Acute Coronary Syndromes and Suspected Stroke
Acute Coronary Syndromes
Recognition and early actions
Acute coronary syndrome includes ST-elevation myocardial infarction, non-ST-elevation myocardial infarction, and unstable angina. Presenting symptoms may be typical (substernal pressure radiating to the arm or jaw, diaphoresis, nausea) or atypical, especially in women, older adults, and people with diabetes - dyspnea, fatigue, indigestion, or syncope. Obtain a 12-lead ECG and interpret it within 10 minutes of arrival, place the patient on a monitor, establish IV access, and give aspirin 162–325 mg chewed (non-enteric coated) unless contraindicated.
Reperfusion
For STEMI, the priority is reperfusion: primary percutaneous coronary intervention with a door-to-balloon time of 90 minutes or less at a PCI center, or fibrinolysis within 30 minutes of arrival if PCI cannot be achieved within 120 minutes and there are no contraindications. Nitroglycerin relieves ischemic pain but must be avoided in hypotension, suspected right ventricular infarction, and within 24–48 hours of phosphodiesterase-5 inhibitor use. Morphine may be used for pain unrelieved by nitrates.
Traps
Classic distractors: withholding aspirin until troponin results return, giving nitroglycerin to a patient who took sildenafil, giving nitrates in an inferior STEMI with hypotension and clear lungs, and giving fibrinolytics for an NSTE-ACS. Also beware answers that ignore the ECG because the pain has resolved.
Rule of thumb
ECG first, aspirin second, and then ask the one question that changes management: can this patient get to a cath lab within 120 minutes?
Suspected Stroke
Recognition and time zero
Stroke care is built on time. Establish the last known well time - the moment the patient was last seen normal, not when symptoms were discovered - because every treatment window depends on it. Screen with a validated tool such as BE-FAST (balance, eyes, face, arm, speech, time) or the Cincinnati scale. Check and treat hypoglycemia, which can mimic stroke, and perform a focused neurologic exam and stroke severity score. Activate the stroke team and pre-notify the receiving hospital so imaging and labs can be ready on arrival.
Imaging and treatment windows
Obtain a noncontrast head CT (or MRI) within about 20 minutes of arrival to exclude hemorrhage; the door-to-needle goal is 60 minutes or less. Intravenous thrombolysis with alteplase or tenecteplase is indicated for eligible patients within 3 hours of onset, and up to 4.5 hours in selected patients. Endovascular thrombectomy may benefit selected patients with large vessel occlusion up to 24 hours with advanced imaging. Blood pressure must be below 185/110 mm Hg before thrombolysis and below 180/105 afterward; in patients not receiving thrombolysis, do not lower blood pressure unless it exceeds about 220/120 mm Hg. Avoid antiplatelet or anticoagulant therapy for 24 hours after thrombolysis.
Traps
Distractors include treating blood pressure aggressively in a stable stroke patient, delaying CT until the neurologic exam is complete, using the time symptoms were found rather than last known well, and giving dextrose-containing fluids routinely.
Rule of thumb
Ask "when were they last normal?" before anything else - a correct exam with the wrong time window loses the treatment.