Care Process Model

MARCH

2013

GUIDELINES FOR DIAGNOSIS AND MANAGEMENT OF

Acute Coronary Syndrome (ACS)

at Intermountain Healthcare Emergency Departments 03/04/2013 update

These guidelines were developed by Intermountain Healthcares Cardiovascular Clinical Program. They are intended to guide diagnosis and treatment of
patients presenting to any Intermountain Emergency Department with signs and symptoms that suggest acute coronary syndrome (ACS). Recommendations
are based on stratification into ACS-probability categories, along with capabilities of individual facilities. The guidelines may need to be adapted to meet the
individual needs of a specific patient and should not replace clinical judgment.
The inside pages of this tool provide a quick reference table to guide the diagnosis and management of ACS. The table can be folded open and posted in your
facility. Medication dosing tables are on the back side (page 4). Links are provided for medication guidelines and other related resources.

Basic Principles for ACS:

STEMI patients should have rapid reperfusion (unless contraindicated):
- Primary PCI (PPCI) in <90 minutes is preferred (on-site or transfer to a hospital with
interventional capabilities) OR
- If PPCI in 90 minutes cannot be achieved, fibrinolytic in 30 minutes from ED presentation
along with rapid transfer to an interventional facility for rapid angiography OR
- If transfer PPCI can be assured within 120 minutes, consider PPCI instead of fibrinolytic

All

All HIGH Probability ACS patients should be transferred to a hospital with interventional
capabilities within 24 hours. This will allow diagnostic catheterization and revascularization
to be performed within the time requirements of national guidelines.

All STEMI and High Probability ACS patients should have evaluation of left ventricular function
performed during their initial hospitalization.

For MODERATE and LOW Probability ACS patients presenting to the ED, initial negative Troponin-I
and ECG are not enough to rule out ACS. Also required are a second set of Troponin-I and
follow-up ECG at 3 hours from ED arrival. In most cases, a negative stress test is also required.

Key References:
OGara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA Guideline for
the Management of ST-Elevation Myocardial Infarction: Executive Summary:
A Report of the American College of Cardiology Foundation/American
Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol.
2013;61(4):485-510.
Jneid H, Anderson JL, Wright RS, et al. 2012 ACCF/AHA focused update of
the guideline for the management of patients with unstable angina/non-STelevation myocardial infarction (updating the 2007 guideline and replacing
the 2011 focused update): a report of the American College of Cardiology
Foundation/American Heart Association Task Force on Practice Guidelines.
J Am Coll Cardiol. 2012;60(7):645-81.

GUIDELINES FOR DIAGNOSIS AND MANAGEMENT OF

Acute Coronary Syndrome (ACS) - 2013 update (Rev 03/04/2013)

Use the tables below to guide the diagnosis and management of ACS presenting at Intermountain emergency departments.

Diagnosis: Assign the patient to an ACS-probability category based on signs and symptoms.
HIGH Probability ACS:

STEMI

MODERATE
Probability ACS

Non-ST-Elevation MI (NSTEMI) OR
Definite Unstable Angina

(ST-elevation MI)

LOW
Probability ACS

Symptoms

Typical of or consistent with ischemia/

infarction

Strongly suggestive of ischemia/infarction

Strongly suggestive of ischemia

Suggestive but atypical for ischemia

ECG

Ischemic ST elevation in 2 or more

contiguous leads OR
Hyperacute T-waves OR
Signs of acute posterior MI OR
LBBB obscuring ST-segment analysis with
MI symptoms

ST depression >1 mm OR
Deep T-wave inversion

Normal or non-specific, with or without pain.

(Must be normal at 0 and 3 hours from ED
arrival, and consider ECG at 6, 12, and 18 hours.
If abnormal, continue with HIGH Probability
ACS column.)

Normal or non-specific, with or without pain.

(Must be normal at 0 hours and at 3 to 6 hours
from ED arrival. If abnormal, continue with
HIGH Probability ACS column.)

Troponin-I (cTnI)

May or may not be elevated at 0 hours;

typically elevated at 6 hours
Initial diagnosis and reperfusion decision
must be made immediately, before Troponin-I
results are available.

Carefully evaluate signs, symptoms, ECG,

and risks to establish diagnosis. Elevated
troponin is most helpful (see below), but
consider other causes for troponin elevation,
(both absolute and change in CtNI levels).

