Emergency Department Care

The ACS spectrum concept is a useful framework for developing therapeutic strategies. Antithrombin therapy and antiplatelet therapy should be administered to all patients with an ACS regardless of the presence or the absence of ST-segment elevation. Patients presenting with persistent ST-segment elevation are candidates for reperfusion therapy (either pharmacological or catheter based) to restore flow promptly in the occluded epicardial infarct-related artery. Patients presenting without ST-segment elevation are not candidates for immediate pharmacological reperfusion but should receive anti-ischemic therapy and PCI when appropriate. "Time is myocardium" is a dictum to be remembered as survival has been shown to correlate with time to reperfusion in patients with acute MI. Many centers set goals for, and routinely record, door-to-ECG, door-to-needle (thrombolytic therapy), or door-to-vascular access (for patients receiving PCI) times as measures of quality of care provided.

• Goals of ED care are rapid identification of patients with STEMI, exclusion of alternative causes of nonischemic chest pain, and stratification of patients with acute coronary ischemia into low- and high-risk groups.
• Obtain intravenous access, administer supplemental oxygen, and provide telemetry monitoring if these procedures have not already been accomplished in the prehospital phase. In addition, obtain a 12-lead ECG as soon as possible after arrival.
• Complete a history and physical examination, with focus on risk factors for coronary ischemia; onset, duration, and pattern of symptoms; and early identification of complications of myocardial ischemia (eg, new murmurs, CHF).
• Perform frequent reassessment of vital signs and symptoms in response to administered therapies.
• Serial ECGs and continuous ST-segment monitoring may be useful.
• Many EDs have an observation unit that may be an appropriate disposition for patients who meet admission criteria.
• Medical therapy, as discussed in Medication, is indicated.

Consultations

Cardiology or interventional cardiology consultation may be indicated for patients with any of the following:

• STEMI - Depending on the center, the patient may be a candidate for PCI, and immediate interventional cardiology consultation is indicated.
• Ongoing symptoms highly suggestive of acute coronary ischemia and nondiagnostic ECG (eg, left bundle-branch block [LBBB])
• Ongoing symptoms refractory to aggressive medical therapy
• Hemodynamic instability
• Evidence of acute valvular dysfunction
• Shock
• Known severe aortic stenosis and ongoing symptoms
• Uncertainty of the diagnosis

Date: 2015-01-12; view: 796