Acute Coronary Syndromes

1. Chest pain or equivalent present for at least 30 minutes
2. Duration of chest pain less than 12 hours
3. New ST Elevation of at least 0.1mV in two contiguous leads or presence of new Left BBB pattern
4. EKG changes which do not resolve after sublingual nitroglycerin

• ASA 160 mg chewable ASAP. Give 600mg suppository if unable to take po. Morphine 2-4 mg IV q 5-30 minutes titrated for pain
• Oxygen at 2 l/min for first 2-3 hours, maintain SaO2 > 90%
• Nitroglycerin for first 24-48 hours.

_____5-100 mcg/min IV infusion; titrate prn chest pain and keep SBP>100 and <160.
OR_____ 0.4 mg SL, repeated X 2 at 5 min intervals
OR_____ Spray: 2 metered doses under or onto tongue
OR_____Paste 1”-2” q 6 hr as tolerated.

• Metoprolol 5 mg IV q 5 min X 3 if hemodynamically stable. 15 minutes after last IV dose, begin metoprolol ___25mg___50mg___100 mg po q 12 hr if no CHF or AV Block.
• Consider thrombolytic therapy as follows, after patient screened for exclusion criteria.
• Goal: Door to drug time 30 minutes.

• Give as single IV bolus over 5 seconds. Do not administer with any glucose containing solution
• Weight based dosing regimen: Dose_______

< 60 kg 30 mg
60-69 kg 35 mg
70-79 kg 40 mg
80-89 kg 45 mg
>90 kg 50 mg

• Baseline PT/PTT, CBC, creatinine
• Lovenox 30 mg IV, immediately followed with 1mg/kg SQ. Then begin Lovenox 1 mg/kg SQ q12h, but maximum dose for each of first two SQ doses should be 100mg. For creatinine clearance <30ml/min, use 0.75 mg/kg.

• New ST depression (at least 1mm) in two contiguous leads
• Minimal ST elevation (1mm) in two contiguous leads lasting less than 20 minutes
• New T-wave inversion in contiguous leads of 3 mm or more in three or more limb leads or four or more precordial leads excluding lead V1
• T-wave pseudonormalization in two contiguous leads

• ASA 160 mg chewable ASAP. Give 600 mg suppository if unable to take po.
• Morphine 2-4 mg IV q 5-30 minutes titrated for pain.
• Oxygen at 2 l/min for first 2-3 hours. Maintain SaO2 >90%.
• Nitroglycerin for first 24-48 hours.

_____5-100mcg/min IV infusion; titrate prn chest pain, keep SBP>100 and <160.
OR_____ 0.4 mg SL, repeated X 2 at 5 min intervals
OR_____ Spray; 2 metered doses under or onto tongue
OR_____Paste 1”-2” Q 6 hr as tolerated.

• Lovenox 1mg/kg SQ now and q 12 hours. For creatinine clearance < 30 ml/min use 0.75mg/kg.
• Metoprolol 5 mg IV q 5 min X 3 if hemodynamically stable. 15 minutes after last IV dose, begin metoprolol ___25mg___50mg___100 mg po q 12 hr if no CHF or AV Block.
• Consider GP IIB-IIIA Inhibitor therapy as follows, after patient screened for exclusion criteria. See ACLS algorithms on Acute Coronary Syndrome and Ischemic chest pain for patient selection.

• ______ 180mcg/kg loading dose given IV Push over 1-2 minutes, followed by 2 mcg/kg/min infusion with maximum infusion rate 15 mg/hr for _______hours. (24-48 hours with 72 hr maximum)
• ______For patients with serum creatinine 2-4 mg/dl, 180mcg/kg loading dose given IV Push over 1-2 minutes, followed by 1 mcg/kg/min infusion with maximum infusion rate of 7.5 mg/hr for _____hours.
• Contraindicated for patients with serum creatinine > 4mg/dl or on hemodialysis
• If PCI planned by cardiologist within 3-4 hours, give second bolus of 180 mcg/kg 10 minutes after first bolus. If patient on infusion for >3-4 hours by the time of PCI, no need for second bolus.
• Prior to infusion, draw CBC, PT, PTT, creatinine.
• Check platelets 2-4 hours and 24 hours after bolus given and gtt initiated.