Heart Education Awareness Resource and Training through eLearning (HEARTe)
Further management
On transfer to CCU Hamish’s chest pain settles and he is reviewed by a cardiologist and starts ACS and anti-anginal treatment. The cardiologist tells Hamish he has had a small heart attack. This is sometimes referred to as a Non ST Elevation Myocardial Infarction (NSTEMI). He explains that he will require further investigations including coronary angiography. He also requires to be commenced on medication.
QUIZ: What medications should Hamish be prescribed during his stay in hospital?
Right with explanation
Wrong with explanation
Aspirin – All patients with a diagnosis of NSTEMI should be prescribed aspirin 75mg a day.
Clopidogrel – All patients with a diagnosis of NSTEMI should be prescribed a second antiplatelet drug in addition to aspirin. This could be clopidogrel, ticagrelor or prasugrel. The dose of clopidogrel is 75mg daily although 150mg may be given for the first 7 days after PCI. If Ticagrelor is used instead, the maintenance dose is 90mg twice daily and if Prasugrel is used, the dose is 5-10mg once daily.
Bisoprolol – A beta-blocker should be used a soon as possible to reduce the chances of a further cardiac event, assuming the patient is not bradycardic or hypotensive or has a contraindication such as asthma. The initial dose will be low but should be increased to control heart rate at around 60 beats per minute. Other beta-blockers may be used instead.
Simvastatin – All ACS patients should be started on a statin. The usual dose of simvastatin is 40mg at night although this may be reduced if other medicines interact with it. Atorvastatin, up to 80mg once daily, may be used instead.
Ramipril – Angiotensin converting enzyme (ACE) inhibitors are usually used after a NSTEMI, especially if there is evidence of impaired heart function on echocardiography or the patient develops heart failure. Not usually started in the first 24 hours because of the risk of hypotension. The initial dose will be low but should be increased to target dose (5mg twice daily) eventually.
GTN spray – All patients diagnosed with an ACS should have a GTN spray even if they don’t have a history of angina and have had no further chest pain since admission. Patients need to be educated about its use, particularly what to do if it doesn’t work.
Fondaparinux or Enoxaparin – This should have been continued until PCI or, discharge for up to a maximum of 8 days. When the treatment dose is stopped some patients may continue on enoxaparin DVT prophylaxis until discharge.
Amlodipine – Only used if the patient has persistent angina after PCI or is for medical management only. May also be used if the patient is hypertensive despite a beta-blocker and ACE inhibitor.
Furosemide – Only used if there are signs or symptoms of pulmonary or peripheral oedema. The smallest dose possible that controls oedema should be used.
Isosorbide mononitrate – Only used if the patient has persistent angina after PCI or is for medical management only.
Morphine – Should be prescribed for use intravenously as required if Hamish has ongoing chest pain in case sublingual GTN is ineffective.
Metoclopramide – Should be prescribed for use intravenously if morphine is prescribed.
Pulse point
NSTEMIs are often referred to as small or mild heart attacks. Patients shouldn’t take reassurance from that as they are still at risk of further complications.
One way of determining the risk of mortality is by utilising a risk assessment tool such as GRACE Risk Score.
The global registry of acute coronary events (GRACE) uses these diagnostic criteria for acute myocardial infarction and unstable angina. This has categorised many patients with very small rises in troponin concentrations as having sustained a myocardial infarction despite the absence of major tissue damage. Modest rises in troponin concentration are associated with a substantial increase in the risk of death and patients with modest troponin rises have a similar one and six month mortality to those sustaining a major clinical myocardial infarction.
