EXERPT from 'Guidelines for the management of acute coronary syndromes 2006'

Source: The Medical Journal of Australia at https://www.mja.com.au/journal/2006/184/8/guidelines-management-acute-coronary-syndromes-2006

Note: This is only an exerpt. Highlights are my own.

Summary of key recommendations
Acute management of chest pain

• The most important initial need is access to a defibrillator to avoid early cardiac death resulting from reversible arrhythmias.
• Aspirin should be given early (ie, by emergency or ambulance personnel) unless already taken or contraindicated.
• Oxygen should be given, as well as glyceryl trinitrate and intravenous morphine as required.
• Where appropriate, a 12-lead electrocardiogram (ECG) should be taken en route and transmitted to a medical facility.
• Where formal protocols are in place, prehospital treatment (including fibrinolysis in appropriate cases) should be facilitated.

Investigations

• The ECG is the sole test required to select patients for emergency reperfusion (fibrinolytic therapy or direct percutaneous coronary intervention [PCI]).
• Patients with STEMI who present within 12 hours of the onset of ischaemic symptoms should have a reperfusion strategy implemented promptly.
• Patients with a suspected ACS without ST-segment elevation on ECG should undergo further observation and investigation to rule out other diagnoses, enable risk stratification and determine the most appropriate treatment strategy.
• Patients whose ECG and cardiac marker levels are normal after a suitable period of observation should, where practicable, undergo provocative testing (eg, stress test) before discharge.

Management of patients with ST-segment-elevation myocardial infarction

Adjuvant therapy in association with reperfusion

• All patients undergoing reperfusion therapy for STEMI (PCI or fibrinolysis) should be given aspirin and clopidogrel unless these are contraindicated.
• Antithrombin therapy should be given in combination with PCI or fibrinolytic therapy with fibrin-specific fibrinolytic agents, but antithrombin therapy in conjunction with streptokinase is optional.
• It is reasonable to use abciximab with primary PCI, but glycoprotein (GP) IIb/IIIa inhibitors should generally be avoided with full or reduced doses of fibrinolytic therapy.

Choice of reperfusion strategy

• Time delay (both to first medical contact and potential PCI or fibrinolytic therapy) plays a major role in determining best management of STEMI.
• In general, PCI is the treatment of choice, providing it can be performed promptly by a qualified interventional cardiologist in an appropriate facility.
• In general, the maximum acceptable delay from presentation to balloon inflation is:
• • 60 minutes if a patient presents within 1 hour of symptom onset; or
  • 90 minutes if a patient presents later.

Note: for patients who present late (between 3 and 12 hours after symptom onset) to a facility without PCI capability, it is appropriate to consider transfer for primary PCI if balloon inflation can be achieved within 2 hours (including transport time).

• All PCI facilities should be able to perform angioplasty within 90 minutes of patient presentation.
• Fibrinolysis should be considered early if PCI is not readily available, particularly in rural and remote areas.
• When there are major delays to hospitalisation (ie, more than 30 minutes), prehospital fibrinolysis should be considered.
• Reperfusion is not routinely recommended in patients who present more than 12 hours after symptom onset and who are asymptomatic and haemodynamically stable.

Choice of fibrinolytic agent

• Second-generation fibrin-specific fibrinolytic agents that are available as a bolus (ie, reteplase, tenecteplase) are the fibrinolytics of choice.
• These agents should be available at all centres where fibrinolysis may be required.
• Streptokinase is an inappropriate choice in Aboriginal and Torres Strait Islander patients, or in patients with previous exposure to the drug.

Management of patients with non-ST-segment-elevation acute coronary syndromes

• All patients with non-ST-segment-elevation acute coronary syndromes (NSTEACS) should have their risk stratified to direct management decisions.
• All patients with NSTEACS should be given aspirin, unless contraindicated.
• High-risk patients with NSTEACS should be treated with aggressive medical management (including aspirin, clopidogrel, unfractionated heparin or subcutaneous enoxaparin, intravenous tirofiban or eptifibatide and a β-blocker), and arrangements should be made for coronary angiography and revascularisation, except in those with severe comorbidities.
• Intermediate-risk patients with NSTEACS should undergo an accelerated diagnostic evaluation and further assessment to allow reclassification as low or high risk.
• Low-risk patients with NSTEACS, after an appropriate period of observation and assessment, may be discharged on upgraded medical therapy for outpatient follow-up.

Long-term management after control of myocardial ischaemia

• Before discharge, patients with an ACS should be initiated on a medication regimen, including antiplatelet agent(s), β-blocker, angiotensin-converting enzyme inhibitor, statin and other therapies as appropriate.
• Patients should be given advice on lifestyle changes that will reduce the risk of further coronary heart disease (CHD) events, including smoking cessation, nutrition, alcohol, physical activity and weight management as relevant.
• All patients should have access to, and be actively referred to, comprehensive ongoing prevention and cardiac rehabilitation services.
• All patients should be provided with a written action plan for chest pain.
• Depression and CHD frequently coexist, and in patients with CHD, the presence of depression is more likely to lead to poorer outcomes. Social isolation and lack of social support are also associated with worse outcomes. All patients with CHD should be assessed for depression and level of social support.

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