Immediate Management
• A patient who is considered to have an ACS should be placed in an environment with
continuous ECG monitoring and defibrillation capability where a 12-lead ECG can be
obtained expeditiously and definitively interpreted, ideally within 10 min of arrival in
the ED.
• Patients diagnosed as having STEMI or ECG true posterior MI, which can masquerade
as NSTEMI, should be managed according to the ACC/AHA Guideline for the
Management of ST-Elevation Myocardial Infarction (http://content.onlinejacc.
org/data/Journals/JAC/926277/11018.pdf; http://circ.ahajournals.org/content/
early/2012/12/17/CIR.0b013e3182742c84.full.pdf ).
ÎÎThe history, physical examination, 12-lead ECG, and initial cardiac
biomarker tests should be integrated to assign patients with chest
pain into 1 of 4 categories: a noncardiac diagnosis, chronic stable
angina, possible ACS, and definite ACS. (I-C)
The most urgent priority of early evaluation is to identify patients with ST-elevation MI
(STEMI) who should be considered for immediate reperfusion therapy and to recognize
other potentially catastrophic causes of patient symptoms, such as aortic dissection.
ÎÎPatients with probable or possible ACS but whose initial 12-lead
ECG and cardiac biomarker levels are normal should be observed
in a facility with cardiac monitoring (eg, chest pain unit or hospital
telemetry ward). Repeat ECG (or continuous 12-lead ECG monitoring)
and repeat cardiac biomarker measurement(s) should be obtained at
predetermined, specified time intervals. (I-B)
ÎÎIn patients with suspected ACS in whom ischemic heart disease
is present or suspected, if the follow-up 12-lead ECG and cardiac
biomarker measurements are normal, perform a stress test (exercise
or pharmacological to provoke ischemia) in the ED, in a chest pain
unit, or on an outpatient basis in a timely fashion (within 72 h) as an
alternative to inpatient admission. (I-C)
Low-risk patients with a negative diagnostic test can be managed as outpatients.
ÎÎIn low-risk patients who are referred for outpatient stress testing (see
above), give precautionary appropriate pharmacotherapy (eg, ASA,
sublingual NTG, and/or beta blockers) while awaiting results of the
stress test. (I-C)
ÎÎHospitalize patients with definite ACS and ongoing ischemic
symptoms, positive cardiac biomarkers, new ST-segment deviations,
new deep T-wave inversions, hemodynamic abnormalities, or a positive
stress test for further management. Admission to the critical care
unit is recommended for those with active, ongoing ischemia/injury
or hemodynamic or electrical instability. Otherwise, a telemetry stepdown unit is reasonable. (I-C)
ÎÎPatients with possible ACS and negative cardiac biomarkers who
are unable to exercise or who have an abnormal resting ECG should
undergo a pharmacological stress test. (I-B)
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