Acute coronary syndrome management

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Initial ABCDE approach

Follow usual ABCDE approach if critically ill.

Short-term management of ACS

Initial management – MOAN

• Morphine: 10mg in 10ml slow IV – titrate to pain (+ 10mg metoclopramide IV)
• Oxygen: only if saturations below target range
• Aspirin: 300mg PO loading dose (then 75mg OD)
• Nitrates: sublingual GTN if not hypotensive (then PRN)

Other medications 

• Second antiplatelet and anticoagulant: 
  • P2Y₁₂-receptor inhibitor (prasugrel or ticagrelor or clopidogrel) – cardiologist will start during PCI
  • ACS-dose anticoagulation (e.g. unfractionated heparin, fondaparinux, or enoxaparin)
    • in STEMI patients/patients having immediate PCI, cardiologist will start during PCI
    • in NSTEMI patients not having immediate PCI, start before PCI if low bleeding risk
• Early long term medications to consider:
  • β-blocker 
  • ACE-inhibitor (once haemodynamically stable)
  • Statin

Reperfusion therapy (Percutaneous Coronary Intervention – PCI)

• STEMI → immediate PCI (<2h)
  • ! STEMIs that don’t look like STEMIs:
    • Posterior STEMI: ST depression and tall R waves in V1-3. If there is ST↓ in V1-3 in a patient with chest pain, always check posterior leads.
    • Wellens syndrome (proximal LAD occlusion): deeply inverted/biphasic T waves in V2-3
• Non-ST elevation ACS
  • Very high-risk (haemodynamically unstable, ongoing/recurrent pain/ischaemic changes, acute heart failure, arrhythmias, mechanical complications) → immediate PCI (<2h)
  • High-risk (rise and fall in troponin compatible with NSTEMI, dynamic ischaemic changes, GRACE score >140) → early PCI (<24h)
  • Non-high risk → selective PCI

Other points

• All patients should have an echocardiogram to assess LV function
• Check electrolytes regularly and ensure patients are on cardiac monitoring while in hospital
• STEMI patients with complete revascularisation may be discharged after 2-3 days; low-risk NSTEMI patients with complete revascularisation may be discharged within 24 hours

Long-term management of ACS

Antiplatelet therapy 

• Patient without AF: aspirin (lifelong) + P2Y₁₂-receptor inhibitor (for 1 year)
• Patient with AF: DOAC (lifelong) + clopidogrel (for 1 year) + aspirin (for 1 week)
• Give with PPI if patient is at risk of GI bleeding

NB: these regimens are examples only. Cardiology will decide on case-by-case basis depending on bleeding and thrombosis risk. 

Cardiovascular risk reduction

• Statin
• BP control
• Lifestyle modifications/cardiac rehabilitation and smoking cessation 

Other treatments 

• β-blocker (lifelong if LV dysfunction; for at least 1 year and consideration of lifelong use if not)
• ACE inhibitor (lifelong)
• Aldosterone antagonist, e.g. eplerenone (if LV dysfunction) 

References: NICE ‘NG185 Acute coronary syndromes’ 2020; European Society of Cardiology ‘Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation’ 2020; European Society of Cardiology ‘Guidelines on Management of Acute Myocardial Infarction in Patients Presenting with ST-Segment Elevation’ 2017

Test your knowledge

What are the definitions of STEMI, NSTEMI and unstable angina

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What are the three patterns of unstable angina?

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In which ECG leads would ST changes be present in for each of the following myocardial infarctions? Which coronary artery would be involved for each? 1. Inferior 2. Anteroseptal 3. Anterolateral 4. Lateral 5. Posterior

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What is the GRACE score and which factors does it take into account?

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Now for some stations!

1. Acute assessment – chest pain
2. STEMI
3. Chest pain history 1
4. Chest pain history 2
5. More here!