Non-AMI Causes of Elevated Troponin-I

CHF
Malignancy
Viral or stress cardiomyopathy Pulmonary embolus
Myocarditis, pericarditis
Infiltrative diseases
Trauma
Toxicity or sepsis
Stroke
Renal failure
Subarachnoid hemorrhage
Ablation procedures

Baseline cTnl (ng/mL)

<0.04 ng/mL
Low clinical risk
and cTnl more than
4-6 hrs since onset
of chest pain

Stress test

0.1 to <2.0 ng/mL

>2.0 ng/mL

Retest cTnl at 3 hrs

Retest cTnl at 3 hrs

AMI

Increase
<50%

Increase
>50%

Increase
<20%

Increase
>20%

Stress test

AMI

Stress test

AMI

Higher
clinical
risk

Retest cTnl at 3 hrs

<0.04

0.04 to <0.1 ng/mL

0.04 to <0.1

>0.1

Retest at 3 hrs

AMI

<0.1

Early invasive
strategy*

>0.1

Early invasive strategy*

*Admit to hospital: ASA, enoxaparin;

consider BB; eptifibatide if ongoing
chest pain; cath procedure

Early invasive strategy*

High-risk
indicators for
adverse CV event
Note: Presence of risk
indicators may warrant
moving patient to a
higher ACS probability
category.

Anteroseptal MI
Hypotension, cardiogenic shock
ST changes of inferoposterolateral MI
RV infarction
New significant arrhythmia or heart block
Heart failure
Age >75

Elevated troponin
3 traditional risk factors for CAD
3 traditional risk factors for CAD
Hypotension
Prior coronary stenosis >50%
Prior coronary stenosis >50%
Dynamic ECG changes with pain
Use of ASA within past 7 days
Use of ASA within past 7 days
Prolonged ischemic pain or recurrent pain
Recurrence of pain after initial relief
Recurrence of pain after initial relief
after initial relief
>2 anginal events within prior 24 hours
>2 anginal events within the prior 24 hours
New significant arrhythmia or heart block
Heart failure
Heart failure
>2 anginal events within the prior 24 hours Age >75
Age >75
Heart failure
Age >75
If evaluation is negative for ischemia, consider pulmonary embolism, pericarditis, aortic dissection, and GI as potential causes.

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Management: Admit and treat patient based on ACS-probability category.

HIGH Probability ACS:

STEMI

Non-ST-Elevation MI (NSTEMI) OR
Definite Unstable Angina

(ST-elevation MI)

Admit Status
Diagnostic and
therapeutic care

Initial medications
and treatment
(unless contraindicated;
see footnotes and
back for notes and
contraindications)

Note: See Antiplatelet

Guidelines for Stent
Placement for details
on dosing P2Y12 agents
(clopidogrel, prasugrel,
ticagrilor) and P2Y12
function testing

Adjunct care
(unless contraindicated;
see footnotes and
back for notes and
contraindications)

Cath lab / CCU

CCU

Immediate Cath/PCI1
( 90 minute door to PCI)

Delayed Cath/PCI
(>90 minutes door to PCI)

URGENT REPERFUSION
Primary PCI (PPCI) in 90
minutes door-to-balloon time
(see STEMI Orders:
Primary PCI)
ECG and Troponin-I at 0, 3
to 6, 12 and 18 hours from
ED arrival
Lipids and BNP

ECG and Troponin-I at ECG and Troponin-I at

URGENT REPERFUSION
0, 3-6, 12, and 18 hours
0, 3-6, 12 and 18 hours
Fibrinolytic in 30 minutes
from ED arrival
from ED arrival
(see dosing on back). Do not
give GPI (GP IIb/IIIa inhibitor) Cath with
Cath or transfer to
with fibrinolytic
interventional center within
intervention (ASAP
24 hours (preferably 12) or
ECG and Troponin-I at
for ongoing chest pain or
immediately if ongoing pain.
0, 3 to 6, 12 and 18 hours
hemodynamic instability)
from ED arrival
Lipids and BNP
Lipids and BNP
Transfer immediately to
interventional center for
cath/PCI
Lipids and BNP

In the ED:
Aspirin, NTG, and O2
Heparin bolus only (see
STEMI UFH Bolus... on back)
Morphine, prn
In the cath lab:
Clopidogrel 600 mg
OR ticagrelor 180 mg OR
prasugrel2 60 mg
PO (load)
Anticoagulant: heparin or
bivalirudin
GPI per cardiologist (eg, for
high clot burden)

