Acute Coronary SyndromeICU / resuscitation

Cardiology · Ward Pathways · Free — no sign-in

By Dr Javed Akhtar · Last reviewed 2 October 2026

Casualty: crushing substernal chest pain; risk factors (HTN, smoking, dyslipidaemia)

ABCDE

Oxygen only if SpO₂ <90% (not routine); IV access, continuous ECG; aspirin + 2nd antiplatelet; analgesia; activate reperfusion.

Calculators:
  1. Initial orders: ECG (≤10 min) + Troponin; Aspirin 162–325 mg chewed immediately, then 75–100 mg daily + Nitroglycerin SL (morphine only for refractory pain — not routine)
  2. Add 2nd antiplatelet: ticagrelor or prasugrel preferred over clopidogrel — DAPT unless high bleeding risk or on oral anticoagulation (then individualize)
  3. Give also: β-blocker (metoprolol) — avoid if cardiogenic shock, acute HF, bradycardia, hypotension, or high-grade AV block; ACE inhibitor; high-intensity statin (atorvastatin 80 mg or rosuvastatin 20–40 mg); anticoagulation in both STEMI and NSTEMI — agent per reperfusion strategy (UFH with PCI/fibrinolysis; enoxaparin/fondaparinux in NSTEMI)
  4. STEMI — reperfuse: Primary PCI preferred: FMC-to-device ≤90 min (≤120 min if transfer needed). If not achievable → fibrinolysis (tenecteplase preferred) up to 12 h from onset, door/FMC-to-needle ≤30 min, then routine angiography 2–24 h (pharmacoinvasive)
  5. Fibrinolysis only for: STEMI (or true STEMI-equivalent — Sgarbossa/modified Sgarbossa criteria with clinical correlation in LBBB/paced rhythm) — NOT for NSTEMI. New LBBB alone is NOT an automatic STEMI equivalent.
Decision tree
STEMI criteria (incl. Sgarbossa if LBBB/paced)?
Yes
PCI available within 120 min?
Yes
Primary PCI (door-to-balloon <90 min)
No
Thrombolysis ≤12 h (door-to-needle <30 min), then transfer for PCI
No
NSTEMI/UA pathway: dual antiplatelet + anticoagulant; risk-stratify (GRACE) → early angiography

Order set

  • ECG ≤10 min
  • Troponin (serial)
  • Aspirin 162–325 mg chewed + 2nd antiplatelet
  • U&E, FBC, glucose, lipids
  • CXR
  • Reperfusion pathway (PCI/lysis)

Monitor

  • 0 minECG + troponin; dual antiplatelet; reperfusion decision
  • 10 minDoor-to-ECG done; activate cath lab if STEMI
  • 90 minTarget door-to-balloon (PCI)
  • 3–6 hRepeat troponin; telemetry
  • 24 hEcho (EF), lipids, secondary prevention

Escalate / ICU

  • Ongoing ischaemia / cardiogenic shock
  • Sustained VT/VF or high-grade block
  • Mechanical complication (acute MR, VSD, rupture)
  • Killip III–IV / pulmonary oedema

Criteria

AdmitAll ACS
ICUCardiogenic shock, malignant arrhythmia, mechanical complication
IntubateCardiac arrest / severe pulmonary oedema
VasopressorsCardiogenic shock (consider mechanical support)
TransfuseHospitalized AMI: transfusion to ~10 g/dL reasonable (2025 ACS guideline 2b, MINT; AABB 2025) — not restrictive 7–8
DischargeReperfused/pain-free, no arrhythmia, EF assessed, secondary prevention + rehab

Never

  • Give thrombolytics for NSTEMI
  • Delay aspirin — give immediately, chewed

Key

  • High-sensitivity troponin is the preferred biomarker — 0/1-h or 0/2-h rule-out algorithms; myoglobin/CK-MB no longer routine (CK-MB only for suspected reinfarction).
  • Posterior ECG V7–V9 when posterior MI suspected; right-sided ECG V3R–V4R in inferior STEMI.
  • Radial access preferred for PCI.
  • Immediate bedside echo if shock or mechanical complication (papillary muscle rupture, VSD, free-wall rupture).
  • NSTEMI risk-tiered angiography (<2 h very-high-risk, ≤24 h high-risk).
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
  • Ongoing pain
  • Hypotension/shock
  • New murmur
  • Malignant arrhythmia
Differentials
  • Aortic dissection
  • PE
  • Pericarditis
  • GORD/musculoskeletal
Common mistakes
  • Thrombolysis for NSTEMI
  • Delaying aspirin
  • Missing posterior/RV MI
Disposition & follow-up

CCU/monitored bed; echo, secondary prevention, cardiac rehab.

Discharge package
MedicationsDual antiplatelet, high-intensity statin, β-blocker, ACEi; colchicine 0.5 mg daily may be considered (2b)
Follow-upCardiology + echo; cardiac rehab
VaccinationInfluenza
LifestyleSmoking cessation, diet, activity per rehab
Warning symptomsRecurrent chest pain, breathlessness, syncope
💊 Treatment detail — doses & preparation
Aspirinantiplatelet
DoseACS: 162–325 mg chewed immediately, then 75–100 mg daily. PV/stroke prevention: 75 mg OD
Preparation300 mg dispersible (chew/dissolve for loading); 75 mg enteric-coated maintenance
MonitorBleeding, dyspepsia; avoid in viral illness in children
TicagrelorP2Y12 inhibitor
DoseLoad 180 mg PO, then 90 mg BD
Preparation90 mg tablets (crushable for NG)
MonitorAvoid in prior intracranial haemorrhage/active bleeding; may cause dyspnoea, bradyarrhythmia; bleeding; avoid with strong CYP3A4 inhibitors
ClopidogrelP2Y12 inhibitor
DoseLoad 300–600 mg PO, then 75 mg OD
Preparation75/300 mg tablets
MonitorBleeding; CYP2C19 poor metabolisers — consider ticagrelor
Unfractionated heparinIV anticoagulant
DoseUFH 60 U/kg (max 4000 U) bolus, then 12 U/kg/h (max 1000 U/h), titrate aPTT 1.5–2.5× — ACS dosing (the 80/18 regimen is for VTE)
Preparation25,000 U in 250 mL NS (100 U/mL) via pump
MonitoraPTT q6h, platelets day 3–14 (HIT)
Glyceryl trinitrate (nitroglycerin)IV/SL vasodilator
DoseSL 400 mcg spray/tablet; IV 10–200 mcg/min infusion
Preparation50 mg in 250 mL D5W (200 mcg/mL) in glass bottle/non-PVC set; start 10 mcg/min, titrate q5 min
MonitorBP, headache; tolerance after 24 h — nitrate-free interval
Atorvastatinstatin
DoseHigh-intensity: atorvastatin 80 mg OD post-ACS (or rosuvastatin 20–40 mg)
Preparation10/20/40/80 mg tablets, any time of day
MonitorLFTs baseline, muscle symptoms; target LDL reduction ≥50%
📖 ESC ACS / ACC-AHAReviewed July 2026

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