Prescribing in Chest Pain

Investigations
1. Bedside test & bloods:
o ECG.
o Troponin:
(a) If chest pain occurred < 6 hours ago, do baseline troponin & repeat after 3 hours.
(b) If chest pain occurred > 6 hours ago, only need to do troponin once  if not raised at 6 hours, can
rule out MI.
o Routine bloods – FBC, CRP, U&Es, LFTs, TFTs, clotting, blood glucose.

2. Imaging:
o CXR.
o Transthoracic echocardiogram.
o Coronary angiogram.
o Cardiac magnetic resonance.

NSTEMI Prescribing
o High-flow O2 via non-rebreathe mask (15L of 100% O2).
o GTN sublingual spray 1-2 sprays (can give GTN infusion 2-10mg/ hour if on-going chest pain, but monitor
BP to ensure it is SBP > 90).
o Morphine IV 5-10mg.
o Metoclopramide IV 10mg.
o Aspirin PO 300mg.
o Clopidogrel PO 300mg  continue at 75mg.
o Enoxaparin SC 1mg/ kg BD for min. 2 days (2-8 days)  if renal impairment, give only OD.

NSTEMI – compare to old ECG to check if T-wave inversion is new/ old.

To determine whether NSTEMI patient requires PCI, use risk-stratifying scores (e.g. TIMI score or
GRACE score).

Thrombolysis in Myocardial Infarction (TIMI) risk score:

If patients are at medium-high risk, they should be offered early in-hospital PCI.

STEMI Prescribing
o Same initial management as NSTEMI.
o DO NOT give Enoxaparin in STEMI  if for PCI, giving enoxaparin increases risk of bleeding in PCI.
o In PCI/ catheter lab, patient should be given 2 antiplatelet/ anticoagulation drugs to reduce risk of
immediate vascular occlusion - Refer to Trust’s guidelines for which drugs to give (e.g. Prasugrel + Aspirin,
or Heparin + Glycoprotein IIb/ IIIa).
o Offer fibrinolysis (IV Alteplase) to acute STEMI presenting within 12 hours of onset of symptoms, if 1 PCI
cannot be delivered within 120 minutes of the time when fibrinolysis could have been given.
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Long-Term Post-MI Management: For 2 Prevention of Further MI (Cardiology Cocktail)
o ACEI – Ramipril 2.5mg OD (PO)  increase to 5mg after 3 days.
o -blocker – Bisoprolol 2.5mg OD (PO)  target pulse 50-70bpm.
o Aspirin 75mg OD (PO)  indefinitely.
o Clopidogrel 75mg OD (PO)  for 12 months
o Atorvastatin 80mg OD (PO).
o GTN PRN.

Complications of MI
DARTH VADER:
Early o Death.
o Arrhythmia.
o Ruptured ventricle.
o Thrombus (mural).
o Heart failure/ cardiogenic shock.

Late o Ventricular aneurysm/ septal rupture.

o Another MI
o Dressler’s syndrome (pericarditis).
o Emboli
o Regurgitation murmur/ ventricular septal defect.

Diabetes & ACS

o Keep blood glucose < 11mol/ L while avoiding hypoglycaemia.
o If hyperglycaemia, start sliding- scale insulin.

Warfarin & ACS:

o Send bloods for INR.
o If warfarin continuation NOT mandatory (AF)  stop warfarin and start enoxaparin when INR < 2.
o If warfarin mandatory (mechanical heart valves), do not prescribe enoxaparin.

Atrial Fibrillation
1. Life-threatening (haemodynamically unstable) vs. clinically stable AF:
Haemodynamically Unstable Emergency electrical (DC) cardioversion is required, WITHOUT delaying
to achieve anticoagulation.
Anticoagulation should be continued for 4 weeks after cardioversion.

Clinically Stable
Favouring Rate Control o Older patients, age > 65.
o Hx of CAD/ IHD.
o With contraindications to antiarrhythmic
drugs.
o Unstable for cardioversion.

Favouring Rhythm o Younger patients, age < 65.

Control o New-onset AF (1st presentation of lone
AF).
o AF secondary to a reversible/ treated
precipitant (e.g. alcohol).
o Symptomatic AF.
o Congestive heart failure.

Anticoagulation o CHADS2-VASc stroke risk score vs.

HASBLED major bleeding risk score.

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2. Rate control:
1st-Line Cardio-selective β1-blockers (class II): (absolute CI in asthma)
o Bisoprolol
o Metoprolol

Calcium-channel blockers (class IV):

o Verapamil (cardio-selective)
o Diltiazem

2nd-Line Digoxin monotherapy (cardiac glycoside), suitable for chronic AF in:

o sedentary patients
o hypotension
o heart failure

3rd-Line Amiodarone (K+-channel blocker class III)  DO NOT offer for long-term rate control.

3. Rhythm control:
Electrical Cardioversion 1. For AF persisting > 48 hours, offer electrical (rather than
pharmacological) cardioversion.

2. Echocardiogram is performed before cardioversion.

3. As cardioversion is associated with increased risk of TED

(thromboembolic disease), anticoagulation is required for:
(a) at least 3 weeks before (INR > 2), and
(b) 4 weeks after

Pharmacological Cardioversion For clinically stable patients:

IV Flecainide o If there is no structural heart disease, 1st-line
drug is infusing IV flecainide.
o Flecainide is Na+-channel blocker (class I
drug), which reduces maximum rate of
depolarisation during phase of rapid
depolarisation.

IV Amiodarone o If there is structural heart disease, give IV

amiodarone.
o SEs include hyperthyroidism/ hypothyroidism
& thrombophlebitis.

e
Pacemaker Insertion 1. In poorly controlled/ medically refractory & symptomatic AF,
+ complete AV nodal block can be deliberately induced by ‘pace &
Catheter Ablation ablate’ strategy.

2. A permanent pacemaker is required for maintenance of adequate

ventricular rate, before catheter ablation of AVN (atrioventricular
node).

3. AVN is then ablated using radiofrequency energy.

4. Need for lifelong pacemaker dependency & anticoagulation following

this procedure.

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4. Causes of AF: MITRAL
o mitral valve disease
o ischaemic heart disease
o thyrotoxicosis
o raised BP
o alcohol
o idiopathic/ LVH