Initial hospital management and analgesia in acute coronary syndrome
THE CONTEXT
Early acute coronary syndrome carries a risk of death and recurrent myocardial ischaemia, requiring urgent admission, risk assessment and adequate analgesia.
Admission and risk assessment
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All patients with suspected acute coronary syndrome should be admitted urgently, ideally to a dedicated cardiac unit with monitoring, resuscitation facilities and appropriate expertise.
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Appropriate medical therapy can reduce early death or recurrent myocardial ischaemia by at least 60%.
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Clinical risk assessment using tools such as the GRACE score helps select patients for intensive treatment and early inpatient coronary angiography. Although thresholds vary, a score of at least 140 supports early intervention.
Low-risk recovery and follow-up
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Patients without complications who are at low risk can be mobilised from the second day and discharged after 2–3 days.
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Low-risk patients without spontaneous angina may undergo an exercise tolerance test or outpatient coronary angiography after 4–6 weeks to identify a need for further intervention.
Analgesia and route of administration
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Adequate analgesia relieves distress and lowers adrenergic drive, thereby reducing vascular resistance, blood pressure, infarct size and susceptibility to ventricular arrhythmias.
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Intravenous opiates and antiemetics should be administered and titrated until the patient is comfortable. Initial doses stated are morphine sulphate 5–10 mg or diamorphine 2.5–5 mg, with metoclopramide 10 mg.
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Intramuscular injections should be avoided because poor skeletal muscle perfusion may delay their clinical effect, and thrombolytic or antithrombotic therapy may cause a painful haematoma.