1st February 2007
Scottish Intercollegiate Guidelines Network
Summary,

Source: National Guidelines Clearinghouse

GUIDELINE OBJECTIVE(S)

To provide evidence-based recommendations on the in-hospital management of patients with an acute coronary syndrome (ACS), as well as the duration of clopidogrel use beyond hospital discharge following non-ST elevation ACS

TARGET POPULATION

Adult patients with acute coronary syndromes (ACS)

INTERVENTIONS AND PRACTICES CONSIDERED

Diagnosis/Evaluation

1. Immediate assessment by an appropriate healthcare professional
2. 12 lead electrocardiogram
3. Measurement of serum troponin concentration

Management/Treatment

Initial Management

1. Patient management within a specialist cardiology service
2. Continuous cardiac rhythm monitoring
3. Oxygen therapy
4. Antiplatelet therapy with pharmacologic including aspirin, clopidogrel, and intravenous glycoprotein IIb/IIIa receptor antagonist
5. Anticoagulant therapy with low molecular weight heparin or fondaparinux therapy or intravenous glycoprotein IIb/IIIa receptor antagonist
6. Immediate intravenous and oral beta blockade
7. Intensive blood glucose control
8. Percutaneous coronary intervention, including treatment with a glycoprotein IIb/IIIa receptor antagonist and intracoronary stent implantation
9. Thrombolytic therapy with a fibrin-specific agent
10. Development of local protocols for rapid treatment of patients
11. Rescue percutaneous coronary interventions

Surgical and Pharmacological Interventions

1. Risk stratification using clinical scores and assessment of cardiac functions
2. Coronary angiography and revascularisation
3. Early pharmacologic intervention with anti-platelet therapy ([aspirin, clopidogrel], statins, beta-blockers, nitrates, calcium channel blockers, angiotensin-converting enzyme [ACE] inhibitors, angiotensin receptor blockers, aldosterone receptor antagonists)

Treatment of Hypoxia and Cardiogenic Shock

1. Non-invasive positive airway pressure ventilation
2. Intravascular volume loading
3. Inotropic therapy
4. Intra-aortic balloon counter pulsation
5. Coronary revascularisation
6. Corrective surgery for mechanical complications of acute myocardial infarction

Counseling

1. Early psychosocial assessment and individualised psychosocial intervention
2. Provision of patient information based on individual patient needs, inclusion of partner/family in receiving information, and use of appropriate audiovisual materials
3. Physician involvement in providing information to patients

MAJOR OUTCOMES CONSIDERED

• Accuracy and timeliness of diagnosis and initiation of appropriate treatment
• Short-term and long-term mortality
• Morbidity
• Cardiac events (e.g. myocardial infarction/reinfarction, cardiac rupture, ventricular fibrillation, cardiogenic shock, cardiac arrest, heart failure)
• Psychological distress