Protocol for the Management of Acute Coronary Syndrome (ACS)

Acute Coronary Syndrome (ACS) Recognition, Management, and Treatment Strategies

Acute Coronary Syndrome (ACS) – a constellation of clinical signs or symptoms that raise suspicion of unstable angina or acute myocardial infarction (AMI) with or without ST-segment elevation. The term ACS can be used descriptively in the initial contact between the physician and the patient and implies managing the patient with ACS as a case of unstable angina or myocardial infarction.

(Article “Acute Coronary Syndrome” (ACS))

ACS (Possibility of Acute Myocardial Infarction):

1. Gather complaints, medical history, clinical examination, assess chest pain and equivalents, and monitor hemodynamic parameters (blood pressure, heart rate). Record a 12-lead electrocardiogram (ECG); additional recordings (V7-9, V3-4R) are necessary when the location of the myocardial infarction is inferior and in all cases where the ECG is not clear. Call the ambulance team mentioning the reason for the call – “Acute Coronary Syndrome.” Limit physical activity (placing the patient in bed, preventing self-movement).
2. Alleviate chest pain:
   • Nitroglycerin 0.5 mg sublingually or in spray form, 1-2 doses; if there is no response, repeat twice every 5-7 minutes while monitoring blood pressure and heart rate.
   • If chest pain is not relieved by nitrates, gradually administer opioid analgesics intravenously or subcutaneously (the latter – only for uncomplicated ACS without ST-segment elevation) depending on the severity of chest pain:
   • Morphine hydrochloride 3-10 mg (1 ml of 1% solution diluted in 10 ml of 0.9% sodium chloride solution, injected slowly intravenously at a dose of 3-5 ml with 5-minute intervals until the pain completely disappears).
3. Acetylsalicylic acid (250-500 mg to chew, do not use enteric-coated form of the drug).
4. Clopidogrel (concurrently with acetylsalicylic acid) orally:
   • If the patient is under 75 years old – 300 mg
   • If the patient is over 75 years old – 75 mg
5. Anticoagulant therapy:
   • Unfractionated heparin 60-70 international units/kg (maximum 4000 international units) by intravenous injection.
   Provide medication intake as soon as possible:
   A) Beta-blockers:
   • Bisoprolol 2.5 mg orally, or
   • Carvedilol 3.125 mg orally when heart rate reaches 60-70 beats per minute under blood pressure monitoring.
   • B) Angiotensin-converting enzyme inhibitors:
   • Captopril initial dose 6.25-12.5 mg or,
   • Enalapril initial dose 2.5-5.0 mg
   • C) Statin compounds:
   • Atorvastatin 40-80 mg once daily
   In case of indications, provide intravenous administration of nitroglycerin (10 ml of 0.1% solution in physiological saline) rapidly starting at 10 micrograms/minute with subsequent increments of 5 micrograms/minute every 5-10 minutes. Consider contraindications! Monitor heart rate to ensure it does not exceed 100 beats per minute, and systolic blood pressure does not drop below 100 mmHg.
   Notify the ambulance team of the time: onset of ACS, and head to the outpatient clinic for medical assistance, and the time of the first medical contact.
   Transfer the patient to the nearest hospital (in cardiac intensive care units).