What are the guidelines for Acute Coronary Syndrome (ACS) management in primary care in the United Kingdom (UK)?

From the Guidelines

The management of Acute Coronary Syndrome (ACS) in UK primary care should prioritize rapid assessment, initial treatment with aspirin and nitrates, and urgent referral to a specialist care unit, as outlined in the 2015 ESC guidelines 1. When a patient presents with suspected ACS, the initial evaluation should be done promptly, with a delay of ≤10 min between first medical contact and ECG. The working diagnosis of NSTE-ACS and the initial management should be based on the following parameters:

• Chest pain characteristics, duration, and persistence, as well as a symptom-oriented physical examination
• Assessment of the probability of CAD based on chest pain characteristics, age, gender, CV risk factors, known CAD, and non-cardiac manifestations of atherosclerosis
• 12-lead ECG to detect ST deviation or other abnormalities suggestive of myocardial ischemia or necrosis The initial treatment measure should include:
• Aspirin 300mg to chew, unless contraindicated
• Nitrates (sublingual or i.v.) if there is persisting chest pain
• Oxygen therapy only if saturation is below 94%
• Consider additional medications if appropriate, such as clopidogrel 300mg loading dose, pain relief with morphine, and a beta-blocker if there are no contraindications After discharge, primary care management includes secondary prevention with:
• Dual antiplatelet therapy (aspirin 75mg daily plus either ticagrelor 90mg twice daily or clopidogrel 75mg daily)
• High-intensity statin therapy (atorvastatin 80mg daily)
• Blood pressure control (target <140/90mmHg)
• An ACE inhibitor (ramipril starting at 2.5mg daily, titrating up) Lifestyle modifications are essential, including smoking cessation, regular physical activity, weight management, and dietary changes. Regular follow-up should occur at 1-2 weeks post-discharge, then at 3,6, and 12 months, with cardiac rehabilitation referral, as recommended by the European Society of Cardiology guidelines 1.

From the FDA Drug Label

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From the Research

Diagnosis of Acute Coronary Syndrome (ACS)

• The diagnosis of ACS begins with a thorough clinical assessment of a patient's presenting symptoms, electrocardiogram, and cardiac troponin levels as well as a review of past medical history 2
• Prompt and accurate assessment is crucial to establish the patient's condition and ensure timely initiation of the appropriate treatment 3
• In primary care, an electrocardiogram (ECG) is the only investigation required for most patients while referral is made to hospital 4

Management of ACS in Primary Care

• Initial treatment may include aspirin, glyceryl trinitrate and oxygen if required 4
• Key components in the management of ACS include coronary revascularization when indicated; prompt initiation of dual antiplatelet therapy and anticoagulation; and consideration of adjuvant agents including β blockers, inhibitors of the renin angiotensin system, and HmG-coenzyme A reductase inhibitors 2
• If ACS is suspected as the cause of the symptoms, urgent referral for definitive risk stratification is required 4

Role of Healthcare Professionals

• Nurses play a crucial role in patient assessment and management of ACS 3
• Physicians of all fields should be cognizant of the various presentations of acute coronary syndrome (ACS), as its prompt diagnosis and treatment profoundly decreases mortality and morbidity 5
• It is essential for clinicians to take an individualized approach to treatment and consider long-term safety and efficacy when managing patients with a history of ACS after hospital discharge 2

Guidelines and Recommendations

• Guidelines for the optimal management of patients with acute coronary syndromes are published by the American College of Cardiology Foundation and the American Heart Association 5
• The assessment and management of patients with ACS should be based on evidence-based guidelines 6