What makes me think they have ACS?
 Elevated cardiac biomarkers
o NT-BNP
o Troponin I, T
o C-reactive protein
o APTT (activated prothrombin time) → used to assess clotting risk
 Signs and symptoms
o Haemodynamic instability (compromised BP)
 cool peripheries
 sweating
 systolic BP <90mmHg
 hypoxia (if sat O2 is < 93%)
o Syncope (fainting)
o Arrythmia
o ST depression ≥ 0.5mm OR T-wave inversion ≥2mm (on ECG) or ST-elevation
o Chest pain (angina)
o Prior MI
o LVEF <40% (HFrEF or cardiomyopathy)
What do we do first? → follow suspected ACS assessment protocol
 Aspirin 300mg
o If contraindicated, use clopidogrel or ticagrelor
 GTN (short acting nitrate), tablet 0.3 – 0.6 mg or sublingual spray 0.4 – 0.8mg, given every 5 minutes up to a
maximum of 3 doses
 Opioid management (Morphine or fentanyl IV), if pain persists
 O2 supplementation, if hypoxic
 Other therapies require diagnosis of ACS, triage
How do we figure out what they have?
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Assess presenting complaints
Send for ECG, blood tests
Risk stratification (TIMI/GRACE and CRUSADE) if NSTEAC to assess time to progression of MI
Haemodynamic assessment (assess for high-risk features of possible cardiac causes of chest pain = what
made me think it was ACS)
We have confirmed they have ACS, now what?
 Depending on availability at site, protocol follows point of care assay OR sensitive lab-based assay OR highly
sensitive lab-based assay
 For sensitive lab-based assay and highly sensitive lab-based assay, assess TIMI score if MI suspected
 Repeat troponin testing according to protocol
 If ECG changes or increase in troponin levels occurs, treat as high risk
o If there is no change = low risk for AMI
 Assess for CAD and need for objective testing
How do we determine what level of risk they are at of having ACS? → Thrombolysis in Myocardial Infarction (TIMI)
 The TIMI score is used to:
o Stratify risk in patients with ischaemic chest pain
o Predict the chances of having or dying from an MI in the next 14 days
 Calculated by adding 1 point/issue
Acute management of NSTEACS
 Indicates the speed of response required, whether they need to be transferred and admitted at a PCIhospital and the speed at which invasive treatment is required
 Risk stratification determines treatment
o Very high risk = pharmacological or immediate invasive if possible
o High risk = pharmacological or invasive if early possible
o Intermediate risk = delayed invasive, re-test and re-assess risk, pharmacological intervention
o Low risk = non-invasive testing, exercise stress test for CAD/IHD, pharmacological intervention
 Invasive therapy = angiography + revascularisation using PCI or CABG +/ Pharmacological management involves:
o Antiplatelet + anticoagulant + BB
o then consider either the PCI or glycoprotein.
 This will be dependent on the risks of the surgery, age, frailty, intolerances to anaesthetics
etc.
 It may not be possible for a percutaneous coronary intervention in rural communities due to
speciality and equipment.
Acute management of STEMI
 Invasive therapy is required for STEMI ASAP
o Time to primary PCI centre determines management strategy for invasive therapy and reperfusion
o Needed to re-establish blood flow → high ischaemic risk
 If fibrinolytic therapy is required due to primary PCI centre being >90 minutes away, what do we give?
o Parenteral thrombolytics and anticoagulants
 DAPT (Aspirin 300mg + clopidogrel 300mg oral) = antiplatelet therapy
 Tissue plasminogen activators (tPa) = Alteplase, Reteplase, Tenecteplase =
thrombolytic/fibrinolytic
 Absolute contraindicated in ischaemic stroke within 3 months, head trauma within 3
months, active bleeding (except menses), prior intercranial haemorrhage
 Relative contraindications BP ≥180/110mmHg, major surgery within 3 weeks,
internal bleeding e.g PUD, TIA within last 6 months, advanced liver disease
 Glycoprotein IIIa/IIb inhibitors (enoxaparin, dalteparin) = anticoagulation
 If large MI, use enoxaparin for ≥5 days [goal = INR≥ 2 for 2 days), then cease and start
warfarin
 If PCI regimen used, what do we give?
o DAPT using ticagrelor or prasugrel
o Glycoprotein IIIa/IIb
o Anticoagulation required prior to operation:
 Bivalirudin for increased bleeding risk patients in PCI (monotherapy)
 Enoxaparin
 UFH
Discharge day! How do we manage them long term?
Non-pharmacological
 Cardiac rehabilitation = liase with GP
o SNAP
o Dietician referral
o Exercise physiologist referral
 Chest pain plan
 Education support
 Manage CV risk factors
Pharmacological
 DAPT = aspirin (75 – 100mg) + clopidogrel (75mg,
oral, 1D) for 6 – 12 months
 High intensity statin therapy (e.g. atorvastatin, 40 –
80mg, 1D OR rosuvastatin)
 Beta blocker (consider B1 selective =
cardioselective)
 ACEI/A2RB
 GTN spray or sublingual tablets
 Aldosterone antagonist (epleronone preferred) if
HF and ventricular dysfunction after ACS
 Annual influenza vaccine