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ACUTE CORONARY SYNDROMES MANAGEMENT GUIDELINES

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

July 2006
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

Acute Coronary Syndromes Management Guidelines Prepared by Trust Consultant Cardiologists ..................................... July 2006 Approved by Medicines Management Committee ............................. 14th September 2006 Review Date .......................................................................................... September 2008

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Acute Coronary Syndromes Management Guidelines Prepared by Trust Consultant Cardiologists ..................................... July 2006 Approved by Medicines Management Committee ............................. 14th September 2006 Review Date .......................................................................................... September 2008

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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 Aspirin 300 mg (if not already given by ambulance service) Morphine for pain 5-10mg i.v. initially repeated if necessary after 5 minutes. Antiemetic should be given with the first dose of morphine 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. Oxygen should be prescribed for the first few hours after acute MI by mask or nasal prongs.

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Initial investigations 6) Blood tests on admission: Electrolytes CK Glucose Random cholesterol Full Blood Count CXR later on CCU (not in A and E for straightforward MI). Thrombolysis (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. 9) Choice of Thrombolytic Agent: Streptokinase is first line agent for non-anterior myocardial infarction Tenecteplase is the thrombolytic of choice in the following circumstances:
Acute Coronary Syndromes Management Guidelines Prepared by Trust Consultant Cardiologists ..................................... July 2006 Approved by Medicines Management Committee ............................. 14th September 2006 Review Date .......................................................................................... September 2008 Page 3 of 16

7) 8)

1. 2. 3. 4. 10)

Anterior MI Previous use of Streptokinase (ever) Hypotension (systolic BP < 100mmHg) New LBBB

Guidelines for thrombolysis (see appendices for administration protocol for tenecteplase and streptokinase) Thrombolysis should be considered for all patients with a qualifying ECG presenting within 12 hours of onset of chest pain unless there are contraindications. 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 incfreased 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 Syndromes Management Guidelines Prepared by Trust Consultant Cardiologists ..................................... July 2006 Approved by Medicines Management Committee ............................. 14th September 2006 Review Date .......................................................................................... September 2008

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

Contraindications to thrombolysis Relative: Consult Registrar/Consultant A. B. C. D. E. F. Any Previous stroke Traumatic cardiopulmonary resuscitation for this episode Uncontrolled Hypertension: BP>180/110mmHg (repeat half hourly) (see guideline 10) Pregnancy Previous GI bleeding Hypotension: Systolic BP < 90mmHg YES/NO YES/NO YES/NO YES/NO YES/NO 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 Syndromes Management Guidelines Prepared by Trust Consultant Cardiologists ..................................... July 2006 Approved by Medicines Management Committee ............................. 14th September 2006 Review Date .......................................................................................... September 2008

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POST THROMBOLYSIS TREATMENT 12) 13) 14) Aspirin 75mg daily Clopidogrel 300mg initially followed by 75mg daily for 28 days Low Molecular Weight Heparin ) After Tenecteplase: Enoxaparin 1mg/kg bd for at least 48 hrs then 40mg daily until ambulant ) After Streptokinase: Not routinely required 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 after 12 hours. ACE Inhibitors: Should be given to all patients post MI unless contraindicated. Mild renal impairment (serum creatinine < 200) should not be regarded as a contraindication. Renal function must be monitored. Start after 24 hours. Statins: Consider for all patients post MI regardless of cholesterol on admission. First line treatment should be Simvastatin commencing at 40 mg at night. Simvastatin may increase the risk of myopathy when used with certain other drugs (incl. Amiodaraone and verapamil - see BNF for full list). In such cases an alternative should be considered. Anticoagulation should be considered for patients with atrial fibrillation, left ventricular aneurysm or LV thrombus. Potassium Replacement should be considered in patients with K<3.5 especially if arrhythmias are present. In patient coronary angiography may be required for patients with recurrent chest pain post myocardial infarction or patients with minimal CK rise as a result of early thrombolysis. In patient angiography is not usually required for patients who are pain free post MI with a significant CK rise or development of Q waves on the ECG. DIABETES MANAGEMENT IN ACUTE MYOCARDIAL INFARCTION 21) Existing oral hypoglycaemics should be stopped while intravenous insulin is being given. All known and newly diagnosed patients with diabetes should be treated with intravenous insulin and glucose for at least 24 hours (see CCU protocol). Patients already on insulin should be recommenced on their previous regime once stable. New diabetics or patients previously on oral
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Acute Coronary Syndromes Management Guidelines Prepared by Trust Consultant Cardiologists ..................................... July 2006 Approved by Medicines Management Committee ............................. 14th September 2006 Review Date .......................................................................................... September 2008

