Acute Coronary syndrome
Unstable Angina NSTEMI STEMI
ECG Normal ST depression ST segment elevation
T wave inversion T wave inversion
ST inversion
troponin none Positive positive
Myocardia none Myocardial injury Myocardial necrosis (death)
l damage
occlusion partial partial total
pain Chest Chest Suffocating and squeezing pain
occurs at res, minimal occurs at res, minimal ✅
exertion. Can radiate to exertion. Can radiate to
arms or jaw arms or jaw
Initial diagnosis (risk stratification) ✅
Angina symptoms
Clinical history
ECG
Renal function (coronary angiography can cause kidney damage, also to see medication
considerations as the medication will be given quickly).
Cardiac troponin (used in the body during muscle contraction, myocardium death or damage will
cause the release of troponin).
Other symptoms: nausea, vomiting, crushing, heaviness, and tightness.
What do we do after we diagnose?
NSTEMI
TIMI risk score
30-day and 1-year mortality.
For NSTEMI.
A score above 3=benefit from LMW heparin, GP 2b,3a inhibitors and invasive strategies.
GRACE risk score✅
Predicts in hospital vs post-discharge mortality.
High score=above 140.
If a high score, early invasive strategies are looked at.
TIMI is faster, but GRACE is more thorough so done if more time is available.
CRUSADE risk score✅
Bleeding risk score
In NSTEMI patients.
Initial medications depend on these risk scores.
Initial Anti-ischemic therapies
ALL ACS PATIENTS
Morphine=opioid used for chest pain and vasodilation.
, Oxygen=used if pO2<94%
Nitro-glycerine=nitrates used for vasodilation and pain
Aspirin =inhibits platelet aggregation, and pain, reduces mortality, and clopidogrel if intolerant or allergy.
Beta blocker=beta 1 selective, decreases ischemia and stops arrhythmias
Beta-blockers should be given within 24 hours if not contraindicated (heart block, heart failure,
asthma, reactive airway disease).
Oral beta blockers are safer as IV increases the risk of shock.
NSTEMI/unstable angina
Offer 300mg single-loading aspirin and fondaparinux (Heparin IV) unless there is a high bleeding
risk or immediate angiography.
✅
Low TIMI score<3
Consider management via medication rather than angiography.
No bleeding risk: offer ticagrelor with aspirin.
High-risk bleeding: clopidogrel with aspirin
Ischemia testing before discharge
If ischemia comes up on this testing, then consider doing an angiography.
Assess left ventricular function and record in their record.
Moderate/High TIMI score>3
Offer angiography within 72 hours with follow on PCI.
Or immediately if the condition is unstable.
Offer prasugrel or ticagrelor with aspirin unless already taking an anticoagulant.
Prasugrel should only be offered if PCI is intended.
If already taking one: offer clopidogrel with aspirin.
Offer unfractionated heparin unless contraindicated even if they’ve already been given
fondaparinux.
PCI: Offer a drug-eluting stent=slow-release medication to prevent blood clots from forming in
the stent.
Both: finish with cardiac rehabilitation and secondary prevention.
STEMI
Offer aspirin 300mg maintenance dose then 75mg indefinitely unless contraindicated.
Diagnose within 10 minutes.
Assess eligibility for reperfusion therapy (PCI or fibrinolysis).
Deliver the reperfusion therapy as soon as possible.
Don’t offer G protein inhibitors or fibrinolysis if PCI is planned.
Decide to start between primary PCI or fibrinolysis.
If the wait time is less than 2 hours for a PCI start it within 90 minutes
If not start fibrinolysis within 10 minutes.
If not at a PCI centre transfer to one.
PCI preferred to fibrinolysis.
PCI therapy
Angiography with follow on primary PCI
Offer PCI within 2 hours if symptoms started 12 hours or less previously.
Consider radial vs femoral access (hand vs pelvis/groin, radial=lower risk and fewer
complications).
Drugs taken with PCI
not previously taken anticoagulant: offer prasugrel with aspirin.
previously taking anti-coagulant: clopidogrel with aspirin.
