1️⃣ Recognition & Immediate Actions
- 🎯 Suspect in chest pain ± atypical symptoms (esp. women, elderly, diabetics).
- 📊 Record 12-lead ECG (repeat q15–20 min if pain continues); attach continuous cardiac monitoring.
- 🫁 O₂ only if SpO₂ <94% (avoid hyperoxia); defibrillator at bedside.
- 💉 Establish IV access, take baseline obs, NEWS score, initiate telemetry.
2️⃣ Investigations
- 🧪 Bloods: Troponin, FBC, U&E, LFTs, glucose, coagulation, lipid profile.
- ⏱️ Serial Troponin: Repeat at 3–6h → dynamic change confirms NSTEMI.
- 📷 Imaging: CXR (exclude dissection/oedema); Echo (LV function, wall motion defects).
- 🔎 Exclude mimics: D-dimer (PE), CRP/ESR (myocarditis, pericarditis).
3️⃣ Risk Stratification
- ⚠️ High-risk features: recurrent chest pain, elevated troponin, dynamic ST/T changes, GRACE >140, haemodynamic instability, LV dysfunction (EF <40%), VT/VF, recent PCI.
- 📊 Use TIMI / GRACE / HEART scores → guide invasive vs conservative pathway.
4️⃣ Immediate Medical Therapy
- 💊 Aspirin: 300 mg PO stat → 75 mg OD lifelong.
- 💊 P2Y12 inhibitor: Ticagrelor 180 mg stat (preferred) OR Prasugrel 60 mg OR Clopidogrel 300–600 mg.
- 💉 Anticoagulation: Fondaparinux 2.5 mg SC OD (unless immediate PCI).
Alternative: Enoxaparin SC or UFH if peri-PCI.
- 🌬️ Nitrates: GTN 400 mcg SL; infusion if SBP >110 mmHg.
- 💉 Analgesia: Morphine 2.5–5 mg IV + Metoclopramide 10 mg IV.
- 🫀 Beta-blocker: Metoprolol 25–50 mg PO (avoid in asthma, bradycardia, hypotension, LVF).
- 🧴 Statin: Atorvastatin 80 mg nocte.
- 💊 ACE inhibitor: Start once haemodynamically stable; titrate slowly.
5️⃣ Early Invasive Strategy
- 🚑 Immediate (<2h): haemodynamic collapse, refractory angina, VT/VF, cardiogenic shock.
- 🕐 Early (<24h): GRACE >140, troponin rise, dynamic ECG changes.
- 📅 Within 72h: diabetes, renal impairment, recurrent angina, LVEF <40%, prior PCI/CABG.
6️⃣ Supportive Measures
- 🛏️ Strict bed rest until stabilised, continuous arrhythmia monitoring.
- 💉 Manage LVF → diuretics if pulmonary oedema.
- 🩸 Treat arrhythmias as per ACLS protocol.
- 🧪 Control glucose: Insulin infusion if >11 mmol/L (target 6–11 mmol/L).
7️⃣ Secondary Prevention (Long-term)
- 💊 DAPT: Aspirin + P2Y12 inhibitor for 12 months (review bleeding risk).
- 🧴 Statin: High-intensity lifelong (e.g. atorvastatin 80 mg).
- 💊 ACEi/ARB: Lifelong if LV dysfunction, diabetes, or HTN.
- 🫀 Beta-blocker: Indefinite if LV dysfunction or previous MI.
- 🧪 Aldosterone antagonist: If EF <40% with HF or diabetes.
- 🚭 Lifestyle: Smoking cessation, Mediterranean diet, 150 min exercise/week.
- 🏥 Refer to cardiac rehabilitation programme.
8️⃣ Discharge & Follow-up
- 📚 Education: Chest pain advice, adherence, risk factor modification.
- 📞 Arrange GP + cardiology clinic follow-up.
- 🧠 Screen for depression/anxiety; offer social support.
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