ACLS FOR ACUTE CORONARY SYNDROME (ACS)
Acute Coronary Syndrome (ACS) is a medical emergency that results from sudden, reduced blood flow to the heart. It includes:
Unstable Angina (UA) – No myocardial infarction (MI), but high risk. Non-ST-Elevation Myocardial Infarction (NSTEMI) – MI without ST elevation. ST-Elevation Myocardial Infarction (STEMI) – MI with full-thickness heart damage.
Why It’s Important:
Early recognition and rapid intervention reduce heart muscle damage. Immediate treatment improves survival and prevents complications. Timely reperfusion (PCI or fibrinolytics) is critical for STEMI patients.
RECOGNIZING ACS: SIGNS & SYMPTOMS
Classic Symptoms: Chest pain or discomfort – Pressure, squeezing, tightness, or burning sensation. Pain radiation – To arms, shoulders, neck, jaw, or back.
Associated Symptoms: Shortness of breath Nausea/vomiting Diaphoresis (sweating) Lightheadedness or syncope (fainting)
Key Takeaway: ACS should be suspected in ANY patient with chest discomfort—early ECG and intervention are crucial!
INITIAL ASSESSMENT & STABILIZATION (PRIMARY ACLS INTERVENTIONS)
Step 1: Airway, Breathing, Circulation (ABCs)
Ensure a patent airway. Assess breathing and oxygenation (SpO₂ goal: ≥90%). Monitor circulation (pulse, blood pressure, perfusion).
Step 2: Obtain a 12-Lead ECG (within 10 minutes)
Essential to determine STEMI vs. NSTEMI/Unstable Angina. STEMI requires immediate reperfusion therapy.
Step 3: Establish IV Access
For medication administration and fluids.
MEDICATIONS FOR INITIAL ACS MANAGEMENT (MONA-B)
| Medication | Dosage & Indication | Notes |
|---|---|---|
| M – Morphine | 2-4 mg IV every 5-15 min PRN | For pain unrelieved by nitroglycerin. Avoid if hypotensive. |
| O – Oxygen | If SpO₂ <90% | Routine oxygen is NOT needed unless hypoxic. |
| N – Nitroglycerin | 0.3-0.6 mg SL every 5 min (max 3 doses) | Avoid if SBP <90 mmHg, RV infarct, or PDE-5 inhibitors (e.g., Viagra). |
| A – Aspirin | 162-325 mg PO (chewed) | Give ASAP unless contraindicated. |
| B – Beta-Blockers | Metoprolol 5 mg IV every 5 min (Max: 15 mg) | Start within 24 hrs unless contraindicated. |
Key Takeaway: MONA-B is the foundation of early ACS treatment, but STEMI requires additional interventions!
DIFFERENTIATING STEMI VS. NSTEMI/UNSTABLE ANGINA
| Feature | STEMI | NSTEMI/Unstable Angina |
|---|---|---|
| ECG Findings | ST elevation in ≥2 contiguous leads | ST depression, T-wave inversion, or normal ECG |
| Cardiac Biomarkers | Elevated troponins | Elevated (NSTEMI) or normal (UA) |
| Pathophysiology | Complete coronary artery occlusion | Partial occlusion |
| Treatment Goal | Immediate Reperfusion (PCI or Fibrinolytics) | Antiplatelets & Anticoagulation |
STEMI = EMERGENCY! Immediate PCI within 90 minutes OR fibrinolytics within 30 minutes.
STEMI MANAGEMENT: IMMEDIATE REPERFUSION
PCI (Percutaneous Coronary Intervention) = GOLD STANDARD! Preferred if available within 90 minutes. Coronary stent placement restores blood flow.
Fibrinolytic Therapy (If PCI Unavailable Within 120 Minutes) Give within 30 minutes of arrival. Examples:
- Alteplase (tPA) – 15 mg IV bolus, then infusion.
- Reteplase – 10 U IV over 2 min, repeat in 30 min.
- Tenecteplase – Weight-based IV bolus.
Contraindications to Fibrinolytics:
Active bleeding, history of hemorrhagic stroke, recent major surgery, severe hypertension (>185/110).
Antiplatelet & Anticoagulation Therapy (For ALL STEMI Patients) Dual Antiplatelet Therapy (DAPT)
- Aspirin (162-325 mg) + P2Y12 inhibitor (e.g., Clopidogrel, Ticagrelor). Anticoagulation
- Heparin, Enoxaparin, or Bivalirudin until PCI is performed.
Key Takeaway: Reperfusion within 90 minutes for PCI or 30 minutes for fibrinolysis saves lives!
NSTEMI/UNSTABLE ANGINA MANAGEMENT
NSTEMI does NOT require immediate fibrinolysis. Focus on medical therapy & risk stratification:
Antiplatelets (DAPT) – Aspirin + Clopidogrel/Ticagrelor. Anticoagulation – Heparin or Enoxaparin. Beta-Blockers – Reduce myocardial oxygen demand. Nitroglycerin – For symptom relief. Statins – High-intensity therapy (e.g., Atorvastatin 80 mg). Evaluate for PCI – If high-risk, perform early invasive strategy.
Key Takeaway: NSTEMI is treated with aggressive medication management & risk-based PCI.
TRANSPORT TO A CARDIAC CENTER
STEMI patients MUST be transferred to a PCI-capable facility!
Primary PCI goal: Within 90 minutes of first medical contact. Fibrinolytics if PCI unavailable within 120 minutes. Ongoing monitoring for arrhythmias, hypotension, or worsening ischemia.
COMMON MISTAKES & HOW TO AVOID THEM
| Mistake | Impact | Prevention |
|---|---|---|
| Delaying ECG (>10 minutes) | Misses early STEMI diagnosis | Obtain ECG immediately! |
| Not giving aspirin | Increased clot formation | Give 162-325 mg ASAP unless contraindicated. |
| Using nitroglycerin in RV infarct | Can cause severe hypotension | Avoid NTG if ST elevation in leads II, III, aVF. |
| Delaying reperfusion therapy | Increased myocardial damage | PCI within 90 min, fibrinolytics within 30 min! |
Key Takeaway: Time is muscle—delays lead to worse outcomes!
SUMMARY: MASTERING ACLS FOR ACS
Recognize ACS early – obtain a 12-lead ECG within 10 min. MONA-B for all ACS patients (Morphine, Oxygen, Nitroglycerin, Aspirin, Beta-blockers). STEMI requires immediate reperfusion (PCI or fibrinolytics). NSTEMI is treated with medications and risk-based PCI. Rapid transport to a PCI-capable facility is essential.
Takeaway: Quick recognition, early ECG, and timely intervention save lives in ACS!