Initial Approach at Primary Care Level
Evaluation
- Airway
- Breathing
- Circulation
- Vital Signs
- Focused exam
- Cardiac, pulmonary, vascular, character of pain
ECG
- Perform ECG, if ST elevated or suspicious, immediately refer to hospital.
Initial Approach at PHC Level
Management While Awaiting Transfer
- Monitor BP, Pulse, O2 saturation
- Give sublingual glyceryl trinitrate and IV morphine (if required).
- Give 300 mg aspirin
- Give 300 mg clopidogrel if evidence of ischemia on ECG or elevated troponin levels
- Only administer oxygen if the patient is breathless, oxygen saturation is <93%, has heart failure, or is in cardiogenic shock.
Oxygen Treatment
Should only be administered to:
- Breathless patients
- Hypoxic, i.e. oxygen saturation < 93%
- Have heart failure &
- In cardiogenic shock
Management Strategy for STEMI
- MONA - Morphine, oxygen, nitro, aspirin
- Beta blockers, ACE inhibitors
- Early invasive strategy with either thrombolytic therapy or percutaneous coronary intervention (preferred)
STEMI Management
- ADMIT DR.:
- Referred by:
- Confirmed By: MONA REED MD
| I | aVR | V1 | V4 | ||
| II | aVL | V2 | V5 | ||
| III | aVF | V3 | V6 | ||
| V1 | |||||
| II | |||||
| V5 |
Management Strategy for NSTEMI
Initial Therapy - MONA
- Morphine for pain
- Oxygen if hypoxic
- Nitro spray/drip for pain
- Aspirin
Management Strategy for NSTEMI/NST Chest Pain
- Establish risk level using the TIMI scoring system:
- Low risk: May be discharged after symptom control
- Moderate risk: Admit for further evaluation; add beta blockers, ACE inhibitors. Follow cardiac enzyme levels. If MI ruled out, Exercise or Adenosine stress test before discharge
- High Risk: Admit for cardiac catheterization
Treatment of Unstable Angina
- Antiplatelet therapy: Aspirin, clopidogrel, or both.
- Anticoagulants: A heparin (unfractionated or low molecular weight heparin).
- Antianginal therapy, usually nitroglycerin.
- Beta-blocker
- Angiotensin-converting enzyme (ACE) inhibitor
- Statin.
Post MI medications
- aspirin
- second Antiplatelet - stop one of them after year?
- BB
- Statin
- Ace or Arb inhibitors