In the ED:
Aspirin, NTG, and O2
Clopidogrel:
Age <75, 300 mg by mouth
Age 75, 75 mg by mouth
Enoxaparin (see dosing
on back)
Morphine, prn
(GPI or anticoagulant agent
administered in cath lab per
cardiologist)

Onsite Urgent or Early

Invasive (<12 hours)

Elective Invasive or Transport

Patient (Ideally <48 hours)

In the ED:
Aspirin, NTG, and O2
Heparin (see ACS/NonSTEMI UFH... on back)
Eptifibatide or GPI
per cardiologist (see
dosing on back)
Morphine, prn

In the ED:
Aspirin, NTG, and O2
Enoxaparin (see dosing
on back)
Eptifibatide or GPI per
cardiologist (see dosing
on back)
Morphine, prn
In the cath lab:
In the cath lab:
Clopidogrel 600 mg OR Clopidogrel 600 mg OR
ticagrelor 180 mg OR
ticagrelor 180 mg OR
prasugrel2 60 mg
prasugrel2 60 mg
PO (load) if PCI
PO (load) if PCI
Additional enoxaparin
Heparin or bivalirudin
(per guideline)

Statin - high dose; start ASAP

GPI - consider discontinuing 4 hrs after clopidogrel load or 2 hrs after prasugrel/ticagrilor load, or consider infusing up to
18 hours for highest risk cases
Bivalirudin without GPI - requires concomitant P2Y12 therapy (see Antiplatelet Guidelines); consider discontinuing shortly
after stenting
Oral beta blocker3
ACEI (or ARB) - when BP stable (required for EF <40%)
Aldosterone blocker - if EF <40% and symptomatic heart failure or diabetes
P2Y12 inhibitor for at least 12 months4 clopidogrel (75-150 mg/day for one week followed by 75 mg/day) OR
ticagrelor (90 mg twice daily) OR prasugrel (10 mg/day)2
Aspirin 81 mg per day

MODERATE
Probability ACS

LOW
Probability ACS

Hospital telemetry >18 hours

ER/Observation

ECG and Troponin-I at 0 and 3

hours from ED arrival (consider 6,
12, and 18 hours from arrival)
If higher risk: Transfer for
cath/PCI within 48 hours (preferably
<12 hours) immediately if
ongoing pain.
If low-moderate risk with normal
enzymes, negative ECG, and no
recurrent chest pain, imaging stress
test before discharge. OR, discharge
after 24 hours on aspirin and beta
blocker; arrange for imaging stress
test within 48 hours.
Lipids and BNP

ECG and Troponin-I

at 0 and 3 hours from
ED arrival (consider 6,
12, and 18 hours from
arrival)
Lipids and BNP
If higher risk:
imaging stress test
before discharge or
within 48 hours.
If low-moderate risk
and stable vitals:
consider discharge and
imaging stress test
within 72 hours.

Aspirin, NTG, and O2

Enoxaparin (see Enoxaparin
dosing on back)
Oral beta blocker3
Morphine, prn

Medications as

Statin
ACEI (or ARB) when BP stable
if EF <40%
Aldosterone blocker if EF <40%
and symptomatic HF or DM

As indicated

indicated

If PCI, P2Y12 inhibitor for at

least 12 months5 for bare metal
stent or drug-eluting stent
clopidogrel (75 mg/day) OR
ticagrelor (90 mg twice daily) OR
prasugrel2 (10 mg/day)

1. Immediate Cath/PCI: On-site cath lab or transferable to interventional center in <60 minutes from ER to receiving hospital cath lab. Refer to STEMI Orders: Primary PCI or STEMI Orders: Fibrinolytic Pathway.
2. Prasugrel: Avoid if CVA or TIA history; increases bleeds in patients >75 years or <60 kg. In patients <60 kg, manufacturer suggests 5 mg daily maintenance dose, but no prospective clinical trial data exist to support this recommendation.
Clopidogrel, prasugrel, and ticagrelor: Consider platelet function testing for all ACS and high-risk elective PCI patients; see Antiplatelet Guidelines.
3. Oral beta blocker (BB) within 24 hours for patients without signs of HF, low-output, risk for cardiogenic shock, or other relative contraindications. Avoid IV BB except in STEMI patients with hypertension or tachyarrythmias and
without signs of HF, low-output, risk for cardiogenic shock, or other relative contraindications.
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4. May discontinue P2Y12 inhibitor earlier, especially for bare metal stent, if patient is at high bleeding risk.

