Section II: ACS

HPI: Symptoms of chest pain, dyspnea, diaphoresis.

PMH: Coronary artery disease (CAD), prior myocardial infraction (MI), hypertension (HTN), hyperlipidemia, diabetes.

FH: Premature CAD or MI.

SH: Smoking, alcohol.

Labs: Elevated troponin or CKMB.

UA/NSTEMI = Unstable Angina/Non-ST Elevation MI.

PCI = Refer for Percutaneous Coronary Intervention.

MED-TX = MEDical management = oxygen, aspirin, clopidogrel, nitroglycerine, morphine, metoprolol, unfractionated heparin or enoxaparin (see chapter on initial management of US/NSTEMI).

GP2B3A = GlycoProtein IIb/IIIa (2B3A) inhibitors = use either of these:

Eptifibatide: 180 mcg/kg bolus (maximum 20 mg) IV over 2 minutes, then 2 mcg/kg/min infusion) (maximum 15 mg/hr) for up to 72 hours. Reduce maintenance dose to 1 mcg/kg/min if creatinine clearance <50 mL/min; contraindicated if creatinine clearance <20 mL/min.

Tirofiban: loading infusion: 0.4 mcg/kg/min over 30 minutes, then 0.1 mcg/kg/min infusion for up to 72 hours. Reduce loading and maintenance infusion by 50% in patients with creatinine clearance < 30 mL/min.

HIGHR = HIGH Risk: patients with non-ST-elevated chest pain with one or more of the following characteristics are at a high risk for an adverse cardiovascular event: hemodynamic instability or cardiogenic shock; severe LVD or HF; persistent angina despite medical therapy; new or worsening mitral regurgitation or VSD; or sustained ventricular arrhythmias.

TIMI = TIMI risk score calculated by assigning 1 point for each of the following factors (pneumonic ARCS-ARCS):

• Age ≥65 years

• Risk factors ≥3 (HTN, DM, H/lipid, active smoker, FamHx premature CAD = myocardial infarction, coronary revascularization, or sudden death <55 years old [father/1st degree male rel] or <65 years old [female/1st deg rel])

• CAD (known stenosis > = 50%)

• Salicylate, ie, use of aspirin in prior 7 days

• Angina Recent and severe (> = 2 anginal episodes in past 24 hours).

• Cardiac enzymes elevated (cTnI or CKMB)

• ST deviation (new or transient) on ECG > = 0.5 mm

TIMI LOW = TIMI LOW risk: score between 0 and 2.

TIMI HIGH = TIMI HIGH risk: score between 3 and 7.

SRT = Refer patient for stress imaging study to evaluate for inducible ischemia.

SRT-POS = StRess Testing POSitive: imaging study showing significant reversible ischemia, left ventricular dysfunction, ejection fraction < 0.35, or other high risk findings.

UA/NSTEMI + HIGHR = MED + GP2B3A + PCI

UA/NSTEMI + TIMI LOW = MED + SRT

UA/NSTEMI + TIMI LOW + SRT-POS = MED + PCI

UA/NSTEMI + TIMI HIGH = MED + GP2B3A + PCI

• – Patients at initial presentation may not have elevated cardiac serum biomarkers and could have a falsely low TIMI risk score.

• – TIMI risk score can be correlated an increased risk of death, new or recurrent MI, or recurrent at ischemia requiring revascularization at 14 days:

  Score  Risk %

  0–1   4.7

  6–7   40.9

1. Antman EM, et al. The TIMI Risk Score for Unstable Angina/Non–ST Elevation MI: A Method for Prognostication and Therapeutic Decision Making. JAMA. 2000;284(7):835–842.

2. Wright RS, et al. 2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients with Unstable Angina/Non–ST-Elevation Myocardial Infarction. Circulation. 2011;123;2022–2060.

HPI: Chest pain (tightness, squeezing) radiating to left arm with instant onset, dyspnea.

PMH: Coronary artery disease, hypertension, diabetes, hyperlipidemia.

FH: Coronary artery disease.

SH: Smoking, alcohol, drug use.

Stress Echo: Left ventricular ejection fraction and baseline function.

Radionuclide myocardial perfusion scan: Detect areas of myocardial perfusion defects and ischemia.

UA/NSTEMI = Patient with definite or working diagnosis of unstable angina or non-ST-elevation myocardial infarction.

