Management of acute coronary syndrome

ACUTE CORONARY SYNDROME
MANAGEMENT PROCEDURE
AND CHECK-LIST
QUALITY ASSURANCE PROGRAMME
(UNDER HNPSP)
DIRECTORATE GENERAL OF HEALTH SERVICES
MOHAKHALI, DHAKA-1212
ANTIDOTE
• Tranexamic Acid 10mg/kg body weight by slow I/V injection TABLE OF CONTENTS
(1mL/min); can be repeated after 6-8 hours. • Administer cryoprecipitate or fresh blood if severe bleeding 1. Management of acute coronary syndrome
2. Management strategy at tertiary health care level or
HYPERSENSITIVITY REACTION:
3. Management strategy at secondary health care
4. Management strategy at primary health care (Upazila
• Restart infusion at half rate when BP recovered. • Inj. Adrenaline 1 mg I.V. if there is Anaphylactic Shock. 5. Check-list for initial work-up
6. Criteria for thrombolysis
7. Thrombolytic therapy check list
CONTRIBUTORS FOR THE FINALIZATION OF SOPS

8. Protocol for streptokinase therapy
Group 01: Acute Coronary Syndrome
9. Contributors for the finalization of SOP Associate Professor, Dhaka Medical College PROTOCOL FOR STREPTOKINASE THERAPY
MEDICATION:
• Streptokinase 1,500,000 units in 50-100mL of normal saline, • Give hydrocortisone 100mg IV, before starting streptokinase. • Start ASPIRIN 300mg orally and then 75mg daily, after food. • Use other drugs as usual (Beta blockers, Statins, ACE • BP, heart rate, ST segment every 15 minutes for 4 hours. • Watch for hypotension, bradycardia, arrhythmias, allergic STOP infusion if
• Severe bleeding occurs. • Anaphylactic reaction occurs MANAGEMENT OF ACUTE CORONARY SYNDROME
Contraindications to thrombolysis – Relative:
( To Consult with Consultant)
Acute coronary syndrome (ACS) is an emergency situation requiring systolic blood pressure >180 mm Hg or diastolic blood pressure >110 mm Hg (repeat half hourly) Components of ACS
History of chronic severe, poorly controlled YES/NO • Unstable angina (UA) • Non ST-elevation myocardial infarction (NSTEMI) Traumatic or prolonged (>10 minutes) CPR • ST-elevation myocardial infarction (STEMI). The spectrum of ACS extends from abrupt occlusion with acute Recent (within 2 to 4 weeks) internal bleeding ischaemia leading to infarction- STEMI through partial coronary obstruction and distal ischaemia with minor enzyme release- NSTEMI to non-occlusive thrombosis with normal cardiac enzymes- Streptokinase therapy more than 5 days ago or prior Diagnosis of ACS
THROMBOLYTIC THERAPY CHECK LIST
• ST elevation >1mm in 2 or more limb or chest leads : 1. Clinical assessment
• Chest pain usually central, but can be elsewhere in the Contraindications to thrombolysis – Absolute
• Usually comes on suddenly, often with activity • Feels like a tightness, heaviness, squeezing or dullness Known structural cerebral vascular lesion • Spread to one or both arms, back, neck or jaw • Also have shortness of breath, cold sweats, nausea or 2. Electrocardiographic findings
Closed head or facial trauma within 3 months a. ST-elevation
myocardial infarction (STEMI)
• Elevation of ST segment in 2 or more contiguous leads ( >1 mm in limb leads and >2 mm in chest leads) Non ST-elevation myocardial infarction (NSTEMI)
• Depression of ST segment of >1 mm Unstable angina (UA)
Relative contraindications
• Depression of ST segment of >1 mm • History of chronic severe, poorly controlled hypertension • Severe uncontrolled hypertension on presentation (systolic blood pressure >180 mm Hg or diastolic blood pressure >110 3. Cardiac biomarker assay
• History of prior ischemic stroke greater than 3 months, dementia, or known intracranial pathology not covered in Rising titres in serial measurements are more important. • Traumatic or prolonged (greater than 10 minutes) CPR or • Recent (within 2 to 4 weeks) internal bleeding 4. Diagnosis of STEMI
