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  • Clinical: new angina, increasing angina, or angina at rest. Diaphoresis, hypotension, new MR murmur, pulmonary edema or rales, JVD
  • EKG (Figures 200-1 and 200-2): ST segment elevation (≥0.2 mV in men or ≥0.15 mV in women in leads V2–V3 and/or ≥0.1 mV in other leads) or depression (>0.05 mV in two contiguous leads), T-wave inversion, new blocks especially LBBB
  • Echo: wall motion abnormality, new MR (papillary muscle dysfunction)
  • Lab: cardiac enzymes (troponin) serially STAT (for baseline) and q6 hours × 3
  • DDx:
    • Elicit cocaine use
    • PE, aortic dissection: CT angiography to rule out


NB: See Chapter 5 for more details on EKG changes.

Figure 200-1. Electrocardiographic Signs of Ischemia
Graphic Jump Location

Patterns of ischemia and injury. Reproduced from Morgan GE, Mikhail MS, Murray MJ. Clinical Anesthesiology. 4th ed. Figure 20-3. Available at: Copyright © The McGraw-Hill Companies, Inc. All rights reserved.

Figure 200-2. Location of MI (Coronary Supply, Myocardium) and Corresponding EKG Leads
Graphic Jump Location

Blood supply to the myocardium (A) and areas of infarction resulting from the most frequent sites of coronary artery occlusion (relative frequency expressed as a percentage). (B–D) The exact area of myocardium affected will vary depending on normal anatomic variation in blood supply and the extent of collateral circulation that exists at the time of coronary occlusion. Reproduced from Chandrasoma P, Taylor CR. Concise Pathology. 3rd ed. Figure 23-1. Available at: Copyright © The McGraw-Hill Companies, Inc. All rights reserved.


  • Oxygen 2–4 L/min by NC; attach monitors and get IV access
  • NTG 0.4 mg sublingual × 3; if no relief, then morphine 2–4 mg IV; repeat q5–15 minutes
  • Beta-blockers such as metoprolol 25 mg PO if no CHF, hypotension, or bradycardia. If hypertensive, give IV metoprolol 5 mg q5 minutes up to three times
  • Aspirin 160–325 mg non-enteric coated, ideally chewable
  • Atorvastatin 80 mg PO stat if not on statin


  • PCI within 90 minutes of presentation. Call cardiology stat
  • Fibrinolysis within 30 minutes of presentation if known PCI not possible within 90 minutes, symptoms <12 hours, and no contraindications (ICH, ischemic stroke <3 months, cerebral AVMs or malignancy, aortic dissection, bleeding diathesis or active bleeding, except menses; head trauma <3 months)
  • Antiplatelet therapy (in addition to aspirin):
    • Prasugrel 60 mg: with PCI and no risk of bleeding
    • Or clopidogrel 600 mg. Discuss with cardiologist
  • Glycoprotein IIb/IIIa inhibitor in consultation with cardiologist
  • Give anticoagulant therapy to all patients:
    • Unfractionated heparin (UFH):
      • PCI with GP IIb/IIIa inhibitor: 50–60 U/kg IV bolus then infusion for aPTT 50–75 s
      • Without GP IIb/IIIa inhibitor: 60–100 U/kg IV bolus (maximum 4,000 U)
  • Enoxaparin: for non-PCI patients with normal kidney function load with 30 mg IV bolus and 1 mg/kg SC q12 hours. UFH preferred in ESRD patients


  • Give antiplatelet therapy (in addition to aspirin): prasugrel 60 mg—with PCI and no risk of bleeding or clopidogrel 600 mg. Discuss with cardiologist
  • ...

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