Start adjunctive treatments as

Indicated (see text for contraindication)

Do not delay reperfusion
-adrenergic receptor blockers
Clopidogrel
Heparin (!H or "#$H)
Start adjunctive treatments as
Indicated (see text for contraindication)
Do not delay reperfusion
-adrenergic receptor blockers
Clopidogrel
Heparin (!H or "#$H)
Start adjunctive treatments as
Indicated (see text for contraindication)
%itroglycerin
-adrenergic receptor blockers
Clopidogrel
Heparin (!H or "#$H)
&lycoprotein Iib'IIIa in(ibitor
Start adjunctive treatments as
Indicated (see text for contraindication)
%itroglycerin
-adrenergic receptor blockers
Clopidogrel
Heparin (!H or "#$H)
&lycoprotein Iib'IIIa in(ibitor
Develops (ig( or intermediate
risk criteria ()able)
*+
)roponin-positive,
Develops (ig( or intermediate
risk criteria ()able)
*+
)roponin-positive,
Consider admission to -D c(est
pain unit or to monitored bed in -D
!ollo./
Serial cardiac markers (including
troponin)
+epeat -C&'continous S) segment
monitoring
Consider stress test
Consider admission to -D c(est
pain unit or to monitored bed in -D
!ollo./
Serial cardiac markers (including
troponin)
+epeat -C&'continous S) segment
monitoring
Consider stress test
Develops (ig( or intermediate risk
criteria ()able) *+
)roponin-positive,
Develops (ig( or intermediate risk
criteria ()able) *+
)roponin-positive,
If no evidence of isc(emia or infarction0
can disc(arge .it( follo.-up
If no evidence of isc(emia or infarction0
can disc(arge .it( follo.-up
1dmit to monitored bed
1ssess risk status ()able)
1dmit to monitored bed
1ssess risk status ()able)
)ime from onset of symptoms
23 (ours,
)ime from onset of symptoms
23 (ours,
+eperfusion strategy/
)(erapy defined by patient and center criteria
(table)
4e a.are of reperfusion goals/
Door-to-ballon inflation (5Cl) goal of 67 min
Door-to-needle (fibrinolysis) goal of 87 min
Continue adjunctive t(erapies and/
1C- in(ibitor'angiotensin receptor blocker
(1+4) .it(in 39 (ours of symptom onset
H#& Co1 reductase in(ibitor (statin t(erapy)
+eperfusion strategy/
)(erapy defined by patient and center criteria
(table)
4e a.are of reperfusion goals/
Door-to-ballon inflation (5Cl) goal of 67 min
Door-to-needle (fibrinolysis) goal of 87 min
Continue adjunctive t(erapies and/
1C- in(ibitor'angiotensin receptor blocker
(1+4) .it(in 39 (ours of symptom onset
H#& Co1 reductase in(ibitor (statin t(erapy)
Hig(-risk patient ()able)
+efractory isc(emic c(est pain
+ecurrent'persistent S) deviation
:entricular tac(ycardia
Hemodynamic instability
Signs of pump failure
-arly invasive strategy0 including cat(eteri;ation and
revasculari;ation for s(ock .it(in 9< (ours of an 1#I
Continue 1S10 (eparin0 and ot(er t(erapies as indicated=
1C- in(ibitor'1+4
H#& Co1 reductase in(ibitor (statin t(erapy)
%ot at (ig( risk/ cardiology to risk-stratify
Hig(-risk patient ()able)
+efractory isc(emic c(est pain
+ecurrent'persistent S) deviation
:entricular tac(ycardia
Hemodynamic instability
Signs of pump failure
-arly invasive strategy0 including cat(eteri;ation and
revasculari;ation for s(ock .it(in 9< (ours of an 1#I
Continue 1S10 (eparin0 and ot(er t(erapies as indicated=
1C- in(ibitor'1+4
H#& Co1 reductase in(ibitor (statin t(erapy)
%ot at (ig( risk/ cardiology to risk-stratify
> 23 (ours
>es
%o
>es
%o
23 (ours
Chest discomfort
suggestive of Ischemia
Chest discomfort
suggestive of Ischemia
-#S assessment and care and (ospital preparation
#onitor0 support 14Cs= 4e prepare to provide C*+ and defibrillation
1dminister oxygen, aspirin, nitroglycerin, and morphine if need
If available00 obtain 23 ?lead -C&@ if S)-elevation/
%otify receiving (ospital .it( transmission or interpretation
4egin fibrinolytic c(ecklist
%otified (ospital s(ould mobili;ed (ospital resources to respond to
%S)-#I
-#S assessment and care and (ospital preparation
#onitor0 support 14Cs= 4e prepare to provide C*+ and defibrillation
1dminister oxygen, aspirin, nitroglycerin, and morphine if need
If available00 obtain 23 ?lead -C&@ if S)-elevation/
%otify receiving (ospital .it( transmission or interpretation
4egin fibrinolytic c(ecklist
%otified (ospital s(ould mobili;ed (ospital resources to respond to
%S)-#I
+evie. initial 23-lead -C&
+evie. initial 23-lead -C&
S) elevation or ne. or
presumably ne. "444@ strongly
suspicious for injury
ST-elevation MI (STEMI)
S) elevation or ne. or
presumably ne. "444@ strongly
suspicious for injury
ST-elevation MI (STEMI)
Immediate -D assessment (A 27 minutes)
C(eck vital signs@ evaluate oxygen saturation
-stablis( I: access
*btain'vie. 23-lead -C&
5erform brief0 targeted (istory0 p(ysical exam
+evie.'complete fibrinolytic c(ecklist@ c(eck
contraindication
*btain initial cardiac marker levels0 initial electrolytes and
coagulation studies
*btain portable c(est x-ray (A 87 minutes)
Immediate -D assessment (A 27 minutes)
C(eck vital signs@ evaluate oxygen saturation
-stablis( I: access
*btain'vie. 23-lead -C&
5erform brief0 targeted (istory0 p(ysical exam
+evie.'complete fibrinolytic c(ecklist@ c(eck
contraindication
*btain initial cardiac marker levels0 initial electrolytes and
coagulation studies
*btain portable c(est x-ray (A 87 minutes)
Immediate -D general treatment
Start oxygen at 9 "'min@ maintain *
3
sat B 67C
spirin 2D7 ? 83E mg (if not given by -#S)
!itroglycerin sublingual0 spray0 or I:
Morphine I: if pain not relieved by
nitroglycerine
Immediate -D general treatment
Start oxygen at 9 "'min@ maintain *
3
sat B 67C
spirin 2D7 ? 83E mg (if not given by -#S)
!itroglycerin sublingual0 spray0 or I:
Morphine I: if pain not relieved by
nitroglycerine
S) depression or dynamic )-.ave
inversion@ strongly suspicious for isc(emia
"igh ris# unsta$le angina% non-ST-
elevation MI (&%!STEMI)
S) depression or dynamic )-.ave
inversion@ strongly suspicious for isc(emia
"igh ris# unsta$le angina% non-ST-
elevation MI (&%!STEMI)
%ormal or non-diagnostic
c(ange in S)-segment or )-.ave
Intermediate % lo' ris# &
%ormal or non-diagnostic
c(ange in S)-segment or )-.ave
Intermediate % lo' ris# &