ED in first 10 minutes:
- check vital signs and oxygen saturation
- establish IV access
- perform brief history and physical exam
- review/compile fibrinolytic checklist
- obtain initial cardiac marker levels
- obtain portable chest x-ray

immediate ED general treatment (why, when, how, watch out)
- use oxygen if saturation < 94% (4L/min); be careful for COPD patients, who can hypoventilate due to hypoxic ventilatory drive
- aspirin 160-325mg if not given by the EMS
- nitroglycerin sublingual or spray
- morphine IV if discomfort is not relieved by nitroglycerin

aspirin: chew, blocks formation of thromboxane A2; reduces overall mortality, nonfatal reinfarction, nonfatal stroke
- administer ASAP, within minutes of arrival
- contraindicated in patients w/ hypersensitivity, active peptic ulcer disease or asthma, stop any other NSAIDs

nitroglycerin: reduces pain of ischemia, increases venous dilation, decreases preload and cardiac O₂ consumption, dilates coronary arteris, increases cardiac collateral flow
- use in ischemic discomfort (class I), recurrent ischemia, CHF
- sublingual tablet, 5mg every 5 min up to 3 doses; spray aerosol 1-2 metered doses at 5 min. intervals; IV infusion of 12.5 – 25µg bolus, 10-20 µg/min infusion
- contraindicated for systolic BP < 90mmHg, RV infarction (inferior wall, use complete right ventricular ECG or right-sided V4), severe brady/tachycardia, use of phosphodiesterase inhibitors in past 24-48 hours
- watch for headache, drop in BP, syncope, tachycardia; tell patient to sit or lie down during administration, do not shake the aerosol spay

morphine: use to reduce pain of ischemia, anxiety; used in chest pain unresponsive to nitrates & acute cardiogenic pulmonary edema
- 2-4mg titrated to effect with 5-15min interval to eliminate pain
- watch for drops in BP (esp. in patients w/ volume depletion or RV infarction), ventilation depression, nausea/vomiting
- reverse with naloxone

clopidogrel: I/IIa, irreversibly inhibits the platelet ADP receptor
- given in all STEMIs up to age 75 (class I) and ACS patients with elevated markers or new ECG changes unable to take ASA (Class IIa)
- 300mg oral dose

beta-blockers: reduces HR, BP, contractility; decreases AV conduction, incidence of primary CF, size of infarct, incidence of cardiac rupture
- oral in ED for all types of ACS (class I); use IV for tachyarrhythmias of HTN (class IIa); given irrespective of need for revasculation

- absolute contraindications: severe CHF/PE, SBP <100 mmHg, acute asthma, 2^nd or 3^rd degree AV block
- cautioned in mild/moderate CHF, HR <60bpm, history of asthma, peripheral vascular disease

heparin: indirect inhibitor of thrombin, class IIa
- unfractionated: 60E/kg (max 4000), infused at 12E/kg/hr; target aPTT of 50-70s, used in those >75 and when Cr > 2 or 2.5 (female, male)
- LMWH may be better if age <75
- increases bleeding complications

ACE inhibitors: reduces BP by inhibiting ACE à lowers PVR by vasodilation; alters post-AMI LV remodeling by inhibiting tissue ACE
- reduces mortality and CHF from AMI
- rec. in first 24 hours if LV <40% in absence of hypotension (class I)
- all other AMI if no hypotension (IIa); IV contraindicated