🟥 ACUTE CORONARY SYNDROME (ACS) – INDIA

✅ COMPREHENSIVE DUAL-LEVEL CARE PROTOCOL (REVISED v4.0)

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🏥 LEVEL OF CARE CLARIFICATION

What Happens WHERE?

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🟢 PART 1 — PRIMARY CARE / FIRST-MEDICAL-CONTACT LEVEL

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1️⃣ PRIMARY CARE GOALS & OVERVIEW

🎯 The 5 Primary Care Objectives

Priority	Goal	Target Time
1	Recognise ACS	< 5 min
2	Stabilise (ABC)	< 10 min
3	Start life-saving drugs (DAPT, Anticoagulation, Statin)	< 15 min
4	Classify: STEMI vs NSTEMI vs UA	< 10 min
5	TRANSFER to higher centre	ASAP (based on urgency)

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2️⃣ PRIMARY TRIAGE & STABILISATION (0–10 MIN)

🩺 Immediate Actions Checklist

Step	Action	Details	Done ☑️
1	Airway	Assess patency, position patient	☐
2	Breathing	RR, SpO₂ monitoring	☐
3	Circulation	BP (both arms), HR, peripheral pulses	☐
4	Oxygen	Only if SpO₂ <90%, distress, or shock	☐
5	IV Access	2 large-bore cannulas (16-18G)	☐
6	12-lead ECG	Within 10 minutes of FMC	☐
7	RBS	Rule out hypoglycemia	☐
8	Baseline Bloods	If available (do NOT delay treatment)	☐

📊 Vital Parameters to Record

Parameter	Normal Range	Critical Values
SpO₂	95-100%	< 90%
SBP	100-140 mmHg	< 90 or > 180 mmHg
DBP	60-90 mmHg	> 110 mmHg
Heart Rate	60-100 bpm	< 50 or > 120 bpm
RR	12-20/min	> 24/min
RBS	70-140 mg/dL	< 70 or > 400 mg/dL

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3️⃣ PRIMARY CARE "FIRST DOSE" MEDICATION PROTOCOL

💊 Complete First-Dose Medication Table

Category	Drug	Dose	Route	Timing	Critical Notes
ANTIPLATELET	Aspirin	325 mg	Chewed	STAT	Non-enteric coated preferred
	Clopidogrel	300 mg	PO	STAT	Standard at primary level
	OR Ticagrelor	180 mg	PO	STAT	If available and PCI transfer planned
ANTICOAGULANT	Enoxaparin	1 mg/kg	SC	STAT	Preferred if CrCl > 30 mL/min
	OR UFH	60 IU/kg (max 4000 IU)	IV bolus	STAT	If CrCl unknown or < 30 mL/min
ANTI-ISCHEMIC	Nitroglycerin	0.4 mg	SL	q5min × 3	Only if SBP > 100; avoid in RV infarct
ANALGESIA	Morphine	2-4 mg	IV slow	PRN	If pain persists after NTG
STATIN	Atorvastatin	80 mg	PO	STAT	High-intensity mandatory
	OR Rosuvastatin	40 mg	PO	STAT	Alternative high-intensity
BETA-BLOCKER	Metoprolol	25 mg	PO	If stable	See contraindications below

⚠️ Beta-Blocker Contraindications

Contraindication	Reason
SBP < 90 mmHg	Risk of cardiogenic shock
HR < 50 bpm	Risk of complete heart block
Acute LV failure (Killip III-IV)	Negative inotropy worsens failure
Active bronchospasm/Asthma	Beta-blockade causes bronchospasm
2nd/3rd degree heart block	Risk of asystole
PR interval > 240 ms	Risk of complete block
Signs of RV infarct	Preload dependent

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4️⃣ ECG INTERPRETATION & ACS CLASSIFICATION

📈 ECG Findings Classification Table

ACS Type	ECG Criteria	Troponin	Action at Primary Level
STEMI	ST elevation ≥1 mm in ≥2 contiguous leads OR New LBBB with ischemic symptoms	+ (may be negative initially)	Immediate Transfer
NSTEMI	ST depression ≥0.5 mm OR T-wave inversion ≥1 mm	Positive	Stabilise + Transfer
Unstable Angina	Normal or transient/non-diagnostic changes	Negative	Stabilise + Transfer

🫀 STEMI ECG Criteria (Complete Definition)

Criterion	Details
ST Elevation	≥1 mm (0.1 mV) in ≥2 contiguous leads
OR
New LBBB	New or presumably new LBBB with ischemic symptoms
Contiguous Leads	Adjacent leads in same anatomical territory

