CP/USA/NSTEMI admission

Usually the patient presents with substernal chest pain radiating towards neck, jaw or left arm, may be associated with Dyspnea, diaphoresis, nausea, vomiting and gets worse with exertion. It could resemble pain similar to prior episode when patient had MI.

Cardiac Risk Factors: Diabetes, HTN, Hyperlipidemia, Smoking, Family History of premature CAD (1stdegree: male< 55, Female< 65)

EMS:

IV fluids

NTG SL

Oxygen

ASA 4 tablets of 81 mg each

EKG

ER:

Routine labs, CXR

EKG (If there is STEMI, you probably won’t be involved as Cardiology takes over)

ASA PO or Plavix if allergic to ASA

Avoid Beta blocker in chest pain patients from cocaine as it leads to unopposed alpha stimulation

Calcium Channel blocker if patient can not tolerate beta blocker

NTG SL q 5min, max of 3 times or Nitropaste-not if patient is using Viagra

Cardiac enzymes Q 6-8hrs total of 3-4 times

oxygen

Morphine iv 2mg Q 5 min for severe CP

Hospitalist:

ASA 81mg PO

Lipid panel

2D ECHO

Heparin gtt/ SQ Lovenox 1mg/kg for USA/NSTEMI

NitroPaste/NTG drip if chest pain continues

NPO in AM for Stress test-Exercise stress test if they can run to get HR more than 85% of max predicted (220-age), Dobutamine stress test in Asthma and COPD or else pharmacologic stress test if unable to exercise, LBBB etc.

Avoid Coffee and Beta blocker morning of exercise stress test

Smoking Cessation and Exercise counseling

TIMI risk score: Each one gets one point. (0,1-5%, 2-8%, 3-13%, 4-20%, 5-26%, 6,7-41% risk of Death, MI, Urgent Revascularization by 14 days )

Age>=65

>= 3 risk factors for CAD

Known CAD >50% stenosis

ASA use in last 7 days

Severe Angina 2 or more episodes in last 24hrs

ST deviation>=0.5mm

Positive cardiac markers

By Cardiologist:

Catheterization and if stented then Bare metal stents need bare minimum of one month and Drug eluting stents need 6-12 months of Plavix

Beta Blocker PO

Statin PO

CT Surgeon:

CABG for severe coronary disease

Acute Pericarditis: pain often pleuritic, relieved with sitting up, ST segment elevation, upward concave, PR segment depression, usually see leukocytosis, consider ASO, 60% have effusion on echo

Treatment is generally NSAIDs, then Steroids: use Colchicine for recurrent pericarditis if creatinine ok.

Earn CME from UpToDate: Overview of the acute management of non-ST elevation acute coronary syndromes

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