Diagnosis
- Following medical treatment including aspirin and anti-thrombin (LMWH Fondaparinex), a formal risk assessment for 6 month mortality should be carried out including previous CVD HX, Exam, 12 lead ECG, Biomarkers. > 1.5% low, > 6 % considered high
Investigation
- Risk assessment: Global Registry of Acute Cardiac Events [GRACE]
Management
Drug Management
- Aspirin 300 mg loading dose unless contra-indicated
- Clopidogrel 300 mg if 6 mth risk > 1.5% OR who may undergo PCI within 24 hrs OR Any patient whose had an NSTEMI, for up to 12 mths post event
- Glycoprotein IIb,IIIa inhibitors (Eptifibatide) if risk > 3 %, and schedule angiography within 96 hrs
- LMWH Fondaparinex unless coronary angiography planned within 24 hrs, and who do not have high bleed risk
- Unfractionated heparin if coronary angiography within 24 hrs, or if renally impaired (eGFR < 30)
- Note: Consider Bivalirudin instead of heparain and GPI if angiography within 24 hrs
Interventions:
- Coronary angiography with PCI as necessary within 24 hrs if 6 mth mortality risk > 3 %, or if initially < 3 % but subsequently experiences ischaemia
- If revascularisation unclear then involve surgeon and interventionalist
- Consider ischaemia testing before discharge
NICE Source: CG94 Unstable angina and NSTEMI: early management. Summary compiled by Dr D P Sheppard MBBS.
