Part 8: Stabilization of the patient with acute Coronary Syndromes A cute myocardial infarction(AMI)and unstable angina rest "and Part 7.3: " Management of Symptomatic Brady (UA)are part of a spectrum of clinical di ardia and Tachycardia") ively identified as acute coronary syndromes(ACS). The pathophysiology common to this spectrum of disease is a An overview of recommended care for the ACS patient is ruptured or eroded atheromatous plaque. -s The electrocar illustrated in Figure l, the Acute Coronary Syndrom diographic (ECG) presentation of these syndromes encom- Igorithm. Part 8 provides details of the care highlighted in asses ST-segment elevation myocardial infarction (STEMD), the numbered algorithm boxes. Box numbers in the text ST-segment depression, and nondiagnostic ST-segment and correspond to the numbered boxes in the algorithm T-wave abnormalities. A non-ST-elevation myocardial in- In this part the abbreviation AMI refers to acute myocar- rction (NSTEMi) is diagnosed cardiac markers are positive with ST-segment depression or with nonspecific or The diagnosis and treatment of AMI, however, will often normal ECGs. Sudden cardiac death may occur with any of differ for patients with STEMI versus NSTEMI. Note care- these conditions. ACS is the most common proximate cause fully which is being discussed of sudden cardiac death 6-10 Effective interventions for patients with ACS, particularly Out-of-Hospital Management STEMI, are extremely time-sensitive. The first healthcare Recognition(Figure 1, Box 1) providers to encounter the ACS patient can have a big impact Treatment offers the greatest potential benefit for myocardial on patient outcome if they provide efficient risk stratification, salvage in the first hours of STEMI. Thus, it is imperative that critical that basic life support(BLS)and advanced cardiovas- ACS as quickly as possible. Delays to therapy occur during 3 cular life support(ACLS)healthcare providers who care for intervals: from onset of symptoms to patient recognition, ACS patients in the out-of-hospital, emergency department during out-of-hospital transport, and during in-hospital eval (ED), and hospital environments be aware of the principles and priorities of assessment and stabilization of these uation. Patient delay to symptom recognition often constitutes the longest period of delay to treatment. atients These guidelines target BLS and ACLs healthcare provid The classic symptom associated with ACs is chest discom ers who treat patients with ACS within the first hours after fort, but symptoms may also include discomfort in other areas onset of symptoms, summarizing key out-of-hospital, ED of the upper body, shortness of breath, sweating, nausea, and and some initial critical-care topics that are relevant to lightheadedness. The symptoms of AMI are characteristically more intense than angina and last >15 minutes. Atypical tions from the acciaha Guidelines, 1.12 which are used symptoms or unusual presentations of ACS are more com- throughout the United States and Canada. 3 As with an medical guidelines, these general recommendations must be Public education campaigns increase public awareness and knowledge of the symptoms of heart attack but have only rea wl tion to individual patients by knowledgeable he transient effects. 20 For patients at risk for ACS(and for their families), physicians should discuss the appropriate use of The primary goals of therapy for patients with ACS are to nitroglycerin and aspirin, activation of the emergency medi- cal services(EMS) system, and location of the nearest Reduce the amount of myocardial necrosis that occurs in hospital that offers 24-hour emergency cardiovascular care. patients with MI, preserving left ventricular (LV) function ecent ACC/AHA guidelines recommend that the patient or and preventing heart failure family members activate the EMS system rather than call Prevent major adverse cardiac events(MACE): death, their physician or drive to the hospital if chest discomfort nonfatal MI, and need for urgent revascularization unimproved or worsening 5 minutes after taking I nitroglyc Treat acute, life-threatening complications of ACS, such as erin tablet or using nitroglycerin spray. 12 ntricular fibrillation (VF)/pulseless ventricular tachycardia(VT), symptomatic bradycardias, and unstable Initial EMS Care(Figure 1, Box 2) chycardias(see Part 7. 2:"Management of Cardiac Ar lalf of the patients who die of AMI do so before reaching the hospital. VF or pulseless VT is the precipitating rhythm in (Circulation. 2005: 112: TV-89-IV-110) o 2005 American Heart Association most of these deaths, 2-23 and it is most likely to develop during the first 4 hours after onset of symptoms. 24-27 Com- This special supplement to Circulation is freely available at munities should develop programs to respond to out-of- hospital cardiac arrest that include prompt recognition of DOI: 10.1161/CIRCULATIONAHA. 