Lesson 1Immediate pharmacologic measures for suspected MI: aspirin dosing, P2Y12 inhibitors selection and timing (clopidogrel, prasugrel, ticagrelor)This section outlines immediate pharmacologic steps for suspected MI, emphasising rapid aspirin administration, selection and timing of P2Y12 inhibitors, loading doses, integration with anticoagulation and reperfusion plans, and documentation of allergies or prior therapy.
Aspirin loading dose and formulationsChoosing initial P2Y12 inhibitor in EDTiming of loading relative to PCI or lysisManaging prior DAPT or recent anticoagulantsDocumenting allergies and prior stent historyLesson 2Oxygen therapy and adjunctive measures: indications for supplemental oxygen and non-invasive ventilationThis section reviews indications for supplemental oxygen and non-invasive ventilation in ACS, emphasising avoidance of routine oxygen in normoxia, thresholds for initiation, device selection, and integration with haemodynamic and analgesic management.
Evidence against routine oxygen in normoxiaSpO2 thresholds to start supplemental oxygenChoosing nasal cannula vs mask vs HFNCIndications for CPAP or BiPAP in ACSMonitoring respiratory status and escalationLesson 3Reperfusion decision-making: criteria for primary PCI vs fibrinolysis vs conservative managementThis section guides reperfusion decisions in STEMI and selected NSTEMI, outlining criteria for primary PCI, when fibrinolysis is appropriate, timing thresholds, contraindications, and when conservative management is preferred based on ischaemic and bleeding risk.
STEMI criteria and symptom onset timingDoor-to-balloon and door-to-needle goalsAbsolute and relative lysis contraindicationsWhen to choose primary PCI over lysisConservative strategy in high-risk NSTEMILesson 4Fibrinolytic agents: indications, dosing (tenecteplase, alteplase), contraindications, and management of bleeding complicationsThis section covers fibrinolytic therapy for STEMI, including indications when PCI is delayed, weight-based dosing of tenecteplase and alteplase, adjunctive antithrombotics, absolute and relative contraindications, and recognition and management of bleeding.
STEMI patients eligible for fibrinolysisTenecteplase dosing by weight and ageAlteplase STEMI dosing protocolsAdjunct aspirin and anticoagulation useManaging intracranial and systemic bleedingLesson 5Special scenarios: cardiogenic shock, cardiac arrest with STEMI, right ventricular infarction — tailored reperfusion and pharmacologic adjustmentsThis section addresses complex ACS scenarios, including cardiogenic shock, cardiac arrest with STEMI, and right ventricular infarction, focusing on tailored reperfusion strategies, haemodynamic support, and careful adjustment of vasopressors and vasoactive drugs.
Identifying and grading cardiogenic shockMechanical support options in shockPost–cardiac arrest STEMI pathwaysRight ventricular infarction recognitionAdjusting preload, afterload, and inotropesLesson 6Nitrates, morphine, and haemodynamic considerations: indications, contraindications, and administration routesThis section examines nitrates and morphine in ACS, including indications for symptom relief, contraindications such as hypotension or RV infarction, routes of administration, dosing, and their haemodynamic effects on preload, afterload, and coronary perfusion.
Contraindications to nitrate therapySublingual vs IV nitrate administrationMorphine dosing and monitoringImpact on preload and afterloadInteractions with phosphodiesterase-5 inhibitorsLesson 7Renal dysfunction and drug selection: dose adjustments, contrast nephropathy prevention, and anticoagulation changes in CKDThis section focuses on ACS patients with CKD, detailing dose adjustments for antithrombotics and contrast agents, strategies to prevent contrast-associated kidney injury, fluid management, and balancing ischaemic and bleeding risks in advanced renal disease.
Estimating kidney function in the EDAdjusting anticoagulants in CKD and ESRDP2Y12 and statin choices in renal diseaseHydration and contrast minimization tacticsPost-contrast monitoring and nephrology consultsLesson 8Anticoagulation choices in ACS: UFH, bivalirudin, enoxaparin — dosing, monitoring, renal adjustments, and periprocedural considerationsThis section compares anticoagulant options in ACS, including UFH, enoxaparin, and bivalirudin, with emphasis on dosing in STEMI and NSTEMI, monitoring strategies, renal dose adjustments, and periprocedural management during PCI or CABG.
UFH bolus and infusion dosing in ACSEnoxaparin dosing and timing with PCIBivalirudin indications and dosingMonitoring ACT, aPTT, and anti-Xa levelsBridging and holding anticoagulants for CABGLesson 9Antiplatelet management in NSTEMI: timing of loading doses before coronary angiography and scenarios favouring conservative vs early invasive approachThis section addresses antiplatelet therapy in NSTEMI, focusing on timing of aspirin and P2Y12 loading relative to angiography, choice of agent, and how ischaemic and bleeding risk, comorbidities, and planned procedures influence conservative versus early invasive strategies.
Risk scores guiding invasive strategyTiming of P2Y12 loading before cathChoosing clopidogrel vs ticagrelor vs prasugrelManaging patients likely to need CABGDe-escalation and duration of DAPT in NSTEMILesson 10Primary PCI pathways: door-to-balloon targets, transfer protocols, pre-PCI medications, and antithrombotic strategyThis section details primary PCI workflows, including door-to-balloon targets, activation and transfer protocols, pre-PCI antiplatelet and anticoagulant regimens, and tailoring antithrombotic strategies to bleeding risk and lesion complexity.
ED triage and cath lab activation stepsInterfacility transfer and transport timingPre-PCI aspirin and P2Y12 loadingChoice of UFH, bivalirudin, or enoxaparinPost-PCI antithrombotic continuation plansLesson 11Beta-blockers and ACE inhibitors/ARBs in acute setting: when to give, contraindications, initial dosing and monitoringThis section reviews early use of beta-blockers and ACE inhibitors or ARBs in ACS, including timing after stabilisation, contraindications such as shock or bradycardia, initial dosing strategies, titration, and monitoring for hypotension, renal injury, and hyperkalaemia.
Hemodynamic criteria before beta-blockersOral vs IV beta-blocker selectionStarting and titrating ACEI or ARBContraindications and caution flagsMonitoring blood pressure, creatinine, potassiumLesson 12High-intensity statin initiation in ED: rationale, dosing, and hepatic safety checksThis section explains why high-intensity statins are started in the ED for ACS, covering evidence for early use, appropriate agents and doses, baseline hepatic assessment, monitoring of liver enzymes, and managing suspected statin intolerance or injury.
Evidence for early statin in ACS outcomesChoosing atorvastatin vs rosuvastatinInitial high-intensity dosing regimensBaseline liver tests and contraindicationsMonitoring and managing hepatic adverse events
