Acute coronary syndromes (ACS) General Mx + Discharge Rx ‘MONARCH BASIC’
1. Prevent further worsening
2. Re-vascularise vessel if occluded
3. Rx pain
Definition acute coronary syndromes (ACS) is an umbrella Morphine Oxygen (only if SpO2 <96%) Nitrates Aspirin Reperfusion
term describing acute presentations of ischaemic heart (Primary PCI/thrombolysis) Clopidogrel Heparin
Beta-blocker Anticoagulation (dual) Statin Inhibitors (ACEi) Correction of
disease:
RFs
ST-elevation myocardial infarction (STEMI)
Non-ST elevation myocardial infarction (NSTEMI) Management of STEMI
Unstable angina Primary PCI to patients < 12 hours of onset of symptoms
ACS develops in patients w/ IHD- coronary heart /artery If they cannot be sent to a PCI centre < 120 mins fibrinolysis
disease due to gradual fatty plaque build-up 2 possible Sublingual GTN + IV morphine + metoclopramide
Aspirin 300mg
outcomes: + 2nd antiplatelet e.g. ticagrelor, prasugrel, Clopidogrel
1. Gradual narrowing angina/hypoperfusion to + Heparin (LMWH/unfractionated)
myocardium
2. Plaque rupture embolus Management of NSTEMI
+ Fondaparinux
Not high bleeding risk
Risk factors: Having angiography within the next 24hr? Yes; No? Give
Modifiable Smoking, DM, HTN, high cholesterol, obesity: unfractionated heparin
Non-modifiable: Increased age, M > F, Positive FHx + Clopidogrel 300mg continued for 12 months
+ IV glycoprotein IIb/IIIa antagonist
Signs + symptoms ‘Chest pain’ > 20 minutes + Risk assessment w/ GRACE score Coronary angiography ≤
96 hrs of admission + 6-month mortality > 3.0%
Central/left-sided
May radiate to jaw/left arm
Heavy/constricting
Certain patients i.e. elderly/diabetic = no chest
pain/silent
GRACE score
Other symptoms In-hospital risk score 6-month risk score Interpretation
Dyspnoea, sweating, nausea + vomiting Age Age < 1.5% lowest risk
Raised JVP, Increased pulse/BP changes, Pallor + anxiety HR Hx of CHF > 1.5%- 3.0% low risk
Ix SBP Hx of MI > 3.0% - 6.0%
Serum CK HR intermediate
1. ECG ST elevation? ST depression? Inverted T waves? Killip class (HF) SBP > 6.0% high
New LBBB? Pathological Q waves? Cardiac arrest on ST segment
2. CXR: Cardiomegaly? Pulmonary oedema? Widening of admission depression
Elevated cardiac Serum CK
mediastinum? markers Elevated cardiac
3. Bloods cardiac biomarkers (Troponin I + Troponin T) ST segment markers
4. Angiography deviation No in-hospital PCI
1. Prevent further worsening
2. Re-vascularise vessel if occluded
3. Rx pain
Definition acute coronary syndromes (ACS) is an umbrella Morphine Oxygen (only if SpO2 <96%) Nitrates Aspirin Reperfusion
term describing acute presentations of ischaemic heart (Primary PCI/thrombolysis) Clopidogrel Heparin
Beta-blocker Anticoagulation (dual) Statin Inhibitors (ACEi) Correction of
disease:
RFs
ST-elevation myocardial infarction (STEMI)
Non-ST elevation myocardial infarction (NSTEMI) Management of STEMI
Unstable angina Primary PCI to patients < 12 hours of onset of symptoms
ACS develops in patients w/ IHD- coronary heart /artery If they cannot be sent to a PCI centre < 120 mins fibrinolysis
disease due to gradual fatty plaque build-up 2 possible Sublingual GTN + IV morphine + metoclopramide
Aspirin 300mg
outcomes: + 2nd antiplatelet e.g. ticagrelor, prasugrel, Clopidogrel
1. Gradual narrowing angina/hypoperfusion to + Heparin (LMWH/unfractionated)
myocardium
2. Plaque rupture embolus Management of NSTEMI
+ Fondaparinux
Not high bleeding risk
Risk factors: Having angiography within the next 24hr? Yes; No? Give
Modifiable Smoking, DM, HTN, high cholesterol, obesity: unfractionated heparin
Non-modifiable: Increased age, M > F, Positive FHx + Clopidogrel 300mg continued for 12 months
+ IV glycoprotein IIb/IIIa antagonist
Signs + symptoms ‘Chest pain’ > 20 minutes + Risk assessment w/ GRACE score Coronary angiography ≤
96 hrs of admission + 6-month mortality > 3.0%
Central/left-sided
May radiate to jaw/left arm
Heavy/constricting
Certain patients i.e. elderly/diabetic = no chest
pain/silent
GRACE score
Other symptoms In-hospital risk score 6-month risk score Interpretation
Dyspnoea, sweating, nausea + vomiting Age Age < 1.5% lowest risk
Raised JVP, Increased pulse/BP changes, Pallor + anxiety HR Hx of CHF > 1.5%- 3.0% low risk
Ix SBP Hx of MI > 3.0% - 6.0%
Serum CK HR intermediate
1. ECG ST elevation? ST depression? Inverted T waves? Killip class (HF) SBP > 6.0% high
New LBBB? Pathological Q waves? Cardiac arrest on ST segment
2. CXR: Cardiomegaly? Pulmonary oedema? Widening of admission depression
Elevated cardiac Serum CK
mediastinum? markers Elevated cardiac
3. Bloods cardiac biomarkers (Troponin I + Troponin T) ST segment markers
4. Angiography deviation No in-hospital PCI
