Appendix
Cardiology

Acute Coronary Syndrome (NSTE-ACS / STEMI)

Myocardial ischemia from plaque rupture/erosion; time to reperfusion determines outcome.

I21.4
I21.3
I20.0
Reviewed 2026-10-02
  • 12-lead ECG within 10 minutes of arrival
    GRADE 1B
  • STEMI → activate cath lab; door-to-balloon ≤ 90 min
    GRADE 1A
  • Cardiogenic shock, VT/VF, refractory pain, acute HF → immediate invasive strategy (< 2 h)
  • Aspirin 162–325 mg chewed unless true allergy
    GRADE 1A
  • High-sensitivity troponin 0/1 h or 0/2 h algorithm
    GRADE 1B
  • Serial ECGs; posterior leads (V7–V9) if ST depression V1–V3
  • Coronary angiography — gold standard
  • Echo for wall motion, EF, mechanical complications
  • CBC, BMP, lipid panel, HbA1c, coagulation
HEART
0–3 low (discharge pathway) · 4–6 moderate · 7–10 high → early invasive
GRACE
> 140 → invasive strategy within 24 h
TIMI (UA/NSTEMI)
0–2 low · 3–4 intermediate · 5–7 high
  • DAPT: aspirin + P2Y12 inhibitor (ticagrelor or prasugrel preferred)
    GRADE 1A
  • Parenteral anticoagulation until revascularization
    GRADE 1A
  • High-intensity statin regardless of baseline LDL
    GRADE 1A
  • Beta-blocker within 24 h if no HF, shock or bradycardia
    GRADE 1B
Aspirin
PO
Adult
Load 162–325 mg, then 81 mg daily
Renal
No adjustment
Duration
Lifelong
Ticagrelor
PO
Adult
Load 180 mg, then 90 mg BID
Renal
No adjustment; avoid on dialysis
Duration
12 months
Enoxaparin
SC
Adult
1 mg/kg q12h
Renal
CrCl < 30: 1 mg/kg q24h
Duration
Until PCI or 8 days
1/kg
Atorvastatin
PO
Adult
80 mg daily
Renal
No adjustment
Duration
Lifelong
  • Aspirin allergy: clopidogrel monotherapy or aspirin desensitization
  • High bleeding risk / on OAC: clopidogrel preferred over ticagrelor/prasugrel
  • Prasugrel contraindicated if prior stroke/TIA; reduce to 5 mg if < 60 kg or ≥ 75 yrs
  • STEMI with PCI delay > 120 min: fibrinolysis within 12 h of symptom onset
    GRADE 1A
  • Pregnancy: aspirin safe; PCI preferred; clopidogrel if P2Y12 required
  • Telemetry ≥ 24 h; monitor for arrhythmia, recurrent ischemia
  • Mechanical complications day 2–7: VSR, papillary muscle rupture, free wall rupture
  • Discharge: DAPT, statin, beta-blocker, ACEi/ARB if EF ≤ 40%, cardiac rehab referral
  • LDL target < 55 mg/dL (1.4 mmol/L); recheck lipids at 4–6 weeks
  • guideline
    ESC Guidelines for Acute Coronary Syndromes — ESC, 2023
  • guideline
    ACC/AHA Guideline for Management of ACS — ACC/AHA, 2025
  • trial
    PLATO: ticagrelor vs clopidogrel — NEJM, 2009
  • trial
    HEART Pathway validation — Circ CQO, 2015

Decision support only. Verify against local protocols and current labeling.