Recommendations
Your Organisational Guidance
ebpracticenet urges you to prioritise the following organisational guidance:
Behandeling acuut coronair syndroom in een urgente situatie (in afwachting van hospitalisatie)Published by: Werkgroep Ontwikkeling Richtlijnen Eerste Lijn (Worel)Last published: 2022La prise en charge du syndrome coronarien aigu (SCA) en situation d'urgence (en attente d'hospilatisation)Published by: Groupe de Travail Développement de recommmandations de première ligneLast published: 2022Urgent
Get urgent input from a senior colleague or cardiology to arrange immediate invasive coronary angiography (with the intent to perform revascularisation) if you suspect an NSTEMI (and other acute coronary syndromes [ACS]) and the patient is clinically unstable or has any very high-risk features (as outlined below). Do not wait for the results of troponin testing.[5] This includes any patient with:[5][72][73]
Ongoing or recurrent pain despite treatment
Haemodynamic instability (low blood pressure or shock) or cardiogenic shock; see Shock
Recurrent dynamic ECG changes
Acute left ventricular failure, presumed secondary to ongoing myocardial ischaemia; see Acute heart failure
A life-threatening arrhythmia (ventricular tachycardia or ventricular fibrillation) or cardiac arrest after presentation; see Sustained ventricular tachycardias[5]
Mechanical complications such as new-onset mitral regurgitation.[5]
Give all patients with suspected ACS a single loading dose of aspirin as soon as possible, unless they have aspirin hypersensitivity or significant risk of bleeding:[5][72][74]
In practice, assess the patient’s risk of bleeding using the HAS-BLED score. [ HAS-BLED Bleeding Risk Score Opens in new window ] Ensure the patient has intravenous access and discuss with a senior colleague if they have high bleeding risk or are actively bleeding.
Check your local protocol or discuss the patient with a senior colleague if they have hypersensitivity to aspirin.
In practice, monotherapy with a P2Y12 inhibitor may be used.[1]
Do not give oxygen routinely. Offer oxygen only if the patient has oxygen saturations <90% or respiratory distress.[5]
Offer pain relief with glyceryl trinitrate as soon as possible. Add morphine early if glyceryl trinitrate is not effective.[74]
In practice, observe all patients in the accident and emergency department or a chest pain unit until a diagnosis of NSTEMI is confirmed or ruled out.
In the community, refer all patients to hospital as an emergency if you suspect ACS and they:[74]
Currently have chest pain
Are currently pain free, but have had chest pain within the last 12 hours and a resting 12-lead ECG is abnormal or unavailable
Have had a recent ACS (confirmed or suspected) and develop further chest pain.
Key Recommendations
Risk assessment soon after presentation is useful to guide diagnostic and therapeutic decision-making in patients presenting with ACS, including decisions about timing of invasive coronary angiography (ICA) and subsequent management.[5]
Use a validated risk scoring system that predicts 6-month mortality (e.g., Global Registry of Acute Cardiac Events [GRACE]).[72] [ GRACE Score for Acute Coronary Syndrome Prognosis Opens in new window ]
For patients with a working diagnosis of non-ST-elevation acute coronary syndrome (NSTE-ACS):
An inpatient invasive strategy is recommended in most cases
An immediate invasive strategy is recommended in patients with very high-risk features
An early (within 24 hours) invasive strategy is recommended in patients with high-risk features.
Further acute management depends on the patient’s clinical presentation and later risk assessment:
Guidelines recommend dual antiplatelet therapy with aspirin plus a P2Y12 inhibitor, unless there are contraindications or excessive risk of bleeding.
Long-term management should include aspirin (plus a P2Y12 inhibitor normally given for up to 12 months as part of dual antiplatelet therapy), anticoagulation, an ACE inhibitor, a beta-blocker, a statin, a sodium-glucose cotransporter-2 (SGLT2) inhibitor, as well as cardiac rehabilitation and modification of risk factors for cardiovascular disease.[1][5][72]
Aim to alleviate pain and anxiety and prevent recurrence of ischaemia in any patient with NSTEMI.[72]
Clinically unstable patients
Get urgent input from a senior colleague or cardiology to arrange immediate invasive coronary angiography (with the intent to perform revascularisation) for any patient who has suspected NSTEMI and is clinically unstable or very high risk. Do not wait for the results of troponin testing.[5] This includes any patient with:[72]
Ongoing or recurrent pain despite treatment
Haemodynamic instability (low blood pressure or shock) or cardiogenic shock; see Shock
Recurrent dynamic ECG changes
Acute left ventricular failure, presumed secondary to ongoing myocardial ischaemia; see Acute heart failure
A life-threatening arrhythmia (ventricular tachycardia or ventricular fibrillation) or cardiac arrest after presentation; see Sustained ventricular tachycardias[5]
Mechanical complications such as new-onset mitral regurgitation.[5]
Give initial treatments (i.e., aspirin, oxygen, morphine, glyceryl trinitrate) to all clinically unstable patients with suspected NSTEMI. However, seek advice from cardiology about use of anticoagulation and a P2Y12 inhibitor to determine the type, dose, and timing of these.