105.166561 symptoms of ACS, early activation of the EMS system, anPart 8: Stabilization of the Patient With Acute Coronary Syndromes Acute myocardial infarction (AMI) and unstable angina (UA) are part of a spectrum of clinical disease collec￾tively identified as acute coronary syndromes (ACS). The pathophysiology common to this spectrum of disease is a ruptured or eroded atheromatous plaque.1–5 The electrocar￾diographic (ECG) presentation of these syndromes encom￾passes ST-segment elevation myocardial infarction (STEMI), ST-segment depression, and nondiagnostic ST-segment and T-wave abnormalities. A non–ST-elevation myocardial in￾farction (NSTEMI) is diagnosed if cardiac markers are positive with ST-segment depression or with nonspecific or normal ECGs. Sudden cardiac death may occur with any of these conditions. ACS is the most common proximate cause of sudden cardiac death.6 –10 Effective interventions for patients with ACS, particularly STEMI, are extremely time-sensitive. The first healthcare providers to encounter the ACS patient can have a big impact on patient outcome if they provide efficient risk stratification, initial stabilization, and referral for cardiology care. It is critical that basic life support (BLS) and advanced cardiovas￾cular life support (ACLS) healthcare providers who care for ACS patients in the out-of-hospital, emergency department (ED), and hospital environments be aware of the principles and priorities of assessment and stabilization of these patients. These guidelines target BLS and ACLS healthcare provid￾ers who treat patients with ACS within the first hours after onset of symptoms, summarizing key out-of-hospital, ED, and some initial critical-care topics that are relevant to stabilization. They also continue to build on recommenda￾tions from the ACC/AHA Guidelines,11,12 which are used throughout the United States and Canada.13 As with any medical guidelines, these general recommendations must be considered within the context of local resources and applica￾tion to individual patients by knowledgeable healthcare providers. The primary goals of therapy for patients with ACS are to ● Reduce the amount of myocardial necrosis that occurs in patients with MI, preserving left ventricular (LV) function and preventing heart failure ● Prevent major adverse cardiac events (MACE): death, nonfatal MI, and need for urgent revascularization ● Treat acute, life-threatening complications of ACS, such as ventricular fibrillation (VF)/pulseless ventricular tachycardia (VT), symptomatic bradycardias, and unstable tachycardias (see Part 7.2: “Management of Cardiac Ar￾rest” and Part 7.3: “Management of Symptomatic Brady￾cardia and Tachycardia”) An overview of recommended care for the ACS patient is illustrated in Figure 1, the Acute Coronary Syndromes Algorithm. Part 8 provides details of the care highlighted in the numbered algorithm boxes. Box numbers in the text correspond to the numbered boxes in the algorithm. In this part the abbreviation AMI refers to acute myocar￾dial infarction, whether associated with STEMI or NSTEMI. The diagnosis and treatment of AMI, however, will often differ for patients with STEMI versus NSTEMI. Note care￾fully which is being discussed. Out-of-Hospital Management Recognition (Figure 1, Box 1) Treatment offers the greatest potential benefit for myocardial salvage in the first hours of STEMI. Thus, it is imperative that healthcare providers evaluate, triage, and treat patients with ACS as quickly as possible. Delays to therapy occur during 3 intervals: from onset of symptoms to patient recognition, during out-of-hospital transport, and during in-hospital eval￾uation. Patient delay to symptom recognition often constitutes the longest period of delay to treatment.14 The classic symptom associated with ACS is chest discom￾fort, but symptoms may also include discomfort in other areas of the upper body, shortness of breath, sweating, nausea, and lightheadedness. The symptoms of AMI are characteristically more intense than angina and last
15 minutes. Atypical symptoms or unusual presentations of ACS are more com￾mon in elderly, female, and diabetic patients.15–19 Public education campaigns increase public awareness and knowledge of the symptoms of heart attack but have only transient effects.20 For patients at risk for ACS (and for their families), physicians should discuss the appropriate use of nitroglycerin and aspirin, activation of the emergency medi￾cal services (EMS) system, and location of the nearest hospital that offers 24-hour emergency cardiovascular care. Recent ACC/AHA guidelines recommend that the patient or family members activate the EMS system rather than call their physician or drive to the hospital if chest discomfort is unimproved or worsening 5 minutes after taking 1 nitroglyc￾erin tablet or using nitroglycerin spray.12 Initial EMS Care (Figure 1, Box 2) Half of the patients who die of AMI do so before reaching the hospital. VF or pulseless VT is the precipitating rhythm in most of these deaths,21–23 and it is most likely to develop during the first 4 hours after onset of symptoms.24 –27 Com￾munities should develop programs to respond to out-of￾hospital cardiac arrest that include prompt recognition of symptoms of ACS, early activation of the EMS system, and (Circulation. 2005;112:IV-89-IV-110.) © 2005 American Heart Association. This special supplement to Circulation is freely available at http://www.circulationaha.org DOI: 10.1161/CIRCULATIONAHA.105.166561 IV-89