ADULT INTERNAL MEDICINE

ACUTE CORONARY SYNDROME

AIMS
Beware:
- Any arm/chest pain
- New onset "indigestion"
- Diaphoresis/Nausea
- Determine Risk Group:
- Ask re cardiac risk factors
- Atypical Sx: (diabetics, indigenous, elderly,
women)
- Serum marker (troponin)
- High Risk chest pain
- at rest
- prolonged (>10 mins)
- recurrent
- assoc with syncope, LVF
Bleeding risk
- major bleeding or transfusion are strong
predictors of mortality
- assess bleeding risk all High Risk NSTEACS
patients
- Elevated Troponin
-Search for alternative cause in Acute illness
(esp. aortic dissection, pulmonary embolism,
sepsis, tachy or brady arrhythmias;
acute neurological disease incl stroke or SAH
Dx :
Establish Risk Stratification
High risk pts
Intermediate risk pts
Low risk pts
HIGH RISK PATIENTS: (6/12 risk death or MI
>10%)
- Repetitive ,Prolonged(>10min) or Ongoing pain
- ST depression (> 0.5mm) or new T-wave
inversions(2mm) in >2 leads
- Transient ST elevation (0.5mm) in >2 contiguous
leads
- Elevated serum Troponin
- Prior PCI (within 6/12) or prior CABG
- Heart failure, shock or syncope
- (EF<40% ; SBP<90mmHg)
- new mitral regurgitation
- Diabetes (+ typical Sx ACS)
- CRF (eGFR <60ml/min + typical Sx ACS)
INTERMEDIATE RISK PTS:
(6/12 risk death or MI 2-10%)
- History of prolonged, repetitive chest pain or pain
at rest (last 48 hrs; currently resolved)

Two or more Risk factors

- known HTN
- family Hx
- active smoking
- hyperlipidaemia
Known CHD - prior AMI with LVEF40%
Coronary disease >50% stenosed coronary arteries
Age over 65 yrs
Diabetes + atypical Sx of ACS
eGFR <60 ml/min + atypical Sx of ACS

LOW RISK PTS:

(i) Chest pain resolved & not recurred
(ii) Normal ECG
(iii) No detectable troponin
(iv) No high/intermediate risk features
ie. Includes:
- onset angina past month
- worsening severity, freq of angina
Tx:
Low risk pts
Intermediate risk pts
High risk pts
1. LOW RISK PTS:
Principal = discharge on upgraded medical Rx PLUS
urgent cardiac follow-up
- Check meds make sure patient has:
- Aspirin daily
- GTN PRN
- Repeat Troponin 3 hrs after onset of pain if initial test
negative then at 6 hrs
- Should be referred for a cardiac assessment within 4
wk's (EST or Sistemibi scan)
2. INTERMEDIATE RISK PTS:
Principal = risk stratify + reclassify into HIGH or LOW
risk
Obs: Telemtery
- Intensive observation (telemetry) & investigation
for at least 8 hrs
- Cardiac monitoring
- Frequent ECG's Q3H or ST segment monitoring
- Repeat Troponin 6 hrs after onset of pain (if +ve)
and 3 hours post Sx if ve
Initial Mx (MONA)
- O2 if SaO2 <93%
- GTN
- Aspirin 300mg + 150mg daily/ consider
clopidogrel 300mg stat + 75mg daily
Invx
- ECG
- CXR
- Bloods: Tp, FBC, Coags, CK

Aim to reclassify within 24 hrs

(high / low risk)
- If pt. remains pain free with all tests negative then
exercise stress test before discharge
ANY POSITIVE RESULTS CALL FOR A
RECLASSIFICATION AS HIGH RISK
cardiology consult!!! Re- lysis or PCI
3. HIGH RISK PTS:
Principal =
- Aggressive medical Rx + coronary
angiography / revascularisation
- Balance of Ischaemic Risk & Bleeding Risk for
individual patient essential
- seek early Cardiology advice
Tx
Obs: Telemtery
- Intensive observation (telemetry) & investigation
for at least 8 hrs
- Cardiac monitoring
- Frequent ECG's Q3H or ST segment monitoring
- Repeat Troponin 6 hrs after onset of pain (if +ve)
and 3 hours post Sx if ve
Initial Mx (MONA)
- O2 if SaO2 <93%
- GTN
- Aspirin 300mg + 150mg daily/ consider
- + Clopidogrel 300mg stat + 75mg daily
Invx
- ECG
- CXR
- Bloods: Tp, FBC, Coags, CK
Definitive Management (by cardiology team)
- LMWH
- 72 hrs 1mg/kg b.d. - reduce dose in elderly or
renal impairment
(0.8mg/kg b.d. or 1mg/kg once daily)
- IF increased bleeding risk consider IV. Heparin
- bolus 4000 u/s infusion 800 - 1000 u/s per
hour APTT monitoring
- Clopidogrel
- 300mg stat plus 75 mg daily (unless surgery
likely within 5 days)
- IF undergoing PCI consider high dose regime
(600mg bolus plus 150mg/d ) - seek advice
- Tirofiban (GII/PIII) anti-platelet
- Continue supportive treatment with morphine
(2.5mg IV. bolus prn.) & nitrates
Nitrates
- Early use of below unless C-Ind in all patients
with ACS
- Beta blockers

- Ace inhibitors
- Statin High Dose (eg atorvastatin 80mg)
Cardiology team to arrange for:
- Angiography within 48 hrs recommended
- Percutaneous coronary intervention
- Bypass surgery
LONG TERM Mx
(i) Cardiac Rehabilitation Program
- Education
- Risk factor modification
- Regular exercise
- GTT if not Dx diabetic
(ii) Written action plan for Chest Pain
(iii) Depression
- common
- poorer outcomes
NOTES
Bleeding risk increased
Troponin
Timi score
1. BLEEDING RISK INCREASED
- age >75
- female
- Hx bleeding (esp. recent)
- Hx stroke, TIA
- creatinine clearance <60mL/min
- diabetes
- heart failure
- PVD
- anaemia
- concomitant use of GP IIb/IIIa inhibitor
- enoxaparin 48 hrs prior to intervention
- body weight < 60kg
2. TROPONIN
- High sensitivity assays recommended (TnT or
TnI )
- Positive test IF - level > 99%ile
OR
- change of >50% above an initial baseline level
- Negative test IF
- not positive (above)
- one assay taken >6 hrs from Sx onset
- Action on Positive test
- cardiac consultation if ACS suspectted (usually
changing levels)
Search for alternative cause
- Acute illness (usually changing levels)
esp. aortic dissection, pulmonary embolism,
sepsis, tachy or brady arrhythmias, acute
neurological disease incl. stroke or SAH
- Subacute / Chronic conditions (usually stable
levels over 24 hr period)
i.e. Cardiac contusion or surgery; CCF acute or
chronic; aortic valve disease; HOCM; severe pulm
HPT; renal failure; inflammatory cardiac disease

(eg. pericarditis SBE); burns > 30%; infiltrative

disease; extreme exertion
3. TIMI Score: 1-7 (risk of death)
Score 1 for each category:
- age >65
- 2 cardiac RF's including diabetes
- >1 episode chest pain at rest <24hrs
- prior angiographic stenosis >50%

- ST depression >=0.5mm
- elevated cardiac markers
- use of aspirin previous 7 days
Result /7
- 4/7 or greater high risk of death or MI in next 2
weeks
- Seek specialist advice - early transfer appropriate