What are the immediate admission orders for acute coronary syndrome (ACS)?

Immediate Admission Orders for Acute Coronary Syndrome

Upon admission for suspected ACS, immediately obtain a 12-lead ECG within 10 minutes, establish continuous cardiac monitoring, administer aspirin 162-325 mg (chewed), initiate oxygen therapy if oxygen saturation is <94%, establish IV access, and draw blood for high-sensitivity troponin, complete blood count, basic metabolic panel, and lipid profile. 1

Critical First 10 Minutes: ECG and Monitoring

• Obtain 12-lead ECG within 10 minutes of arrival to differentiate STEMI from NSTE-ACS, as this determines the entire treatment pathway 1, 2
• Establish continuous cardiac monitoring immediately to detect life-threatening arrhythmias 1
• Perform serial ECGs at 15-30 minute intervals during the first hour if initial ECG is nondiagnostic 1
• Consider supplemental leads V7-V9 in patients with initial nondiagnostic ECG at intermediate/high risk 1
• Check vital signs including blood pressure, heart rate, respiratory rate, and oxygen saturation 1, 3

Immediate Pharmacological Orders

Antiplatelet Therapy

• Administer aspirin 162-325 mg (non-enteric coated, chewed) immediately unless contraindicated by aspirin allergy or active gastrointestinal bleeding 1, 4, 2
• Add a second antiplatelet agent (dual antiplatelet therapy) with either clopidogrel (300 mg loading dose, then 75 mg daily), ticagrelor, or prasugrel for most patients 5, 4
• The aspirin effect is additive to other therapies and produces near-total inhibition of thromboxane A2, reducing mortality and recurrent ischemic events 1

Anticoagulation

• Initiate parenteral anticoagulation with unfractionated heparin, low-molecular-weight heparin (enoxaparin), bivalirudin, or fondaparinux 1, 4
• Choice should be based on bleeding risk, renal function, and planned invasive strategy 1

Anti-Ischemic Therapy

• Administer sublingual nitroglycerin for ongoing chest pain (may repeat every 5 minutes for maximum of 3 doses) 1, 3
• Provide intravenous morphine titrated to pain severity if chest pain is unrelieved by nitroglycerin 3, 6
• Administer oxygen therapy if oxygen saturation <94%, signs of heart failure, shock, or breathlessness are present 1, 3
• Consider intravenous beta-blockers (e.g., metoprolol) if tachycardia or hypertension present without contraindications 3, 6

Laboratory Orders

• Measure high-sensitivity cardiac troponin (cTnI or cTnT) at presentation 1, 2
• Repeat troponin at 1-3 hours if high-sensitivity assay is used, or at 3-6 hours after symptom onset if standard assay is used 1
• Draw complete blood count (hemoglobin, hematocrit, platelet count) 1
• Obtain basic metabolic panel including serum creatinine and blood glucose 1, 3
• Check INR if patient is on vitamin K antagonists 1
• Obtain lipid profile in the early phase of admission 1
• Results of troponin measurements should be available within 60 minutes 1

Risk Stratification

• Calculate TIMI Risk Score using seven variables: age ≥65 years, ≥3 CAD risk factors, prior coronary stenosis ≥50%, ST deviation on ECG, ≥2 anginal events in prior 24 hours, aspirin use in prior 7 days, and elevated cardiac biomarkers 1
• TIMI scores of 0-2 indicate low risk (5-8% event rate), 3-4 indicate intermediate risk (13-20%), and 5-7 indicate high risk (26-41%) 1
• Risk stratification models guide management decisions regarding timing of invasive strategy 1

Additional Immediate Orders

• Establish intravenous access for medication administration and fluid management 3
• Consider echocardiography to assess left ventricular function, identify regional wall motion abnormalities, and rule out other cardiovascular causes of chest pain 1, 3
• Place defibrillator patches if ongoing ischemia is present until urgent revascularization is performed 1
• Admit to appropriate unit: patients with confirmed NSTE-ACS require interdisciplinary emergency department or chest pain unit observation 1

Critical Timing Considerations for Reperfusion

For STEMI (ST-Segment Elevation)

• Primary PCI should be performed within 90-120 minutes (door-to-balloon time) as this reduces mortality from 9% to 7% 2
• Administer fibrinolytic therapy within 30 minutes (door-to-needle time) if PCI will be delayed >120 minutes 4, 2
• Fibrinolytic options include alteplase, reteplase, or tenecteplase at full dose for patients <75 years, or half dose for patients ≥75 years 2

For NSTE-ACS (Non-ST-Elevation)

• Very high-risk patients (ongoing ischemia, hemodynamic instability, life-threatening arrhythmias) require immediate invasive strategy within 2 hours 1
• High-risk patients should undergo invasive coronary angiography within 24-48 hours, which reduces mortality from 6.5% to 4.9% 2
• Fibrinolytic therapy is typically not recommended for NSTE-ACS 4

Common Pitfalls to Avoid

• Do not delay treatment waiting for cardiac biomarker results - initial management should be based on clinical presentation and ECG findings 3
• Do not assume atypical presentations exclude ACS - women and elderly patients frequently present with dyspnea, fatigue, or nausea rather than classic chest pain, and approximately 40-48% of patients present with nonspecific symptoms 7, 3, 2
• Relief of chest pain with nitroglycerin is NOT predictive of ACS - one study showed nitroglycerin relieved symptoms in 35% of ACS patients versus 41% without ACS 1
• Avoid consultation delays that postpone reperfusion therapy as these are associated with increased mortality 7, 3
• Balance bleeding risk against antithrombotic benefit, particularly in elderly patients or those with renal impairment 7
• Consider proton pump inhibitors to prevent bleeding in patients at higher than average risk of gastrointestinal bleeding who are receiving dual antiplatelet therapy and anticoagulation 4

Additional Therapies to Initiate

• Statin therapy should be initiated early 4
• ACE inhibitors should be started unless contraindicated 4, 6
• Beta-blockers reduce myocardial oxygen consumption through decreased heart rate, blood pressure, and contractility 6