Internal Medicine

0521779407-C03 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:54

Coronary Syndromes, Acute 409

Intermediate risk features:

T wave inversions of >0.2 mV

Pathologic Q waves

Low risk feature:

Normal ECG or no change with episode of chest pain

differential diagnosis

■Consider non “plaque rupture” mechanisms of angina

➣Anemia, sepsis, thyrotoxicosis, etc. (increased O 2 demand or

decreased O 2 delivery with stenosis due to stable coronary

plaque)

■Consider non-coronary but cardiac chest pain

➣Uncontrolled hypertension, hypertrophic cardiomyopathy, peri-

carditis, Mitral prolapse

■Consider noncardiac chest pain

➣GERD, PUD, esophageal spasm, biliary disease

➣Musculoskeletal

➣Cervical disc disease

➣Pulmonary process

➣Aortic Dissection

management

What to Do First

■Assess likelihood of ACS and stratify risk of death by history, physical,

ECG, and cardiac enzymes.

■Initiate therapy

General Measures

■Control ischemia

■Control platelets and coagulation

■Consider revascularization

specific therapy

Indication for therapy: ACS

Treatment Options

■Anti-ischemic therapy

➣Bed rest (wih continuous ECG monitoring for ischemia, arrhyth-

mia)

➣Nitroglycerin SL PRN followed by IV, titrate upward to relieve

ischemia

➣Supplemental O 2 if pulse oximetry <90% or respiratory distress

or cyanosis present