ACUTE CORONARY SYNDROMES

MANAGEMENT GUIDELINES

(Including ST Elevation MI, Non ST Elevation
MI, Unstable Angina)



July 2010


Trust-wide Guidelines for
Calderdale Royal Hospital and
Huddersfield Royal Infirmary


These guidelines are based on ACC/AHA and ESC guidelines, NICE
recommendations, the NSF and previous CCU guidelines from
Huddersfield Royal Infirmary and Calderdale Royal Hospital.

Authors Dr. Bloomer
Dr. Grant
Dr. Rashid
Dr. Stevenson
Dr Welsh
Dr Winter
Alison Eales


Acute Coronary Syndrome Management Guidelines
Approved by Medicines Management Committee.......................................................................8
th
July 2010
Review Date......................................................................................................................................... July 2012


Acute Coronary Syndrome Management Guidelines.................................................................. Page 1 of 14
Approved by Medicines Management Committee.......................................................................8
th
July 2010
Review Date......................................................................................................................................... July 2012
Index

Guidelines for Acute S-T Elevation Myocardial Infarction........................Page 2
Initial assessment and treatment.........................................................Page 2
Initial Investigations .............................................................................Page 2
Choice of thrombolytic.........................................................................Page 3
Guidelines for thrombolysis .................................................................Page 3

Thrombolytic Therapy Check List...............................................................Page 4

Management Post Primary PCI or Thrombolysis ......................................Page 5

Diabetes Management in Acute Myocardial Infarction .............................Page 6

Discharge from CCU....................................................................................Page 6

Treatment of Complications of MI...............................................................Page 7
Left Ventricular Failure ........................................................................Page 7
LVF with hypotension/Cardiogenic Shock...........................................Page 7
Right Ventricular Infarction

Arrhythmias ..................................................................................................Page 7
Ventricular ectopics or non-sustained VT............................................Page 7
Sustained Broad Complex Tachycardia (usually VT) ..........................Page 7
Atrial fibrillation or atrial flutter .............................................................Page 8
Supraventricular tachycardia (SVT, AVNRT).......................................Page 8
Symptomatic Sinus Bradycardia..........................................................Page 8

Guidelines for Acute Coronary Syndromes Presenting with Acute S-T
Elevation .......................................................................................................Page 9
Definitions............................................................................................Page 9
Management........................................................................................Page 9
Treatment..........................................................................................Page 10

Protocol for Tenecteplase Therapy ..........................................................Page 12

24hr Referral Protocol for Primary PPCI ..................................................Page 13
GUIDELINES FOR ACUTE S-T ELEVATION MYOCARDIAL
INFARCTION

Initial assessment and treatment

1) Initial assessment should include brief history and examination and 12
lead ECG
If there is ST elevation of >1mm in 2 limb leads or >2mm in 2 chest leads
or new LBBB, AND symptoms less than 12 hours, refer immediately to
GI for primary angioplasty follow Primary PCI protocol (see back page) L

If patient is not accepted proceed as below.

2) Aspirin 300mg (if not already given by ambulance service)

3) Clopidogrel 300mg orally (Prasugrel 60mg if sent for primary PCI)

4) Diamorphine for pain 2.5-5mg i.v. repeated if necessary after 5 minutes

5) Antiemetic should be given with the first dose of diamorphine unless
already given prior to hospital admission. Metoclopramide 10mg i.v. is
first line, Cyclizine 50mg i.v. second line. Prochlorperazine is not
licensed for i.v. use.

6) Oxygen should be prescribed for the first few hours after acute MI by
mask or nasal prongs.

Initial investigations

7) Blood tests on admission: Electrolytes
Glucose
Full Blood Count

8) Thrombolysis for those declined a primary PCI by LGI (Target time <
30 minutes from admission)



ECG Criteria for Thrombolysis
ST elevation >1mm in 2 or more limb leads or >2mm in 2 or more chest
leads

Left Bundle Branch Block (unless known to have LBBB previously)

Posterior changes: Deep ST depression and tall R waves in leads V1 to
V3

Do not thrombolyse ST depression alone, T inversion alone or
normal ECG.


