NSTEMI and Unstable angina management

Question 1

flow chart of NSTEMI and unstable angina management

Answer 1

1. 12 lead ECG + admit to CCU
2. O2 2-4L aim for SpO2 94-98%
3. IV access (Bloods for FBC, U+E, glucose, lipids, Troponin)
4. Brief Assessment (Hx of CVD and risk factors, CV exam)
5. Antiplatelet (Aspirin 300mg PO (then 75mg/d) + Clopidogrel 300mg PO)
6. Anticoagulate (Fondaparinux 2.5mg SC)
7. Analgesia (Morphine 5-10mg IV + Metoclopramide 10mg IV)
8. Anti-ischaemia (GTN: 2 puffs or 1 tablet SL
   + β-B: atenolol 50mg/24h PO (CI: asthma, LVF) + IV GTN if pain continues)
9. Assess Cardiovascular risk using GRACE/TIMI score
10. Continuing therapy

Question 2

management if low-risk

Answer 2

• No further pain, flat or inverted T waves or normal
  ECG, negative trop.
• May discharge if 12h trop is negative.
• Outpatient tests: angio, perfusion scan, stress echo

Question 3

management if intermediate/high risk

Answer 3

• Persistent/recurrent ischaemia, ST depression, DM,
  positive trop.
• Glycoprotein IIb/IIIa antagonist (tirofiban)
• Angiography (±PCI) w/i 96hrs
• Clopidogrel 75mg/d for one year

Question 4

continuing therapy for NSTEMI and unstable angina

Answer 4

• ACEi (e.g. lisinopril 2.5mg)
• β-blocker (e.g. bisoprolol 10mg OD) or (CCB)
• Cardiac rehabilitation (group exercise and info) / Heart Manual
• Stop antithrombotic therapy when pain free (but give 3-5d)
• Statin (e.g. atorvastatin 80mg)
• Continue clopidogrel for 1yr following NSTEMI
• Continue aspirin indefinitely.