Usually the patient presents with substernal chest pain radiating towards neck, jaw or left arm, may be associated with Dyspnea, diaphoresis, nausea, vomiting and gets worse with exertion. It could resemble pain similar to prior episode when patient had MI.
Cardiac Risk Factors: Diabetes, HTN, Hyperlipidemia, Smoking, Family History of premature CAD (1stdegree: male< 55, Female< 65)
EMS:
IV fluids
NTG SL
Oxygen
ASA 4 tablets of 81 mg each
EKG
ER:
Routine labs, CXR
EKG (If there is STEMI, you probably won’t be involved as Cardiology takes over)
ASA PO or Plavix if allergic to ASA
Avoid Beta blocker in chest pain patients from cocaine as it leads to unopposed alpha stimulation
Calcium Channel blocker if patient can not tolerate beta blocker
NTG SL q 5min, max of 3 times or Nitropaste-not if patient is using Viagra
Cardiac enzymes Q 6-8hrs total of 3-4 times
oxygen
Morphine iv 2mg Q 5 min for severe CP
Hospitalist:
ASA 81mg PO
Lipid panel
2D ECHO
Heparin gtt/ SQ Lovenox 1mg/kg for USA/NSTEMI
NitroPaste/NTG drip if chest pain continues
NPO in AM for Stress test-Exercise stress test if they can run to get HR more than 85% of max predicted (220-age), Dobutamine stress test in Asthma and COPD or else pharmacologic stress test if unable to exercise, LBBB etc.
Avoid Coffee and Beta blocker morning of exercise stress test
Smoking Cessation and Exercise counseling
TIMI risk score: Each one gets one point. (0,1-5%, 2-8%, 3-13%, 4-20%, 5-26%, 6,7-41% risk of Death, MI, Urgent Revascularization by 14 days )
Age>=65
>= 3 risk factors for CAD
Known CAD >50% stenosis
ASA use in last 7 days
Severe Angina 2 or more episodes in last 24hrs
ST deviation>=0.5mm
Positive cardiac markers
By Cardiologist:
Catheterization and if stented then Bare metal stents need bare minimum of one month and Drug eluting stents need 6-12 months of Plavix
Beta Blocker PO
Statin PO
CT Surgeon:
CABG for severe coronary disease
Acute Pericarditis: pain often pleuritic, relieved with sitting up, ST segment elevation, upward concave, PR segment depression, usually see leukocytosis, consider ASO, 60% have effusion on echo
Treatment is generally NSAIDs, then Steroids: use Colchicine for recurrent pericarditis if creatinine ok.
Earn CME from UpToDate: Overview of the acute management of non-ST elevation acute coronary syndromes
