Non-ST Elevation Myocardial Infarction is medical emergency characterized with chest pain that is increasing in frequency and/or severity or occurring at rest. The chest pain is associated with elevated cardiac enzymes and ST segment depression or T wave inversion or normal ECG 14, 16

Pharmacological

Adjunctive therapy

Control cardiac pain

Glyceryl trinitrate (Nitroglycerine) sub–lingual/ spray 0.5mg (make sure patient hasn’t taken phosphodiesterase–5 inhibitor).

For persistent pain and if oral therapy is insufficient

Glyceryl Trinitrate (Nitroglycerine) IV, 1–2 µg/kg/min titrated with chest pain over 8–24 hours.

OR

Morphine, IV, 1–2 mg/minute dilute 10 mg up to 10 mL with sodium chloride solution 0.9%. Total maximum dose10 mg, repeat after 4 hours if necessary15.

Note: But pain not responsive to this dose may suggest ongoing unresolved ischaemia. This requires immediate referral to high level of care where resources available to manage cute Coronary Syndrome or to exclude differential diagnosis

Antiplatelet Therapy

Aspirin 300mg start (PO) then followed by 75mg/100mg daily

AND

• Clopidogrel 300mg /600mg start then followed by 75mg daily Statin high dose

• Simvastatin 80mg start then 40mg daily

OR

• Atorvastatin 80mg start then 40mg daily

• Rosuvastatin 10mg-40mg daily

Anticoagulant

Heparin UFH 70–100U/Kg body weight IV a day

OR

Enoxaparin 1mg/kg body weight SC 12 hourly

Beta blocker (ß –blockers)

In case of LV dysfunction

Carvedilol initial dose 6.25mg (PO) 12 hourly preferred, titrate the dose upward. Max. dose 25mg (PO) 12 hourly

OR

Others ß –blockers in the settings of normal LV systolic function

Atenolol 25–50mg once daily,

OR

• Metoprolol 25–50mg once daily Angiotensin Converting Enzyme Inhibitors (ACEIs)

• Enalapril 10mg (PO) 12 hourly

OR

Captopril 6.25mg–25mg (PO) 8 hourly

OR

Perindopril 4mg–8mg (PO) daily

Referral

High suspicion index of acute coronary syndrome immediate consider referral to high level of care where resources are available to manage.

In acute settings before referral from low to high level of care if available consider giving the following urgently:

• Glyceryl trinitrate (Nitroglycerine) sub-lingual 0.5mg/ spray prn for intolerable chest pain • Aspirin 300mg stat. oral

• Clopidogrel 300mg/600mg stat oral

• High dose statin simvastatin 80mg stat OR atorvastatin 80mg stat oral

Non pharmacological

Supportive Therapy

Admit patient into high dependent ward/ICU/CCU for haemodynamic monitoring, bed rest in

Fowler’s position and reassurance.

• Oxygen via nasal blog cannula or face mask if saturation < 92%

• Establish Peripheral Intravenous - IV line for intravenous fluid or drug administration

• Haemodynamics blood pressure, heart rate and electrocardiogram rhythm monitor