Acute Coronary Syndrome Management Guidelines.................................................................. Page 2 of 14
Approved by Medicines Management Committee.......................................................................8
th
July 2010
Review Date......................................................................................................................................... July 2012


Acute Coronary Syndrome Management Guidelines.................................................................. Page 3 of 14
Approved by Medicines Management Committee.......................................................................8
th
July 2010
Review Date......................................................................................................................................... July 2012
9) Choice of Thrombolytic Agent:

Tenecteplase is now used for all thrombolysable infarcts.

10) Guidelines for thrombolysis (see appendix for administration
protocol for tenecteplase)

Thrombolysis should be considered for all patients with a qualifying
ECG presenting within 12 hours of onset of chest pain unless there
are contraindications and only if declined a primary PCI by LGI

The benefit of thrombolysis reduces steadily from the onset of chest pain
such that treatment is contraindicated beyond 24 hours. Decision to treat
should be based on the time of onset of severe or continued pain.

The benefits of thrombolysis are greatest for patients at higher risk i.e.
anterior infarction, LBBB or haemodynamic compromise. Lower risk
patients (small infarct, no ongoing pain or haemodynamic compromise)
benefit little from late thrombolysis. The risk of haemorrhagic stroke after
thrombolysis with Tenecteplase increases with age and hypertension.
This should be taken into account when considering thrombolysis of
patients over 75 after 6 hours or more.

Severely hypertensive patients can be Thrombolysed after medical
control of blood pressure with either intravenous nitrates 2-10 mg/hour
increased at 5 minute intervals if blood pressure target not reached or
intravenous metoprolol 5-10mg slowly i.v. (unless beta blockers
contraindicated). Nitrates and intravenous beta blockers may be
combined if necessary.

Stable patients with CHB should be thrombolysed first without temporary
pacing as CHB often resolves after thrombolysis.


Acute Coronary Syndrome Management Guidelines.................................................................. Page 4 of 14
Approved by Medicines Management Committee.......................................................................8
th
July 2010
Review Date......................................................................................................................................... July 2012
THROMBOLYTIC THERAPY CHECK LIST

ST elevation (>1mm in 2 or more limb leads or 2mm in 2 or more chest
leads) ................................YES/NO

Left Bundle branch block (assume new unless clear evidence from
previous notes) .................YES/NO

11) Contraindications to thrombolysis - Absolute

A. Haemorrhagic stroke YES/NO
B. Suspicion of dissecting aortic aneurysm YES/NO
C. Active peptic ulcer or GI bleed in last 3 months YES/NO
D. Major surgery/trauma in last 3 months YES/NO
E. Recent internal bleeding YES/NO
F. Coagulation defects YES/NO
G. Warfarin treatment with INR >4.0 YES/NO
H. Bleeding diathesis YES/NO

Contraindications to thrombolysis Relative: Consult Registrar/
Consultant

A. Any Previous stroke YES/NO
B. Traumatic cardiopulmonary resuscitation for this episode YES/NO
C. Uncontrolled Hypertension: BP>180/110mmHg (repeat
half hourly) (see guideline 10)
YES/NO
D. Pregnancy YES/NO
E. Previous GI bleeding YES/NO
F. Hypotension: Systolic BP <90mmHg YES/NO

Please sign to confirm this checklist has been completed and the patient
has been informed of the risks of thrombolysis and their verbal consent
obtained.

The risk of haemorrhagic stroke is about 1% with thrombolysis (about
0.5% without thrombolysis in acute MI)

Signature __________________________________
Designation _______________________________
Date ___________________

Reason for patients refusal of thrombolysis :
_____________________________________________________
_____________________________________________________


Acute Coronary Syndrome Management Guidelines.................................................................. Page 5 of 14
Approved by Medicines Management Committee.......................................................................8
th
July 2010
Review Date......................................................................................................................................... July 2012
MANAGEMENT POST PRIMARY PCI or THROMBOLYSIS

12) Measure CK on days 2 and 3, and random cholesterol

13) Chest X ray on CCU (not during the night unless required for heart
failure).

14) Aspirin 75mg daily

15) Clopidogrel 75mg daily for 28 days (or 1 year if PCI and stent)

16) Fondaparinux 2.5mg s/c once daily for up to 8 days or discharge
(thrombolysed patients only). Fondaparinux is not required after primary
PCI.

