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Contents.
Page
• Treatment pathway for the management of patients with suspected ACS 2
• Pathway for anti-platelet therapy in patients prescribed warfarin 3
• Clinical management – specific elements of treatment / management
o Presentation with Suspected ACS 4
o ECG 5
o Blood Tests 5
o When acute coronary syndrome is confirmed 5
• Appendix 1 6
• References 7
* For patients with renal impairment (SeCr >265µmol/L or EGFR <20mL/min) OMIT FONDAPARINUX and prescribe ENOXAPARIN
1mg/kg S/C OD
Troponin T on admission if history of chest pain for 12 hrs at the time of arrival.
Warfarin used for AF / VTE: Suspected ACS Warfarin used for valve
prosthesis:
STAT doses of each:
STAT doses of each:
• Aspirin 300mg PO
• Aspirin 300mg PO
• Clopidogrel 300mg PO
• Clopidogrel 300mg PO
• Fondaparinux 2.5mg SC
• Continue warfarin
Withhold warfarin
If INR 2 the give additional
fondaparinux 2.5mg SC OD
Trop. T 12 hours after until INR therapeutic
onset of pain
If > 30ng/L and
diagnosis of ACS
confirmed
Clinical judgment should still be used when considering use of antiplatelet agents patients with
confirmed ACS – balance treatment of ACS vs. risk of bleeding with combination therapy
For patients with renal impairment (SeCr >265µmol/L or EGFR <20mL/min) OMIT FONDAPARINUX
and prescribe ENOXAPARIN 1mg/kg S/C OD
2. ECG
2.1 All patients with suspected ACS should have a 12 lead ECG performed immediately on
admission.
2.2 Patients with persistent ST elevation or new left bundle branch block - refer to Pink Book for
STEMI / PPCI guidelines and pathway.
2.3 Patients without ST elevation - repeat ECG at 15 minute intervals if pain is ongoing or
recurrent. Only discontinue when the ECG is unchanging. Utilise ST segment monitoring if
available.
2.4 All patients with abnormal ECG (ST depression - transient ST elevation) should have blood
samples taken for Troponin T to aid diagnosis.
3. Blood tests
3.1 Blood sample for cardiac Troponin T should be taken 12 hours after cardiac event / onset of
symptoms if timing is accurate.
3.2 Where symptoms were experienced greater than 12 hours ago send blood sample for cardiac
Troponin T immediately.
3.3 As a guide the following has been agreed to aid diagnosis of NSTEMI:
Detection of a rise (or fall – if late presentation) of troponin with at least one result above
29ng/l together with evidence of myocardial ischaemia as recognised by at least one of the
following:
- Symptoms of ischaemia
- ECG changes of new ischemia (ESC 2007)
Those patients with high suspicion of cardiac pain and with borderline rises in troponin (14 -
30ng/l) should have a further troponin 6hrs or more later, to clarify if the troponin level is still
rising, and hence confirming the diagnosis of NSTEMI.
Clinicians must be aware that troponin levels can rise in non-ischaemic related conditions e.g.
sepsis, tachyarrhythmia, severe renal impairment and pulmonary embolus, so caution should
be taken when making diagnoses on the basis of a biomarker alone.
3.3 Blood should also be taken for: FBC, U&E, Glucose, lipids & LFT
Appendix 1
Probability of Death
Risk Category GRACE
Post-discharge to
(Tertiles) Risk Score
6 Months (%)
References
Clinical guidelines for the management of suspected ACS/NSTEMI from Peterborough and Stamford
Hospital.(2009) Author: Karen Wilkinson
British Cardiac Society Guidelines and Medical Practice Committee, and Royal College of Physicians
Clinical Effectiveness and Evaluation Unit. (2001) Guideline for the management of patients with acute
coronary syndromes without persistent ECG ST segment elevation. Heart; 85:p133-142
Department of Health (2000). National Service Framework. Coronary Heart Disease. Heart attacks & other
acute coronary syndromes: Chapter 3:12:p5
The European Society of Cardiology (2007) Safety and efficacy of combined antiplatelet-warfarin therapy
after coronary stenting. European Heart Journal (2007)28,
726-732
The TIMI risk score for Unstable Angina/Non-ST Elevation MI (2000) Antman et al JAMA vol 284 no.7,
835-842
Granger CB, Goldberg RJ, Dabbous OH et al. for the Global Registry of Acute Coronary Events
Investigators. Predictors of hospital mortality in the global registry of acute coronary events. Arch Intern
Med 2003;163:2345–2353.