Acute Coronary Syndromes Algorithm – 2015 Update

This flowchart depicts Acute Coronary Syndromes Algorithm, as updated in 2015. It consists of numbered boxes and hexagons linked together with arrows. It originates at the top with box number 1. This orange box says, “Symptoms suggestive of ischemia or infarction.” From here, an arrow points downward to box 2. This green box is titled, “EMS assessment and care and hospital preparation.” It contains five main points:
  • Monitor, support ABCs. Be prepared to provide CPR and defibrillation.
  • Administer aspirin and consider oxygen, nitroglycerin, and morphine if needed.
  • Obtain 12-lead ECG. If S.T. elevation: notify receiving hospital with transmission or interpretation; note time of onset and first medical contact.
  • Notified hospital should mobilize hospital resources to respond to Stemi.
  • If considering prehospital fibrinolysis, use fibrinolytic checklist.
An arrow points downward to box 3, which is green. A faint line separates this box into two columns. The heading on the left says, “Concurrent E.D. assessment (less than 10 minutes).” It is followed by six main points:
  • Check vital signs; evaluate oxygen saturation.
  • Establish I.V. access.
  • Perform brief, targeted history, physical exam.
  • Review or complete fibrinolytic checklist; check contraindications.
  • Obtain initial cardiac marker levels, initial electrolyte and coagulations studies.
  • Obtain portable chest x-ray (less than 30 minutes).
The column on the right is titled, “Immediate E.D. general treatment.” It has four main points:
  • If O2 saturation is less than 90%, start oxygen at 4 liters per minute, titrate.
  • Aspirin: 160 to 325 milligrams (if not given by E.M.S.).
  • Nitroglycerin sublingual or spray.
  • Morphine IV if discomfort not relieved by nitroglycerin.
From this box, an arrow points down to item 4, which is a red hexagon titled, “ECG interpretation.” A line leads downward and branches into three pathways, which will be explained one by one. The first arrow points down and to the left to box 5, which is white. It contains the text: “S.T. elevation or new or presumably new LBBB; strongly suspicious for injury.” It concludes with bold text: “S.T.-elevation M.I. (Stemi).” Continuing to follow this pathway, an arrow points down to box 6. This green box contains two points:
  • Start adjunctive therapies as indicated.
  • Do not delay reperfusion.
An arrow leads downward to item 7. This red hexagon asks the question, “Time from onset of symptoms less than or equal to 12 hours?” If the answer is “less than or equal to 12 hours,” an arrow leads down to box 8, which is green and titled “Reperfusion goals.” Its text says, “Therapy defined by patient and center criteria. Door-to-balloon inflation (or PCI) goal of 90 minutes. Door-to-needle (or fibrinolysis) goal of 30 minutes.” It the answer is “more than 12 hours,” an arrow points to the right to box 10, which is orange. (The contents of this box will be covered momentarily.) Going back to the second pathway following hexagon 4, which is titled ECG interpretation, an arrow points straight down to box 9. This white box says, “S.T. depression or dynamic T-wave inversion; strongly suspicious for ischemia.” It concludes with bold text: “High-risk non-ST-elevation ACS .(N.S.T.E.-A.C.S.).” An arrow points straight down from box 9 to orange box 10, mentioned earlier. It contains the text: “Troponin elevated or high-risk patient. Consider early invasive strategy if:
  • Refractory ischemic chest discomfort.
  • Recurrent or persistent S.T. deviation.
  • Ventricular tachycardia.
  • Hemodynamic instability.
  • Signs of heart failure.
Start adjunctive therapies (for example, nitroglycerin or heparin) as indicated.” The third pathway points from the ECG Interpretation” hexagon down and to the right to box 11. This white box says, “Normal or nondiagnostic changes in S.T. segment or T wave.” It concludes with bold text: “Low- or intermediate-risk ACS.” An arrow points downward to the final box in the pathway. Box 12, which is orange, instructs: “Consider admission to Emergency Department chest pain unit or to appropriate bed for further monitoring and possible intervention.” This figure is copyright 2015 by the American Heart Association.