ACLS review: Acute Coronary Syndromes Part 6

Myocardial Ischemia with Inverted T waves

Myocardial Ischemia with Inverted T waves in I, II, AVF, V3, V4, V5, V6

Anteriolateral Ischemia with inverted T waves

Anteriolateral ischemia with inverted T waves in V1-V4, V5-V6

Adjunctive Treatments

·         Beta blockers IV

·         Nitroglycerine IV

·         UF Heparin IV or LMWH

·         Ace Inhibitors

Beta blockers

·         Decrease catecholamine levels

·         Reduce discharge from the sinus node

·         Lower blood pressure

·         Reduce myocardial contractility

·         Reduce myocardial oxygen consumption

Note:  For patients with ACS, there is no evidence to support the routine administration of IV β-blockers in the prehospital setting or during initial assessment in the ED. IV β-blocker therapy may be considered as reasonable in specific situations such as severe hypertension or tachyarrhythmias in patients without contraindications
Current ACC/AHA Guidelines recommend β-blockers be initiated orally within the first 24 hours after hospitalization.

Beta blocker contraindications

·         Moderate to severe LV failure

·         Pulmonary edema

·         Signs of poor peripheral perfusion

·         Bronchospasm or reactive airway disease

·         Bradycardia (<60)

·         Hypotension (SBP < 100)

·         Heart blocks

Nitroglycerin

·         Decreases pain in ischemia

·         Increases venous dilation

·         Decreases venous return to the heart

·         Decreases preload and oxygen consumption

·         Dilates coronary arteries

·         Increases cardiac collateral flow

Nitroglycerin dosage

·         IV infusion: 10-20ug/min, increase by 5-10ug/min every 5-10minutes.

·         Sublingual 0.3-0.4mg SL. May repeat q5minutes up to three doses

Nitroglycerin precautions

·         Use with extreme caution if SBP < 90 mm Hg

·         Limit drop in BP to 10% in normotensive patients

·         Limit drop in BP to 30% in hypertensive patients

·         Use with extreme in RV failure

·         Watch for headache, drop in BP, syncope, tachycardia

·         Do not use pain as a way of titrating the infusion rate of NTG. Goal isn’t to control pain with NTG but alter hemodynamics.

·        Do not use NTG as a substitute for narcotic analgesics to achieve pain control