Acute Coronary Syndrome

This guideline from SIGN has been updated. There are a couple of interesting points in it that I was not aware of:

  • Patients should be advised to take GTN at the start of angina pain, then up to 3 times at 5 minute intervals. If after 15 mins in total, the pain still hasn’t gone, they should call 999. This formalises the advice to give patients.
  • Aspirin should obviously be given to all patients acutely. I was not aware that in some cases adding clopidogrel is also beneficial acutely and further reduces mortality. 300mg clopidogrel should be added if there are ECG changes suggestive of ST Elevation MI (or if troponin is positive).
  • A2RB. We commonly use Angiotensin Receptor Blockers instead of ACEi if they aren’t tolerated. However, not all the evidence shows non-inferiority to ACEi. The evidence has also only been done in patients with Heart Failure or Left Ventricular Systolic Dysfunction (LVSD), so that is when SIGN advises their use. QOF and NICE advise that all patients with a history of cardiovascular disease be on ACEi or A2RB, so probably think twice before changing practice here…
  • Eplerenone. The new spironolactone that has fewer side-effects. This should be used only if the patient doesn’t have renal impairment or high potassium and if they have:
    • Clinical MI AND
    • Left ventricular dysfunction (EF < 40%) AND either:
      • Clinical signs of heart failure OR
      • Diabetes

NB – these criteria are picked because they were the criteria used in the trials.

Louise Hudman

I'm a freelance GP locum in Winchester & Southampton locum chambers, and Pallant Medical Chambers Clinical Guidelines Lead Partner.

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