Management of Suspected Acute Coronary Syndrome (ACS)

Assessment / monitoring

Record ECG, take a good history, perform all general assessment measures for an acute admission, request immediate bloods including high-sensitivity cardiac troponin (hs-cTNT) and follow the 'Suspected ACS / Acute Chest Pain Pathway' clinical management flow chart below.

Initial management of in-hospital STEMI

STEMI (ST elevation myocardial infarction) on ECG: >2mm in 2 adjacent chest leads or >1mm in 2 adjacent limb leads or new LBBB or >2mm ST depression V1-V3 (posterior).

If a patient self-presents with STEMI, or suffers STEMI while in hospital, the patient will be referred for percutaneous coronary intervention (PCI) by immediate ambulance transfer after consultation with consultant staff and the interventional cardiologist at Hairmyres Hospital following the steps below. PCI is the treatment of choice and most patients will be eligible. This is most effective when done as early as possible. If there are logistical reasons causing a significant delay to PCI, IV tenecteplase should be considered (see Box 2 below).

Step 1: Oxygen if desaturated (unless contraindicated) and monitor ECG

Step 2: Commence medical treatment (see Box 1 below)

Step 3: Fax ECG to Hairmyres Hospital (fax 01355 584807) and phone their CCU on 01355 584819 to provide clinical patient information

Step 4: Arrange Blue Light transfer to Hairmyres Hospital if deemed appropriate following consultation

If patient is for PCI go to Box 1.
If patient is for Thrombolysis go to Box 2.

Note: some patients with multiple co-morbidities may not be candidates for PCI or thrombolysis.

Box 1 – Procedure for patients with STEMI who are eligible for PCI

Prescribe and administer the following:

  • Aspirin oral 300mg stat dose unless patient has already received a dose
  • Clopidogrel oral 600mg stat dose*
  • Heparin IV 5000units (if not anticoagulated)
  • Sublingual GTN spray / morphine 2.5-5mg by slow IV injection (give metoclopramide IV 10mg with first dose of morphine)

*Patients who receive PCI will be switched to prasugrel by the coronary intervention centre unless contraindicated (previous TIA / CVA / ICH, patients on anticoagulation, severe hepatic impairment, patients for thrombolysis, propensity to bleeding i.e. anaemia, GI bleed).  

Box 2 – Procedure for patients with STEMI who are for thrombolysis rather than PCI

Initial management of in-hospital NSTEMI

For a non-diagnostic event on ECG, refer to 'Suspected Acute Coronary Syndrome / Acute Chest Pain Pathway' above.

For NSTEMI (non-ST elevation myocardial infarction) on ECG with new horizontal or downsloping ST-depression ≥2mm or deep symmetrical T-wave inversion in 2 adjacent leads, seek senior review or cardiology referral, and consider high risk NSTEMI GJUNH pathway (see 'Suspected Acute Coronary Syndrome / Acute Chest Pain Pathway' above). Therapeutic management is detailed below.

Prescribe and administer the following:

  • Aspirin oral 300mg stat dose unless patient has already received a dose
  • Sublingual GTN spray / morphine 2.5-5mg by slow IV injection (give metoclopramide IV 10mg with first dose of morphine)
  • Consider clopidogrel oral 300mg stat dose
  • Fondaparinux SC 2.5mg (if not anticoagulated). Avoid fondaparinux if CrCl <20ml/min. Instead, use dalteparin SC 100units/kg twice daily, up to a maximum of 9000units twice daily

 

For ongoing therapeutic management following this initial guidance above, please refer to Drugs for Secondary Prevention of MI.

 

Guideline reviewed August 2023
Page updated October 2023



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