📝ED #Order for suspected ACS/unstable angina or non-STEMI

▪️Imp:suspected ACS/unstable angina or non-STEMI
▪️Cond: Emergency
▪️Diet: NPO
▪️act: CBR and bed sides up
post: supine

🔹Initial assessment and interventions:

▪️CVS
▪️POM and CM
▪️ IV line fix

▪️supplemental oxygen if hypoxia (sat<90)
🔺supplemental O2 without hypoxia can increase infarct size

▪️ECG stat then q 10-15min initial ECG is nondiagnostic but clinical suspicion remains high (initial ECG often not diagnostic).
▫️Non-STEMI or unstable angina: STD or deep T-wave inversions without Q waves or possibly no ECG changes.

▪️Check hs Trop at 0 and 1, 2 or 3 hours
* اگه h.s نبود با توالی 0.3.6 میفرستیم
🔺a single set of negative trop is not sufficient to rule out AMI.
▫️cardiac trop I and T detect elevations within 2 to 3 hours, peak at 12 hours, and remain elevated for 7 to 10 days.

▪️Check CBC, Bun, Cr, Basic electrolyte (Na, K, Mg, Ca), PT, PTT,INR
*ESR, CRP, BNP and NT pro-BNP,LFTs, Bill T and D if needed and based on the condition


▪️Portable CXR STAT as necessary (rule out other causes, e.g., aortic dissection, pneumothorax).

▪️Bedside echo if time permits

▪️Aspirin 325 mg (nonenteric coated) chewed and swallowed then 75 to 100 mg/PO/D (nonenteric coated)
🔺In patient without concern for aortic pathology(eg. Aortic dissection) or GI perforation

▪️Sublingual nitroglycerin tablets (0.4 mg) q5min up to 3 doses
▫️Drip Nitroglycerin 5-10mcg/min IV infusion. (titrate dose q10min by adding 5mcg/min) for persistent symptoms
▫️use in patient with persistent chest discomfort, hypertension, or signs of HF
🔺be careful(or contraindicated)if there are sign of hemodynamic compromise (eg, RV infarction), severe aortic stenosis, HCM, hypotension(SBP <90 mm Hg or a change in SBP >30 mm Hg below baseline), marked bradycardia or tachycardia and recent use of phosphodiesterase inhibitors (eg, Viagra)
▫️Tachyphylaxis may occur after approximately 24 h.

▪️Tab metoprolol tartrate(immediate release) 25 to 50 mg PO q6-12h
▫️Tab metoprolol succinate(extended release) 25 to 50 mg PO/Daily
🔺if no signs of heart failure and not at high risk for HF and no signs of hemodynamic compromise, bradycardia, or severe reactive airway disease. (Relative contraindications -- asthma, COPD, PR interval > 0.24 sec, AV block)
▫️If hypertensive, may initiate beta blocker IV instead (eg, metoprolol tartrate 5 mg intravenous every 5 minutes for 3 doses as tolerated).

▪️Amp Morphine sulfate 2 to 4 mg slow IV push every 5 to 15 minutes
▫️Morphine sulfate is indicated for chest discomfort refractory to nitrates and other antiischemic therapies.
🔺May delay the effects of oral P2Y12 therapy

▪️Tab atorvastatin 80mg orally then 40mg/D
▫️as early as possible and preferably before PCI in patients not on statin. If patient is taking a low- to moderate-intensity statin, switch to atorvastatin 80 mg. (high dose)

▪️Consider the treatment of HF as necessary
▫️Give afterload-reducing agent (eg, nitroglycerin sublingual tablet and/or IV drip at 40 mcg/minute provided no hypotension and no phosphodiesterase inhibitors [eg, for erectile dysfunction]; titrate drip up quickly based on response);
▫️give loop diuretic (eg, intravenous furosemide 20-40 mg bolus);
▫️administer noninvasive positive pressure ventilation (eg, BIPAP) to appropriate patients.

▪️Obtain emergency cardiology consultation for ACS patients with cardiogenic shock, left heart failure, or sustained ventricular tachyarrhythmia.

🔹Acute management of unstable angina or non-STEMI:

🔸Give antiplatelet therapy (in addition to aspirin) to all patients: