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Acute coronary syndrome management

Initial ABCDE approach

Follow usual ABCDE approach if critically ill.

Include in assessment

  • 12 lead ECG (then cardiac monitoring)
  • Bloods: usual bloods (FBC, U&Es, LFTs, CRP, glucose) plus high-sensitivity troponin, magnesium, phosphate, lipids
  • Chest X-ray (LVF signs, other causes)

High-sensitivity troponin testing

  • Value peaks at 12 hours after pain onset but value will be rising before this
  • Interval testing is used in non-STEMI patients to look for a significant change for diagnosis of MI (or exclusion in low risk patients with normal ECG)
  • It is usually tested at presentation and 3 hours later 
  • The definition of ‘significant change’ varies depending on the assay used
  • A normal value ≥6 hours post-pain onset rules out MI

Types of ACS

  • STEMI: ST-elevation or new LBBB
  • NSTEMI: ACS without ST-elevation/ new LBBB but with raised troponin 
  • Unstable angina: ACS without ST-elevation/new LBBB or raised troponin 
    • (3 patterns: exertional angina increasing in frequency over a few days or provoked by less exertion; angina occurring recurrently and unpredictably, not related to exercise; or unprovoked, prolonged episode of pain)

Short-term management of ACS

Initial management – MONA

  • 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) – IV infusion can also be used 

Other medications 

  • Second antiplatelet and anticoagulant: 
    • P2Y12-receptor inhibitor (prasugrel or ticagrelor or clopidogrel) – cardiologist will start during PCI
    • ACS-dose anticoagulation (fondaparinux or unfractionated heparin)
      • 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
  • Non-ST elevation ACS
    • Unstable clinical condition (haemodynamically unstable, acute heart failure, arrhythmias, ongoing/recurrent pain/ischaemic changes, mechanical complications) → immediate PCI
    • Intermediate/high-risk GRACE score (6‑month mortality >3.0%) → within 72 hours 
    • Low-risk GRACE score (6‑month mortality ≤3.0%) → non-invasive testing may be appropriate (e.g. stress echocardiography)

NB: GRACE score is a measure of probability of ACS mortality at 6 months. It takes into account age, heart rate, SBP, creatinine, and the presence of ST deviation, troponin, cardiac arrest or LVF (Eagle et al. 2004).

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 

  • give with PPI if patient is at risk of GI bleeding
  • Patient without AF: aspirin (lifelong) + ticagrelor/prasugrel/clopidogrel (for 1 year)
  • Patient with AF: DOAC (lifelong) + clopidogrel (for 1 year) + aspirin (for 1 week)

NB: durations depend on bleeding and thrombosis risk, and they may modified on a case-by-case basis. 

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) 

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