Red Flags
- ST elevation ≥1 mm in two contiguous leads or new LBBB with chest pain — immediate reperfusion[1]
- Cardiogenic shock complicating ACS — emergent revascularisation; consider mechanical support[1]
- Mechanical complications (acute MR, VSR, free-wall rupture) — emergent surgical consult[1]
- High-risk NSTE-ACS (GRACE >140, dynamic ECG, refractory ischaemia) — early invasive strategy within 24 h[1]
First-line treatment
Interventions
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Aspirin[1] | Antiplatelet (loading) | 162–325 mg chewed at first medical contact then 75–100 mg daily lifelong | — | All ACS unless contraindicated |
| Ticagrelor or prasugrel[1] | P2Y12 inhibitor | Ticagrelor 180 mg load → 90 mg BD × 12 months; prasugrel 60 mg load → 10 mg daily | — | Preferred over clopidogrel in PCI-treated ACS without high bleeding risk |
| Atorvastatin 80 mg[1] | High-intensity statin | 80 mg PO once daily started during admission | — | LDL-C goal <55 mg/dL post-ACS |
| Metoprolol succinate[1] | Beta-blocker | 25–200 mg PO once daily | — | Within 24 h if no contraindication (shock, severe HF, heart block) |
| Ramipril or perindopril[1] | ACE inhibitor | Ramipril 1.25–5 mg BD; perindopril 4–8 mg daily | — | Within 24 h, especially with anterior MI, LVEF <40%, HF, or diabetes |
| Unfractionated heparin or enoxaparin[1] | Parenteral anticoagulant | UFH 60 U/kg IV bolus + 12 U/kg/h infusion (PCI-driven); enoxaparin 1 mg/kg SC BD | — | Reduce enoxaparin dose if eGFR 15–30; UFH preferred if eGFR <15 |
Aspirin[1]
Antiplatelet (loading)
- Adult
- 162–325 mg chewed at first medical contact then 75–100 mg daily lifelong
- Paediatric
- —
All ACS unless contraindicated
Ticagrelor or prasugrel[1]
P2Y12 inhibitor
- Adult
- Ticagrelor 180 mg load → 90 mg BD × 12 months; prasugrel 60 mg load → 10 mg daily
- Paediatric
- —
Preferred over clopidogrel in PCI-treated ACS without high bleeding risk
Atorvastatin 80 mg[1]
High-intensity statin
- Adult
- 80 mg PO once daily started during admission
- Paediatric
- —
LDL-C goal <55 mg/dL post-ACS
Metoprolol succinate[1]
Beta-blocker
- Adult
- 25–200 mg PO once daily
- Paediatric
- —
Within 24 h if no contraindication (shock, severe HF, heart block)
Ramipril or perindopril[1]
ACE inhibitor
- Adult
- Ramipril 1.25–5 mg BD; perindopril 4–8 mg daily
- Paediatric
- —
Within 24 h, especially with anterior MI, LVEF <40%, HF, or diabetes
Unfractionated heparin or enoxaparin[1]
Parenteral anticoagulant
- Adult
- UFH 60 U/kg IV bolus + 12 U/kg/h infusion (PCI-driven); enoxaparin 1 mg/kg SC BD
- Paediatric
- —
Reduce enoxaparin dose if eGFR 15–30; UFH preferred if eGFR <15
Safety-net
Referral criteria
- Diagnostic STEMI ECGActivate cath lab; transfer to PCI-capable centre if not on-site (FMC-to-device ≤120 min)[1]
- Cardiogenic shock or mechanical complicationHeart team plus mechanical circulatory support consideration[1]
- High-risk NSTE-ACSCardiology for coronary angiography within 24 h[1]
- Post-ACS LVEF ≤35% at 40 days despite optimal therapyCardiology for primary prevention ICD evaluation[1]
Clinical summary
Diagnostic and reperfusion management of STEMI and NSTE-ACS, anchored on early revascularisation and dual antiplatelet therapy.