🫀 STEMI Localization by ECG Leads

Territory	Leads with ST Elevation	Reciprocal Changes	Culprit Artery
Anterior	V1, V2, V3, V4	II, III, aVF	LAD
Anteroseptal	V1, V2, V3	None	Proximal LAD/Septal
Anterolateral	V4, V5, V6, I, aVL	II, III, aVF	LAD/Diagonal/LCx
Lateral	I, aVL, V5, V6	II, III, aVF	LCx/Obtuse Marginal
Inferior	II, III, aVF	I, aVL	RCA (80%) / LCx (20%)
Posterior	V7, V8, V9 (ST↑)	V1-V3 (ST↓, tall R)	RCA/LCx
RV Infarct	V4R (ST ≥1 mm)	—	Proximal RCA

🚨 RV Infarct – Special Considerations

Feature	Implication
Hypotension with clear lungs	Preload dependent – give fluids
⚠️ Avoid nitrates	Causes profound hypotension
⚠️ Avoid morphine excess	Vasodilation worsens hypotension
⚠️ Avoid diuretics	Reduces preload critically
Treatment	IV fluids 200-300 mL bolus, inotropes if needed

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5️⃣ PRIMARY CARE DECISION PATHWAYS & TRANSFER

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🔴 PATHWAY A: STEMI MANAGEMENT AT PRIMARY CARE

STEMI Diagnostic Criteria (Must Meet)

Criterion	Description	Met?
Clinical	Ischemic chest pain/equivalent symptoms	☐
ECG	ST elevation ≥1 mm in ≥2 contiguous leads OR New LBBB with ischemic symptoms	☐

Step-by-Step Management

Step	Action	Time Target
1	Confirm STEMI on ECG (ST elevation ≥1 mm in ≥2 contiguous leads OR New LBBB)	≤ 10 min
2	Aspirin 325 mg chewed	Immediately
3	Clopidogrel 300 mg (or Ticagrelor 180 mg)	Immediately
4	Enoxaparin 1 mg/kg SC (or UFH 60 IU/kg IV)	Immediately
5	Atorvastatin 80 mg	Immediately
6	NTG SL if SBP >100 and no RV infarct	PRN for pain
7	Morphine 2-4 mg IV if pain persists	PRN
8	IMMEDIATE TRANSFER to PCI-capable centre	ASAP
9	Pre-alert receiving hospital	Before transfer

📋 STEMI Transfer Priority

Clinical Status	Transfer Urgency
All STEMI (stable)	IMMEDIATE
STEMI with cardiogenic shock	IMMEDIATE (highest priority)
STEMI with arrhythmias	IMMEDIATE
STEMI with mechanical complications	IMMEDIATE

⛔ Do NOT delay transfer for any reason. Time = Myocardium.

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🟡 PATHWAY B: NSTEMI MANAGEMENT AT PRIMARY CARE

NSTEMI Diagnostic Criteria

Criterion	Description	Met?
Clinical	Ischemic symptoms	☐
ECG	ST depression ≥0.5 mm OR T-wave inversion OR Non-diagnostic	☐
Troponin	Positive (elevated above normal)	☐

Step-by-Step Management

Step	Action
1	Confirm NSTEMI (ischemic symptoms + positive troponin ± ECG changes)
2	Aspirin 325 mg chewed
3	Clopidogrel 300 mg
4	Enoxaparin 1 mg/kg SC or UFH
5	Atorvastatin 80 mg
6	Beta-blocker (Metoprolol 25 mg) if stable
7	NTG for ongoing pain (if SBP >100)
8	Morphine if pain persists
9	TRANSFER based on risk category

📋 NSTEMI Transfer Urgency Table

If patient has...	Risk Level	Transfer Timing
Cardiogenic shock	🔴 Very High	IMMEDIATE (<2 hrs)
Refractory chest pain despite treatment	🔴 Very High	IMMEDIATE (<2 hrs)
Life-threatening arrhythmias (VT/VF)	🔴 Very High	IMMEDIATE (<2 hrs)
Hemodynamic instability	🔴 Very High	IMMEDIATE (<2 hrs)
Acute heart failure	🔴 Very High	IMMEDIATE (<2 hrs)
Mechanical complications	🔴 Very High	IMMEDIATE (<2 hrs)
Troponin positive with dynamic ECG changes	🟠 High	Urgent (<24 hrs)
Diabetes mellitus	🟠 High	Urgent (<24 hrs)
Chronic kidney disease	🟠 High	Urgent (<24 hrs)
Known LV dysfunction (EF <40%)	🟠 High	Urgent (<24 hrs)
Prior PCI or CABG	🟠 High	Urgent (<24 hrs)
GRACE score >140	🟠 High	Urgent (<24 hrs)
None of the above	🟢 Moderate	Early (<72 hrs)

