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