Feb 03. Ver.

2
Management of Acute Coronary Syndromes
St. Joseph Mercy Health System, Ann Arbor, Michigan

Chest Pain or Equivalent

ST- elevation MI
(STEMI) or LBBB
ER evaluation including vital signs, A
12 lead ECG, focused H&P

Probable noncardiac Possible ACS

Chronic Stable Angina
Definite/Possible ACS
with low risk
-Recent CP at rest Definite ACS:
-not entirely typical -typical angina that is
-pain free new, severe or
-normal or unchanged accelerating pattern of
ECG previous stable angina
-normal cardiac marker (especially if at rest or
within 2 weeks of MI)

CPC or OP follow up
CPC
Unstable Angina
Negative or equivocal
cardiac markers

Low Risk High Risk

- no nonspecific or new ECG changes - new ST/Twave changes
- no high risk features - high risk features
NonSTEMI:
- EF < 40% -Pos Cardiac markers
- VT (TnI/CK-MB)
- Hemodynamic instability - new ST/TW changes
CPC - Recurrent angina at rest
- Angina with CHF/S-3
- PCI within 6 months or
> 2 Intermediate risk features for
prior CABG
ACS:
- CHD or CHD equivalent risk profile
(DM, PVD, carotid disease or > 3
cardiac risk factors) Admit CCU/ Telemetry
- > 2 anginal events within 24 hours
- new nonspecific ECG changes
- Equivocal cardiac markers Treatment :ASA, beta blockers,
No Yes nitrates, LMWH
Consider eptifibatide
ETT Treatment: ASA,
LMWH, beta blockers
Negative Positive Cardiac Cath
(clopidogrel 300mg PO, if
Discharge Cardiology Consult PCI planned)
Feb 03. Ver. 2
STEMI or LBBB
A EM physician
discusses risks &
benefits of cath/ poss
PCI
Call cardiology (M-F 8a-
5p page rounder 1. At
other times call
cardiologist on call.
Include 911 suffix in the
page to encourage prompt
response)
EM physician and
cardiologist consultation
Cardiologist calls cath lab staff 1-
734-417-8259 cell phone or 1-734-
670-7974 back up pager (be sure to
include area code) then
interventionalist on call (CCU has
backup numbers)
Treat pt with 325 mg ASA
(chewed) and IV UFH at 60 U
hg bolus and 12 U/kg/hr
Lopressor 5mg IV X 3 per
protocol if HR > 60 & SBP >
100 & if no evidence of CHF
To cath lab for emergent
revascularization
Cardiac Markers:
CK: Normal = 20-232 IU/I
CK/MB: Normal = 0-9 ng/ml
TnI normal = 0-0.3 ng/ml
TnI abnormal at 0.3-0.8 ng/ml (can be seen in
non-cardiac illness)
TnI > 0.8 ng/ml indicative of myonecrosis
Equivocal Cardiac Injury Profile
-Myoglobin > 100 ng/ml
-Myoglobin > 2x over baseline
- CK Index > 2.8% and CKMB < 9 ng/ml
- CK > 200 and CK index < 2.8%
- TnI > 0.3 and < 0.9 ng/dl
Acute MI
Positive cardiac markers, plus at least one of the
following:
1. ischemic symptoms
2. development of pathologic Q waves
3. ECG changes of ischemia (ST segment elevation or
depression)
4. coronary artery intervention within 24-48 hours
AMI after PCI
1. CK-MB must be > 3 times the upper limit of normal
2. No ECG changes or symptoms are required
AMI after CABG
1. CK-MB > 5 times upper limit of normal and new Q
waves or CK-MB > 10 times upper limit of normal
(with or without Q waves)
2. No symptoms required