Acute coronary syndromes (ACS) represent a spectrum of diseases identified according to their associated ECG changes. The ECG may be normal or nondiagnostic (low-/intermediate-risk ACS), abnormal with ischemic changes, or abnormal with evidence of acute injury (i.e., ST elevation myocardial infarction or STEMI).

Patients with coronary atherosclerosis may develop any of these based on the degree or severity of coronary artery occlusion. Occlusion can lead to sudden cardiac death. Thus, the identification and treatment of ACS are vital.

Limiting damage to the heart is time-sensitive when ischemia or infarction occurs. The ACS algorithm guides treatment decisions when a patient presents with symptoms of ischemia.

Patient clutches chest, a potential sign of acute coronary syndrome.

Acute Coronary Syndromes

Short Description

This algorithm outlines the steps guiding the clinician to efficiently assess and manage acute coronary syndrome (ACS).

Goals for the Management of ACS

The clinician must fulfill the following goals to successfully manage ACS:

• Recognize possible ACS and intervene with CPR and defibrillation as necessary.
• Identify STEMI and triage for early reperfusion therapy. 
• Relieve ischemic chest discomfort. 
• Prevent major adverse cardiac events.
• Treat acute, life-threatening complications of ACS (VF/VT, symptomatic bradycardia, and unstable tachycardia).

Algorithm at a Glance

• The clinician recognizes and intervenes in ACS using CPR, medications, and defibrillation, as necessary.
• The identification of ischemia is made early in the process.
• EMS and prehospital responders are essential to stabilize and transport the patient with ACS to definitive care.
• The goal is to provide PCI therapy in < 90 minutes from first medical contact to balloon or fibrinolysis within 30 minutes of ED arrival.

In the emergency department, the type of MI is categorized based on whether or not the 12-lead ECG reveals ST elevation. The ECG is interpreted as STEMI or NSTE-ACS. Patients with STEMI are rapidly evaluated for fibrinolytic or PCI therapy. Patients with NSTE-ACS are further classified as high risk or intermediate/low risk.