MON = MONitor: Perform 12-lead ECG. If does not show changes and patient still symptomatic, repeat after 10 minutes. Place patient on telemetry monitoring. Monitor oxygen saturation and use oxygen generously to keep SaO₂ > 94%. Send for immediate cardiac biomarkers (cardiac troponin I and creatinine kinase MB) and repeat q8h.

AC = AntiCoagulate. For antiplatelet therapy, immediately give aspirin 325 mg chewed/swallowed. Give clopidogrel 600 mg oral loading dose (if the patient will likely need cardiac bypass surgery this can be held until time of angiography if angiography is performed acutely). Start heparin infusion at 60 units/kg IV bolus followed by 12 units/kg/hr and titrate to keep PTT between 60–90 seconds.

PAIN = Relieve PAIN. If no contraindications, try sublingual nitroglycerin 0.4 mg q5 min × 3. If still chest pain, begin nitroglycerin 5 mcg/min IV and titrate up by 5 mcg/min q5 min to max dose of 20 mcg/min. Contraindications to nitroglycerin include right ventricular infarction, patient has taken phosphodiesterase inhibitors (ex. sildenafil) in last 48 hours, or hypotension (SBP < 100 mm Hg). Can also use morphine sulfate, try 2 mg IV push and re-administer/titrate dose depending on response.

NORM = NORMalize blood pressure: Nitroglycerin (see PAIN) used for angina will lower the blood pressure. Can also use metoprolol tartrate 5 mg IV q5 min × 3 or 25 mg PO q12h if no contraindications to beta blockers. Do not be overly aggressive with IV medication. If patient is hypotensive see chapter on cardiogenic shock.

STRAT = Decide treatment STRATegy: Namely early invasive with PCI versus conservative strategy. See chapter on TIMI risk score and NSTEMI/UA.

MED-TX = MEDical management: In addition to above, patient should have certain medications that have mortality benefit started prior to discharge (not given emergently). Beta blockers such as metoprolol tartrate 25 mg PO bid. ACE inhibitors such as lisinopril 5 mg PO daily. Aspirin should be continued at 81 m PO daily. If patient had a NSTEMI, clopidogrel should be continued at 75 mg PO daily for one year regardless of angiography results.

• – Troponins are more sensitive than CK-MB for the diagnosis of acute STEMI, as more troponin is found in the heart per gram of myocardium.

1. Wright RS, et al. 2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients with Unstable Angina/Non–ST-Elevation Myocardial Infarction. Circulation. 2011;123;2022–2060.

HPI: Retrosternal chest pain (tightness, squeezing) radiating to left arm with instant onset, dyspnea; symptoms lasting more than 15 minutes.

PMH: Coronary artery disease, hypertension, diabetes, hyperlipidemia.

FH: Coronary artery disease.

SH: Smoking, alcohol, drug use.

Early changes (< = 2 hours): Hyperacute T-waves, ST-segment elevation.

Late changes (> 2 hours): Q waves.

STEMI = Patient with definite or working diagnosis of ST-elevation myocardial infarction.

MON = MONitor: Perform 12-lead ECG. If does not show changes and patient still symptomatic, repeat after 10 minutes. Place patient on telemetry monitoring. Monitor oxygen saturation and use oxygen generously to keep SaO₂ > 94%. Send for immediate cardiac biomarkers (cardiac troponin I and creatinine kinase MB) and repeat q8h.

RPF = reperfusion. Optimal will be immediate percutaneous coronary intervention (PCI). See chapter on Acute STEMI RePerFusion therapy to decide startegy. Except for circumstances immediately life-threatening (ex. severe hypotension or hypoxia), DO NOT delay PCI when available for other treatments.

AC = AntiCoagulate. For antiplatelet therapy, immediately give aspirin 325 mg chewed/swallowed. Give clopidogrel 600 mg oral loading dose (if the patient will likely need cardiac bypass surgery this can be held until time of angiography if angiography is performed acutely). Start heparin infusion at 60 units/kg IV bolus followed by 12 units/kg/hr and titrate to keep PTT between 60–90 seconds.

PAIN = Relieve PAIN. If no contraindications, try sublingual nitroglycerin 0.4 mg q5 min × 3. If still chest pain, begin nitroglycerin 5 mcg/min IV and titrate up by 5 mcg/min q5 min to max dose of 20 mcg/min. Contraindications to nitroglycerin include right ventricular infarcton, patient has taken phosphodiesterase inhibitors (ex. sildenafil) in last 48 hours, or hypotension (SBP < 100 mm Hg). Can also use morphine sulfate, try 2 mg IV push and re-administer/titrate dose depending on response.