17) Beta blockers: Oral beta blockers should be given unless there are clear
contraindications such as asthma, severe bradycardia (HR<50) or severe
heart failure. Diabetes and PVD should not be regarded as
contraindications for beta blockade in acute MI. Start as soon as patient
is haemodynamically stable

18) ACE Inhibitors: Should be given to all patients post MI unless
contraindicated. Mild renal impairment should not be regarded as a
contraindication. Renal function must be monitored. Start as soon as
patient is haemodynamically stable. Usual treatment is Ramipril 2.5mg
od, use 1.25mg initially in frail patients or if hypotensive (BP<100mmHg
systolic).

19) Statins: Should be prescribed for all patients post MI regardless of
cholesterol on admission unless previously intolerant. First line treatment
should be Atorvastatin commencing at 80mg at night for at least 3
months, then the choice of statin to be selected by the GP on their
review. Subsequent statin therapy may be detemined on an individual
basis. LDL target is 2.5mmol/l. If intolerant of statins a fibrate should be
started instead (Bezafibrate or Gemfibrozil).

20) Anticoagulation should be considered for patients with atrial fibrillation,
left ventricular aneurysm or LV thrombus. Generally patients should not
receive Aspirin, Clopidogrel and Warfarin concurrently. If Warfarin is
required, it is reasonable to stop the Aspirin and continue Warfarin and
Clopidogrel in combination, switching to Warfarin and Aspirin when
Clopidogrel stops (28 days for unrevascularised STEMI, 1 year for PCI
with stent).
21) Potassium Replacement should be considered in patients with K<3.5
especially if arrhythmias are present. Usually not required once ACE
inhibitors are introduced.


Acute Coronary Syndrome Management Guidelines.................................................................. Page 6 of 14
Approved by Medicines Management Committee.......................................................................8
th
July 2010
Review Date......................................................................................................................................... July 2012
22) In patient coronary angiography should be considered for all patients post
STEMI unless unfit for angiography or revascularisation. (Primary PCI
patients dont routinely need further angiography).


DIABETES MANAGEMENT IN ACUTE MYOCARDIAL
INFARCTION
23) Diabetics have a worse prognosis than non diabetics. Tight glycaemic
control is required with a target blood glucose between 5 and 7.8mmol/L.
Existing treatment can be continued or modified to achieve this. Newly
diagnosed diabetics should be treated with insulin initially (subcutaneous
or by intravenous infusion as required), then reviewed by the diabetic
team to determine the best long term treatment on an individual basis.


DISCHARGE FROM CCU
24) Patients may be discharged from CCU 24-48 hours after admission
provided they are pain free with no arrhythmias. Most patients can be
discharged home after 4-5 days. Patients post uncomplicated primary
PCI may be discharged at 72 hours
All patients with MI should be referred to the cardiac rehabilitation team
as soon as possible.

25) Management post discharge. All able patients who have not undergone
PCI should be exercise tested prior to returning to outpatients. Outpatient
follow up should be at 6-8 weeks.

26) Angiography should be considered for patients with positive exercise test
at low or moderate workload, or post infarction angina.



Acute Coronary Syndrome Management Guidelines.................................................................. Page 7 of 14
Approved by Medicines Management Committee.......................................................................8
th
July 2010
Review Date......................................................................................................................................... July 2012
27) TREATMENT OF COMPLICATIONS OF MI
28) Left Ventricular Failure:
High dose Oxygen by mask (60%)
Intravenous morphine 5-10 mg particularly if the patient is acutely
distressed
Intravenous nitrate infusion should be used providing systolic blood
pressure is >100mm Hg.
Intravenous diuretics (Frusemide 50 mg i.v.) may be required
particularly if there is radiological evidence of pulmonary oedema.
Hypotension is not a contraindication to diuretics in this case. Patients
with renal impairment usually need higher doses of diuretics for clinical
effect.

