1๏ธโฃ Recognition & Immediate Actions
- ๐ฏ Suspect in chest pain ยฑ atypical symptoms (esp. women, elderly, diabetics).
- ๐ Record 12-lead ECG (repeat q15โ20 min if pain continues); attach continuous cardiac monitoring.
- ๐ซ Oโ only if SpOโ <94% (avoid hyperoxia); defibrillator at bedside.
- ๐ Establish IV access, take baseline obs, NEWS score, initiate telemetry.
2๏ธโฃ Investigations
- ๐งช Bloods: Troponin, FBC, U&E, LFTs, glucose, coagulation, lipid profile.
- โฑ๏ธ Serial Troponin: Repeat at 3โ6h โ dynamic change confirms NSTEMI.
- ๐ท Imaging: CXR (exclude dissection/oedema); Echo (LV function, wall motion defects).
- ๐ Exclude mimics: D-dimer (PE), CRP/ESR (myocarditis, pericarditis).
3๏ธโฃ Risk Stratification
- โ ๏ธ High-risk features: recurrent chest pain, elevated troponin, dynamic ST/T changes, GRACE >140, haemodynamic instability, LV dysfunction (EF <40%), VT/VF, recent PCI.
- ๐ Use TIMI / GRACE / HEART scores โ guide invasive vs conservative pathway.
4๏ธโฃ Immediate Medical Therapy
- ๐ Aspirin: 300 mg PO stat โ 75 mg OD lifelong.
- ๐ P2Y12 inhibitor: Ticagrelor 180 mg stat (preferred) OR Prasugrel 60 mg OR Clopidogrel 300โ600 mg.
- ๐ Anticoagulation: Fondaparinux 2.5 mg SC OD (unless immediate PCI).
Alternative: Enoxaparin SC or UFH if peri-PCI.
- ๐ฌ๏ธ Nitrates: GTN 400 mcg SL; infusion if SBP >110 mmHg.
- ๐ Analgesia: Morphine 2.5โ5 mg IV + Metoclopramide 10 mg IV.
- ๐ซ Beta-blocker: Metoprolol 25โ50 mg PO (avoid in asthma, bradycardia, hypotension, LVF).
- ๐งด Statin: Atorvastatin 80 mg nocte.
- ๐ ACE inhibitor: Start once haemodynamically stable; titrate slowly.
5๏ธโฃ Early Invasive Strategy
- ๐ Immediate (<2h): haemodynamic collapse, refractory angina, VT/VF, cardiogenic shock.
- ๐ Early (<24h): GRACE >140, troponin rise, dynamic ECG changes.
- ๐
Within 72h: diabetes, renal impairment, recurrent angina, LVEF <40%, prior PCI/CABG.
6๏ธโฃ Supportive Measures
- ๐๏ธ Strict bed rest until stabilised, continuous arrhythmia monitoring.
- ๐ Manage LVF โ diuretics if pulmonary oedema.
- ๐ฉธ Treat arrhythmias as per ACLS protocol.
- ๐งช Control glucose: Insulin infusion if >11 mmol/L (target 6โ11 mmol/L).
7๏ธโฃ Secondary Prevention (Long-term)
- ๐ DAPT: Aspirin + P2Y12 inhibitor for 12 months (review bleeding risk).
- ๐งด Statin: High-intensity lifelong (e.g. atorvastatin 80 mg).
- ๐ ACEi/ARB: Lifelong if LV dysfunction, diabetes, or HTN.
- ๐ซ Beta-blocker: Indefinite if LV dysfunction or previous MI.
- ๐งช Aldosterone antagonist: If EF <40% with HF or diabetes.
- ๐ญ Lifestyle: Smoking cessation, Mediterranean diet, 150 min exercise/week.
- ๐ฅ Refer to cardiac rehabilitation programme.
8๏ธโฃ Discharge & Follow-up
- ๐ Education: Chest pain advice, adherence, risk factor modification.
- ๐ Arrange GP + cardiology clinic follow-up.
- ๐ง Screen for depression/anxiety; offer social support.
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