NORM = NORMalize blood pressure: Nitroglycerin (see PAIN) used for angina will lower the blood pressure. Can also use metoprolol tartrate 5 mg IV q5 min × 3 or 25 mg PO q12h if no contraindications to beta blockers. Do not be overly aggressive with IV medication. If patient is hypotensive see chapter on cardiogenic shock.

MED-TX = MEDical management: In addition to above, patient should have certain medications that have mortality benefit started prior to discharge (not given emergently). Beta blockers such as metoprolol tartrate 25 mg PO bid. ACE inhibitors such as lisinopril 5 mg PO daily. Aspirin should be continued at 81 m PO daily. Clopidogrel should be continued at 75 mg PO daily.

• – Troponins are more sensitive than CK-MB for the diagnosis of acute STEMI as more troponin is found in the heart per gram of myocardium.

1. Antman EM, et al. 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction. J Am Coll Cardiol. 2008;51;210–247.

HPI: Retrosternal chest pain (tightness, squeezing) radiating to left arm with instant onset, dyspnea, symptoms lasting more than 15 minutes.

PMH: Coronary artery disease, hypertension, diabetes, hyperlipidemia.

FH: Coronary artery disease.

SH: Smoking, alcohol, drug use.

Early changes (< = 2 hours): Hyperacute T-waves, ST-segment elevation

Late changes (>2 hours): Q waves.

STEMI = Patient with definite or working diagnosis of acute ST-elevation myocardial infarction <12 hours in duration. See chapter on initial management for STEMI.

PCI-90 = Percutaneous Coronary Intervention can be performed in 90 minutes or less from time of first medical contact.

PCI-UNAV = PCI is UNAVailable or cannot be done within 90 minutes of first medical contact.

PCI = Send patient for immediate Percutaneous Coronary Intervention.

FIBR = FIBrinolytic therapy: DO NOT give to patient with absolute contraindications (see contraindications box). Options available:

Streptokinase 1.5 million units IV over 60 minutes

OR

Alteplase, IV bolus 15 mg, infusion 0.75 mg/kg over 30 min (maximum 50 mg), then 0.5 mg/kg (maximum 35 mg) over the next 60 min to an overall maximum of 100 mg

OR

Reteplase, 10 U IV over 2 min, then 30 min later, give 10 U IV over 2 min.

OR

Tenecteplase, IV bolus over 15 seconds:

30 mg for weight < 60 kg; 35 mg (60–69 kg); 40 mg (70–79 kg); 45 mg (80–89 kg); 50 mg (> = 90 kg).

TX-PAT = Transfer PATient: Transfer patient as soon as possible to a facility with interventional cardiology for a higher level of care.

STEMI + PCI-90 = PCI

STEMI + PCI-UNAV = FIBR + TX-PAT

• – PCI compared to fibrinolytic therapy has shown enhanced survival and lower rates of intracranial hemorrhage and recurrent MI.

1. Antman EM, et al. 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction. J Am Coll Cardiol. 2008;51;210–247.

2. Keeley EC. Primary PCI for Myocardial Infarction with ST-Segment Elevation. N Engl J Med. 2007;356:47–54.

HPI: Patient with STEMI s/p fibrinolytic or PCI.

PMH/PSH: Prior angina or MI, CAD PVD Prior interventions

SH: Smoking history, advanced age >70 years.

Labs: Biomarker elevation, electrolyte abnormality Inflammatory markers Leukocyte count (greater necrosis), electrolytes for renal perfusion and cardiac output.

ECG: Recurrent ST elevations, PR depressions (pericarditis?) Arrhythmias/blocks?

ECHO: LV function.

RI = Recurrent Ischemia.

EMT = Escalate Medical Therapy and correct secondary causes of ischemia.

IABP = IAPB if hemodynamic instability/poor LV function, or large area of myocardium at risk.

CATH = Obtain ECG. If no ST elevation and ischemia not controlled, then refer for CATHeterization; if ischemia controlled, then nonurgent PCI or CABG.

FIBRIN = If ST elevation, then FIBRINolytic therapy or PCI based on availability/contraindications.

PULMC = PULMonary Congestion.

FOM = Furosemide 0.5 mg/kg, Oxygen, Morphine.

NITRO = NITROglycerin 10–20 mcg/min if SBP >100.