29) LVF with hypotension/ Cardiogenic shock (BP<90 with oliguria and
peripheral shutdown)
Treatment as above but avoid nitrates if BP <100 mmHg.
Consider inotropic support (dobutamine 5-20 micrograms/kg/min).
Dobutamine may be given peripherally.
N.B: Inotropes have not been demonstrated to improve the outcome in
cardiogenic shock and may increase infarct size due to increased
myocardial oxygen demand.
Consider possibility of acquired VSD or severe MR (usually loud
systolic heart murmur): urgent echocardiography to assess and
discuss with LGI cardiology if appropriate.
Consider emergency referral to LGI cardiology for acute angioplasty.
Where possible these patients should be discussed with a local
cardiologist first.

30) Right Ventricular infarction: This is a special case presenting as
hypotension in the context of an inferior myocardial infarction without
pulmonary oedema. J VP is usually raised. ST elevation may be seen in
leads V3R, V4R. Treatment is with intravenous fluid infusion (up to 500ml
5% dextrose or Haemaccel) with careful monitoring of BP and clinical
reassessment for early signs of pulmonary oedema. Diuretics should
be avoided.

ARRHYTHMIAS
31) Ventricular ectopics or non sustained VT. Usually no treatment
required unless recurrent long runs of NSVT. Beta blockers should be
titrated up. Amiodarone may be required if long recurrent NSVT (as
below).

32) Sustained Broad Complex tachycardia (usually VT)
With haemodynamic compromise (BP<100) proceed to urgent DC
cardioversion under general anaesthetic.


Acute Coronary Syndrome Management Guidelines.................................................................. Page 8 of 14
Approved by Medicines Management Committee.......................................................................8
th
July 2010
Review Date......................................................................................................................................... July 2012
Without haemodynamic compromise i.v. Amiodarone as above or i.v.
magnesium sulphate 8mmol over 15 minutes repeated once if
necessary. If medical treatment fails to terminate ventricular
tachycardia then DC cardioversion should be performed urgently
under general anaesthetic.

33) Atrial fibrillation or atrial flutter. Often revert spontaneously. Check
potassium is >4.5 and correct if necessary.
AF with satisfactory rate and blood pressure no treatment is needed
acutely.
AF with high rate but maintained blood pressure. Commence or
increase Beta blockade (Metoprolol 25mg t.d.s) if no contraindication
or acute heart failure. If beta blockers cannot be administered treat
with oral or i.v.digoxin. Loading dose is 1-1.5mg in divided doses over
24 hours.
AF with high rate and hypotension consider D.C. cardioversion under
general anaesthetic.
Sustained AF( >12 hours) consider amiodarone orally or i.v. and
anticoagulate if no contraindication. Patients with AF should be
kept on full dose LMWH until warfarinised.

34) Supraventricular tachycardia (SVT, AVNRT). This is rare post MI.
Treatment is i.v. adenosine 6mg by rapid i.v. bolus injection, then
12mg if unsuccessful repeated once if necessary. Adenosine is
contraindicated in patients with asthma or history of wheezing or
in patients taking Dipyridamole (Persantin)
If adenosine contraindicated then i.v. verapamil 5 mg repeated after 5
minutes if necessary. Verapamil is contraindicated in patients with
heart failure or taking beta blockers.
Other alternatives i.v. amiodarone or D.C cardioversion under GA.

35) Symptomatic Sinus bradycardia: i.v. Atropine 300-1000 micrograms,
repeated if necessary. High doses of Atropine can cause confusion
especially in elderly patients.
Heart block
1
st
degree no treatment
2
nd
degree or 3
rd
degree heart block with anterior MI temporary pacing
2
nd
or 3
rd
degree heart block with inferior MI: i.v. Atropine as above. If
sinus rhythm not restored then temporary pacing if haemodynamic
compromise (HR<40, BP <100 systolic) or heart failure.

36) Temporary pacing is hazardous and should only be performed by an
experienced operator. The jugular route is safer particularly if
thrombolysis has been given. Subclavian or femoral routes are
alternatives for appropriately trained practitioners.


