factors that may identify high-risk patients include

patients �65 years of age, the presence of at least 3 risk

factors for CAD, known prior coronary stenosis of �50%,

ST-segment deviations on ECG, elevated cardiac markers,

the use of aspirin within the prior 7 days, and at least 2

anginal episodes within the past 24 hours. Further treatment should be dictated by the patient's category of risk

(Figure 14-3).

TREATMENT

The proper management of ACS demands rapid and

aggressive care. These patients require treatment in an

area with ready access to resuscitation equipment including advanced airways and defibrillators. Address the

patient's airway and circulatory status and place the

patient on the cardiac monitor. Obtain N access and

administer supplemental oxygen to maintain an SpO 2

�94%. The immediate goals of therapy are to limit the

supply-demand mismatch by improving coronary perfusion while reducing myocardial oxygen demand. Further

treatment is dictated by condition into either STEMI or

UA/NSTEMI pathways.

..... Nitroglycerin

Nitroglycerin is widely used in patients with ACS and

provides benefit via several different actions. It decreases

myocardial oxygen demand by reducing the ventricular

preload, improves myocardial perfusion by dilating the

coronary vascular bed, and exhibits some mild antiplatelet properties. Start with sublingual doses of 0.4 mg in a

disintegrating tablet or spray. This can be repeated every

3-5 minutes as necessary for refractive pain provided that

the patient maintains a systolic blood pressure > 100 mmHg.

Chest pain that persists after 3-5 doses warrants the

initiation of IV therapy. Start an infusion at 1 0-20 meg/

min and rapidly titrate upward in 1 0-20 meg/min increments to achieve adequate pain control. Immediately stop

CHAPTER 14

Strong concern for myocardial

ischemia (new ST-segment

depressions or T-wave inversions)

UFH or LMWH, IV NTG,

IV 13-blocker + /­

clopidogrel load

• ST-segment depressions

• Elevated Tn

• Persistent chest pain

• Hemodynamic instability

• TIMI score �3*

No high-risk features

Admit to telemetry or

ccu bed for further

work-up

'' TIMI risk score for UA/NSTEMI equals the number of the following 7 risk factors that are present: Age

� 65, �3 CAD risk factors, known CAD, ASA use with in the past week, recent angina, elevated cardiac markers,

and ST-segment deviations � O.Smm. A score of 3 carries a 1 3% risk of an adverse cardiac event (AMI, death,

revascularization) within the next 14 days .

.&. Figure 1 4-3. ACS diagnostic algorithm. ACS, acute coronary syndrome; AMI, acute myocardial infarction;

ASA, aspirin; CAD, coronary artery disease; CCU, critical care unit; ECG, electrocard iogram; G PI, glycoprotein l ib/I l ia

inhi bitors; LBBB, left bundle branch block; LMWH, low-molecular-weight heparin; NTG, nitroglycerin; NSTEMI, nonST-segment elevation myoca rdial infa rction; PCI, percutaneous coronary intervention; STEM!, ST-segment elevation

myocardial infarction; TIMI, Thrombolysis In Myocard ial I nfarction; Tn, troponin; UA, unstable angi na; UFH,