Non-ST Elevation Myocardial Infarction is medical emergency characterized with chest pain that is increasing in frequency and/or severity or occurring at rest. The chest pain is associated with elevated cardiac enzymes and ST segment depression or T wave inversion or normal ECG.

Pharmacological

Adjunctive therapy

Control cardiac pain

Glyceryl trinitrate (Nitroglycerine) sub–lingual/ spray 0.5mg (make sure patient hasn’t taken phosphodiesterase–5 inhibitor).

For persistent pain and if oral therapy is insufficient

Glyceryl Trinitrate (Nitroglycerine) IV, 1–2 µg/kg/min titrated with chest pain over 8–24 hours.

OR

Morphine, IV, 1–2 mg/minute dilute 10 mg up to 10 mL with sodium chloride solution 0.9%. Total maximum dose10 mg, repeat after 4 hours if necessary.

Note: But pain not responsive to this dose may suggest ongoing unresolved ischaemia. This requires immediate referral to high level of care where resources available to manage Acute Coronary Syndrome or to exclude differential diagnosis

Antiplatelet Therapy

Aspirin 300mg start (PO) then followed by 75mg/100mg daily

AND

• D: Clopidogrel 300–600 mg PO stat, then 75 mg every 24 hours,

• OR S: ticagrelor 180 mg PO stat, then 90 mg every 12 hours for the first year after the ACS event and 60 mg every 12 hours after 1 year,

• OR S: prasugrel 60 mg PO stat, then 10 mg every 24 hours.

Statin high dose

• B: Atorvastatin 80 mg PO stat, then 40 mg every 24 hours

OR

• S: Rosuvastatin 10–40 mg PO every 24 hours

Anticoagulant

Heparin UFH 70–100U/Kg body weight IV every 24 hours. ⚠ Dose check note: UFH 70–100 U/kg IV is normally given as a bolus, followed by a continuous infusion adjusted by aPTT; follow the local protocol or senior advice.

OR

Enoxaparin 1mg/kg body weight SC 12 hourly

Beta blocker (ß –blockers)

In case of LV dysfunction

Carvedilol initial dose 6.25mg (PO) 12 hourly preferred, titrate the dose upward. Max. dose 25mg (PO) 12 hourly

OR

Others ß –blockers in the settings of normal LV systolic function

Atenolol 25–50mg once daily,

OR

• C: Metoprolol succinate (SR) 25–200 mg PO every 24 hours,

• OR S: metoprolol tartrate 5 mg IV over 2 minutes (maximum 3 doses), then 50–100 mg PO every 12 hours,

• OR S: bisoprolol 2.5–10 mg PO every 24 hours.

Angiotensin Converting Enzyme Inhibitors (ACEIs)

• C: Enalapril 10 mg PO every 12 hours

OR

Captopril 6.25mg–25mg (PO) 8 hourly

OR

C: Lisinopril 5–10 mg PO every 24 hours

If ACE inhibitors are not tolerated, use an ARB: B: losartan 25–50 mg, OR S: candesartan 8–16 mg, OR S: telmisartan 40–80 mg, OR S: irbesartan 150–300 mg, each PO every 24 hours.

Referral

High suspicion index of acute coronary syndrome immediate consider referral to high level of care where resources are available to manage.

In acute settings before referral from low to high level of care if available consider giving the following urgently:

• C: Glyceryl trinitrate 0.5 mg sublingual or spray as needed for intolerable chest pain,

• AND A: acetylsalicylic acid 300 mg PO stat (chewed),

• AND D: clopidogrel 300–600 mg PO stat,

• AND a high-dose statin: S: rosuvastatin 10–40 mg PO stat OR B: atorvastatin 80 mg PO stat.

Non pharmacological

Supportive Therapy

Admit patient into high dependent ward/ICU/CCU for haemodynamic monitoring, bed rest in

Fowler’s position and reassurance.

• Oxygen via nasal blog cannula or face mask if saturation < 92%

• Establish Peripheral Intravenous - IV line for intravenous fluid or drug administration

• Haemodynamics blood pressure, heart rate and electrocardiogram rhythm monitor