The European Society of Cardiology does not recommend routine pretreatment with a P2Y12 inhibitor for patients with a working diagnosis of NSTE-ACS if the coronary anatomy is unknown and ICA is planned within 24 hours.[5][113] However, in our expert’s opinion, a P2Y12 inhibitor may be given to a clinically unstable patient before ICA if the coronary anatomy is known; if the patient deteriorates they may be unable to swallow tablets.
Unfractionated heparin is used for anticoagulation if the patient is going for immediate ICA but is generally given in the cardiac catheter laboratory by a cardiologist.[72]
Aspirin
Give all patients with suspected ACS a single loading dose of aspirin as soon as possible, unless they have significant bleeding risk or hypersensitivity to aspirin.[5][72][74]
In practice, assess the patient’s risk of bleeding using the HAS-BLED score.[1] [ HAS-BLED Bleeding Risk Score Opens in new window ] Ensure the patient has intravenous access and discuss them with a senior colleague if they have significant bleeding risk or are actively bleeding.
Check your local protocol or discuss the patient with a senior colleague if they have hypersensitivity to aspirin.
In practice, monotherapy with a P2Y12 inhibitor (e.g., prasugrel, ticagrelor, clopidogrel) may be used.[1]
Oxygen
Do not give oxygen routinely. Offer oxygen only if the patient has oxygen saturations <90% or respiratory distress.[5]
Evidence: Oxygen therapy in patients with acute myocardial infarction
There is no evidence from randomised controlled trials (RCTs) to support the routine use of inhaled oxygen in people with acute myocardial infarction (MI) without hypoxia, but guidelines vary on their specific recommendations.
There are different recommendations in guidelines on the thresholds for starting oxygen therapy. Guidelines also vary on recommended upper limits for oxygen saturation once oxygen has been started.
The 2023 European Society of Cardiology guidelines for the management of ACS recommend that routine oxygen is not given if the arterial oxygen saturation is ≥90%.[5] The evidence underpinning this recommendation, the AVOID study, is indirect evidence from people with STEMI. However, the study authors concluded there was some evidence that oxygen therapy given to people with “uncomplicated acute MI” may increase myocardial injury.[114] This guideline recommends oxygen therapy for hypoxic patients with an oxygen saturation <90% (based on limited evidence).
A 2018 BMJ Rapid Recommendation also recommends that oxygen therapy is not initiated in patients with acute MI if the oxygen saturation is ≥90%.[115] This is based on the findings from a large systematic review and meta-analysis that liberal oxygen therapy was associated with higher mortality than conservative oxygen therapy in adults with acute illness (see below).[116]
The National Institute of Health and Care Excellence (NICE) guideline on chest pain of recent onset, last updated in 2016, recommends that supplemental oxygen is not routinely offered to patients with suspected ACS.[74] It recommends oxygen therapy if the patient has an oxygen saturation <94% and is not at risk of hypercapnic respiratory failure, aiming for a saturation of 94% to 98%. For patients with COPD who are at risk of hypercapnic respiratory failure, it recommends a target oxygen saturation of 88% to 92%, until blood gas analysis is available.
The 2016 Scottish Intercollegiate Guideline Network (SIGN) guideline on ACS does not include a specific recommendation on the use of oxygen but does refer to a Cochrane review stating that it found no conclusive evidence to support the routine use of inhaled oxygen in patients with acute MI.[117][118]
There is a lack of evidence to support the routine use of oxygen in patients with acute MI when there is no hypoxia, although oxygen therapy has commonly been used as part of the initial management of patients with acute MI.
