Acute coronary syndrome—without ST-elevation (non STEMI)

First stabilize with medical therapy; early risk stratification will identify those in need of further treatment and prompt angiography (involve cardiologists).

Examination

• Pulse
• BP
• JVP
• Cardiac murmurs
• Signs of heart failure
• Peripheral pulses
• Scars from previous cardiac surgery.

Investigations

• ECG: ST depression; flat or inverted T-waves; or normal;
• CBC
• Urea & Creatinine
• Electrolytes
• Troponin
• Glucose
• Cholesterol
• CXR

Acute Management

• Monitor closely
• ECG while in pain
• Low-flow O2: If SaO2 <90% or breathless
• Morphine 5–10mg IV + metoclopramide 10mg IV
• Nitrates: GTN spray or sublingual tablets as required
• Aspirin: 300mg oral
  • Followed by 75mg once daily.
• Clopidogrel (300mg oral then 75mg once daily, oral)
  • If confirmed ACS
• GRACE score2: Measure troponin and clinical parameters to risk assess
• If GRACE score2: high-risk patient (Invasive strategy)
  • Fondaparinux: 2.5mg once daily SC or LMWH 1mg/kg/12h SC
  • Clopidogrel: 300mg oral then 75mg once daily, oral (if not already given)
  • GTN: 50mg in 50mL 0.9% saline at 2–10mL/h (if pain continues)
    • Titrate to pain
    • Maintain systolic BP >100mmHg
  • Bisoprolol 2.5mg once daily (OR verapamil 80–120mg/8h oral, or diltiazem 60–120mg/8h oral) Do not use Beta-blockers with verapamil—can precipitate asystole.
  • Prompt review for angiography
  • Urgent (<120min after presentation) if ongoing angina and evolving ST changes, signs of cardiogenic shock or life-threatening arrhythmias
  • Early (<24h) if GRACE score >140 and high-risk patient
  • Within 72h if lower-risk patient
• If GRACE score2: low-risk patient (Conservative strategy)
  • May be discharged
  • Retest troponin after delay if necessary
  • Arrange further outpatient investigation e.g. stress test.