Clinical Quick Reference — STEMI, NSTEMI, and Unstable Angina Management
| Topic | Key Change | COR |
|---|---|---|
| CCTA in NSTE-ACS | Now recommended as part of initial imaging workup for patients with suspected NSTE-ACS (previously optional) | 2a |
| Early invasive strategy timing | Expanded to include GRACE risk score >140 as indication for within 24h invasive approach | 1 |
| DAPT in high bleeding risk (HBR) | Options for shortened (3–6 mo) or extended DAPT; single antiplatelet after 1 mo in specific HBR scenarios | 2b |
| CABG DAPT resumption | If DAPT stopped for CABG, resume for remainder of 12-month period | 1 |
| Cancer patients with ACS | Invasive strategy recommended if expected survival ≥6 months; conservative approach if <6 months | 1 |
| Cardiac arrest management | Evaluate neurological status; consider delayed angiography; temperature control ≥37.7°C; early device implantation if needed | 1 |
Sampling times: Blood at 0 h and 1 h (or 0 h and 2–3 h depending on assay). ESC 0/1h rule-in/rule-out algorithms have >99% sensitivity and NPV ≥99%. 1
Central lab preferred: Central laboratory assays have higher sensitivity than point-of-care (POC) tests. POC assays may miss 20–30% of early MI. 1
Clinical variables: Age, renal function, elevated hs-cTn baseline in healthy older adults. Use 0/3h algorithm if hs-cTn negative and no ongoing symptoms or 1h/2h results are inconclusive.
12-lead ECG recorded immediately and interpreted by trained personnel. Repeat if symptoms persist or recur.
| ECG Finding | Working Diagnosis | Action |
|---|---|---|
| ST elevation ≥0.1 mV in ≥2 contiguous leads (or new LBBB) | STEMI | Immediate reperfusion: primary PCI <120 min or fibrinolysis. Door-to-balloon <120 min. |
| ST-depression, T-wave inversion, biphasic T, pseudonormalization of T | NSTE-ACS (high likelihood) | Serial hs-cTn; early invasive strategy if high-risk features; GRACE score for risk assessment. |
| Normal ECG | UA or early ACS | Repeat ECG if symptoms persist. Serial hs-cTn at 0/1 h; if inconclusive, repeat at 3 h. HEART score risk stratification. |
Calculate using the GRACE ACS Risk Calculator or GRACE In-Hospital Calculator. GRACE >140 indicates high risk and warrants early invasive strategy within 24 h. 1
Use the HEART Score Calculator to rapidly stratify chest pain patients into low (<2% 30-day MACE), intermediate, or high-risk categories. Useful in primary care and ED settings.
| Feature | Action |
|---|---|
| Haemodynamic instability or cardiogenic shock | Emergency angiography + revascularization; consider mechanical support (IABP, MCS) |
| Recurrent or refractory chest pain despite medical therapy | Emergency angiography within hours |
| Life-threatening arrhythmias (VF, sustained VT) or cardiac arrest during hospitalization | Emergency angiography after resuscitation; temperature control ≥37.7°C; consider ICU/mechanical support |
| Mechanical complications (papillary muscle rupture, VSD, free wall rupture) | Emergency angiography followed by surgical consultation |
| Risk Category | Timing Recommendation | COR |
|---|---|---|
| Very high-risk (haemodynamic instability, recurrent chest pain, arrhythmias, mechanical complications) | Immediate angiography | 1 |
| High-risk NSTEMI (hs-cTn elevation, GRACE >140, dynamic ECG) | Early invasive within 24 h from diagnosis | 1 |
| Intermediate-risk NSTE-ACS (confirmed NSTEMI, no very high-/high-risk features) | Early invasive strategy within 24 h; selective approach if no high-risk criterion | 2a |
| Low-risk NSTE-ACS (HEART score 0–3, serial hs-cTn negative) | Selective invasive approach; non-invasive stress testing acceptable | 1 |
1 Complete revascularization (within 45 days) recommended in hemodynamically stable NSTEMI patients with multivessel disease. Can be performed at index PCI or staged.
2a Culprit-only PCI acceptable in hemodynamically unstable patients or those with extensive myocardial necrosis.
Door-to-balloon (PPCI): <120 minutes from first medical contact to balloon inflation. 1
Door-to-needle (fibrinolysis): <30 minutes from hospital arrival to fibrinolytic administration. 1
System delay (EMS to PPCI): <60 minutes for single-centre systems; <90 minutes for regional STEMI networks with transfers.