A 2018 systematic review and meta-analysis of seven RCTs (including the AVOID study and the large multicentre DETO2X-AMI trial) and a total of 7702 patients with acute MI without hypoxaemia found that routine supplemental oxygen did not reduce:[119]
Mortality
Arrhythmias
Heart failure
Recurrent ischaemic events.
The systematic review excluded one RCT (n=72) as it included all people with non-ST-segment elevation ACS without hypoxia, not just NSTEMI.[120]
They found that oxygen therapy made no difference to any outcomes including frequency of angina or need for opioid analgesia during the second 24 hours of hospitalisation, or length of hospital stay.
Regarding the upper limit for target oxygen saturation once oxygen has been started, evidence from a large systematic review and meta-analysis on oxygen use in acutely unwell adults not at risk of hypercapnic respiratory failure (including those with MI) supports a 96% upper limit for target oxygen saturation.
One large systematic review (published in 2018) of 25 RCTs and over 16,000 patients, including one meta-analysis, found that in adults with acute illness (including MI, but also including sepsis, critical illness, stroke, trauma, cardiac arrest, and emergency surgery), liberal oxygen therapy (broadly equivalent to a target saturation >96%) is associated with higher mortality than conservative oxygen therapy (broadly equivalent to a target saturation ≤96%).[116]
In-hospital mortality was 11 per 1000 higher with liberal oxygen therapy versus conservative oxygen therapy (95% CI 2 to 22 per 1000 more). Mortality at 30 days was also higher with liberal oxygen (risk ratio [RR] 1.14, 95% confidence interval [CI] 1.01 to 1.29). Studies that were limited to people with chronic respiratory illness or psychiatric illness, on extracorporeal life support, receiving hyperbaric oxygen therapy, or having elective surgery were all excluded from the review.[116]
A lower target oxygen saturation of 88% to 92% is appropriate if the patient is at risk of hypercapnic respiratory failure.[74][121]
Pain relief
Offer pain relief as soon as possible.[74]
Give up to three doses of translingual/sublingual glyceryl trinitrate before considering an intravenous glyceryl trinitrate infusion.[1]
Monitor blood pressure carefully when giving glyceryl trinitrate because it can cause hypotension.[122]
Add morphine early if glyceryl trinitrate is not effective. Consider giving an anti-emetic when giving morphine or if the patient develops nausea or vomiting.[123]
Practical tip
Do not give intravenous glyceryl trinitrate if there is:[5]
Hypotension
Marked bradycardia or tachycardia
Known severe aortic stenosis
Right ventricular infarction
Use of a phosphodiesterase-5 inhibitor (e.g., avanafil, sildenafil, tadalafil, vardenafil) for erectile dysfunction within the last 24-48 hours.
Monitoring
In practice, observe all patients in the accident and emergency department or a chest pain unit until the diagnosis of NSTEMI is confirmed or ruled out. Monitor the following:[74]
Recurrence or increase in intensity of pain or other symptoms
Vital signs
Heart rhythm
Repeated resting 12-lead ECGs
Effectiveness of pain relief.
Anticoagulation
Discuss the patient with the cardiology team before starting anticoagulation; take into account factors such as bleeding risk, contraindications, likelihood and timing of ICA, and degree of renal impairment when making decisions about type and dose of anticoagulation.[1][5][72]
Give fondaparinux if the patient does not have a high bleeding risk unless they are undergoing immediate ICA.[72]
Consider unfractionated heparin as an alternative to fondaparinux if the patient has significant renal impairment (creatinine >265 micromol/L [>3 mg/dL]).[72] Unfractionated heparin is also used if the patient is going for immediate ICA but is generally given in the cardiac catheter laboratory by a cardiologist.[72]
Adjust the dose according to monitoring of clotting function.[72]
Bivalirudin may be an alternative to heparin, though it is not routinely used in the UK.[124]
P2Y12 inhibitor
Give the patient a P2Y12 inhibitor (e.g., prasugrel, ticagrelor, clopidogrel), in addition to aspirin given in the initial phase, as part of dual antiplatelet therapy.[72] Check your local protocol when deciding which P2Y12 inhibitor to use and the timing of this.
The UK National Institute for Health and Care Excellence (NICE) recommends the following:[72]
Prasugrel if the patient is undergoing percutaneous coronary intervention (PCI), the coronary anatomy has been defined, and the patient has no separate indication for ongoing anticoagulation. In practice this is usually prescribed by the cardiologist at the time of ICA.
