Adult Medical Emergency Handbook - Scottish Intensive Care Society

Reperfusion therapy not administered
Some patients may not reach the full electrocardiographic criteria
for reperfusion therapy, have a delayed presentation (>12 hours from
symptom onset) or have significant contra-indications or co-morbidity
that limits the administration of reperfusion therapy.
Patients with ST elevation acute coronary syndrome who do not
receive reperfusion therapy should be treated immediately with a
pentasaccharide (fondaparinux 2.5 mg sc). This should be continued
for eight days, or until hospital discharge or coronary revascularisation.
Contact CCU to discuss immediate PCI.
IMMEDIATE MANAGEMENT OF NON-ST SEGMENT
ELEVATION ACUTE CORONARY SYNDROMES
Patients with non-ST elevation ACS should be treated immediately
with fondaparinux 2.5 mg sc daily. This should be continued for eight
days, or until hospital discharge or coronary revascularisation.
Patients with an ACS who have dynamic ST segment changes,
haemodynamic compromise or acute heart failure are at particularly
high risk. Such patients benefit from early invasive intervention. “Up
stream” use of glycoprotein IIb/IIIa receptor antagonism reduces
events and improves outcomes particularly where the patient has
diabetes mellitus or an elevated troponin.
High-risk patients with non-ST elevation acute coronary syndrome
should be treated with an intravenous glycoprotein IIb/IIIa receptor
antagonist and considered for urgent PCI.
FURTHER MANAGEMENT OF ACUTE CORONARY
SYNDROMES
PATIENTS WITH CLINICAL MYOCARDIAL INFARCTION AND
DIABETES MELLITUS
Patients with clinical myocardial infarction and diabetes mellitus
or marked hyperglycaemia (>11.0 mmol/L) should have immediate
intensive blood glucose control using intravenous insulin and glucose.
This should be continued for at least 24 hours.
Where possible, patients with clinical myocardial infarction should be
commenced on long-term angiotensin-converting enzyme inhibitor
therapy within the first 36 hours.
Patients with clinical myocardial infarction complicated by left
ventricular dysfunction or heart failure should be commenced on
long-term angiotensin receptor blocker therapy if they are intolerant of
angiotensin-converting enzyme inhibitor therapy.
108 adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2009/11