Acute Coronary Syndrome (Assessment and Plan): Difference between revisions
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Author: [[User:William J Gibson|William J Gibson MD, PhD]] | Author: [[User:William J Gibson|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 | 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 2 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: | Dx: | ||
- Serial EKG (Q30 mins initially), if STEMI | - Serial EKG (Q30 mins initially), if STEMI | ||
- Serial troponins (admission, 2H and 6H) if concern ACS rapidly evolving, 3x Q6H for rule-out | - Serial troponins (admission, 2H and 6H) if concern ACS rapidly evolving, 3x Q6H for rule-out | ||
- If 5th generation hsTn: Serial troponins | |||
- TIMI Risk Score (NSTEMI): | |||
https://www.mdcalc.com/timi-risk-score-ua-nstemi | |||
- If high risk: PCI | |||
- If moderate risk | |||
Tx: | Tx: | ||
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Initial therapy: | Initial therapy: | ||
- Anticoagulation/Anti-platelet: ASA (325), Heparin drip (goal PTTT 60-80), | - Anticoagulation/Anti-platelet: ASA (325), Heparin drip (goal PTTT 60-80), defer clopidogrel given unclear if patient will need CABG | ||
- Pain: sublingual nitro PRN, defer morphine given interference with P2Y12 inhibitors and retrospective analyses suggesting increased adverse events. | |||
- | - Long term: ASA 81mg QD, P2Y12 ( | ||
Post-stenting: | Post-stenting: | ||
- if stented will give clopidogrel 75mg PO QD (30 days of BMS, 1 year for DES)<blockquote></blockquote> | - if stented will give clopidogrel 75mg PO QD (30 days of BMS, 1 year for DES) | ||
References: | |||
<blockquote></blockquote> | |||
Revision as of 23:01, 29 June 2018
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 2 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
- If 5th generation hsTn: Serial troponins
- TIMI Risk Score (NSTEMI):
https://www.mdcalc.com/timi-risk-score-ua-nstemi
- If high risk: PCI
- If moderate risk
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), defer clopidogrel given unclear if patient will need CABG
- Pain: sublingual nitro PRN, defer morphine given interference with P2Y12 inhibitors and retrospective analyses suggesting increased adverse events.
- Long term: ASA 81mg QD, P2Y12 (
Post-stenting:
- if stented will give clopidogrel 75mg PO QD (30 days of BMS, 1 year for DES)
References: