Myocardial Infarction CCS Guide
Key Takeaway: MI cases are among the most common and high-yield CCS scenarios. Immediate ECG, aspirin, and troponin are scored for timing — place them within the first 2 minutes.
MI cases are among the most common and high-yield scenarios on CCS. Master the approach to chest pain presentations, from initial workup through disposition.
Recognizing the MI Presentation
MI cases typically present with chest pain, but watch for atypical presentations:
- Classic: Substernal chest pain, pressure, radiating to arm/jaw
- Atypical: Dyspnea, nausea, diaphoresis (especially in elderly, diabetics, women)
- STEMI equivalent: New LBBB, posterior MI signs
Immediate Actions (First 5 Minutes)
These orders should be placed immediately — timing is scored:
Critical First Orders
- ✓ 12-lead ECG — STAT
- ✓ Troponin (serial)
- ✓ Aspirin 325mg — chewed
- ✓ IV access
- ✓ Continuous cardiac monitoring
- ✓ Oxygen if hypoxic
Complete Workup
After immediate stabilization, complete the diagnostic workup:
- CBC, BMP, Mg, Phos
- Coagulation studies (PT/INR, PTT)
- BNP or NT-proBNP
- Lipid panel
- Chest X-ray
- Serial troponins (q3-6h x 3)
Treatment by Type
STEMI
Time to reperfusion is critical:
- PCI preferred — Door-to-balloon <90 min if available
- Fibrinolytics — If PCI not available within 120 min
- Anticoagulation — Heparin or enoxaparin
- P2Y12 inhibitor — Clopidogrel, ticagrelor, or prasugrel
NSTEMI/Unstable Angina
- Anticoagulation (heparin/enoxaparin)
- P2Y12 inhibitor
- Beta-blocker (if no contraindications)
- Statin (high-intensity)
- Consider early invasive strategy based on risk
Scoring Tip: Don't forget beta-blockers unless contraindicated (acute HF, bradycardia, hypotension, cocaine use). This is commonly missed.
Common Pitfalls
- Delaying aspirin — Should be given immediately
- Forgetting anticoagulation — All ACS patients need it
- Missing STEMI — Always check ECG interpretation carefully
- Beta-blocker in cocaine — Contraindicated!
- No statin — Start high-intensity statin early
Disposition
- STEMI: CCU/ICU after cath lab
- NSTEMI: Telemetry unit, cardiology consult
- Low-risk UA: Consider stress testing, outpatient follow-up
Key Orders Checklist
- ☐ ECG (STAT)
- ☐ Aspirin 325mg
- ☐ Troponin x 3 (serial)
- ☐ Heparin or enoxaparin
- ☐ P2Y12 inhibitor
- ☐ Beta-blocker
- ☐ High-intensity statin
- ☐ Cardiology consult
- ☐ Telemetry/CCU admission
- ☐ Echo (if HF suspected)
Practice MI Cases
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