For patients aged 75 years and over, the bleeding risk of using prasugrel needs to be weighed up against its effectiveness.
Ticagrelor if the patient is undergoing PCI and has no separate indication for ongoing anticoagulation OR if the patient is not undergoing PCI and does not have a high bleeding risk.
Clopidogrel if the patient is undergoing PCI and has a separate indication for ongoing anticoagulation OR if the patient is not undergoing PCI and has a high bleeding risk.
NICE also recommends aspirin alone as an alternative if the patient is not undergoing PCI and has a high bleeding risk.
The European Society of Cardiology does not recommend routine pretreatment with a P2Y12 inhibitor if the coronary anatomy is unknown and ICA is planned within 24 hours.[5][113]
Bleeding risk
In practice, always assess the patient’s bleeding risk using HAS-BLED before giving an antiplatelet agent or anticoagulant. [ HAS-BLED Bleeding Risk Score Opens in new window ] Carefully consider the choice and dose of anticoagulant for patients with a high risk of bleeding associated with:[72]
Advancing age
Known bleeding complications
Renal impairment
Low body weight.
Beta-blocker
Start a beta-blocker as soon as a patient with NSTEMI is haemodynamically stable unless there are contraindications (e.g., heart block, active asthma).[1][72]
ACE inhibitor
Start an ACE inhibitor as soon as a patient with NSTEMI is haemodynamically stable.[72]
Give an angiotensin-II receptor antagonist instead of an ACE inhibitor to patients who are intolerant to ACE inhibitors.[72]
Measure renal function, serum electrolytes, and blood pressure before starting an ACE inhibitor or angiotensin-II receptor antagonist.[72] In practice, if the patient has abnormal renal function or blood pressure, start with a low dose and titrate this carefully with close monitoring.
Cardiac monitoring
Admit all patients with NSTEMI to a monitored unit and ensure they have continuous cardiac rhythm monitoring.[1][5]
Early and late risk assessment is useful to guide diagnostic and therapeutic decision-making in patients presenting with ACS.
An inpatient invasive management strategy is recommended for most patients presenting with NSTE-ACS; the timing of this is guided by an early risk assessment, which divides patients into very high risk, high risk, or non-high risk.[5] Very high-risk patients need immediate ICA.[5] High-risk patients should have ICA within 24 hours.[5] Patients without high-risk features can be managed based on clinical suspicion; conservative management without early angiography may be an option for very low-risk patients.[5][72]
Further risk assessment after a final diagnosis has been made and treatment administered guides ongoing management.
The UK National Institute for Health and Care Excellence (NICE) recommends the following as part of risk assessment:[72]
A full clinical history (including age, previous myocardial infarction, and previous PCI or coronary artery bypass grafting [CABG])
A physical examination (including measurement of blood pressure and heart rate)
A resting 12-lead ECG, looking particularly for dynamic or unstable patterns that indicate myocardial ischaemia
Blood tests (such as troponin I or T, creatinine, glucose, and haemoglobin)
A validated risk scoring system that predicts 6-month mortality (e.g., Global Registry of Acute Cardiac Events [GRACE]). Use predicted 6-month mortality to categorise the patient’s risk of future adverse cardiac events as follows:[72]
Predicted 6-month mortality | Risk of future adverse cardiac events |
|---|---|
≤1.5% | Lowest |
>1.5-3.0% | Low |
>3.0-6.0% | Intermediate |
>6.0-9.0% | High |
>9.0% | Highest |
Get urgent input from a senior colleague or cardiology if the patient is clinically unstable or has any very high-risk features (as outlined below) to arrange immediate invasive coronary angiography (with the intent to perform revascularisation). This includes any patient with:[72][73]
Ongoing or recurrent pain despite treatment
Haemodynamic instability (low blood pressure or shock) or cardiogenic shock; see Shock
Recurrent dynamic ECG changes
Acute left ventricular failure, presumed secondary to ongoing myocardial ischaemia; see Acute heart failure
A life-threatening arrhythmia (ventricular tachycardia or ventricular fibrillation) or cardiac arrest after presentation; see Sustained ventricular tachycardias[5]
Mechanical complications such as new-onset mitral regurgitation.[5]
Offer ICA within 24 hours of admission to hospital if the patient has at least one 'high-risk' criteria:[72][73]
A confirmed diagnosis of NSTEMI based on current recommended European Society of Cardiology (ESC) high-sensitivity cardiac troponin (hs-cTn) algorithms
Dynamic ST-segment or T-wave changes
Transient ST-segment elevation
A GRACE risk score >140.
