Acute Coronary Syndrome (ACS) includes STEMI, NSTEMI, and unstable angina (UA). In the era of high sensitivity troponin, UA has become a slippery diagnosis but can still be diagnosed with a convincing story despite a negative troponin.
The basics of acute management are discussed below.
STEMI
From an internist perspective, our job is to make sure we don’t miss this diagnosis, and once it is diagnosed, we immediately involve cardiology. We want the patient to get a coronary angiogram and appropriate intervention as soon as possible.
Once STEMI is diagnosed, give 324mg chewable aspirin and get the patient to the cath lab.
These patients can get very sick very quickly, and cardiology will run the show in terms of management.
If we are waiting for cardiology input, other management steps that can be taken are:
- give a bolus of heparin.
- start a heparin gtt and control the chest pain with nitroglycerin as tolerated by blood pressure.
NSTEMI
Type I
Type I NSTEMI is from a coronary artery that is now blocked.
Give 324mg chewable aspirin.
Control the chest pain with nitroglycerin in some form, be it sublingual, transcutaneous, or titratable IV infusion.
Give a bolus of heparin.
Start a drip.
Consider a dose of IV metoprolol as tolerated by HR and BP.
Type II
NSTEMI Type II is from a myocardial oxygen supply/demand mismatch in the setting of increased demand, such as septic shock in a patient with existing CAD.
The mainstay of treatment is management of the underlying acute condition:
- Give 324mg chewable aspirin if the patient is not bleeding.
- Treat the underlying condition, treat sepsis, transfuse blood for severe anemia, avoid hypoxemia, etc.
UA
Discuss with cardiologist. In general, UA is treated as Type I NSTEMI.
Image credit: Eric Tanenbaum artwork.
