Mx of possible acute coronary syndrome without ST elevation (NSTEACS)

see also:

• the adult patient with chest pain in the ED
• acute coronary syndromes
• acute myocardial infarction (AMI/STEMI/NSTEMI)
• cardiac stress testing
• cardiac markers (troponin)

• this assumes the patient has had consideration of other aetiologies of chest pain as per the adult patient with chest pain in the ED and there is no new LBBB or ST elevation on ECG (see acute myocardial infarction (AMI/STEMI/NSTEMI) for Mx of these patients).
• a patient under the age of 25 years without cardiac risk factors who has chest pains with troponin rise is much more likely to have myocarditis or pulmonary embolism (PE) than an acute coronary syndrome

• triage 2 to a cardiac monitored cubicle
• oxygen if SaO2 < 93% or if in shock (oxygen is no longer advised to be given routinely!)
  • NB. target SaO2 level for patients with COPD is 88–92%
• cardiac monitor as risk of cardiac arrhythmias, basic set of observations
• early 12 lead ECG
  • if acute ST elevation consistent with STEMI, then senior consult ASAP for urgent STEMI call for angioplasty (if unavailable, then consider thrombolysis)
    • see acute myocardial infarction (AMI/STEMI/NSTEMI)
• check BP in each arm
• IV access & send bloods for FBE, U&E, glucose, hs-troponin, (plus clotting profile if thrombolysis likely or patient is on warfarin)
  • consider D-Dimer if possible PE or aortic dissection
• always consider possibility of aortic dissection ASAP
  • if dissection is suspected from risk factors and clinical presentation then discuss with senior doctor for possible urgent CT Angiogram.
• aspirin (acetylsalicylic acid) 300mg o crushed if not already had aspirin that day and not allergic (in which case consider alternatives)
• treat chest pain as appropriate eg GTN, morphine +/- proton pump inhibitors (PPIs) if suspect gastro-oesophageal reflux
• CXR when available preferably whilst on cardiac monitor
• serial ECG's and troponins whilst cardiac monitoring
  • see your local policy on rapid ACS rule out serial troponin algorithms for acute coronary syndrome
• contact cardiology if either:
  • dynamic ECG changes
  • rise in troponin - see ACS rule out algorithm for the adult patient with chest pain in the ED
  • episode of VF or sustained VT
  • ongoing ischaemic sounding chest pain
  • high risk patient
    • National Heart Foundation of Australia high risk category

• if low risk after serial troponins then:
  • consider alternative diagnoses
  • if very low risk for ACS then follow up by LMO
  • if pain is consistent with angina then commence daily aspirin, advise against exertion until further testing:
    • outpatient stress echo if available, or
    • outpatient stress MIBI
    • see cardiac stress testing

• Aust. Heart Foundation - Mx acute coronary syndromes