For patients who do not have very high-risk or high-risk criteria, the strategy can be tailored based on the degree of clinical suspicion. Note that the ESC recommends that all patients presenting with confirmed NSTEMI should have an invasive strategy, unless there is a contraindication to angiography, such as significant comorbidities or terminal cancer.[5] NICE, however, recommends that conservative management can be considered for patients with a low risk of adverse cardiovascular events (<3.0% 6-month mortality).[72] Be aware that some younger people who score as 'low' risk may still be at high risk of adverse cardiovascular events and may benefit from early ICA.[72]
If the patient is having conservative management but subsequently develops symptoms of ischaemia, or if ischaemia is demonstrated by further testing (e.g., stress testing), ICA should be offered.[72]
Evidence: Risk assessment
In people with NSTEMI, risk assessment tools should be used to predict their future risk of adverse cardiovascular outcomes and mortality. European and UK guidelines suggest using the Global Registry of Acute Coronary Events (GRACE) risk score.
In its guidance on ACS (last updated 2020, although evidence not changed from 2013) the UK National Institute of Health and Care Excellence (NICE) evaluated the evidence for methods of patient risk stratification.[72]
NICE included studies where the non-ST-segment elevation ACS population numbered >500 and the study population contained ≥60% people with NSTEMI or unstable angina.
They identified 14 observational studies assessing a total of eight risk scores. Five of these studies compared the performance of two or more different risk scores.
NICE reported discrimination (the ability to accurately distinguish high-risk from low-risk patients, measured with the c-statistic) and calibration (the ability to estimate the actual risk of an adverse outcome).
GRACE versus Platelet glycoprotein IIb/IIIa in Unstable angina: Receptor Suppression Using Integrilin (PURSUIT) risk scores:
Two studies (Canadian ACS-1 [n=2925] and ACS-2 [n=1728] registries) in people with non-ST-segment elevation ACS showed no difference, with both having good discrimination for mortality in-hospital and at 1 year.[92][93]
PURSUIT, however, had poor calibration meaning it consistently overestimated the risks compared with GRACE.[92]
PURSUIT, GRACE, and the Predicting Risk of Death in Cardiac Disease Tool (PREDICT) all seemed to have better discrimination for mortality compared with the Thrombolysis In Myocardial Infarction (TIMI) score.
In the Canadian ACS-2 registry, PURSUIT and GRACE had significantly better discrimination than TIMI for mortality in-hospital and at 1 year (in-hospital mortality: PURSUIT c-statistic 0.80 vs. GRACE c-statistic 0.81 vs. TIMI c-statistic 0.68; 1 year mortality: PURSUIT c-statistic 0.77 vs. GRACE c-statistic 0.79 vs. TIMI c-statistic 0.69).[93]
Based on registry data from the Mayo Clinic in the US (people with confirmed MI, n=717), PREDICT had significantly better discrimination of mortality at 28 days (PREDICT c-statistic 0.78 vs. TIMI c-statistic 0.59, P <0.001 between risk scores).[94]
In the Myocardial Infarction National Audit Project (MINAP) database of people in England and Wales with ACS (n=100,686), complex scores with a greater number of components (PURSUIT and GRACE) were compared with more simple models (Simple Risk Index [SRI] and Evaluation of Methods of Management of Acute Coronary Events [EMMACE]).[95]
All four scores showed similarly high discrimination for predicting mortality in-hospital and at 30 days.
