Management of Acute Coronary Syndrome (ACS)

Unstable Angina
Primary Treatment
Oxygen, morphine, and nitroglycerin should be administered to patients
with presumed cardiac chest pain in the absence of contraindications. Although
experimental results indicate that breathing oxygen may limit ischaemic
myocardial injury, whether this therapy reduces mortality or morbidity in
patients with unstable angina who are not hypoxic is unknown. Oxygen therapy
to maintain oxygen saturation >90%
Antiplatelet therapy should be administered. Start with Aspirin in the
absence of contraindications, in combination with prasugrel, clopidogrel, or
ticagrelor depending on the treatment strategy selected.
Ongoing Treatment
Antiplatelet treatment: Aspirin should be continued indefinitely. For patients
with aspirin allergy, long-term clopidogrel is suggested; this should also be
continued indefinitely.
Statins: Statins are recommended for all patients with non-STEMI-ACS (in the
absence of contraindications), irrespective of cholesterol levels. They should be
initiated early (within 1 to 4 days) after admission, with the aim of achieving lowdensity lipoprotein cholesterol levels <2.6 mmol/L (<100 mg/dL).
Beta-Blockers: Unless contraindicated, beta-blockers should be continued
indefinitely in patients with reduced left ventricular function, with or without
symptoms of heart failure.
ACE Inhibitors: Unless contraindicated, long-term use of ACE inhibitors is
indicated in patients with a LVEF of 40% or less and also in patients with diabetes
mellitus, hypertension, or chronic renal disease, unless contraindicated.
Cardiac Rehabilitation: In addition to adequate control of hypertension,
diabetes mellitus, and hyperlipidaemia, risk-factor intervention is
recommended. This includes lifestyle modifications (smoking cessation; regular
physical activity, with 30 minutes of moderate-intensity aerobic activity at least 5
times/week; a healthy diet based on low salt intake, a decreased intake of
saturated fats, and a regular intake of fruit and vegetables; and weight
reduction).

Non-STEMI Treatment
Acute Presentation
Oxygen: All patients require oxygen and oxygen saturation measurement using
pulse oximetry.
Aspirin: Aspirin should be given on clinical suspicion or diagnosis of acute
coronary syndrome (ACS) and continued indefinitely.
P2Y12 receptor inhibitor: A loading dose of a P2Y12 receptor inhibitor (e.g.
Clopidogrel) is given as soon as possible on admission and then a maintenance
dose is given for up to 12 months.
Glyceryl trinitrate: Use GTN unless GTN is contraindicated such as if there is a
history of recent phosphodiesterase-5 inhibitor use (e.g., sildenafil); it should not
be given if systolic BP is <90 mmHg or there is a concern about right ventricular
infarct.
Morphine: Morphine should be added early if GTN is not sufficient. Morphine, in
addition to its analgesic and anxiolytic properties, has haemodynamic effects
that are potentially beneficial in unstable angina and NSTEMI.
Beta-blockers: beta-blockers are indicated for all patients unless
contraindicated.
Calcium-channel blockers: CCB can be given to patients with continuing or
recurrent ischaemic symptoms after being given adequate nitrate and betablocker therapy, or those who cannot tolerate beta-blockers.
Assess to decide best approach
Assess need for invasive or conservative approach. The latest guidelines
recommend that high-risk patients routinely undergo early (12-24 hours)
coronary angiography and angiographically directed revascularisation unless
patients have serious co-morbidities.

An invasive approach is recommended if any of the following high-risk

features are present: recurrent angina or ischaemia at rest or with lowlevel activities despite intensive medical therapy; elevated cardiac
biomarkers (troponin T or I); new or presumably new ST-segment
depression; signs or symptoms of heart failure or new or worsening mitral
regurgitation; high-risk findings from non-invasive testing; haemodynamic
instability; sustained ventricular tachycardia; percutaneous coronary
intervention within 6 months; prior CABG; high-risk score (i.e., TIMI,
GRACE); reduced left ventricular function (ejection fraction <0.40).

A conservative approach may be appropriate in subsets of patients,

especially those without high-risk features and with a low risk score. These
include low-risk women and older patients.