PRESSOR = Dopamine, dobutamine—check blood pressure and if >100 and not less than 30 below baseline, then start ACEI.

• SPB>100, give nitroglycerin 10–20 mcg/min

• SBP 70–100 and no shock, give dobutamine 2–20 mcg/kg/min

• SBP 70–100 with shock, give dopamine 5–15 mcg/kg/min

• SBP <70 with shock, give norepinephrine 0.5–30 mcg/min

HYPO = HYPOvolemia/HYPOtension.

F = Fluids.

B = Blood D = Diuretics N = Nitrates BB = Beta Blockers.

ACEI = ACE-Inhibitors HTN = HyperTensioN CCB = CalCium Blockers.

DIG = DIGoxin ASA = Aspirin/NSAID SWAN = Place SWAN-Ganz and monitor wedge pressure ADEN = ADENosine CV = CardioVersion.

CS = Cardiogenic Shock A = Arrhythmia BRAD = BRADycardia.

ATRO = ATROpine (caution if unstable, may worsen ischemia with increased HR, pacemaker for heart blocks) SVT = SupraVentricular Tachycardia VTF = Ventricular Tachycardia, Fibrillation.

PM = PaceMaker RVI = RV Infarction PMR = Papillary Muscle Rupture SURG = Urgent SURGical Repair VSR = Ventricle Septal Rupture LV = LVFWR free wall rupture P = Pericarditis.

RI = EMT + IABP ± CATH ± FIBRIN

PULMC = FOM ± NITRO/PRESSOR

HYPO = F + B + PRESSOR + IABP

HTN = N + D + BB + ACEI

CS = SWAN + N + PRESSOR + IABP ± FIBRIN ± CATH

A + BRAD = ATRO

A + SVT = BB or DIG or ADEN or CCB or CV

A + VFT = EMT + CV or BB or AMIO or PM

RVI = F+ PRESSOR

PMR = IABP + PRESSOR + SURG

VSR = IABP + PRESSOR + SURG

LVFWR = SURG

P = ASA

Any new systolic murmur post-MI is likely VSD versus MR.

Increased risk of mortality, reinfarction, hypertension, heart failure, and myocardial rupture associated with NSAID (except ASA).

Avoid beta blockers if heart failure, low output state, heart block, asthma, reactive airway disease.

1. Antman EM, et al. ACC/AHA Guidelines for the Management of Patients with ST Elevation Myocardial Infarction. Circulation. 2004 Aug 21;110 (9):282–292.

2. Antman EM, et al. 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients with ST Elevation Myocardial Infarction. J Am Coll Cardiol. 2008 Jan 15;51(2):210–247.

HPI: Sudden onset of chest pain at rest usually occurring in the early morning.

PMH: Coronary artery disease, hypertension, hyperlipidemia, diabetes, Raynaud's phenomenon.

SH: Smoking, alcohol, cocaine use.

CAD = Coronary Artery Disease.

DILT = DILTiazem 240 mg/day.

INEFF-DILT = DILTiazem is INEFFective.

NIT = Sublingual isosorbide diNITrate 5 mg Q5 minutes, maximum dose 15 mg.

PCI = Percutaneous Coronary Intervention.

RFM = Risk Factor Modification: smoking cessation, blood pressure control (see chapter on hypertension), lipid management (see chapter on LDL management), weight management.

VARANG = patient diagnosed with VARiant ANGina.

VARANG-REF = Variant Angina Refractory to medical therapy.

VARANG = RFM + DILT

VARANG + INEFF-DILT = NIT

VARANG-REF + CAD = PCI

• – Nonselective beta blockers such as propanolol should be avoided in patients with VA as it can further exacerbate coronary vasospasm.

• – Aspirin should be avoided in patients with VA as it inhibits the production of prostacyclin, a vasodilator.

• – PCI is contraindicated in patients with an acute spasm and minimally obstructive disease.

• – Patients with variant angina receiving medical therapy with near-to-normal coronary arteries have a 95% 5-year survival rate.

• – Patients with variant angina receiving medical therapy with multivessel disease have an 80% 5-year survival rate.

1. Anderson JL, et al. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary. J Am Coll Cardiol. 2007;50:e1–e157.

HPI: Patient with coronary artery disease (CAD) who is in need of coronary revascularization.

PMH: CAD, hypertension, hyperlipidemia, diabetes, myocardial infarction, angina, heart failure.

PSH: CABG, percutaneous coronary intervention (angioplasty).

