First take a good history, not ALL chest pain needs to be investigated as ACS. However, its worth noting older patients and women are more likely to have atypical presentations. Be wary that some patients with negative troponin give a history of Unstable Angina and therefore require admission.

ACS Treatment (Not STEMI going for PPCI)

• Aspirin 300mg stat
• Ticagrelor 180mg stat
• Fondaparinux 2.5mg sc stat. 

Anticoagulated with a DOAC, or with Warfarin (with a therapeutic INR),

• Aspirin 300mg stat
• Clopidogrel 300mg stat

ACS &Aspirin Allergy

• If the history suggests intolerance (GI upset, dyspepsia, nausea etc) rather than allergy, aspirin rechallenge is justifiable.
• In TRUE allergy aspirin should be avoided. > Give Ticagrelor 180mg + Fondaparinux 2.5mg (unless contraindicated)
• Any doubts contact Cardiology on-call Con

Treatment STEMI going for PPCI

• Aspirin 300mg stat
• Plus Either:
  • Ticagrelor 180mg stat (Hx of CVA)
  • Prasugrel 60mg stat (NO Hx of CVA)

Direct admissions to CCU

Patients with ST Elevation (if not accepted for primary PCI) or those with CP + new ST Depression should be discussed with a local Cardiologist and come directly to CCU.

As it is difficult to be prescriptive for every other circumstance, a discussion with a senior/cardiologist may be worthwhile in order to best manage and place your patient within the hospital.

Patients where MI is excluded

If patients do exit the pathway (no new symptoms, no new ECG ischemia and troponins that meet the exit criteria to exclude an MI), two other important possibilities still require consideration:

1. Is the history in keeping with unstable angina? (This is still an ACS). If so the patient will require an acute inpatient admission with telemetry and IP cardiology review.
2. Is the chest pain due to a significant alternative diagnosis? If so this still needs to be actively considered/ investigated/ treated.