ACUTE CORONARY SYNDROME-MANAGEMENT (G. NSTEMI)

SUMMARY

VERY HIGH & HIGH RISK PATIENTS
1. Clinical trials have demonstrated the benefit of early invasive management for NSTEACS (coronary angiography & revascularisation [ie. stenting or bypass surgery]).

2. Timing of invasive therapy is determined by the level of acute risk: within 2 hrs of adm. for very high risk, within 24 hrs for high risk, within 72 hrs for intermediate risk.

3. Use: Aspirin 300 mg orally, chewed or dissolved before swallowing, for the first dose, then 100 to 150 mg orally, daily.

4. Give a P2Y₁₂ inhibitor with the aspirin, unless early cardiac surgery is contemplated: Clopidogrel 300 to 600 mg orally, for the first dose, then 75 mg daily OR Prasugrel 60 mg orally, for the first dose, then 10 mg daily OR Ticagrelor 180 mg orally, for the first dose, then 90 mg twice daily.

5. Do not use Prasugrel for patients who weigh < 60 kg, are aged ≥ 75 yrs, or who have had a previous stroke/TIA. Do not use Ticagrelor for patients who have 2^nd/3^rd degree AV block.

6. In addition use parenteral anticoagulation: Enoxaparin, Dalteparin or UFH for those with severe renal impairment.

7. If invasive management, such as an angiogram, is planned for a patient with a high risk of bleeding, consider: Bivalirudin (CrCl 30 mL/min or more) 0.1 mg/kg intravenous bolus, followed by 0.25 mg/kg/hour by intravenous infusion.

8. Start beta-blocker therapy unless contraindicated: Atenolol 25 mg orally, daily, increasing up to 100 mg daily OR Metoprolol tartrate 25 mg orally, twice daily, increasing up to 100 mg twice daily.

INTERMEDIATE RISK PATIENTS
9. Commence either Aspirin or a P2Y₁₂ inhibitor. Monitor the patient and reassess their clinical status, ECG and biochemical markers; depending on the results some patients may be re-stratified.

LOW RISK PATIENTS10. Consider Aspirin/Clopidogrel alone. Further risk stratification and management can be guided by provocative testing for inducible ischaemia.

Reference(s)

Wilkinson, I., Furmedge, D. and Sinharay, R. (2017). Oxford handbook of clinical medicine. Oxford: Oxford University Press. Get it on Amazon.
Feather, A., Randall, D. and Waterhouse, M. (2020). Kumar And Clark’s Clinical Medicine. 10th ed. S.L.: Elsevier Health Sciences. Get it on Amazon.
Hannaman, R. A., Bullock, L., Hatchell, C. A., & Yoffe, M. (2016). Internal medicine review core curriculum, 2017-2018. CO Springs, CO: MedStudy.
Therapeutic Guidelines. Melbourne: Therapeutic Guidelines Limited. https://www.tg.org.au [Accessed 2021].