SH: Smoking, alcohol, illicit drug use.

Stress Echo: Left ventricular ejection fraction and baseline function.

Radionuclide myocardial perfusion scan: Detect areas of myocardial perfusion defects and ischemia.

CABG = Send patient for CABG.

PCI = Send patient for percutaneous intervention.

LMD = Left Main Disease = >50% stenosis in left main coronary artery.

1VD = 1 Vessel Disease = >70% stenosis in 1 non-left main coronary artery vessel

2VD = 2 Vessel Disease = >70% stenosis 2 non-left main coronary artery vessels.

3VD = 3 Vessel Disease = >70% stenosis in 3 non-left main coronary artery vessels.

PROX-LAD = PROXimal LAD stenosis = >70% stenosis in proximal left anterior descending artery.

DM = Diabetes Mellitis.

ISCH = ISCHemia on noninvasive testing.

LVEF-50 = Left Ventricular Ejection Fraction <50%.

LIMA = Left Internal Mammary Artery.

1VD = PCI

2VD = PCI

2VD + PROX-LAD + DM = CABG

2VD + LVEF-50 = CABG

2VD + ISCH = CABG

3VD = CABG

LMD = CABG

• – There are no studies comparing efficacy of CABG to placebo

• – Left main artery lesions are the most dangerous and become the most unstable after cardiac catheterization and are not safe for angioplasty.

• – Grafts usually last 10–15 years.

• – CABG has been shown to have lower-rate major adverse cardiac or cerebrovascular events compared to PCI in patients with left main or 3 vessel disease.

• – Patients treated with CABG versus DES have lower rates of death or MI in multivessel disease and have lower rates of revascularization.

1. Hannan EL, et al. Drug-Eluting Stents vs. Coronary-Artery Bypass. N Engl J Med. 2008;358(4):331–341.

2. Patel MR, et al. Appropriateness Criteria for Coronary Revascularization. Circulation. 2009;119:1330–1352.

3. Serruys P, et al. Percutaneous Coronary Intervention versus Coronary Artery Bypass Grafting for Severe Coronary Artery Disease. N Engl J Med. 2009;360:961–972.

Anteroseptal (V1-3)

Anterolatertal (V3-6, I, aVL)

Lateral (I, aVL, V5, V6)

Inferior (II, III, aVF)

Posterior (V1-3 mirror image)

STEMI = ST segment elevation.

SD = ST Segment Depression

LM = Left Main occlusion.

D-LAD = Distal LAD.

P-LAD = Proximal LAD.

LAT = LATeral.

POST = POSTerior.

CIRC = CIRCumflex.

RCA = Right Coronary.

Q = Q wave location in patient with STEMI.

INF = INFerior.

RV = Right Ventricular.

ANT = ANTerior.

POST = POSTerior.

AP = Antero-septal.

STEMI:

• LM = STEMI in aVR, V1, ST depression in II, aVF, v-V6

• D-LAD = STEMI in V3-V6, II, ST depression in aVR

• P-LAD = STEMI in aVR, aVL, V1-V4, St depression in II, III, aVF

• LAT = STEMI in I, aVL, V5-V6

• POST = SD in V1-V3

• CIRC = STEMI in II/III

• RCA = STEMI in III/II, SD in I, positive T wave in V4R

Q/Infarct:

• INF = Q in II/III/aVF

• RV = Q in V4R-V6R

• ANT = Q in V3-V4

• POST = Q in V1

• AP = Q in V1-V3

Knowing the blood supply can aid in diagnosis:

• – The LAD supplies the anterior wall and interventricular septum.

• – The RCA supplies the inferior wall and sinus and AV node. Occlusion results in inferior MI, sinus bradycardia and heart blocks. Occlusion of the left main coronary leads to anterior MI, pump failure and sudden death. Occlusion of the LAD causes anterior MI, LV failure, arrhythmias, and blocks. Occlusion of the left circumflex leads to lateral infarcts.

Obtain ECG during episodes of chest pain because the findings may be transient. The progression of STEMI is hyperacute T waves to ST elevation to abnormal Q waves to T wave inversion.

If possible compare prior ECG to determine if abnormalities are new or old.

Q waves can also be seen in sarcoid, amyloid, tumor, scleroderma, and myocardial inflammation.