Contact-to-balloon (pre-hospital ECG + PPCI): <120 minutes total system time.
| Agent | Dose | Route |
|---|---|---|
| Tenecteplase (TNK) | Weight-adjusted 30–50 mg | Single i.v. bolus |
| Alteplase (rt-PA) | 15 mg bolus, then 0.75 mg/kg over 30 min (max 50 mg), then 0.5 mg/kg over 60 min (max 35 mg) | i.v. infusion |
| Reteplase | 10 U bolus, repeat 10 U after 30 min | i.v. bolus |
| Agent | Loading Dose | Maintenance | Duration |
|---|---|---|---|
| Aspirin | 150–300 mg oral, or 75–250 mg i.v. | 75–100 mg/day | Lifelong |
| Ticagrelor | 180 mg oral | 90 mg b.i.d. | 12 months (default); shortened if HBR |
| Prasugrel | 60 mg oral (30 mg if <60 kg or ≥75 y) | 5–10 mg/day | 12 months (default); shortened if HBR |
| Clopidogrel | 300–600 mg oral | 75 mg/day | 12 months if prasugrel/ticagrelor unavailable or contraindicated |
1 All ACS patients should receive aspirin + P2Y₁₂ inhibitor for ≥12 months. Prasugrel or ticagrelor preferred over clopidogrel in ACS undergoing PCI.
| Agent | Dosing | Key Features |
|---|---|---|
| UFH (Unfractionated Heparin) | Bolus: 70–100 U/kg i.v.; Infusion: 1.5 U/kg/h; target aPTT 50–70 s | Standard for STEMI + PPCI. Short half-life. Monitor aPTT. HIT risk. |
| Enoxaparin | Loading: 0.5 mg/kg s.c.; Maintenance: 0.1 mg/kg s.c. b.i.d. until stabilization | Subcutaneous; no monitoring. Alternative to UFH. Renal dosing if CrCl <30. |
| Bivalirudin | Bolus: 0.75 mg/kg i.v.; Infusion: 1.75 mg/kg/h for ≤4 h (PCI setting) | Direct thrombin inhibitor. No monitoring. Lower HIT risk. Alternative to UFH at PPCI. |
| Fondaparinux | 2.5 mg s.c. daily (<50 kg: 1.5 mg; >100 kg: 10 mg) | Anti-Xa. Preferred for NSTE-ACS non-invasive management. Caution if PCI <24 h (stent thrombosis risk). |
1 Default: 12 months DAPT (aspirin + P2Y₁₂ inhibitor) for all ACS patients, regardless of stent type or clinical presentation.
After 12 months, continue aspirin indefinitely. P2Y₁₂ inhibitor discontinued (unless indication for extended therapy based on ischemic/bleeding risk).
| Scenario | Duration | COR |
|---|---|---|
| High bleeding risk (HBR) patients; event-free after 3–6 mo DAPT | 3–6 months DAPT | 2a |
| Patients on OAC requiring DAPT; switch to single antiplatelet + OAC | 1 month DAPT, then aspirin + OAC (or OAC alone) | 1 |
2a In patients event-free after 12 months DAPT with high ischemic risk (prior MI, multivessel disease) and low bleeding risk, extending DAPT with a P2Y₁₂ inhibitor may be considered for long-term secondary prevention.
Use the DAPT Score Calculator to guide DAPT duration decisions based on ischemic risk (prior MI, diabetes, age) vs. bleeding risk (age, CrCl, hemoglobin).
1 Lifelong aspirin (75–100 mg/day) for all patients with established coronary artery disease or prior ACS.
1 P2Y₁₂ inhibitor for 12 months post-ACS; beyond 12 months based on ischemic vs. bleeding risk balance using DAPT Score.
1 High-intensity statin: Atorvastatin ≥80 mg or rosuvastatin ≥20 mg daily for all ACS patients.
LDL-C target: <55 mg/dL (<1.4 mmol/L). Add ezetimibe (10 mg/day) if LDL-C ≥55 on statin monotherapy.
PCSK9 inhibitors: Consider if LDL-C remains ≥55 mg/dL despite statin + ezetimibe (evolocumab, alirocumab, inclisiran).
Target: <130/80 mmHg. 1 ACE inhibitor or ARB indicated for post-MI patients with LVEF ≤40% or diabetes, regardless of BP.
Beta-blockers: Recommended for ≥3 years post-MI (especially if LVEF <40%), or indefinitely if recurrent ischemia or arrhythmia.
PCI: 1 Preferred initial strategy for STEMI (primary PCI <120 min). For NSTEMI with multivessel disease, PCI is standard if anatomy suitable.
CABG: Consider in left main stenosis, complex 3-vessel disease, or if PCI failure/contraindication. 2a CABG timing: elective after stabilization, preferably after completing DAPT (if not urgent).
1 Complete revascularization recommended in hemodynamically stable NSTEMI/ACS patients with multivessel disease. Timing: index procedure or staged within 45 days (with PCI of non-culprit lesions).
2a Culprit-only PCI may be used if hemodynamic instability, extensive necrosis, or other factors preclude safe complete revascularization.
1 DAPT resumption after CABG: If DAPT was stopped for CABG surgery, resume DAPT for the remainder of the 12-month ACS period (unless absolute HBR contraindication).