hypoglycaemics should be referred to a diabetologist for consideration of further management. DISCHARGE FROM CCU 22) 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 4-6 days. 1) All patients with ST elevation MI should be referred to the cardiac rehabilitation team. Management post discharge. All suitable patients should be exercise tested prior to returning to outpatients. Outpatient follow up should be at 6-8 weeks. Angiography should be considered for patients with positive exercise test at low or moderate workload, or post infarction angina.

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Acute Coronary Syndromes Management Guidelines Prepared by Trust Consultant Cardiologists ..................................... July 2006 Approved by Medicines Management Committee ............................. 14th September 2006 Review Date .......................................................................................... September 2008

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

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ARRHYTHMIAS 28) Ventricular ectopics or non sustained VT. Usually no treatment required unless recurrent long runs of NSVT. Treatment if required is lidocaine (lignocaine) 50-100 mg i.v. followed by lidocaine infusion. Sustained Broad Complex tachycardia (usually VT) With haemodynamic compromise (BP<100) proceed to urgent DC cardioversion under general anaesthetic.
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Acute Coronary Syndromes Management Guidelines Prepared by Trust Consultant Cardiologists ..................................... July 2006 Approved by Medicines Management Committee ............................. 14th September 2006 Review Date .......................................................................................... September 2008

Without haemodynamic compromise i.v. lidocaine 50-100 mg. If successfully terminated follow up with lidocaine infusion for 2448 hours. If unsuccessful consider i.v. amiodarone 300mg over 1 hour 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.

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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 11.5mg 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 low molecular weight heparin until warfarinised. 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. 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 1st degree no treatment 2nd degree or 3rd degree heart block with anterior MI temporary pacing 2nd or 3rd degree heart block with inferior MI: i.v. Atropine as above. If sinus rhythm not restored then temporary pacing if
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Acute Coronary Syndromes Management Guidelines Prepared by Trust Consultant Cardiologists ..................................... July 2006 Approved by Medicines Management Committee ............................. 14th September 2006 Review Date .......................................................................................... September 2008

haemodynamic compromise (HR< 40, BP <100 systolic) or heart failure. 34) 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 Syndromes Management Guidelines Prepared by Trust Consultant Cardiologists ..................................... July 2006 Approved by Medicines Management Committee ............................. 14th September 2006 Review Date .......................................................................................... September 2008

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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 Definitions: After assessment with serial ECG, CK and Troponin patients without ST elevation can be classified as follows: 1. Non ST elevation MI (raised biochemical markers of cardiac damage with either chest pain or ECG changes) The ACC and ESC recommend a redefinition of MI as above with a raised Troponin even in the presence of a normal CK. This has not been endorsed by the British Cardiac Society currently. The term Acute Coronary Syndrome could also be used in this case. 2. Unstable Angina (negative Troponin and/or CK with or without ECG changes). This is a clinical diagnosis including patients with recent onset severe angina, abrupt worsening of previous angina, or prolonged anginal pain at rest (>20 mins). Non cardiac chest pain (negative Troponin and CK, non ischaemic ECG, negative ETT, perfusion scan or angiogram)

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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 shuold be admistted 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.

Acute Coronary Syndromes Management Guidelines Prepared by Trust Consultant Cardiologists ..................................... July 2006 Approved by Medicines Management Committee ............................. 14th September 2006 Review Date .......................................................................................... September 2008

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Monitoring. Continuous 12 lead monitoring for 24-48 hours especially if there are ECG changes at presentation or a raised troponin. Initial investigations: Blood tests on admission: Electrolytes CK Glucose Random Cholesterol Full Blood Count CXR later on CCU (not in A and E, and only if no recent CXR).

