elevation is present, administer sublingual or IV nitroglycerin immediately and arrange immediate coronary angiography for primary PCI 1, 2
If ST-segment depression or T-wave changes (NSTE-ACS) are present, admit to coronary care unit, initiate dual antiplatelet therapy, and start anticoagulation 2, 3, 5
Door-to-balloon time should be <90 minutes 3

Aspirin 162-325mg loading dose, then 75-100mg daily should be administered for confirmed ACS 5
Clopidogrel 300mg loading dose, then 75mg daily should be administered for confirmed ACS 5
Anticoagulation with enoxaparin or unfractionated heparin should be started for confirmed ACS 3, 5
Beta-blockers should be administered for heart rate and blood pressure control unless contraindicated 5
Statin therapy high-intensity should be started for confirmed ACS 2
ACE inhibitor should be administered if left ventricular dysfunction, diabetes, or hypertension is present 3

High-risk patients require immediate CCU admission 3, 4
Intermediate-risk patients can be managed in chest pain observation unit with 9-12 hour monitoring and serial troponins 4, 7
Continuous cardiac rhythm monitoring is mandatory until diagnosis is clarified 2