Unstable Angina NSTEMI STEMI
ECG Normal ST depression ST segment elevation
T wave inversion T wave inversion
ST inversion
troponin none Positive positive
Myocardia none Myocardial injury Myocardial necrosis (death)
l damage
occlusion partial partial total
pain Chest Chest Suffocating and squeezing pain
occurs at res, minimal occurs at res, minimal ✅
exertion. Can radiate to exertion. Can radiate to
arms or jaw arms or jaw
Initial diagnosis (risk stratification) ✅
Angina symptoms
Clinical history
ECG
Renal function (coronary angiography can cause kidney damage, also to see medication
considerations as the medication will be given quickly).
Cardiac troponin (used in the body during muscle contraction, myocardium death or damage will
cause the release of troponin).
Other symptoms: nausea, vomiting, crushing, heaviness, and tightness.
What do we do after we diagnose?
NSTEMI
TIMI risk score
30-day and 1-year mortality.
For NSTEMI.
A score above 3=benefit from LMW heparin, GP 2b,3a inhibitors and invasive strategies.
GRACE risk score✅
Predicts in hospital vs post-discharge mortality.
High score=above 140.
If a high score, early invasive strategies are looked at.
TIMI is faster, but GRACE is more thorough so done if more time is available.
CRUSADE risk score✅
Bleeding risk score
In NSTEMI patients.
Initial medications depend on these risk scores.
Initial Anti-ischemic therapies
ALL ACS PATIENTS
Morphine=opioid used for chest pain and vasodilation.
, Oxygen=used if pO2<94%
Nitro-glycerine=nitrates used for vasodilation and pain
Aspirin =inhibits platelet aggregation, and pain, reduces mortality, and clopidogrel if intolerant or allergy.
Beta blocker=beta 1 selective, decreases ischemia and stops arrhythmias
Beta-blockers should be given within 24 hours if not contraindicated (heart block, heart failure,
asthma, reactive airway disease).
Oral beta blockers are safer as IV increases the risk of shock.
NSTEMI/unstable angina
Offer 300mg single-loading aspirin and fondaparinux (Heparin IV) unless there is a high bleeding
risk or immediate angiography.
✅
Low TIMI score<3
Consider management via medication rather than angiography.
No bleeding risk: offer ticagrelor with aspirin.
High-risk bleeding: clopidogrel with aspirin
Ischemia testing before discharge
If ischemia comes up on this testing, then consider doing an angiography.
Assess left ventricular function and record in their record.
Moderate/High TIMI score>3
Offer angiography within 72 hours with follow on PCI.
Or immediately if the condition is unstable.
Offer prasugrel or ticagrelor with aspirin unless already taking an anticoagulant.
Prasugrel should only be offered if PCI is intended.
If already taking one: offer clopidogrel with aspirin.
Offer unfractionated heparin unless contraindicated even if they’ve already been given
fondaparinux.
PCI: Offer a drug-eluting stent=slow-release medication to prevent blood clots from forming in
the stent.
Both: finish with cardiac rehabilitation and secondary prevention.
STEMI
Offer aspirin 300mg maintenance dose then 75mg indefinitely unless contraindicated.
Diagnose within 10 minutes.
Assess eligibility for reperfusion therapy (PCI or fibrinolysis).
Deliver the reperfusion therapy as soon as possible.
Don’t offer G protein inhibitors or fibrinolysis if PCI is planned.
Decide to start between primary PCI or fibrinolysis.
If the wait time is less than 2 hours for a PCI start it within 90 minutes
If not start fibrinolysis within 10 minutes.
If not at a PCI centre transfer to one.
PCI preferred to fibrinolysis.
PCI therapy
Angiography with follow on primary PCI
Offer PCI within 2 hours if symptoms started 12 hours or less previously.
Consider radial vs femoral access (hand vs pelvis/groin, radial=lower risk and fewer
complications).
Drugs taken with PCI
not previously taken anticoagulant: offer prasugrel with aspirin.
previously taking anti-coagulant: clopidogrel with aspirin.