Acute Coronary Syndrome Management Guidelines.................................................................. Page 9 of 14
Approved by Medicines Management Committee.......................................................................8
th
July 2010
Review Date......................................................................................................................................... July 2012
GUIDELINES FOR ACUTE CORONARY SYNDROMES
PRESENTING WITHOUT ACUTE S-T ELEVATION
Patients with acute coronary syndromes (excluding ST elevation MI) may
present with chest pain with either:



Normal ECG


Abnormal ECG including:
1. ST Depression
2. T wave inversion
3. Left bundle branch block

D

efinitions:
Unstable Angina: This is a clinical diagnosis including patients with recent
onset severe angina, abrupt worsening of previous angina, or prolonged
nginal pain at rest (>20 mins). a

After assessment with serial ECG, CK and Troponin patients without ST
levation can be classified as follows: e

1. Non ST elevation MI (raised Troponin with either chest pain or ECG
changes in the absence of other causes such as PE, myocarditis, aortic
dissection, heart failure or end stage renal failure)

2. Angina (negative Troponin and/or CK with or without ECG changes)

3. Non cardiac chest pain (negative Troponin and CK, non ischaemic
ECG, negative ETT, perfusion scan or angiogram)

MANAGEMENT

4. Admission to CCU or cardiology ward. Patients with a clinical
diagnosis of ACS should be admitted to CCU for ECG monitoring if
there are ischaemic ECG changes. If this is not possible then admission
to cardiology ward or MAU for monitoring is acceptable for patients
judged to be at lower risk. Generally patients with no ECG changes
should be admitted to MAU with a view to early discharge (failing which
transfer to Cardiology ward). Patients with a high likelihood of
noncardiac chest pain and a normal ECG should not routinely be
admitted to CCU.

5. Monitoring. Continuous 12 lead monitoring for 24 hours especially if
there are ECG changes at presentation or a raised troponin.


Acute Coronary Syndrome Management Guidelines................................................................ Page 10 of 14
Approved by Medicines Management Committee.......................................................................8
th
July 2010
Review Date......................................................................................................................................... July 2012
6. Initial investigations:
Blood tests on admission: Electrolytes
CK
Glucose
Random Cholesterol


Full Blood Count
CXR later (not in A and E, and only if no recent CXR).

7. Troponin I level at least 12 hours after onset of suspected cardiac chest
pain (usually 12 hours after admission unless pain for more than 12
hours prior to admission)

8. Creatine Kinase on day 2, repeated on day 3 unless Troponin negative


TREATMENT
9. Aspirin 300mg initially followed by 75mg daily

10. Clopidogrel 300mg initially followed by 75mg daily. It should not be
given routuinely in the absence of ECG changes or elevated Troponin.
Loading dose pre PCI is 600mg.

11. Fondaparinux 2.5mg s/c once daily for up to 8 days

12. Oral or i.v. nitrates for recurrent chest pain

13. Beta blockers unless contraindicated in which case Diltiazem should be
considered

14. ACE inhibitors should be given to all patients if ischaemic heart disease
is confirmed unless there are contraindications (EGFR <60). Renal
function must be monitored. Initial dose usually Ramipril 2.5 mg once
daily unless renal impairment, frail or hypotensive, then 1.25mg once
daily.

15. Glycoprotein IIb/IIIa inhibitors. These drugs only to be prescribed by
registrar or consultant grades preferably with specialist advice. Consider
in the following circumstance
i. Patients with recurrent or persistent chest pain and ECG
changes despite standard treatment (as outlined above).

16. Lipid management: As for ST elevation MI

17. Risk assessment of patients with ACS. High risk is indicated by:
i. History of unstable angina (see definition above)
ii. ST depression or widespread T inversion


Acute Coronary Syndrome Management Guidelines................................................................ Page 11 of 14
Approved by Medicines Management Committee.......................................................................8
th
July 2010
Review Date......................................................................................................................................... July 2012
iii. Raised Troponin (except patients with ST elevation MI)
iv. General comorbidity, previous MI, poor LV function or diabetes.

High risk patients should be considered for in patient coronary
angiography.

18. Emergency referral for transfer to LGI cardiology should be considered
i. For unstable patients (continuing symptoms, ST depression
despite maximal treatment)
ii. For patients with haemodynamic shock
iii. For patients with arrhythmias of ischaemic origin

Referrals to the LGI should be discussed with a Cardiologist during
normal working hours and with the on call Medical Consultant during
evenings and weekends.
19. Exercise Tolerance Testing: This is recommended for all patients able
to exercise on a treadmill (except those with LBBB or AF) either pre
discharge or shortly after discharge to select patients for elective
angiography. Beta blockers should continued for exercise testing in this
case.