Invasive Approach

Percutaneous coronary intervention (PCI) (Angioplasty): Angioplasty is

coupled with placement of stents or replacement by other new techniques
capable of relieving coronary narrowing or occlusion.
Complications of PCI include PCI-induced MI; coronary perforation, dissection, or
rupture; cardiac tamponade; malignant arrhythmias; cholesterol emboli; and
bleeding from the access site.
Contrast-induced nephropathy is a common and potentially serious
complication. Stent thromboses (early and late) are a catastrophic complication.
Anticoagulation: Unfractionated heparin and low molecular weight heparin are
thrombin inhibitors. Like heparin, the mechanism of action involves binding to
antithrombin III to increase its anticoagulant activity. Unfractionated heparin
should be added to Fondaparinux in patients undergoing percutaneous coronary
intervention.
Glycoprotein (GP) IIb/IIIa inhibitors: GP IIb/IIIa inhibitors block platelet
binding of fibrinogen to the GP IIb/IIIa receptor. This is the final stage before
platelet aggregation and the formation of thrombus. Abciximab or accelerateddose eptifibatide is preferred if percutaneous coronary intervention is expected
soon after presentation.
Invasive Procedure Not Planned
Anticoagulation: Anticoagulation is contraindicated in major bleeding or history
of adverse drug reaction or heparin-induced thrombocytopenia.
Anticoagulation therapy can be subcutaneous low molecular weight heparin or
intravenous unfractionated Heparin, or the alternative agents Fondaparinux or
Bivalirudin. Fondaparinux is a preferred first-line anticoagulant strategy in those
at higher risk of bleeding managed with a non-invasive strategy.
Post Stabilisation
Cardiac rehabilitation: The aims of cardiac rehabilitation are to increase
functional capacity; stop cigarette smoking; modify lipids and lipoproteins;
decrease body weight and fat stores; reduce BP; improve psychosocial wellbeing; prevent progression and promote plaque stability; induce regression of
underlying atherosclerosis; and restore and maintain optimal physical,
psychological, emotional, social, and vocational functioning.
Continue antiplatelet therapy: In patients tolerant to aspirin, it should be
continued indefinitely. In addition, a P2Y12 receptor inhibitor should be continued
for up to12 months in patients treated medically (no stenting) or treated with a
bare metal stent (BMS), and for at least 12 months for those patients treated
with a drug eluting stent (DUS).
Beta-blockers: Beta-blockers should be continued indefinitely.
Statins: Statin therapy should be given before hospital discharge to all patients
with acute coronary syndrome.
ACE inhibitors: ACE inhibitors should be used in all patients with left ventricle
systolic dysfunction (ejection fraction <40%), heart failure, HTN, or other high-

risk features, such as ongoing ischaemia with worsening heart failure, S3 gallop,
new or worsening mitral regurgitation, or haemodynamic instability, without
overt cardiogenic shock. They are started after 24 hours.
Anticoagulation: Most patients do not need to continue anticoagulation after
hospitalisation. A subset of patients who are high risk for a repeat thrombotic
event may be put on chronic oral anticoagulation.

STEMI Treatment
Suspected MI with ongoing chest pain
Aspirin: Aspirin is given immediately.
Oxygen: Oxygen saturation should be maintained over 90% with supplemental
oxygen.
Morphine: Adequate analgesia with morphine is essential to relieve pain and its
related sympathetic activity, which can further increase myocardial oxygen
demand.
Glyceryl trinitrate: Should also be given immediately, if the patient is not
hypotensive, as it reduces myocardial oxygen demand and lessens ischaemia,
and may rarely abort MI if there is coronary spasm. However, it should not be
given in doses that interfere with analgesic therapy.
Haemodynamically Unstable
Emergency Revascularisation: Invasive cardiac revascularisation within
48 hours of MI reduces mortality at 12 months compared with medical treatment
alone. If revascularisation fails, or there is persistent pain or haemodynamic
instability, urgent coronary artery bypass graft (CABG) is recommended.
Inotrope support or intra-aortic balloon pump (IABP): Patients with low
cardiac output states and cardiogenic shock may benefit from a dobutamine
(sympathomimetic drug causing positive inotrope) infusion. An intra-aortic
balloon pump (IABP) is indicated if pharmacological measures do not quickly
improve shocked state. The IABP inflates during diastole, increasing blood flow to
the coronary arteries via retrograde flow. Whilst it actively deflates in systole,
increasing forward blood flow by reducing afterload through a vacuum effect.
Haemodynamically stable with no access to PCI within 90 minutes and
>12 hours of symptom onset
Anticoagulation: Indicated for the treatment of STEMI as it limits secondary
thrombosis, by inhibiting platelet activation and subsequent platelet aggregation.
Aspirin + Clopidogrel or Prasugrel or Ticagrelor: Indicated for the
treatment of STEMI as they limit secondary thrombosis, by inhibiting platelet