1. Wellens HJJ, Conover M. The ECG in Emergency Decision Making. 2nd ed. St. Louis, MO: Saunders, Elsevier; 2006.

2. Wagner GS. Marriotts Practical Electrocardiography. 10th ed. New York, NY: Lippincott Williams and Wilkins; 2000.

Often there is evidence of inferior wall myocardial infarction on a standard ECG. Obtain right side ECG to evaluate right ventricle. ST elevation in II, III, aVF (III > II see "determine the site of infarct on ECG" chapter)

Reciprocal St depression in I, aVL

ST elevation in V4R-V6R

1st or 2nd degree AV block

CXR: Pulmonary edema may be absent.

ECHO: Tricuspid regurgitation, regional RV wall motion abnormalities, dilated RV, decreased ejection fraction.

Swanz: Elevated right atrial pressures > 10 mm Hg, low pulmonary systolic pressures, low wedge pressure.

R-MI = Patient with definite or working diagnosis of acute Right ventricular Myocardial Infarction.

HU = Hemodynamically Unstable: hypotension (systolic BP < 90 mm Hg), significant bradycardia (ventricular rate < 55 bpm or periods of asystole > 3 seconds), or evidence of shock (mental status changes or decreased urine output).

HS = Hemodynamically Stable: normotensive, normal mentation, no evidence of shock.

STAB = STABilize. Give IV fluids wide open if hypotensive. If inadequate response, start dopamine infusion at 5 mcg/kg/min and titrate to MAP > 60 mm Hg. See chapter on cardiogenic shock. For bradycardia, can try atropine 1 mg IV. Often dopamine will increase heart rate as well. If still bradycardic can use temporary pacing with transcutaneous pacing pads or transvenous pacemaker.

MI-TX: See chapter on STEMI for instruction on anticoagulation, monitoring, and reperfusion.

MED-TX: Special considerations: beta blockers may be counterproductive as they worsen bradycardia. Patients are preload dependent- nitrates and diuretics can cause severe hypotension. If mechanical ventilation is required, a strategy with lower PEEP is often used.

R-MI + HS = MI-TX + MED-TX

R-MI + HU = STAB + MI-TX + MED-TX

Do not give nitrates or diuretics (will cause reduction of preload and further hypotension).

Do not confuse presentation with CHF, if the patient has worsening hypotension; then consider RV infarction.

RV infarcts may be difficult to distinguish from CHF, PE, and tamponade.

1. Goldstein JA. Pathophysiology and Management of Right Heart Ischemia. J Am Coll Cardio. 2002;40:841.

2. Isner JM. Right Ventricular Myocardial infarction. JAMA. 1988;259:712.

3. Kinch JW, Ryan TJ. Right Ventricular Infarction. N Eng J Med. 1994;330:1211.

HPI: Chest pain (quality, type, location, duration, aggravating/relieving factors, intensity), any recent viral infections—myocarditis, any chest trauma check for pericardial tamponade, recent chemotherapy that is cardiotoxic.

PE: Assess vitals for high temperature (sepsis/SIRS), blood pressure for volume status (dry mucous membranes, low JVP, low CVP), or hypertensive emergency with organ damage.

Labs: BUN/creatinine for renal failure, hemoglobin to asses for anemia or workup for GI bleed, UDS-look for cocaine.

PM Hx/PSx Hx: CAD (history of MI, CABG, angioplasty, angina) CHF (prior low EF, hx of AICD implant.

Social/Fhx: Drug use.

CLIN-ACS = CLINical ACS: patient presents with a good clinical picture for ACS, ie, positive history and ECG.

CLIN-OT = CLINical OTher: patient presents with a good clinical picture for ACS, but there are other important conditions present that may have precipitated the clinical presentation and need to be addressed promptly, eg, an acute gastrointestinal bleed, severe anemia, supraventricular or ventricular tachycardia, pulmonary embolism.

CKMBNL = CKMB levels Normal making one suspect an alternative diagnosis for the elevated troponin level (normal CKMB will rise in parallel with troponins).

CKMBEL = CKMB levels abnormally ELevated.

TROP-POS = TROPonin POSitive.

ACS = Likely ACS (refer to ACS chapter for further management).

NON-ACS = A NON-ACS case, with elevated troponins likely secondary to another clinical condition such as heart failure, sepsis, pulmonary emboli.

ISBURD = ISchemic BURDen evaluation should be considered once the other clinical issues have been diagnoses and managed appropriately.