20. Cardiac rehabilitation referral: This is appropriate before discharge
for all suitable patients with acute coronary syndromes with positive
Troponin.

21. Further Outpatient Management: Low risk patients i.e. those patients
considered to have cardiac pain but with negative exercise tests or
exercise tests positive only at high workload (stage 3 Bruce or above)
should be reviewed as out patients in 6-8 weeks for consideration of
coronary angiography if there is recurrent angina.

High risk patients with positive exercise tests at low or moderate
workload (stage 1 or 2 Bruce) should have angiography either as an
inpatient or as an urgent outpatient.


Acute Coronary Syndrome Management Guidelines................................................................ Page 12 of 14
Approved by Medicines Management Committee.......................................................................8
th
July 2010
Review Date......................................................................................................................................... July 2012
Appendix 1

PROTOCOL FOR TENECTEPLASE THERAPY

MEDICATION:
1. Heparin I/V bolus 5000 units if over 67kg or
4000 units if under 67kg.
2. Followed by tenecteplase as a single IV bolus injection over 10 seconds
(dose based on body weight)
3. Immediately followed by sub-cutaneous injection of Enoxaparin 1mg/kg
(Fondaparinux 2.5mg) and continue every 12 hours for 48 hours

Start ASPIRIN 300mg orally as soon as possible and then 75mg daily (if
no gastrointestinal contra-indications), to be given after food.

Use of post thrombolysis drugs as usual (Beta blockers, Statins, ACE
inhibitors)

FOLLOW :
BP, heart rate, ST segment every 15 minutes for 4 hours.
Watch for hypotension, bradycardia, arrhythmias, allergic reaction and
anaphylaxis

ANTIDOTE - Use Protamine Sulphate as antidote to I/V Heparin.


Tenecteplase dose based on body weight


Patients
Weight
Volume
Syringe size to use


< 60kg 6ml


60 - 69kg 7ml


70-79kg 8ml
8000 unit pack of
tenecteplase


80 - 89kg 9ml

> 90kg 10ml
10000 unit pack of
tenecteplase


CALDERDALE & HUDDERSFIELD NHS FOUNDATION TRUST

24hr REFERRAL PROTOCOL
FOR PRIMARY PPCI








ELIGIBLE PATIENTS

Symptoms suggestive of Acute Myocardial Infarction
Cardiac symptoms within 12 hours
ECG showing acute myocardial infarction
o ST elevation >1mm in limb leads
o ST elevation >2mm in precordial leads
o New LBBB with appropriate clinical history

















24hr REFERRAL
Contact LGI on: 07920548411
THIS NUMBER IS FOR REFFERAL ONLY. IF YOU NEED TO DISCUSS A PATIENT RING LGI SWITCHBOARD AND ASK TO BE PUT
HROUGH TO THE SpR ON CALL. AT LGI T

If you diagnose a patient as a STEMI ring LGI and ask if they have lab space .
T

here should be no delay / discussion in obtaining a yes / no answer.
IF LGI SAY DECLINE THE PATIENT
OR
IF UNABLE TO CONTACT LGI WITHIN 20 MINS OF HOSPITAL ARRIVAL
OR
IF LGI ASK FOR ECG FAXING (outside protocol so say it is not acceptable)
OR
IF LGI SAY THEY WILL RING BACK (say that is not acceptable)

Then Consider Thrombolysis & refer to own medical team for admission to local CCU






ARRANGE TRANSPORT
Critical Care 999 transfer with Paramedic crew

01924 584999

STATE - EMERGENCY TRANSFER FOR PRIMARY ANGIOPLASTY
MEDICATION

Appropriate analgesia (Nitrates/Opiates)
Aspirin 300mg (if not already given)
Other medication may be given at the clinicians discretion

If accepted for PPCI also give PRASUGREL 60mg orally
Thrombolytics should NOT be given if the patient is accepted for PPCI


Acute Coronary Syndrome Management Guidelines................................................................ Page 13 of 14
Approved by Medicines Management Committee.......................................................................8
th
July 2010
Review Date......................................................................................................................................... July 2012