Table 3. Assessment and treatments to consider in patients who present with an acute coronary syndrome. Patients with ST-segment elevation or new BBB are candidates for the full list.

Initial Assessment

  • Targeted history, including AMI inclusions, thrombolytic exclusion
  • Vital signs and focused physical examination
  • 12-lead ECG; serial ECGs as needed
  • Chest x-ray (preferably upright)
  • ECG monitoring

Initial General Treatment (Memory aid: "MONA")

  • Morphine 2-4 mg q 5-10 min to provide adequate analgesia
  • Oxygen at 4 L/min; continue if arterial oxygen saturation < 90%
  • Nitroglycerin sublingual or IV; test for Prinzmetal's angina, reversible spasm; has anti-ischemic, antihypertensive effects
  • Aspirin 160-325 mg (chew and swallow)

Specific Treatments

  • Reperfusion therapy: goals
    • Thrombolytic agents: door-to-needle time < 30 min
    • Primary PTCA: door-to-dilation time < 60 min
  • Conjunctive therapy (combined with thrombolytic agents)
    • Aspirin
    • Heparin (especially with TPA)
  • Adjunctive therapies
    • ß-Adrenoceptor blockade if eligible
    • IV nitroglycerin (for anti-ischemic and antihypertensive effects)
    • ACE inhibitor (especially large anterior wall MI, heart failure without hypotension [SBP > 100 mm Hg], previous MI)
SBP indicates systolic blood pressure.