• For streptokinase: prior exposure (more than 5 days ago) or a. Classical chest pain for more than 15 minutes • Elevation of ST segment in 2 or more contiguous leads ( >1 mm in limb leads and >2 mm in chest leads) • CK-MB: > 2 folds increase beyond upper limit of normal • Troponin I: Any rise beyond upper limit of normal. Diagnosis of NSTEMI
CRITERIA FOR THROMBOLYSIS
a. Classical chest pain for more than 15 minutes • Ischaemic symptoms within 12 hours of onset • Depression of ST segment of >1 mm • ST elevation >1mm in at least 2 contiguous chest leads or at • New or presumably new left bundle branch block • CK-MB: > 2 folds increase beyond upper limit of normal Contraindications for Thrombolytic Therapy in STEMI
• Troponin I: Any rise beyond upper limit of normal. Absolute contraindications
Diagnosis of UA
a. Classical chest pain for more than 15 minutes • Known structural cerebral vascular lesion (eg, arteriovenous • Known malignant intracranial neoplasm (primary or • Ischemic stroke within 3 months EXCEPT acute ischemic • Active bleeding or bleeding diathesis (excluding menses) • Significant closed head or facial trauma within 3 months Troponin I: Usually within normal limits. CHECK-LIST FOR INITIAL WORK-UP

Has adequate counseling been done to the patient Has thrombolytic therapy been considered? Has primary angioplasty been considered? Has heparin or enoxaparin been considered? Management of Acute Coronary Syndrome
Management Strategy at Tertiary Health Care
Aim should be to shorten door-to-needle time. Level or specialized cardiac hospital:
Outline of management:
a. Emergency Department care:
• Brief evaluation of clinical symptoms and signs • Cardiac biomarker study, if available. • Aspirin 300 mg and Clopidogrel 300 mg to be given orally • If clinical features and ECG are suggestive of ACS, send the patient to the Coronary Care Unit (CCU) without delay. Low-molecular weight heparin Un-fractionated heparin • If the ECG is normal but there is clinical suspicion, keep the patient under observation for 8-12 hours and repeat ECG hourly and cardiac biomarker assay (CK-MB, Troponin I or T) • If the follow up ECG(s) or biomarker assay(s) are suggestive of ACS, send the patient to the CCU without delay; if they are normal discharge the patient with advice for further follow up Management Strategy at Primary Health Care
Aspirin 300 mg and Clopidogrel 300 mg to be given orally (Upazila Health Complex) Level:
Followed by Aspirin 75 mg and Clopidogrel 75 mg to be Upazila Health Complex should have basic facilities for management • Inj. Morphine sulfate 2-4 mg IV with increments of 2-8 mg of ACS and treatment of common complications. There should have repeated every 5-15 minutes if needed, along with Inj. Consultant Cardiologist, cardiac monitors and defibrillators. Prochlorperazine/ Promethazine once, if no contraindication. • Brief evaluation of clinical symptoms and signs • Beta blocker e.g. metoprolol 25 to 50 mg orally stat and BD, • Aspirin 300 mg and Clopidogrel 300 mg to be given orally • Nitrate e.g. Isosorbide mononitrate 10 to 20 mg or GTN 2.6 mg orally stat and BD, if no contraindication • If clinical features and ECG are suggestive of ACS, admit the • Statin e.g. Atorvastatin 10 mg or more orally stat and every • If the ECG is normal but there is clinical suspicion, keep the • Inj. Enoxaparin 1 mg/kg deep subcutaneously stat and BD, in patient under observation for 8 – 12 hours and repeat ECG hourly and perform cardiac biomarker assay (CK-MB), if If the follow up ECG(s) or CK-MB are suggestive of ACS, admit the patient without delay; if they are normal, discharge • Management of associated conditions if any the patient with advice for further follow up at the Outpatient the Secondary / Tertiary Health Care Level or specialized cardiac hospital, if indicated. Further care, preferably by the Consultant, Cardiology