activation and subsequent platelet aggregation. Some institutions limit the

immediate use of oral anticoagulants given the concerns over bleeding if
emergency bypass surgery is required. Prasugrel was found to be superior to
clopidogrel in outcome measures when given for at least 1 year; however, there
is an increased risk of bleeding in patients <60 kg or over 74 years of age. Lower
doses are recommended in these patients.
Beta-blocker: Beta-blockers should be started as soon as possible, as they
decrease infarction size, although care should be taken in patients with evidence
of heart failure, hypotension, bradycardia, or asthma.
Statin: Should be initiated for plaque stabilisation, whatever the results of
serum lipid measurements.
Morphine: Adequate analgesia with morphine is essential to relieve ongoing
chest pain and its related sympathetic activity, which can further increase
myocardial oxygen demand.
Glyceryl trinitrate: Should also be given immediately, if the patient is not
hypotensive, as it reduces myocardial oxygen demand and lessens ischaemia,
and may rarely abort MI if there is coronary spasm. However, it should not be
given in doses that interfere with analgesic therapy.
Oxygen: Guidelines suggest that oxygen should be administered to all patients
with arterial desaturation, and may be administered routinely to all patients with
STEMI in the first 6 hours.
Glucose control: If blood glucose is significantly elevated, an intravenous
insulin infusion may need to be given, but rigid control has not been shown to be
necessary.
Haemodynamically stable with no access to PCI within 90 minutes:
within 12 hours of symptom onset with no contraindications to
thrombolysis
Do everything from No access to PCI within 90 minutes and >12 hours
of symptom onset along with the following:
Thrombolysis: Indicated if PCI is not available within 90 minutes of first medical
contact and patient has no contraindications to therapy. Should be initiated
within 30 minutes of presentation.
Used only once on initial diagnosis, and this must be within 12 hours of symptom
onset (ideally within 3 hours) as the efficacy of fibrinolytic agents in lysing the
thrombus diminishes over time. Therapy within the first 2 hours (particularly the
first hour) can occasionally abort MI and dramatically reduce mortality.
Absolute contraindications: any prior intracranial haemorrhage; known malignant
intracranial lesion or structural cerebral vascular lesion (e.g., arteriovenous
malformations); ischaemic stroke within previous 3 months; suspected aortic
dissection; active bleeding or bleeding diathesis; and significant closed head or
facial trauma within previous 3 months.

Thrombolysis is associated with an increased risk of bleeding and intracranial

haemorrhage.
Transfer for PCI after thrombolysis: PCI after thrombolysis is recommended
in high-risk patients with: ongoing chest pain; haemodynamic, mechanical, or
electrical instability; or shock. Routine PCI is not generally recommended.
Patients should be transferred for PCI as soon as possible. Those transferred
within 6 hours after thrombolytic therapy had significantly fewer ischaemic
complications than those who were only transferred if they had complications.
Haemodynamically stable with no access to PCI within 90 minutes:
within 12 hours of symptom onset with contraindications to
thrombolysis
Do everything from No access to PCI within 90 minutes and >12 hours
of symptom onset along with the following:
Consider PCI: In patients with contraindications to thrombolysis, PCI is indicated
even if it cannot occur within 90 minutes. Patients should be transferred for PCI
as soon as possible.
Haemodynamically stable with access to PCI within 90 minutes
Do everything from No access to PCI within 90 minutes and >12 hours
of symptom onset along with the following:
Revascularisation: Primary PCI with stent placement (using bare metal stents
or drug-eluting stents) is the preferred method of revascularisation, and is
indicated if patient presents to the emergency department within 90 minutes of
first presentation. Drug-eluting stents are preferred. Many hospitals have 24-hour
PCI capacity; however, in facilities without catheterisation laboratories, routine
transfer to a PCI facility should be considered for all patients within 30 minutes of
presentation, and ideally within 30 minutes of symptom onset, provided that the
transfer can be made within 120 minutes at the latest. Emergency
revascularisation with CABG should be strongly considered in patients who fail
PCI, and should be performed within 12 hours of symptom onset, ideally within 6
hours.
Ongoing management post-STEMI
Dual antiplatelet therapy: Recommended for at least 12 months in all
patients whether they were stented or not. Aspirin should be given indefinitely,
and clopidogrel (or prasugrel or ticagrelor) for at least 1 year. However, prasugrel
and ticagrelor are not recommended in patients who have undergone
thrombolysis as they have not been adequately studied in this setting.
Prasugrel was found to be superior to clopidogrel in outcome measures when
given for at least 1 year; however, there is an increased risk of bleeding in
patients <60 kg or over 74 years of age. Lower doses are recommended in these
patients.
ACE inhibitor: Should be started early (i.e., when patient is haemodynamically
stable, optimally on first day in hospital) for a favourable effect on ventricular
remodelling, especially in patients with large anterior wall MI.

Beta-blocker: Should be given indefinitely.

Statin: Should be given indefinitely.