GGC Medicines


Adult Therapeutics Handbook

Management of Suspected Acute Coronary Syndrome (ACS)

Please note: this guideline has exceeded its review date and is currently under review by specialists. Exercise caution in the use of the clinical guideline.

Management of Suspected Acute Coronary Syndrome (ACS)

N.B. Some of the recommendations in this guideline are currently under review and may change. 

Introduction

Chest pain is one of the most common presentations at A&E. There is a long list of differential diagnoses.

Assessment / monitoring

Record ECG (continuous monitoring), take a good history, measure blood pressure and perform all general assessment measures for an acute admission. Follow flow chart below once ACS is established as the most likely cause of the presenting complaint.

Test for troponin if acute coronary syndrome is suspected with a suggestive history (even if no ECG changes) but particularly if there are ECG changes, risk factors for, or known, coronary disease, or there is another good clinical reason for testing. Troponin testing should not be used as a catch-all test in a 'routine' battery.

STEMI

Primary percutaneous coronary intervention (PPCI) is the treatment of choice and most patients will be eligible. This is most effective when done as early as possible. Do not delay in making a decision about this - decisions will almost always be made in the ambulance or in A&E.

Initial management of STEMI presenting to A&E

Step 1: Oxygen and monitor ECG.

Step 2: Call 999 and ask for "Emergency PCI Transfer".

Step 3: Commence medical treatment (see Box 1 below).

Step 4: Contact Golden Jubilee National Hospital (GJNH CCU) 0141 951 5299 and give information of patient transfer.

Step 5: Fax ECG to GJNH if possible (CCU fax 0141 951 5867)

If PPCI is not possible or there are logistical reasons causing a significant delay to PPCI, it may be necessary to administer thrombolytic therapy (see Box 2 below).

Some patients with multiple co-morbidities may not be candidates for PPCI or thrombolysis.

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

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

Contact GJNH - see below for contact details.

Prescribe and administer the following:

  • Morphine 5–10mg by slow IV injection
  • Metoclopramide IV 10mg
  • Soluble aspirin oral 300mg immediately unless patient has already received a dose as per Suspected Acute Coronary Syndrome algorithm above (75mg if already taking aspirin regularly)
  • Ticagrelor oral 180mg stat
  • Heparin IV 5000units (unless patient has already received treatment dose of fondaparinux or enoxaparin)

Consider prescribing the following, or if advised by the GJNH:

  • Glycoprotein IIb/IIIa inhibitor
  • Metoprolol IV 5–15mg or oral 50–100mg if Killip Class 1 (withhold if heart rate <65bpm, systolic <105mmHg)

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

Contraindications to thrombolysis

Absolute contraindication:

  • Haemorrhagic stroke or stroke of unknown origin at any time
  • Ischaemic stroke in preceding 6 months
  • Central nervous system damage / neoplasms
  • Major trauma / surgery / head injury within preceding 3 weeks
  • Gastrointestinal bleeding within the last month
  • Known bleeding disorder
  • Aortic dissection

Relative contraindication – discuss with senior staff before withholding:

  • Transient ischaemic attack in preceding 6 months
  • Oral anticoagulant therapy
  • Pregnancy or within 1 month post partum
  • Non-compressible punctures <24 hours
  • Traumatic resuscitation
  • Refractory hypertension (systolic BP >180mmHg).
  • Advanced liver disease
  • Infective endocarditis
  • Active peptic ulcer
  • Terminal illness

Prescribe and administer tenecteplase in addition to all other drugs in box 1 (provided there are no contraindications), with the exception of the stat dose of ticagrelor, which should be substituted with clopidogrel oral 300mg stat. Then prescribe ticagrelor oral 90mg twice daily starting 24 hours after thrombolysis.

N.B. Patients who receive thrombolysis should still have emergency angiography if clinically fit to do so. The timing of this angiogram is influenced by ST resolution at 90 minutes and patients would usually be transferred to the local intervention centre (GJNH for NHSGGC) in parallel with receiving thrombolysis. It is advisable to keep the intervention team in GJNH aware of the patient's clinical journey.

Tenecteplase single weight adjusted bolus over 10 seconds
Weight Weight imperial Dose Volume
<60kg <9st 6lb 30mg 6ml
60–69.9kg 9st 6lb–11st 35mg 7ml
70–79.9kg 11st 1lb–12st 8lb 40mg 8ml
80–89.9kg 12st 9lb–14st 2lb 45mg 9ml
>90kg >14st 2lb 50mg (max dose) 10ml

Interventional Cardiology Referral Pathway - West of Scotland Regional Heart and Lung Centre

Elective Referrals

Electronic referral should be made via SCI Gateway. The referrals will be reviewed by a cardiologist and the Cardiology Clinical Scheduler. The patient will then be placed on the elective waiting list according to the proposed procedure.

Urgent Referrals

Bed to Bed Transfer - do not withhold low molecular weight heparin on day of referral. Electronic referral should be made via SCI Gateway. Arrange transfer of patient as directed by Clinical Scheduler and ensure all available information is sent with the patient.

Emergency / Immediate Referrals

Call 999 before contacting GJNH for STEMI 0141 951 5299 or for NSTEMI 07976 986 058. The same mobile number will be used 24 hours a day but will divert to CCU out of hours. Discuss the patient with the Cardiology SpR on-call. Transfer patient by A&E ambulance to the GJNH Cath Lab / cardiology HDU as directed. Ensure all available information is sent with the patient.