• Continuous monitoring- heart rate, rhythm and blood • Establishment of IV channel for medications b. Care in the CCU:
Management Strategy at Secondary Health Care
(District Hospital) Level:
• Continuous monitoring- heart rate, rhythm and blood District Hospitals should have adequate facilities for managing ACS • Oxygen inhalation @ 2 – 4 L/min for 4-6 hours. patients including streptokinase therapy. There should have Consultant Cardiologist, cardiac monitors and defibrillators, trained • Establishment of IV channel for medications • Aspirin 300 mg and Clopidogrel 300 mg to be given orally stat if not given earlier. This should be followed by Aspirin 75 mg and Clopidogrel 75 mg to be given orally once daily. a. Emergency Room care:
Inj. Morphine sulfate 2-4 mg IV with increments of 2-8 mg repeated every 5-15 minutes if needed, along with Inj. Prochlorperazine/ Promethazine once – if not • Brief evaluation of clinical symptoms and signs Beta blocker e.g. metoprolol 25 to 50 mg orally stat and BD, • Cardiac biomarker study, if available. • Nitrate e.g. Isosorbide mononitrate 10 to 20 mg or GTN 2.6 • Aspirin 300 mg and Clopidogrel 300 mg to be given orally mg orally stat and BD, if no contraindication stat if not given earlier. This should be followed by Aspirin 75 • Statin e.g. Atorvastatin 10 mg or more orally stat and every mg and Clopidogrel 75 mg to be given orally once daily. • If clinical features and ECG are suggestive of ACS, send the • Inj. Streptokinase, 1.5 million units diluted in normal saline patient to the Coronary Care Unit (CCU) without delay. stat over 1 hour, in case of STEMI and if no contraindication • If the ECG is normal but there is clinical suspicion, keep the and the patient comes within 12 hours of consol of chest patient under observation for 8-12 hours and repeat ECG hourly and cardiac biomarker assay (CK-MB, Troponin I or T) • Inj. Enoxaparin 1 mg/kg deep subcutaneously stat and BD, in case of NSTEMI or UA and if no contraindication • If the follow up ECG(s) or biomarker assay(s) are suggestive • Primary PCI or CABG, if possible, and should be the goal at of ACS, send the patient to the CCU without delay; if they are normal discharge the patient with advice for further follow up Management of associated conditions if any b. Further care, preferably by the Consultant, Cardiology
• Absolute bed rest • Continuous monitoring- heart rate, rhythm and blood • Establishment of IV channel for medications • Aspirin 300 mg and Clopidogrel 300 mg to be given orally stat if not given earlier. This should be followed by Aspirin 75 mg and Clopidogrel 75 mg to be given orally once daily. • Inj. Morphine sulfate 2-4 mg IV with increments of 2-8 mg repeated every 5-15 minutes if needed, along with Inj. Prochlorperazine/ Promethazine once, if there is no contraindication. • Beta blocker e.g. metoprolol 25 to 50 mg orally stat and BD, • Nitrate e.g. Isosorbide mononitrate 10 to 20 mg or GTN 2.6 mg orally stat and BD, if no contraindication • Statin e.g. Atorvastatin 10 mg or more orally stat and every • Inj. Streptokinase, 1.5 million units diluted in normal saline stat over 1 hour, in case of STEMI and if no contraindication, and the patient comes within 12 hours of onset of chest pain. • Inj. Enoxaparin 1 mg/kg deep subcutaneously stat and BD, in case of NSTEMI or UA and if no contraindication • Management of complications if any • Management of risk factors if any. • Referral to the Tertiary Health Care Level or specialized

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