TNKase Dosing Instructions (See TNKase guideline)

Weight (kg)
<60 kg
6069 kg
7079 kg
8089 kg
>90 kg

Notes:
Do not give if GPI (GP IIb/IIIa inhibitor) was
given (e.g., abciximab, eptifibatide, or tirofiban).

Dose
30 mg IV bolus over 5 seconds
35 mg IV bolus over 5 seconds
40 mg IV bolus over 5 seconds
45 mg IV bolus over 5 seconds
50 mg IV bolus over 5 seconds

With TNK bolus, also begin enoxaparin

(see table at right).

Indications

Contraindications

Cautions and Relative Contraindications

ECG showing any of the following:

Ischemic ST elevation
(>1 mm) in 2 or more
contiguous leads
Hyperacute T-waves
Signs of acute posterior MI or
LBBB obscuring ST segment
analysis with MI History
History of acute coronary syndrome
Pain/symptoms within the past 24
hours, with or without
ongoing symptoms

Previous
hemorrhagic stroke at
any time; other strokes
or cerebrovascular
events within 1 year
Known intracranial
neoplasm
Active internal bleeding
(does not include
menses)
Suspected aortic
dissection

Severe, uncontrolled hypertension on presentation

(>180/110 mm Hg) or hx of chronic severe hypertension
History of CVA or known intracerebral pathology
Current anticoagulant therapy (INR >2-3); known
bleeding diathesis
Recent trauma, prolonged CPR (>10 min) or major
surgery (<3 weeks)
Noncompressible vascular punctures
Recent (within 2-4 weeks) internal bleeding
Age > 75 years
Pregnancy
Active peptic ulcer

Enoxaparin Dosing Instructions (See Enoxaparin guideline)

FIBRINOLYTIC STEMI
CrCl > 30 mL/min

CrCl < 30 mL/min

CrCl > 30 mL/min

CrCl < 30 mL/min

<75

30 mg IV bolus followed
15 min later by 1 mg/kg
subcut every 12 hours
(max 100 mg first 2 doses)

30 mg IV bolus followed
15 min later by 1 mg/kg
subcut once daily (max
100 mg first 2 doses)

1 mg/kg subcut
every 12 hours

1 mg/kg subcut
once daily

75

No bolus. 0.75 mg/kg

subcut every 12 hours
(max 75 mg first 2 doses)

No bolus. 1 mg/kg
subcut once daily
(max 75 mg first 2 doses)

Contraindications: Hemodialysis; active major bleeding; recent or planned epidural or dural anesthesia; known or
suspected heparin-induced thrombocytopenia (HIT).

Laboratory monitoring: Draw a baseline BMP, aPTT STAT (include CBC, PT/INR if not done in last 24 hours); draw
CBC every other day while hospitalized; monitor BMP if clinical situation suggests risk of decline in renal function.

Cautions: Thrombocytopenia (platelet count less than 100,000/mm3) or known bleeding diathesis; recent internal
bleeding or uncontrollable active bleeding (hospital admission or transfusion in last 30 days); recent (within the
previous 2 weeks) surgery, major trauma, or thrombotic stroke; acute peptic ulcer disease

Eptifibatide Dosing Instructions (See Eptifibatide guideline)

Start with BOLUS

STEMI: UFH Bolus Only

Patients Going to Cath Lab
Weight (kg)

Less than 46 kg
4652 kg
5361 kg
6270 kg
7180 kg
8190 kg
Over 90 kg

IV Bolus Dose (60 unit/kg)

2500 units
3000 units
3500 units
4000 units
5000 units
5500 units
6000 units

Steps (non-STEMI):
1. Draw baseline aPTT
STAT (include CBC,
PT/INR if not done in
last 24 hours).
2. Give initial dosage as
in Table 1 above.
3. Use aPTT testing to
monitor and adjust
dose as per
Table 2 at right.

