Acute Coronary Syndrome – The ACS Algorithm
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Article at a Glance
- The Acute Coronary Syndromes include STEMI, NSTEMI, and unstable angina.
- A 12-lead ECG helps distinguish among the ACS categories.
- Pre-hospital acute coronary syndrome treatment is essential to reducing morbidity and mortality.
- Timely reperfusion therapy increases survival rates.
Clinicians must know how to identify and manage patients with acute coronary syndromes (ACS). Patients with acute myocardial ischemia (unstable angina), non-ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI) fall under the ACS umbrella. Acute coronary syndromes include STEMI, NSTEMI, and unstable angina, heart conditions associated with sudden, reduced blood flow to the heart. A 12-lead ECG helps clinicians distinguish one condition from another. Based on ECG results, a patient with ACS may be diagnosed with: (1) ST-segment elevation with ongoing acute myocardial infarction, (2) ST-depression myocardial ischemia, or (3) non-diagnostic or normal ECG. Early ACS management via reperfusion intervention is critical to treatment success. Acute ischemia may rapidly progress, resulting in sudden cardiac arrest or hypotensive bradyarrhythmia.1 Clinicians must examine the patient’s clinical history, physical examination, and 12-lead ECG findings to anticipate treatment strategies. Treatment may involve defibrillation, drug therapies, and pacing for symptomatic bradycardia. A 12-lead ECG helps clinicians determine the type of acute coronary syndrome. Read: Cardiac Arrest Circular Algorithm ExplainedIntroduction
The Acute Coronary Syndrome Algorithm
Clinicians should follow the Acute Coronary Syndrome Algorithm to direct treatment.
Related Video – Understanding the Acute Coronary Syndrome Algorithm
ACS patients are prone to developing ventricular fibrillation (VF) during the first four hours after the onset of chest pain.2 VF or pulseless ventricular fibrillation (pVT), especially in the out-of-hospital cardiac arrest patient, may be fatal. Ventricular fibrillation features a rapid and erratic heart rhythm. Laypersons in the pre-hospital setting should be trained in basic life support (BLS) and first aid. Further, EMS must determine if the patient is experiencing myocardial infarction or another type of chest pain. If necessary, EMS performs early defibrillation with an AED. The provider’s primary goal is to provide reperfusion therapy as soon as possible to increase survival rates.3 Reperfusion therapies dilate the occluded coronary artery (or arteries). It involves percutaneous coronary intervention, or stenting, and uses fibrinolytics and drug therapies which dissolve occlusion and improve blood flow to the myocardium. A stent is placed in a coronary artery to reperfuse the heart. The ACS algorithm shows responders the necessary steps to assess and manage patients presenting with ACS symptoms. In the prehospital setting, EMS is responsible for the immediate assessment and initial intervention. ACS treatments may involve the use of oxygen supplementation, aspirin, nitroglycerin, and morphine. EMS must quickly record the patient’s 12-lead ECG to inform hospital clinicians and other field EMS what intervention they should perform next. Depending on the 12-lead ECG findings, responders may start adjunctive therapies or perform a reperfusion intervention, such as administration of a fibrinolytic. Some patients may require close monitoring and serial troponins to rule out ACS. Responders have a checklist to evaluate if the patient can undergo medical treatment by fibrinolysis. The ACS algorithm aims to triage patients based on symptoms and the ECG interpretation.4 Clinicians may request tests when the patient arrives at the hospital. For example, providers should order labs, which may include CK-MB, troponin, coagulation studies, and other tests. For STEMI patients, providers may administer fibrinolytic therapy or perform diagnostic coronary angiography with possible angioplasty. The three acute coronary syndromes are STEMI, NSTEMI, and unstable angina. It’s paramount that providers know how to read and interpret a 12-lead ECG to diagnose a patient. EMS and other providers must know how to treat an ACS patient in the prehospital setting. Keep in mind, reperfusion therapy increases survival rates.Goals for Management of ACS Patients
Related Video – One Quick Question: What are ACLS Algorithms?
Summary
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Editorial Sources
ACLS Certification Association (ACA) uses only high-quality medical resources and peer-reviewed studies to support the facts within our articles. Explore our editorial process to learn how our content reflects clinical accuracy and the latest best practices in medicine. As an ACA Authorized Training Center, all content is reviewed for medical accuracy by the ACA Medical Review Board.
1. EuroIntervention. Cardiac arrhythmias in acute coronary syndrome. 2014.
2. Justine Bhar-Amato, William Davies, and Sharad Agarwal. Ventricular Arrhythmia after Acute Myocardial Infarction: ‘The Perfect Storm’. National Library of Medicine. 2017.
3. Eric R. Bates. Reperfusion Therapy Reduces the Risk of Myocardial Rupture Complicating ST‐Elevation Myocardial Infarction. Journal of the American Heart Association. 2014.
4. B. B. L. M. IJkema, J. J. R. M. Bonnier, D. Schoors, M. J. Schalij, and C. A. Swenne. Role of the ECG in initial acute coronary syndrome triage: primary PCI regardless of presence of ST elevation or of non-ST elevation. National Library of Medicine. 2014.
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