Definition: Systolic BP <90 mmHg for ≥30 min (or requiring vasopressor/inotropic support) due to inadequate cardiac output despite adequate/elevated filling pressures.
1 Early revascularization (PCI or CABG): Strongly recommended. Percutaneous mechanical circulatory support (IABP, extracorporeal membrane oxygenation [ECMO], or other devices) as bridge to definitive therapy. 1
Pharmacotherapy: Vasopressors (norepinephrine preferred) + inotropes (milrinone, dobutamine); optimize filling pressures; vasodilators if elevated afterload.
| Complication | Clinical Clues | Diagnostic Confirmation | Management |
|---|---|---|---|
| Acute mitral regurgitation (papillary muscle rupture) | Acute pulmonary edema, hypotension, new holosystolic murmur, prominent V wave on PA catheter | Echocardiography: flail leaflet, ruptured papillary muscle | Emergency surgery after hemodynamic stabilization; vasodilators (nitroprusside) as bridge |
| Ventricular septal defect (VSD) | Acute pulmonary edema, hypotension, palpable thrill, systolic murmur at LSB, elevated RV saturation on oximetry | Echocardiography: septal discontinuity + left-to-right shunt; cardiac catheterization: step-up in saturation at RV | Emergency surgery after stabilization; IABP/mechanical support |
| Free wall rupture | Sudden cardiogenic collapse, electromechanical dissociation, cardiac tamponade | Echo: pericardial fluid + pseudoaneurysm or rupture site | Emergency surgery; aggressive resuscitation with fluids + vasopressors pending OR |
Atrial fibrillation: 2a Rate control (beta-blocker, non-dihydropyridine calcium channel blocker) preferred acutely. OAC indicated for CHA₂DS₂-VASc ≥1 in women or ≥2 in men (use CHA₂DS₂-VASc Calculator). Triple therapy (aspirin + P2Y₁₂ inhibitor + OAC) if both DAPT and OAC indicated.
Ventricular arrhythmias (VT/VF): 1 Amiodarone or other antiarrhythmics for hemodynamically significant rhythms. ICD placement if LVEF ≤35% after 40 days post-MI and optimal medical therapy.
ACS management follows same principles as younger patients. Assess frailty, cognitive status, and comorbidities (CKD, anemia, prior bleeding).
1 Invasive strategy: Recommended based on functional status and clinical presentation, not age alone.
2a DAPT duration: Consider shortened DAPT (6–9 mo) in elderly with high bleeding risk and low ischemic risk.
Prasugrel dosing: Reduce maintenance to 5 mg/day if ≥75 years (instead of standard 10 mg).
Estimate renal function using CKD-EPI eGFR or Cockcroft-Gault CrCl for drug dosing.
| CKD Stage | eGFR | Drug Adjustments for ACS |
|---|---|---|
| Stage 3a–3b | 30–59 mL/min/1.73m² | No major adjustments. Monitor renal function and potassium. |
| Stage 4 | 15–29 mL/min/1.73m² | Enoxaparin: caution (increased bleeding risk). Fondaparinux: avoid. Monitor renal function closely. |
| Stage 5 (ESRD) | <15 mL/min/1.73m² | UFH preferred over LMWH. Avoid fondaparinux. Prasugrel caution (consider reduced loading/maintenance). Dialyze before elective procedures. |
1 Early invasive strategy: Recommended for diabetic ACS patients. All should receive high-intensity statin therapy and LDL-C <55 mg/dL target.
SGLT2 inhibitor: Consider if reduced LVEF or heart failure to improve outcomes (empagliflozin, dapagliflozin).
1 Expected survival ≥6 months: Treat ACS with standard strategies (PCI if appropriate, dual antiplatelet therapy, high-intensity statin).
1 Expected survival <6 months: Conservative medical management may be considered, but should not automatically exclude invasive therapy if patient desires aggressive approach.
1 DAPT resumption after CABG: If DAPT was stopped pre-operatively, resume for ≥12 months total ACS duration (unless HBR). Consider allograft-related complications (SVG patency, progression of native CAD).
Chest pain risk stratification: low (<2% 30-day MACE), intermediate, or high risk in emergency department.
6-month mortality prediction for acute coronary syndrome. GRACE >140 indicates high risk.
In-hospital mortality risk assessment for ACS to guide invasive strategy intensity.
Guide DAPT duration shortening vs. extension post-PCI. Balances ischemic vs. bleeding risk.
Stroke risk in atrial fibrillation. Essential if AF develops post-ACS.
Bleeding risk assessment to guide antithrombotic therapy intensity and DAPT duration.
Estimated glomerular filtration rate for renal function assessment and drug dosing.
Alternative creatinine clearance calculation for renal drug dosing.
Correct QT interval for heart rate; monitor during antiarrhythmic or other QT-prolonging therapy.