ACS/Non-STEMI: UFH Bolus + Infusion

(See Heparin, unfractionated for ACS guideline)

Table 1. Non-STEMI initial dosage and
infusion rate (standard concentration of 100
units/mL)
Weight (kg)
Bolus Dose Infusion Rate
Less than 46 kg 2500 units
500 units/hour
4652 kg
3000 units
600 units/hour
5361 kg
3500 units
700 units/hour
6270 kg
4000 units
800 units/hour
7077 kg
4000 units
900 units/hour
Over 77 kg
4000 units
1000 units/hour

Table 2. Monitoring and adjustment (non-STEMI)

PTT
Heparin
Infusion rate
Labs
Less than 40 sec Bolus 3000 units Increase by 100 units/hr aPTT every 6 hr x 2
None
Increase by 50 units/hr
aPTT every 6 hr x 2
4049 sec
None
No change
aPTT per protocol*
5070 sec
None
Decrease by 50 units/hr
aPTT every 6 hr x 2
7185 sec
Hold for 30 min Decrease by 100 units/hr aPTT every 6 hr x 2
86100 sec
Hold for 30 min Decrease by 150 units/hr aPTT every 6 hr x 2
101150 sec
Over 150 sec
Hold for 1 hr
Decrease by 300 units/hr aPTT every 6 hr x 2
* After 2 consecutive aPTTs in the therapeutic range of 50-70 seconds, draw aPTT daily in am.

UFH Contraindications: Active major bleeding; recent or planned epidural anesthesia; known or suspected heparin-induced
thrombocytopenia (HIT). For HIT, DO NOT use heparin or LMWH; use a direct thrombin inhibitor.
Cautions: Thrombocytopenia (platelets less than 100,000/mm3) or bleeding diathesis; recent internal bleeding or
uncontrollable active bleeding (admission or transfusion in past 30 days); recent surgery (within the past 2 weeks), major
trauma or thrombotic stroke; acute peptic ulcer disease

Non-STEMI

Age
(yr)

Followed by INFUSION

(180 mcg/kg over 1-2 minutes)*

(Consider discontinuing 4 hours after clopidogrel load or 2 hours after

prasugrel or ticagrelor load. However, consider infusing up to 18 hrs
for highest risk cases.)

Weight (kg)

Amount (mL)

If CrCl >50 mL/min, continuous

infusion at 2 mcg/kg/min

If CrCl <50 mL/min, continuous

infusion at 1 mcg/kg/min

3741 kg
4246 kg
4753 kg
5459 kg
6065 kg
6671 kg
7278 kg
7984 kg
8590 kg
9196 kg
97103 kg
104109 kg
110115 kg
116121 kg
>121 kg

3.4 mL
4.0 mL
4.5 mL
5.0 mL
5.6 mL
6.2 mL
6.8 mL
7.3 mL
7.9 mL
8.5 mL
9 mL
9.5 mL
10.2 mL
10.7 mL
11.3 mL

6 mL/hour
7 mL/hour
8 mL/hour
9 mL/hour
10 mL/hour
11 mL/hour
12 mL/hour
13 mL/hour
14 mL/hour
15 mL/hour
16 mL/hour
17 mL/hour
18 mL/hour
19 mL/hour
20 mL/hour

3 mL/hour
3.5 mL/hour
4 mL/hour
4.5 mL/hour
5 mL/hour
5.5 mL/hour
6 mL/hour
6.5 mL/hour
7 mL/hour
7.5 mL/hour
8 mL/hour
8.5 mL/hour
9 mL/hour
9.5 mL/hour
10 mL/hour

*Notes:
If patient presents to cath lab within 2 hours of first bolus, re-bolus with 180 mcg/kg over 12 minutes.
Do NOT re-bolus if >2 hours after first bolus (platelet inhibition should be therapeutic)

Start aspirin and unfractionated heparin (UFH) or enoxaparin, if not previously done and PCI has not been done:
UFH: Follow conventional ACS/Non-STEMI UFH dosage/admin at left.
Enoxaparin (Lovenox): Follow dosing/admin instructions above.
Obtain platelet count 3 hours after initial eptifibatide bolus.
Eptifibatide Contraindications: Active abnormal bleeding within previous 30 days or history of bleeding diathesis;
stroke within past 30 days or history of hemorrhagic stroke; severe hypertension (systolic >200 or diastolic >110) not
adequately controlled on antihypertensive therapy; major surgery within past 6 weeks; dependency on hemodialysis

2008-2013 Intermountain Healthcare. All rights reserved. Cardiovascular Clinical Program.

Patient and Provider Publications. 801-442-2963 CPM026 - Rev 03/04/2013

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