Acute Coronary Syndrome – Pearls for Inpatient Treatment

  • HEART – Hx, EKG, Age, Risk, Troponin
    • Hx: highly suspicious=2, moderate=1, slightly=1
    • EKG: ST depression=2, non-specific=1, normal=1
    • Age: >65=2, 45-65=1, <45=0
    • Risk: >3=2, 1-2=1, 0=0  (HTN, HLD, DM, smoking, fam hx, obesity)
    • Trop: >3x=2, 1-3x=1, neg=0
    • Score
      • 0-3: 2.5% risk of adverse cardiac event—discharged (0.99% retrospective) (1.7% prospective)
      • 4-6: 20.3% risk of adverse cardiac event—admission 11.6% (16.6% prospective)
      • ≥7: 72.7% risk of adverse cardiac event—early cath 65.2% (50.1% prospective)
  • ACS Guidelines — 10 PEARLS
    • Risk stratisfication for likelihood of ACS and adverse outcomes to decide whether to admit and type of treatment
    • ECG within 10min of arrival
    • Troponin at presentation and 3-6hr after sx onset
    • Oral beta-blocker w/in 24hr
      • Contra BB if–sx of heart failure, low oupt state, increase risk of cardiogenic shock, contra to BB (PR >0.24, 2nd or 3rd block w/o pacemaker, active asthma, reactice airway disease)
    • High intensity statin initiated or continued for all w/ NSTE-ACS
    • Dual-platelet–clopidogrel + aspirin for up to 12mo, ind: treated w/ early invasive or ischemia-guided strategy
        • Clopidogrel for at least 12mo, ind post-PCI w/ stents
      • Anticoagulation in addition to antiplatelet, ind: all pt with NSTE-ACS irrespective of initial treatment strategy, d/c after PCI unless other reason to continue
      • Catheterization (diagnostic angiography w/ intent to perform re-vascularization) – ind: NSTE-ACS w/ refractory angina, hemodynamic or electrical instability (without serious comorbidities or contraindications to such procedures), initially stabilized patients with NSTE-ACS (without serious comorbidities or contraindications to such procedures) who have an elevated risk for clinical events
      • Cardiac rehab – all w/ NSTE-ACS, before hospital discharge or during 1st outpt visit
      • Aftercare – med adherence, f/u, diet, exercise; specific daily exercise–lifting, climbing stairs, yard work, household activities; resumption–driving, work, sex;

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