⛔ NEVER give fibrinolysis in NSTEMI

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🟢 PATHWAY C: UNSTABLE ANGINA MANAGEMENT AT PRIMARY CARE

Unstable Angina Diagnostic Criteria

Criterion	Description	Met?
Clinical	Ischemic symptoms (new onset, crescendo, or rest angina)	☐
ECG	Normal OR transient ST-T changes	☐
Troponin	Negative	☐

Step-by-Step Management

Step	Action
1	Confirm Unstable Angina (ischemic symptoms + negative troponin)
2	Aspirin 325 mg chewed
3	Clopidogrel 300 mg
4	Enoxaparin 1 mg/kg SC or UFH
5	Atorvastatin 80 mg
6	Beta-blocker (Metoprolol 25 mg) if stable
7	NTG for ongoing pain
8	TRANSFER based on clinical status

📋 Unstable Angina Transfer Decision Table

Clinical Status	Action
Ongoing chest pain despite treatment	Transfer urgently
Hemodynamically unstable	Transfer immediately
Dynamic ECG changes	Transfer urgently
Symptoms resolved, stable	Transfer same day/next day for risk stratification
Low-risk, completely stable	Can arrange elective transfer/outpatient evaluation

⛔ NEVER give fibrinolysis in Unstable Angina

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6️⃣ PRIMARY CARE TRANSFER PROTOCOL

🚑 Summary: Who Needs Transfer and When?

Patient Category	Transfer Urgency	Purpose at Higher Centre
STEMI (all)	IMMEDIATE	Primary PCI or Fibrinolysis + PCI
STEMI with shock	IMMEDIATE (highest priority)	PCI + MCS
NSTEMI – very high risk	IMMEDIATE (<2 hrs)	Urgent angiography
NSTEMI – high risk	Urgent (<24 hrs)	Early angiography
NSTEMI – moderate risk	Early (<72 hrs)	Angiography
UA – ongoing symptoms	Urgent	Evaluation + angiography
UA – stabilised	Same day/next day	Risk stratification
Cardiogenic shock (any ACS)	IMMEDIATE	Advanced care + revascularization

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📋 Transfer Documentation Checklist

Document/Information	Details	☑️
ECGs	Initial + all subsequent ECGs	☐
Symptom onset time	Exact time or best estimate	☐
First medical contact time	When patient first seen	☐
All medications given	Drug name, dose, time, route	☐
Vital signs trend	All recorded BP, HR, SpO₂	☐
Allergies	Drug allergies, contrast allergy	☐
Comorbidities	DM, HTN, CKD, prior MI, prior PCI/CABG	☐
Bleeding history	Prior GI bleed, hemorrhagic stroke	☐
Current medications	Especially anticoagulants, antiplatelets	☐
Creatinine/eGFR	If available	☐
Troponin result	If available	☐

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🚑 During Transport Requirements

Requirement	Details
Monitoring	Continuous ECG, SpO₂, BP every 5-10 min
IV Access	Maintain patent IV line
Emergency Medications	NTG, Morphine, Atropine, Adrenaline
Equipment	Defibrillator mandatory; airway equipment
Personnel	ACLS-trained personnel
Communication	Pre-alert receiving hospital with patient details

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🔵 PART 2 — SECONDARY / TERTIARY CARE (PCI-CAPABLE CENTRE)

Setting: Emergency Department → CCU → Cath Lab → ICU

Capabilities: Coronary Angiography, PCI, Fibrinolysis, Mechanical Circulatory Support, Cardiac Surgery (if available)

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7️⃣ SECONDARY TRIAGE & HEMODYNAMIC PROFILING

📊 Killip Classification

Class	Clinical Features	In-Hospital Mortality	Management Focus
I	No heart failure signs	~6%	Standard ACS care
II	Rales in lower lung fields, S3, elevated JVP	~17%	Diuretics, monitor closely
III	Pulmonary edema (rales >50% lung fields)	~38%	Aggressive diuresis, NIV, urgent intervention
IV	Cardiogenic shock	~81%	Vasopressors, MCS, emergent revascularization

🫀 Hemodynamic Profiles (Forrester Classification)

Profile	CI (L/min/m²)	PCWP (mmHg)	Clinical Status	Treatment
I	> 2.2	< 18	Warm & Dry	Standard care
II	> 2.2	> 18	Warm & Wet	Diuretics, vasodilators
III	< 2.2	< 18	Cold & Dry	Fluid challenge
IV	< 2.2	> 18	Cold & Wet	Inotropes, MCS, urgent revasc

