Online ACLS Course

Chapter 13 : Acute Coronary Syndrome

Acute coronary syndrome or ACS is defined as a sudden, reduced blood flow to the heart. ACS is seen in ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI) or unstable angina. Myocardial ischemia occurs when there is not enough blood supply to the heart muscle and that results from coronary artery disease (CAD). ACS is usually caused by atherosclerosis and coronary thrombosis, but can also be associated with cocaine use. Other conditions that cause ACS include:

  • Unstable Angina (UA)
  • Microemboli
  • Occlusive Thrombus
  • Unstable Plaque

The symptoms associated with ACS include:

  • Chest pain radiating to the left arm and left angle of jaw
  • Shortness of breath
  • Nausea
  • Vomiting
  • Diaphoresis
  • Palpitations
Video Demonstration

Acute Coronary Syndrome

ST-Segment Elevation Myocardial Infarction (STEMI) is an elevation > 1mm in 2 or more contiguous or greater than 2 mm in leads V2 and V3.
Unstable Angina (UA) or Non ST-Elevation Myocardial Infarction (NSTEMI) is a depression ≥0.5 mm or greater T-wave inversion.
Low Risk Unstable Angina (UA) is an ST segment deviation of <0.5 mm or T wave inversion of 2 mm. Patients may also have normal ECGs.

ST-Segment Elevation Myocardial Infarction (STEMI)

Scenario:  A 70-year patient comes to the hospital and is complaining of chest pain radiating to his arm and he seems very anxious and out of breath. 


  1. Identify signs and symptoms of ischemia or infarction
  2. Monitor vital signs and cardiac rhythm
  3. Be prepared to do CPR and use the AED
  4. IV access
  5. Check cardiac markers, electrolytes and coagulation status


  1. Give aspirin (160 to 325 mg), oxygen if O2 saturation is <94%, nitroglycerin sublingual every 3 to 5 minutes, and morphine for pain.
  2. Conduct  a 12-lead ECG and diagnose


  1. If STEMI on ECG perform rapid fibrinolytic therapy (“clot buster”) or direct reperfusion
  2. If time of onset of symptoms is ≤12 hours – reperfusion:
    1. Door to balloon inflation (PCI) – 90 minutes
    2. Door to needle fibrinolysis – 30 minutes
  3. If time of onset of symptoms is >12 hours, then invasive treatment is recommended
  4. If high risk UA or NSTEMI on ECG check troponin level and start invasive treatment
  5. Also administer the following as needed:
    1. Nitroglycerin
    2. Heparin
    3. Beta-blockers
    4. Clopidogrel
    5. Glycoprotein IIb/IIIa inhibitor
  6. Monitor and continue heparin and may add ACE inhibitor and HMG CoA reductase inhibitors if needed
  7. If low risk ACS check cardiac markers, repeat ECG, conduct non-invasive diagnostic test
  8. If no ischemia or infarction discharge and schedule a follow-up

Treatments which are used in ACLS algorithm for ACS are:

  • Oxygen
  • Aspirin
  • Nitroglycerin
  • Morphine
  • Fibrinolytic (thrombolytic) therapy
  • Heparin

The following is an algorithm that shows management of ACS in detail: ​