Rule out MI

Admit to Telemetry

• Tele-nurse may reach out to you for > 6 PVCs/min, atrial fibrillation, ventricular fibrillation, > 3 beats of VT.

• Admit as “observation status” if the patient will likely be discharged within 24 hours.

Activity

• Bed rest until ruled out (bedside commode okay for low-risk patient).
• Remember to promote ambulation once myocardial ischemia resolves.

Diet

• NPO except meds if possible cardiac catheterization or functional study in the AM. Applies to most patients, especially as ECGs and biomarkers are being trended.
• Hold beta-blockers before exercise or dobutamine stress testing.
• No nitrates or caffeine before vasodilatory (dipyridamole/ adenosine/regadenason) pharmacologic stress testing. Beta blockers are ok (but hold if unsure what type of test until am).
• Metformin should be held in all patients in case they need to undergo coronary angiography, place on SSI; theoretical risk for lactic acidosis

Nursing

• O2 via nasal cannula, starting at 2 L/min. Goal O2 > 95%. 
• ECG on admission, trend as frequently as indicated (with symptoms, to capture evolving infarct, biomarker check, etc)
• CXR on admission.
• Chest pain protocol: vital signs, ECG, NTG 0.4 mg SL q5 minutes x 3, notify MD. ECG during and upon resolution of symptoms.

Labs

• Trend troponin ~q6-8hrs until peak, chem-panel, PT/PTT, lipids, TSH, and HgA1C
• CK-MB and myoglobin are not useful in diagnosis of ACS with contemporary troponin assays.

Medications

• Aspirin 325 mg PO (chewed), 81mg thereafter
• Statin: Atorvastatin 80 mg PO
• Β-blockers: Metoprolol tartrate 25-100 mg PO q12hr, consider IV if hypertensive. Target HR < 70. Avoid in bradycardia, severe bronchospasm or hypotension/concern for shock
• See Acute Coronary Syndrome: ST Segment Elevation or New LBBB for further details and contraindications.
• Pain Control (pain means ongoing ischemia/infarct):
• Reduce demand if indicated (blood pressure and heart rate control)
• Ensure proper anticoagulation (i.e. heparin is therapeutic); Plavix loading
• Nitrates (titrate up as needed): nitro SL (NTG 0.4 mg q5 minutes x 3)-> nitro paste -> nitro gtt (CCU level of care). Avoid in suspected RV infarct
• Morphine PRN (watchout for hemodynamic effects)

If in doubt, discuss with seniors!

Consult with cardiologist (i.e. catheterization, GP IIb/IIIa gtt, CCU care), especially for persistent chest pain in the concerning patient.

References

Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.J Am Coll Cardiol. 2014;64(24):e139-e228. doi:10.1016/j.jacc.2014.09.017.

Ibanez B et al. Effect of early metoprolol on infarct size in ST-segment-elevation myocardial infarcation patients undergoing primary percutaneous coronary intervention: the Effect of Metoprolol in Cardioprotection During an Acute Myocardial Infarction (METOCARD-CNIC) trial. Circulation. 2013;128(14):1495-503.

Meine TJ, Roe, MT, Chen AY, et al. Association of intravenous morphine use and outcomes in acute coronary syndromes: results from the CRUSADE Quality Improvement Initiative. Am Heart J 2005;149:1043-1049.

Chen ZM, Pan HC, Chen YP, et al, COMMIT (ClOpidogrel and Metoprolol in Myocardial Infarction Trial) collaborative group. Early intravenous then oral metoprolol in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial. Lancet 2005;366:1622-1632.