✅ Advanced Monitoring Requirements

Monitoring	Frequency	Target/Notes
Continuous ECG	Continuous	Detect arrhythmias, ST changes
Arterial BP	Continuous (invasive)	MAP > 65 mmHg
SpO₂	Continuous	> 90%
Urine output	Hourly	> 0.5 mL/kg/hr
Bedside Echo	Within 30 min	LV/RV function, MR, VSD, effusion
Lactate	If shock suspected	Target < 2 mmol/L

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8️⃣ SECONDARY CARE MEDICAL THERAPY (ALL ACS)

💊 Complete Medication Table

Category	Drug Options	Dose	Notes
ANTIPLATELET 1	Aspirin	75-150 mg OD	Lifelong
ANTIPLATELET 2	Ticagrelor	90 mg BD	Preferred in ACS
	OR Prasugrel	10 mg OD (5 mg if <60 kg or >75 yrs)	Only after anatomy known; avoid if prior stroke/TIA
	OR Clopidogrel	75 mg OD	If ticagrelor/prasugrel contraindicated
ANTICOAGULANT	Enoxaparin	1 mg/kg SC BD	CrCl > 30 mL/min
	OR UFH infusion	12 IU/kg/hr	CrCl < 30 or during PCI
	OR Bivalirudin	0.75 mg/kg bolus → 1.75 mg/kg/hr	High bleed risk PCI
STATIN	Atorvastatin	80 mg OD	High-intensity mandatory
	OR Rosuvastatin	40 mg OD	Alternative
ACE-I	Ramipril	2.5-10 mg OD	Start within 24 hrs if stable
	OR Perindopril	2-8 mg OD
ARB (if ACE-I intolerant)	Telmisartan	40-80 mg OD
ARNI	Sacubitril/Valsartan	24/26 to 97/103 mg BD	Post-stabilisation, EF < 40%
BETA-BLOCKER	Metoprolol succinate	25-200 mg OD
	OR Carvedilol	3.125-25 mg BD	Preferred if HF
	OR Bisoprolol	2.5-10 mg OD
MRA	Spironolactone	25-50 mg OD	EF ≤ 40% + HF symptoms
	OR Eplerenone	25-50 mg OD	Fewer side effects
SGLT2-I	Dapagliflozin	10 mg OD	If HF or DM
	OR Empagliflozin	10 mg OD

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📋 P2Y12 Inhibitor Comparison

Feature	Clopidogrel	Ticagrelor	Prasugrel
Loading Dose	300-600 mg	180 mg	60 mg
Maintenance	75 mg OD	90 mg BD	10 mg OD
Onset	2-6 hrs	30 min	30 min
Reversibility	Irreversible	Reversible	Irreversible
Stop before surgery	5 days	3-5 days	7 days
Avoid if	CYP2C19 poor metabolizers	Prior ICH, severe hepatic impairment	Prior stroke/TIA
Special notes	Genetic resistance possible	May cause dyspnea, bradycardia	Most potent; highest bleed risk

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9️⃣ STEMI MANAGEMENT AT SECONDARY CARE

🎯 Reperfusion Strategy Decision

Time from Symptom Onset	Preferred Strategy
< 12 hours	Primary PCI (preferred) OR Fibrinolysis if PCI delay >120 min
12-24 hours	PCI if ongoing ischemia or hemodynamic instability
> 24 hours	Generally NO reperfusion; medical management; PCI only if ongoing ischemia

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⏱️ Time Targets

Metric	Target	Notes
Door-to-ECG	≤ 10 min	Confirm STEMI (ST elevation ≥1 mm in ≥2 contiguous leads OR New LBBB)
Door-to-Balloon	≤ 90 min	For primary PCI
FMC-to-Device	≤ 120 min	Total ischemic time from FMC
Door-to-Needle (if fibrinolysis)	≤ 30 min	If PCI delay expected >120 min
Post-lysis angiography	3-24 hrs	After successful fibrinolysis
Rescue PCI	Immediately	If fibrinolysis fails

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💉 FIBRINOLYSIS PROTOCOL (Secondary Care Only)

⚠️ Fibrinolysis is given ONLY at Secondary/Tertiary Care when PCI cannot be performed within 120 minutes of FMC

When to Give Fibrinolysis: Checklist

Criterion	Met?
✅ STEMI confirmed (ST elevation ≥1 mm in ≥2 contiguous leads OR New LBBB)	☐
✅ Symptom onset < 12 hours	☐
✅ PCI cannot be performed within 120 min of FMC	☐
✅ No absolute contraindications	☐
✅ Door-to-needle time can be < 30 min	☐

