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Acute Coronary Syndromes

Kelly Vogel


  • Completely or partially occluding thrombus on a disrupted atherothrombotic coronary plaque leading to myocardial ischemia/infarction
  • STEMI: Elevated troponin & elevation in ST segment or new LBBB with symptoms
    • > 0.1 mV in at least 2 contiguous leads
    • Exception, in V2-V3:
    • > 0.2 mV in men older than 40 y/o
    • > 0.25 in men younger than 40 y/o
    • > 0.15 mV in women
  • NSTEMI: Evidence of myocardial necrosis (elevated troponin) w/o ST segment elevation
  • Unstable Angina: Angina without evidence of myocardial necrosis (normal troponin)
  • Newer nomenclature: occlusion and non-occlusion MI (OMI and NOMI)
    • Occlusion MI: near or total occlusion with insufficient collateral circulation causing active infarction, further broken into STEMI (+) OMI or STEMI (-) OMI; both considered a type I MI
    • Non-occlusion MI: no occlusion or sufficient collateral circulation to avoid active infarction, further broken into STEMI (+) NOMI or STEMI(-) NOMI; can be either type I or II MI
  • Other causes of myocardial injury: coronary spasm, embolism, imbalance of oxygen demand and supply 2/2 fever, tachycardia, hypo-/hypertension


  • Symptoms
    • Classic Angina: dyspnea on exertion, substernal, pressure or vice-like quality, improved with rest. Note that response nitroglycerin is no longer in the guidelines.
    • Anginal Equivalents: nausea, weakness, epigastric pain (esp. in age > 65 y/o, women, diabetics)
      • Change in pt's baseline angina, especially onset at rest
      • Physical Exam: sinus tachycardia, diaphoresis
      • If large infarct, can present with symptoms of acute heart failure


  • EKG: Compare to prior EKG and assess for
    • New ST elevations or ST depressions
    • T wave inversions: not specific but more concerning if deep (> 0.3mV)
    • Biphasic T waves and deep T wave inversions in leads V2 & V3 (Wellens sign [LAD])
  • Cardiac biomarkers: troponin I is most sensitive for myocardial injury
  • ACC/AHA guidelines recommend both EKG and trop q2-6 hours
    • Consider this if high suspicion for ACS despite normal initial markers
    • If negative x2, OK to stop trending
  • Other labs: lipid panel, TSH, A1C



  • STAT page Cardiology on call via Synergy (whether in VA or Vanderbilt)
  • ASAP: aspirin 325mg, heparin drip (high intensity nomogram, with bolus)
  • Hold P2Y12 until discussed with cards fellow


  • Medical management followed by left-heart catheterization within 48 hours
    • General: bedrest, telemetry, repeat EKG with recurrent chest pain, NPO at midnight
    • Place cath case request (see “pre-catheterization” management below)

Anti-thrombotic therapy

Antiplatelet agents - ASA 325 mg loading dose then 81 mg daily after - Do not give P2Y12 receptor blocker until discussed with cardiology fellow - Clopidogrel: prodrug that is metabolized to active form (can have undermetabolizers), irreversible inhibition - Ticagrelor: reversible inhibitor - Prasugrel: prodrug but more rapidly metabolized than clopidogrel with less variation, irreversible inhibition, do not use w/ age > 75 or weight \< 60 kg - Prasugrel and ticagrelor are superior to clopidogrel but have higher bleeding risk - Cangrelor: IV, rarely used

Anti-coagulants: Unfractionated heparin drip - Type this in Epic and select “nursing managed” protocol for “ACS” - VA: it can be found under the “Orders” tab along the left-hand column. - Enoxaparin (LMWH) can be used but requires preserved renal function (CrCl > 30) and most interventionalists prefer heparin prior to LHC

Pre-Catheterization Care

  • Ensure pt. is NPO at MN for planned cath
  • Continue anticoagulation with heparin gtt
  • Place cardiac catheterization request (must be in cardiology context). Can also call cath lab to ensure pt. is scheduled appropriately

Post-Catheterization Care Catheterization Documentation

  • The most appropriate guidance for post-cath care is in the cardiac catheterization report
  • VUMC: Epic Cardiac tab Cardiac Catheterization/Intervention Report
  • VA: Note tab Post-Procedure note and Cardiac Catheterization note
  • If there is a delay in filing the final report at VUMC: Review the Cardiac Catheterization Nursing Documentation which shows if stents were deployed

Post-Catheterization Heparin

  • Medical management w/o intervention: stop heparin unless directed in report
  • If indication for CABG (ex: Left main, proximal LAD), continue heparin gtt until surgery
  • PCI placed: stop heparin and continue/start DAPT as directed by cardiology
  • Other medical indication for anticoagulation (DVT/PE, atrial fibrillation): restart ~ six hours after catheterization

Cath Site Checks

  • 6 - 8 hours post catheterization (typically can be signed out as 0000 cath check), only needed for femoral arterial access
  • Look, listen, feel: evaluate for hematoma & pseudoaneurysm; call fellow if concerned
    • Small amount of bruising and mild tenderness at the site is normal
    • Listen above and below the site for a bruit; the area should be soft
  • Hypotension after femoral access is concerning for RP bleed
    • Apply pressure, STAT page interventional fellow, do NOT take pt to scanner prior to hearing back, order blood if needed
  • Femoral oozing: Cardiology fellow, will need to hold pressure
  • Radial oozing: instruct nurse to re-inflate the TR band and restart the clock on deflation

Post ACS Care

  • Echo prior to discharge
  • DAPT: Aspirin 81 mg daily and P2Y12 agent
  • Beta blocker in all patients within 24 hours
  • Metoprolol, carvedilol & bisoprolol have proven mortality benefit with reduced EF
  • High intensity statin (ex: rosuvastatin 40 or atorvastatin 80). See outpatient lipids section
  • ACEi/ARB if anterior STEMI
  • Lifestyle Modification: weight loss, smoking cessation, diabetes control
  • See heart failure section for management of HFrEF

ACS Complications

  • VT/VF, sinus bradycardia, third-degree heart block, new VSD, LV perforation, acute mitral regurgitation, pericarditis and cardiogenic shock; More common with STEMI->CCU post-cath