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large-format algorithm posters,
American Heart Association
The Acute Coronary Syndromes Algorithm outlines the steps for assessment and management of a patient with ACS. The algorithm begins with the assessment of chest pain and whether it is indicative of ischemia. The assessment and management begin with the EMS responder outside of the hospital who can give oxygen, aspirin, nitroglycerin, and morphine (if needed for pain). An initial 12-lead ECG can also be obtained. Treatment and assessment continues when the patient arrives at the hospital, following the time sequences suggested in the algorithm. Serial cardiac markers (CK-MB, cardiac troponins) provide additional information and allow refined stratification and treatment recommendations.
An affirmative answer starts the algorithm.
If ST elevation is present, transmit the results to the receiving hospital.
Hospital personnel gather resources to respond to STEMI.
The 12-lead ECG is at the heart of the decision pathway in the management of ischemic chest pain and is the only means of identifying STEMI.
Note:The ECG classification of ischemic syndromes is not meant to be exclusive.
|STEMI (ST-segment elevation myocardial infarction)||High-risk unstable angina (UA) or NSTEMI (non-ST-segment elevation myocardial infarction)||Intermediate or low risk UA|
ST segment elevation greater than 1 mm (0.1 mV) in 2 or more contiguous precordial leads or 2 or more adjacent limb leads
New or presumed new left bundle branch block
Ischemic ST-segment depression of 0.5 mm (0.5 mV) or greater
Dynamic T wave inversion with pain or discomfort
Transient ST elevation of 0.5 mm or greater for less than 20 minutes
Normal or non-diagnostic changes in ST segment or T wave that are inconclusive and require further risk stratification
Includes people with normal ECGs and those who have ST-segment deviation in either direction that is less than 0.5 mm or T wave inversion of 2 mm or 0.2 mV or less
|Classification: INJURY||Classification: ISCHEMIA||Classification: NORMAL?|
Management is based on the results of the ECG.
Confirm how much time has passed since the onset of symptoms.
Results of cardiac markers, chest x-ray, and laboratory studies should not delay reperfusion therapy unless there is a clinical reason.
Start adjunctive treatments for STEMI, as indicated:
Start adjunctive treatments for NSTEMI, as indicated:
Continue ASA, heparin, and other therapies as indicated (ACE inhibitors, statins) for the high-risk patient characterized by:
Consider admitting the patient to hospital or to a monitored bed in ED