The 2023 European Society of Cardiology (ESC) guidelines for the management of ACS recommend that risk scores should be considered for estimating prognosis.[5]
The ESC specifies that the GRACE risk score is the most accurate for risk stratification
In a retrospective study comparing TIMI and GRACE scores, GRACE performed better in predicting mortality (in-hospital and at 6 months).[96]
GRACE performed better than TIMI in a 2012 meta-analysis that included 18 validation cohorts (n=56,673) of people with NSTEMI (TIMI: c-statistic 0.54 [95% CI 0.52 to 0.57] for short-term studies and 0.67 [95% CI 0.62 to 0.71] for long-term studies; GRACE c-statistic 0.83 [95% CI 0.79 to 9.87] for short-term studies and 0.80 [95% CI 0.74 to 0.89] for long-term studies).[97]
GRACE has also been shown to perform better than subjective physician assessment for predicting mortality or myocardial infarction.[98][99]
Get urgent input from a senior colleague or cardiology if the patient is clinically unstable or has any very high-risk features (as outlined below) to arrange immediate ICA (with the intent to perform revascularisation).[5] Do not wait for the results of troponin testing.[5] This includes any patient with:[72][73]
Ongoing or recurrent pain despite treatment
Haemodynamic instability (low blood pressure or shock) or cardiogenic shock; see Shock
Recurrent dynamic ECG changes suggestive of ischaemia
Acute left ventricular failure, presumed secondary to ongoing myocardial ischaemia; see Acute heart failure
A life-threatening arrhythmia (ventricular tachycardia or ventricular fibrillation) or cardiac arrest after presentation; see Sustained ventricular tachycardias[5]
Mechanical complications such as new-onset mitral regurgitation.[5]
Offer ICA within 24 hours of admission to hospital if the patient has at least one 'high-risk' criteria:
A confirmed diagnosis of NSTEMI based on current recommended ESC hs-cTn algorithms
Dynamic ST-segment or T-wave changes
Transient ST-segment elevation
A GRACE risk score >140.
For patients who do not have very high-risk or high-risk criteria, the strategy can be tailored based on the degree of clinical suspicion. Note that the ESC recommends that all patients presenting with confirmed NSTEMI should have an invasive strategy, unless there is a contraindication to angiography, such as significant comorbidities or terminal cancer.[5] NICE, however, recommends that conservative management can be considered for patients with a low risk of adverse cardiovascular events (<3.0% 6-month mortality).[72] Be aware that some younger people who score as 'low' risk may still be at high risk of adverse cardiovascular events and may benefit from early ICA.[72]
If a patient is having conservative management but subsequently develops symptoms of ischaemia, or if ischaemia is demonstrated by further testing (e.g., stress testing), ICA should be offered.[72]
Choice of revascularisation strategy (either percutaneous coronary intervention [PCI] or coronary artery bypass graft [CABG]) should be made based on an informed discussion with the patient and, if needed, with the multidisciplinary team.[72]
Evidence: Use of risk score to guide early invasive strategy
The Global Registry of Acute Coronary Events (GRACE) risk score may be used to identify patients who would benefit from an early invasive strategy.
In its 2020 guidance on ACS, the National Institute for Health and Care Excellence (NICE) identified one study, the Timing of Interventions in Acute Coronary Syndromes (TIMACS) randomised controlled trial, in which the GRACE 6-month mortality model was used to perform a prespecified subgroup analysis of early versus delayed intervention based on patient risk.[72][100]
In patients classified as high risk (GRACE score >140) the primary outcome, a composite of death, myocardial infarction, or stroke at 6 months, occurred less with early intervention (HR 0.65, 95% CI 0.48 to 0.89).
For those at low or moderate risk (GRACE score ≤140) there was no significant difference between early and delayed intervention (HR 1.12, 95% CI 0.81 to 1.56).
NICE has a new recommendation in its 2020 guidance to consider coronary angiography within 72 hours of admission for people with unstable angina and NSTEMI who have a predicted 6-month mortality >3.0%.[72][101][102]
The European Society of Cardiology (ESC) 2023 guidelines recommend a GRACE score >140 as a criterion for early invasive treatment (coronary angiography within 24 hours of hospital admission) based on the TIMACS and Very Early veRsus Deferred invasive evaluation using Computerised Tomography (VERDICT) studies.[5][100][103]
However, it is unclear whether using the GRACE risk score improves overall patient care and outcomes.