CLIN-ACS + TROP-POS = ACS

CLIN-OT + TROP-POS + CKMBNL = NON-ACS

CLIN-OT + TROP-POS + CKMBEL = ISBURD

1. Higgins JP, et al. Elevation of Cardiac Troponin I Indicates More Than Myocardial Ischemia. Clin Invest Med. 2003;26(3):133–147.

HPI: Patient presents with chest pain.

Canadian Cardiovascular Society Classification Angina Grading:

• 1—symptoms with marked exertion

• 2—slight limitation of ordinary activity

• 3—marked limitation of activity

• 4—inability to carry out physical activity

PMH: CAD, MI, hypertension, hyperlipidemia.

SH: Smoking use, alcohol intake.

FH: Premature CAD/MI, PVD/CVD.

CSA = Chronic Stable Angina: characterized by substernal location, provoked by exertion or stress, and relived by rest or nitroglycerine.

FHR = Features of High Risk: pain lasting >20 minutes, age >65 years, ST and T wave changes, pulmonary edema, symptoms refractory to therapy.

CST-POS = Cardiac Stress Test POSitive: if moderate pretest probability for CAD and stable symptoms, then stress ECG testing.

CATH = Cardiac CATHeterization.

TRC = Treat Reversible Causes, eg, hypertension, hyperlipidemia (target LDL <100), CHF, anemia, hypoxemia, glucose control, drug side effect, thyroid disease. Goal Blood pressures:

NTG = Use nitroglycerine 0.4 mg SL q5 min × 3 prn (can use prophylactically).

LAN = Long Acting Nitrate preparations.

ASA = Aspirin (if no contraindications) 81 mg orally each day.

BB = Beta Blockers (atenolol, metoprolol) to reduce symptoms (caution in Printzmetal angina).

CCB = Calcium Channel Blockers (amlodipine, nifedipine) for coronary vasodilation (indicated for Printzmetal angina).

ACEI = Angiotensin Converting Enzyme Inhibitors = in patients with diabetes or LV systolic dysfunction, LVEF <40%.

DIET = DIET modification (reduced cholesterol, fat).

EXER = EXERcise program.

CSA = TRC + NTG + LAN + ASA + BB/CCB + ACEI + DIET + EXER

FHR = CATH

CST-POS = CATH

Significant CAD is stenosis >70% if one major epicardial artery or 50% of LAD. The goal of treatment is to reduce ischemia and risk factors for coronary artery disease. The subendocardial layer is most vulnerable to ischemia and receives blood during diastole. Medical therapy aims at increasing coronary blood supply, decreasing myocardial oxygen demand, and stabilization of vulnerable plaques.

Patients with left main, three-vessel, or two-vessel CAD with significant stenosis of the proximal LAD may have a survival advantage with revascularization. Low-risk patients with chronic stable angina should be treated with medical therapy prior to any intervention.

Nitroglyercine should be renewed every 3–6 months; allow intervals of 8–10 hours to avoid tolerance.

Percutaneous coronary intervention provides better symptomatic relief than medical therapy but does not decrease future risk of MI or death.

1. Gibbons RJ, et al. ACC/AHA 2002 Guideline Update for the Management of Patients with Chronic Stable Angina. Circulation 2002.

2. Rosendorff C, et al. Treatment of Hypertension in the Prevention and Management of Ischemic Heart Disease. Circulation. 2007;115(21):2761–2788.

CV: Hypotension, weak diminished pulses, murmur of MR/AS.

Resp: Pulmonary crackles.

ECHO: Determine if mitral regurgitation (papillary muscle rupture or ventricular septal rupture).

Determine if depressed LVEF or cardiogenic shock.

CXR: Pulmonary congestion.

IABP = Refer for intra-aortic balloon pump (IABP) counterpulsation.

CI-IABP = ContraIndication to IntraAortic Balloon Pump:

1. AR or AV shunting

2. AAA or aortic dissection

3. Sepsis

4. Bleeding disorder

5. Bilateral PVD/femoral popliteal bypass grafts

NO-CI-IABP = NO CI-IABP.

CG-SHOCK = CardioGenic SHOCK (SBP <90 mm Hg or 30 mm Hg below baseline) not amenable by pressors/inotropes.

SPT-HIGHR = SuPporT for HIGH-Risk catheterization/percutaneous coronary intervention/cardiac surgery.

ACS-SEV-ISCH = ACS patients (UA/NSTEMI/STEMI) with continuing SEVere ISCHemia despite intensive medical therapy.