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Troponin I level at least 12 hours after onset of suspected cardiac chest pain. Creatine Kinase on day 2, repeated on day 3 unless Troponin negative

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TREATMENT 9. 10. 11. 12. Aspirin 300mg initially followed by 75mg daily Low molecular weight heparin (Enoxaparin 1mg/kg twice daily) Oral or i.v. nitrates for recurrent chest pain Beta blockers unless contraindicated in which case Diltiazem should be considered ACE inhibitors should be given to all patients if ischaemic heart disease is confirmed unless there are contraindications (serum creatinine >200). Renal function must be monitored. Clopidogrel: Should be given to the following groups of patients and continued for 12 months. i. Aspirin intolerant patients ii. Patients with ACS already on Aspirin iii. Patients with raised Troponin iv. Patients with ST depression on resting ECG v. Patients with ACS after recent MI vi. Patients being transerred to LGI for angioplasty Dose is 300mg initially then 75mg once daily. Clopidogrel should be not be used routinely for patients with suspected cardiac pain in the absence of ECG changes or raised Troponin.
Acute Coronary Syndromes Management Guidelines Prepared by Trust Consultant Cardiologists ..................................... July 2006 Approved by Medicines Management Committee ............................. 14th September 2006 Review Date .......................................................................................... September 2008 Page 12 of 16

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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). Lipid management: As for ST elevation MI 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 iii. Raised Troponin (except patients with ST elevation MI) iv. General co-morbidity, previous MI, poor LV function or diabetes. High risk patients should be considered for in patient coronary angiography. 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.

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

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Acute Coronary Syndromes Management Guidelines Prepared by Trust Consultant Cardiologists ..................................... July 2006 Approved by Medicines Management Committee ............................. 14th September 2006 Review Date .......................................................................................... September 2008

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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 Syndromes Management Guidelines Prepared by Trust Consultant Cardiologists ..................................... July 2006 Approved by Medicines Management Committee ............................. 14th September 2006 Review Date .......................................................................................... September 2008

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Appendix 1

PROTOCOL FOR TENECTEPLASE THERAPY


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

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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. W atch for hypotension, bradycardia, arrhythmias, allergic reaction and anaphylaxis

STOP infusion if:


1. 2. Severe bleeding occurs. Anaphylactic reaction occurs.

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


Tenecteplase dose based on body weight Patients Weight < 60kg 60 - 69kg 70 - 79kg 80 - 89kg > 90kg Volume 6ml 7ml 8ml 9ml 10ml 10000 unit pack of tenecteplase 8000 unit pack of tenecteplase Syringe size to use

Acute Coronary Syndromes Management Guidelines Prepared by Trust Consultant Cardiologists ..................................... July 2006 Approved by Medicines Management Committee ............................. 14th September 2006 Review Date .......................................................................................... September 2008

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APPENDIX 2 PROTOCOL FOR STREPTOKINASE THERAPY

MEDICATION: 1) Streptokinase 1,500,000 units in 100mL. of 5% Glucose, infuse slowly I/V over 1 hour. Therapeutic dose subcutaneous Enoxaparin is not routinely required after Streptokinase. 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. W atch for hypotension, bradycardia, arrhythmias, allergic reactions and anaphylaxis. STOP infusion if 1. Severe bleeding occurs. 2. Anaphylactic reaction occurs ANTIDOTE 1. Tranexamic Acid 10mg/kg body weight by slow I/V injection (1mL/min); can be repeated after 6-8 hours. 2. Administer cryoprecipitate if severe bleeding continues. ANAPHYLAXIS 1. Stop infusion 2. Give hydrocortisone 100mg iv 3. Restart infusion at half rate when BP recovered

Acute Coronary Syndromes Management Guidelines Prepared by Trust Consultant Cardiologists ..................................... July 2006 Approved by Medicines Management Committee ............................. 14th September 2006 Review Date .......................................................................................... September 2008

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