A cluster-randomised trial, the Australian GRACE Risk score Intervention Study (AGRIS), investigated the impact of the GRACE risk score compared with standard care on inpatient angiography, prescription of guideline-recommended medications, and referral to cardiac rehabilitation.[104] The results showed that the impact of GRACE was limited to inpatient angiography.[105]
Another cluster-randomised trial, the UK GRACE Risk score Intervention Study (UKGRIS), compared use of the GRACE risk score and associated guidelines with standard care and found no difference in adherence to guideline-recommended management, or in time to a subsequent cardiovascular event at 12 months.[106]
Ensure all patients are given the following (while taking into account any contraindications):
Dual antiplatelet therapy with aspirin and a P2Y12 inhibitor (unless the patient has a separate indication for anticoagulation - seek specialist advice).[5][72]
Check your local protocol or discuss the patient with a senior colleague if the patient has hypersensitivity to aspirin. In practice, monotherapy with a P2Y12 inhibitor may be used; the UK National Institute of Health and Care Excellence recommends clopidogrel.[72]
The European Society of Cardiology recommends 12 months of dual antiplatelet therapy as the default strategy, although alternative regimens can be considered in certain circumstances depending on bleeding and ischaemic risks:[5]
Single antiplatelet therapy (preferably with a P2Y12 inhibitor) for patients who are event-free after 3 to 6 months of dual antiplatelet therapy and who are not high ischaemic risk
Aspirin or P2Y12 inhibitor monotherapy after 1 month of dual antiplatelet therapy in patients with high bleeding risk
Abbreviated dual antiplatelet therapy strategies and de-escalation of dual antiplatelet therapy can be considered in patients at high risk of bleeding.[5]
Practical tip
Evidence on the selection and duration of antiplatelet therapy following coronary revascularisation is evolving rapidly, with studies showing potential benefits from different strategies.[125][126]
In the UK, you should check the patient’s clinical report for an individualised plan written by the interventional cardiology team. This should specify what antiplatelet therapy is advised for long-term management, based on current evidence, individual patient factors, and the specific interventions undertaken for each patient.
An ACE inhibitor[72]
Start this as soon as the patient is haemodynamically stable and continue it indefinitely.[72]
In patients with heart failure, long-term use of ramipril improves survival.[127]
Offer an angiotensin-II receptor antagonist as an alternative if the patient is intolerant to an ACE inhibitor.[72]
Measure renal function, serum electrolytes, and blood pressure before starting an ACE inhibitor or angiotensin-II receptor antagonist.[72] In practice, if the patient has abnormal renal function or blood pressure, start with a low dose and titrate this carefully with close monitoring.
A beta-blocker[72]
Continue the beta-blocker for at least 12 months if the patient does not have reduced left ventricular ejection fraction (LVEF).[72]
Continue the beta-blocker indefinitely if the patient has reduced LVEF.[72]
Evidence shows that a beta-blocker may reduce the short-term risk of a reinfarction and the long-term risk of all‐cause mortality and cardiovascular mortality in patients with acute myocardial infarction.[128][129][130][131]
High-intensity statin therapy.[65][72] Patients with established coronary artery disease are at very high risk for cardiovascular events, so consider statin treatment regardless of low-density lipoprotein cholesterol (LDL-cholesterol) levels.[5][46][132] The aim is to reduce LDL-cholesterol by >50% from baseline and to achieve LDL-cholesterol <1.4 mmol/L (<54 mg/dL). Consider intensification of lipid-lowering therapy for patients who were on treatment before admission.[5]
Non-adherence to statin therapy and failure to achieve lipid targets is associated with an increased cardiovascular mortality following acute MI.[133] Patients should be counselled on the importance of drug adherence.
Target LDL-cholesterol is <1.4 mmol/L (<55 mg/dL) and a ≥50% LDL-cholesterol reduction from baseline. If these targets are not achieved on maximal statin therapy, add ezetimibe.[5][65]
A proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor monoclonal antibody (e.g., evolocumab, alirocumab) may be added to maximal statin and ezetimibe therapy if the patient is at very high risk of future events and LDL-cholesterol targets are not achieved.[5][46][65][134][135] Treatment can be started during ACS admission or at outpatient follow-up 4-6 weeks later.
An aldosterone antagonist (e.g., eplerenone, spironolactone) if the patient has heart failure with reduced LVEF (<40%).[72] Start this within 3 to 14 days of NSTEMI and preferably after starting an ACE inhibitor.[72]
A sodium-glucose cotransporter-2 (SGLT2) inhibitor (e.g., dapagliflozin, empagliflozin) for patients with heart failure when they are clinically stable, regardless of their LVEF.[5][136][137][138]
Offer cardiac rehabilitation to all patients. This should include an exercise component, health education, stress management, and psychological and social support. Advise all patients on lifestyle changes such as:[5][72][139]
Changes to diet
Reduction of alcohol consumption
Smoking cessation
Weight management
Physical exercise
Reduced sedentary time.
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