NSTEMI/UA(first line) Drugs IV (DIA)MORPHINE 2.

5-10 mg IV + IV METOCLOPRAMIDE 10 mg, if pain severe Note: though there is some evidence that opiates can cause harm in ACS [Ref] PO ASPIRIN 300 mg stat, then 75 mg od PO CLOPIDOGREL 300 mg stat, then 75 mg of for 1 year (use only CLOPIDOGREL if ASPIRIN allergy) Note: give higher dosages even if on one/both drugs already SC ENOXAPARIN 1 mg/kg bd Note: some junior doctors wait for a registrar review, if it can be quick (eg do you want to give 3 anticoagulant drugs, in a frail older patient, if this is NOT an ACS?); don't give ENOXAPARIN, if on WARFARIN SL GTN 1-2 tabs; consider IV GTN infusion 10-200 mcg/min (start high, if systolic BP >100 mmHg) if pain does not improve/recurrent IV line (cardiac arrest possible at any time, especially in 1st 24h) OXYGEN, high flow, if hypoxic [Ref] Treatment - STEMI (first line) Drugs IV (DIA)MORPHINE 2.5-10 mg IV + IV METOCLOPRAMIDE 10 mg, if pain severe Note: though there is some evidence that opiates can cause harm in ACS [Ref] PO ASPIRIN 300 mg stat, then 75 mg od PO CLOPIDOGREL 600 mg stat, then 75 mg of for 1 year (use only CLOPIDOGREL if ASPIRIN allergy) Note: give higher dosages even if on one/both drugs already Either, IV ALTEPLASE (rt-pA) 10-15 mg (see BNF) or TENECTEPLASE 30-50 mg over 10 secs, if indication below; if <12h; f no contraindication (also below) and unless having PCI Note: thrombolysis reduces mortality by 2-3%; rt-PA has greater risk of CVA (mainly haemorrhagic) to streptokinase but lower risk of major bleed and reinfarction Or, Primary percutaneous intervention (PCI); if local policy, and <12h SL GTN 1-2 tabs; consider IV GTN infusion 10-200 mcg/min (start high, if systolic BP >100 mmHg) if pain does not improve/recurrent IV (cardiac arrest possible at any time, esp in 1st 24h) OXYGEN, high flow, if hypoxic: [Ref] Benefit of thrombolysis and PCI Most benefit of thrombolysis occurs in first 6h. In one meta-analysis of the 9 randomised trials with more than 1000 patients, there was a 3.5% reduction in mortality in first 1 hr, 2.5% in next 2-3 hrs and 1.9% in 3-6 hrs This gives an NNT of 15 in first hr; and 27 in next 2-3 hrs: [Ref] .

 The advantage of PCI over thromolysis is unclear. There is some evidence that pre-hospital thrombolysis has the most effect on mortality. PCI may be 'better' unless thrombolysis can be done in first 3 hrs So, why does neither technique have a huge effect on mortality? Perhaps because in 2/3rds of cases, there is spontaneous thrombolysis of the clot. Also the 'before hospital' mortality is high (50%) and some in-hospital ones (eg bad LVF) have a poor prognosis. Ie, the 'good ones' get better and the 'bad ones' die whatever you do Prescribing issues Round up dose of ENOXAPARIN (calculated in mg/kg) to available dose (20, 40, 60, 80 + 100 mg) Thrombolysis: indications, contraindications Indications 1. ST elevation >1mm in 2 or more limb leads 2. >2mm in 2 or more consecutive chest leads 3. New LBBB 4. Posterior infarction Contraindications 1. Cardiac Suspected aortic dissection Prolonged cardiopulmonary resuscitation (>5 mins) 2. Neurological Previous stroke Known intracranial neoplasm Recent head trauma Other intracranial pathology Severe hypertension (BP>180/110mmHg) 3. Gastro/surgery Acute peptic ulcer Acute internal bleeding Recent (less than 1 month) internal bleeding Recent (less than 1 month) major surgery 4. Haematological Known bleeding diasthesis 5. Other: Advanced CRF/CLF; current use of anticoagulants? Key management decision (STEMI) PCI or Thrombolysis Admit? Always Bed plan CCU, or straight to cardiac catheter laboratory Referrals

Medical Cardiology Other Cardiac rehabilitation nurse