AMI-HIGHR = Acute Myocardial Infarction patients who are severely ill and thus at HIGH Risk and undergoing acute myocardial revascularization (cardiac catheterization, percutaneous coronary intervention, surgical revascularization).

AMI-MECO = Acute Myocardial Infarction with MEchanical COmplications (ventricular septal defect, papillary muscle rupture/severe mitral regurgitation).

REFRAC AN-HF-VA = Patient with REFRACtory Angina/Heart Failure/Ventricular Arrhythmias despite medical therapy.

WEAN-CPB = Patient needing assistance on WEANing from CardioPulmonary Bypass.

CG-SHOCK + NO-CI-IABP = IABP

SPT-HIGHR + NO-CI-IABP = IABP

ACS-SEV-ISCH + NO-CI-IABP = IABP

AMI-HIGHR + NO-CI-IABP = IABP

AMI-MECO + NO-CI-IABP = IABP

REFRAC AN-HF-VA + NO-CI-IABP = IABP

WEAN-CPB + NO-CI-IABP = IABP

During diastole, blood is displaced to proximal aorta via inflation to aid in coronary blood flow.

During systole, afterload and myocardial oxygen consumption are reduced by a vacuum effect created by deflation.

Use of IABP is beneficial for hemodynamic support and stabilization during high-risk angiography and revascularization.

Note factors that can increase complication rate include PVD, age >70, female sex, diabetes/HTN, prolonged support, large catheter/large body surface area.

Complications include limb ischemia, bleeding, balloon leak, IABP failure, arterial dissection.

1. Stone GW, et al. Contemporary Utilization and Outcomes of Intra-aortic Balloon Counterpulsation in Acute Myocardial Infarction: The Benchmark Registry. J Am Coll Cardiol. 2003;41:1940–1945.

2. Antman EM, et al. 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction. J Am Coll Cardiol. 2008;51;210–247.

3. Wright RS, et al. 2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients with Unstable Angina/Non–ST-Elevation Myocardial Infarction. Circulation. 2011;123;2022–2060.

HPI: Patient presenting with chest pain, palpitations, dyspnea, anxiety.

SH: Drug use, smoking, alcohol.

Labs: Urine drug screen positive for cocaine, positive cardiac biomarkers.

CICP = Cocaine-Induced Chest Pain.

1STLT = 1ST Line Therapy: aspirin, nitroglycerine, oxygen (see chapter on UA/NSTEMI) and in addition give lorazepam 1 mg IV every 5 minutes (max 8 mg); or diazepam 5–10 mg IV, then 5 mg IV every 20 minutes (max 20 mg).

2NDLT = 2ND Line Therapy: phentolamine (1 mg IV, then 2.5 mg IV q15 minutes until blood pressure controlled) or verapamil 2.5 mg IV over 2 minutes; if no response, give 5 mg every 20 minutes (maximum 20 mg total).

PCI = Refer for PerCutaneous Intervention.

NO-PCI = NO PCI facilities available.

TL = Administer ThromboLytics if no contraindications (see STEMI chapter).

CCP = Continuing Chest Pain.

STEMI = ST-Elevation Myocardial Infarction (see STEMI chapter).

Steps in management of patient with cocaine-induced chest pain:

1. CICP = 1STLT

2. 1SLT + CCP = 2NDLT

3. 2NDLT+ CCP = PCI

   2NDLT + STEMI = PCI

   2NDLT + STEMI + NO-PCI = TL

• – Beta blockers should be avoided because of the risk of exacerbating coronary vasospasm effect of cocaine. If beta blocker is needed, use with caution, and use labetalol or carvedilol for its alpha blockade effects.

• – If decision is made to place stent, then bare metal stent is preferred.

• – Majority of cocaine-induced myocardial infarctions occur within 24 hours of use.

• – Concomitant use of cigarettes with cocaine can exacerbate coronary artery vasoconstriction and further increase myocardial oxygen demand.

• – Ingestion of ethanol with cocaine produces metabolite cocaethylene, which blocks the reuptake of dopamine in the synaptic cleft and potentiates the toxic effects of cocaine.

1. McCord J, et al. Management of Cocaine-Associated Chest Pain and Myocardial Infarction. Circulation. 2008;117:1897–1907.

2. Lange RA, et al. Cardiovascular Complications of Cocaine Use. N Engl J Med. 2001;345:351–358.

3. Hollander JE, et al. Management of Cocaine Associated Myocardial Ischemia. N Engl J Med. 1995;333:1267–1272.