EMmedonline

Evaluation of a suspected ACS

• A 12 lead ECG must be taken within 10mins of presentation to ED. (Class I,C)

• If initial ECG is not diagnostic but patient remains symptomatic serial ECG should be taken at 15 -30 min interval. (Class I,C)

• Continuous monitoring with 12 lead ECG may be reasonable in patients whose initial ECG is non-diagnostic and who are at intermediate/ high risk of ACS. (Class IIb,B).

• Serial cardiac troponin I or T levels should be obtained at presentation amd 3-6 hrs after symptom onset in all patients who present with symptoms consistent with ACS to identify a rising and or falling pattern of values. (Class I,A).

• Additional troponin levels should be obtained beyond 6hrs after symptom onet in patients with normal troponin levels on serial examination when changes on ECG & or clinical presentation confer an intermediate or high index of suspicion for ACS. (Class I,A)

• Use risk score to asses prognosis in patients with NSTE-ACS. (Class I,A)

• BNP or NT-pro- BNP may be considered to asses risk in patients with ACS.

• Contemporary tropinin assays,CK-MB and myoglobin are not useful for diagnosis of ACS. (Class III,A)

ECG

DISCHARGE RECOMMENDATIONS FROM THE ED

MANAGEMENT

• Supplemental oxygen to keep Spo2>90%. (Class I,C)

Anti ischemic and Analgesics

Nitrates

• Patients with NSTE-ACS with ischemic pain should receive sublingual NTG 0.3 mg – 0.4 mg every 5 minutes for upto 3 doses. (Class I,C)

• Intravenous NTG is indicated for patients with persistent ischemia, HF or hypertension if no contraindication persists. (Class I,B)

• Nitrates should not be administrated in patients with NSTE-ACS who recently received a phosphodiesterase inhibitor, especially within 24 hrs of sildenafil or vardebafil or within 48 hrs of tadalafil.

Analgesics

• It is reasonable to Morphine sulphate if there is continued ischemic pain despite treatment with maximally tolerated anti ischemic medication.

• NSAID's should not be initiated and should be discontinued in NSTE-ACS because of increased risk of adverse cardiac events associated with their use. (Class III,B)

Beta Blockers

• Oral beta blocker should be initiated within 24hrs unless there is a contraindication. (Class I,A).

• In patients with concomitant NSTE-ACS and stabilised HF and reduced systolic function, it is recommended to continue beta blocker therapy with drugs proven to reduce mortality with HF like metoprolol, carvedilol or bisoprolol. (Class I,C).

• Patients with contraindication for beta blockers within first 24 hrs should be reevaluated for their subsequent eligibility. (Class I,C).

• Administration of beta blockers is potentially harmful in patients with NSTE-ACS who have risk factors for shock (Class III)

Calcium Channel Blockers

• In patinets with NSTE-ACS continuing or frequently recurring ischemia and a contraindication to betablockers, a nondihydropyridine calcium channel blocker should be given in the absence of contraindication.

• Oral nondihydropyridine calcium antagonist are recommended in patients with NSTE-ACS who have recurrent ischemia in the absence of contraindication, after appropriate use of beta blocker and nitrates.

Ranolazine

IABP

• IABP (Intra aortic balloon pump) is reasonable in NSTE-ACS to treat severe persistent or recurrent ischemia especially in patients awaiting invasive angiography and revascularisation, despite intensive medical therapy.

• IABP counterpulsation increases diastolic BP and coronary blood flow and potentially augments cardiac output while diminishing LV end diastolic pressure.

Cholestrol Management

• High intensity statin therapy should be initiated or continued in all patients with NSTE-ACS and no contraindication to its use. (Class I,A)

• It is reasinable to obtain FLP in patients with NSTE-ACS, preferably within 24 hrs.

Renin Angiotensin Aldosterone Sytsem Inhibitors

• ACE inhibitor should be administrated orally within 24h in patients with LV EF <40%, HTN, DM or stable CKD. (Class I,A)

• If intolerated Angiotensin receptor blocker can used.(Class I,A)

• Aldosterone blockade is recommended in patients post MI without significant renal dysfunction (Cr > 2.5 mg/dl in men or >2.0 mg/dl in women) or hyperkalemia >5.0 mEq/L. (Class I,A)

Antiplatelet & Anticoagulant Therapy

• Non entric coated chewable Aspirin 162 – 325mg is administrated & to be continued indefinitely (75 – 162mg). (Class I,A)

• Clopidogrel is administrated in patients who are unable to take aspirin because of hypersensitivity or major GI intolerance, a loading dose of clopidogrel followed by maintenance dose should be administrated. (Class I,B)

• DAPT (Dual Antiplatelet Therapy) should be administrated for upto 12 months to all patients with NSTE-ACS.

• It is reasonable to use ticagrelor in preference to clopidogrel .(Class IIa,B)

• In patients with NSTE-ACS treated with an early invasive strategy and DAPT with intermediate/ high risk features, a Gp IIb/IIIa inhibitor may be considered as part of initial antiplatelet therapy.

• Drug	Loading Dose	Maintenance Dose
  Aspirin (Chewable)	162 *- 325 mg	81 – 162 mg
  Clopidogrel	300 – 600 mg	75 mg
  Ticagrelor	180 mg	90 mg BD

• Anticoagulation is recommended in all patients with NSTE-ACS in addition to antiplatelet therapy.

• Enoxaparin : 1mg/kg SC BD, continued for the duration of hospitalization or until PCI is performed. (Class I,A)

• Fondaparinux : 2.5 mg SC OD, continued for duration of hospitalization or until PCI Is performed.(Class I,B)

• If PCI is perfomed while th patient is on fondaparinux, an additional anticoagulant with anti IIa (UFH or Bivaluridin) activity should be administrated because of the risk of catheter thrombosis.

• Bilavuridin can also be used as an alternative.

• Unfractioned heparin exerts it's anticoagulation effect by accelerating the action of circulating antithrombin, a proteolytic enzyme that inactivates factor IIa , factor Ixa, factor Xa. It prevents propagation but doesn't lyse clot. DOSE : 60 U/kg IV bolus then 12U perkg/hr to maintain aPTT at 1.5 -2 times the control. It is continued for atleast 48h or until discharge.

Invasive v/s conservative strategy

• An early invasive strategy (diagnostic angiography with intent to perform revascularisation) is indicated in NSTE-ACS patients who have recurrent angina or hemodynamic instability & in initially stabilised UA/NSTEMI patients who have an elevated risk for clinical events.

• An early invasive strategy is not recommended in patients with extensive co-morbidities.

Coronary Revascularisation

• A strategy of multivessel PCI, in contrast to culprit lesion only PCI, may be reasonable in patients undergoing coronary revasculrisation as a part of treatment for NSTE-ACS.

CABG

• It is recommended for patients with significant left main CAD.

• It is recommended for patients with 3 vessel disease.

• It is recommended for 2 vessel disease with significant proximal left anterior descending CAD and either abnormal LV function.

• It is recommended in patients whom PCI is not optimal .

• CABG is done in patients with multivessel disease with suitable coronary anatomy with normal LV function & without diabetes.

Vaccination

• Pneumococcal vaccine is recommended for patients 65 years of age and older and in high risk patients with cardiovascular disease.

• Annual influenza vaccine is recommended for patients with cardiovascualr disease.

Updated on 21/11/2014

Reference

• 2014 AHA Guideline for the management of patients with NSTE-ACS. Circulation Sep