If ALL boxes checked → Proceed with Fibrinolysis

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💉 Fibrinolytic Agent Dosing

Drug	Dose	Administration	Notes
Tenecteplase (TNK)	Weight-based (see below)	Single IV bolus over 5-10 sec	Preferred – easiest
Streptokinase	1.5 million IU	IV over 60 min	Cheapest; avoid if prior exposure
Alteplase (tPA)	15 mg bolus → 0.75 mg/kg over 30 min → 0.5 mg/kg over 60 min	IV infusion (max 100 mg)
Reteplase	10 U × 2 boluses	IV bolus 30 min apart

📊 Tenecteplase Weight-Based Dosing

Patient Weight	TNK Dose	Volume (if 50 mg/10 mL)
< 60 kg	30 mg	6 mL
60-69 kg	35 mg	7 mL
70-79 kg	40 mg	8 mL
80-89 kg	45 mg	9 mL
≥ 90 kg	50 mg	10 mL

📌 Age > 75 years: Consider half-dose Tenecteplase

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❌ Fibrinolysis Contraindications

🚫 ABSOLUTE Contraindications (NEVER Give)

Contraindication
Prior intracranial hemorrhage (ICH) – ever
Known structural cerebrovascular lesion (AVM, aneurysm)
Known malignant intracranial neoplasm
Ischemic stroke within 3 months
Suspected aortic dissection
Active bleeding (excluding menses)
Significant head/facial trauma within 3 months
Intracranial/intraspinal surgery within 2 months

⚠️ RELATIVE Contraindications (Weigh Risk vs Benefit)

Contraindication	Consideration
Severe uncontrolled HTN (SBP >180 / DBP >110)	Control BP first
History of chronic severe hypertension	Higher bleeding risk
Ischemic stroke > 3 months ago	Discuss risk/benefit
CPR > 10 minutes	Relative
Major surgery within 3 weeks	Assess surgical site
Recent internal bleeding (2-4 weeks)	GI, GU bleeding
Non-compressible vascular punctures	Recent subclavian, jugular
Pregnancy	Relative
Active peptic ulcer	Increased GI bleeding risk
Current anticoagulant use (high INR)	Higher bleeding risk
Prior Streptokinase (>5 days ago)	Use TNK or Alteplase instead

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✅ Mandatory Post-Fibrinolysis Medications

Drug	Dose	Duration
Aspirin	75-150 mg OD	Continue indefinitely
Clopidogrel	75 mg OD	At least 14 days, up to 12 months
Enoxaparin	1 mg/kg SC BD	Until revascularization or 8 days
OR UFH	12 IU/kg/hr (max 1000 IU/hr)	48 hours (aPTT 50-70 sec)

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📋 Post-Fibrinolysis Assessment (at 60-90 minutes)

Sign	Finding	Interpretation
ST segment	≥50% resolution	✅ Successful reperfusion
Chest pain	Significant relief	✅ Successful reperfusion
Arrhythmias	AIVR	✅ Reperfusion arrhythmia (usually benign)
ST segment	<50% resolution	❌ Failed → Rescue PCI
Chest pain	Persistent/worsening	❌ Failed → Rescue PCI

Post-Fibrinolysis Disposition

Scenario	Action
Successful reperfusion	Routine angiography within 3-24 hours
Failed reperfusion	Immediate Rescue PCI
Complications	Manage appropriately; may need urgent PCI

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💉 CATH LAB PROTOCOL (Primary PCI)

Cath Lab Antithrombotic Protocol

Agent	Dose	When to Use
UFH	70-100 IU/kg bolus	Standard anticoagulation for PCI
UFH (with GP IIb/IIIa)	50-70 IU/kg bolus	Reduced dose if using GP IIb/IIIa
Bivalirudin	0.75 mg/kg bolus → 1.75 mg/kg/hr	High bleeding risk patients
Tirofiban	25 μg/kg bolus → 0.15 μg/kg/min	Bail-out only
Eptifibatide	180 μg/kg bolus × 2 → 2 μg/kg/min	Bail-out only

Note: GP IIb/IIIa inhibitors are NOT routine; used only for bail-out situations

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🌫️ No-Reflow Management Protocol

No-reflow: TIMI flow <3 despite patent epicardial vessel

Step	Drug	Dose	Route
1	Adenosine	100-200 μg	Intracoronary bolus (repeat ×3-4)
2	Nitroprusside	50-200 μg	Intracoronary bolus
3	Nicorandil	2 mg	Intracoronary
4	Verapamil	100-200 μg	Intracoronary
5	GP IIb/IIIa inhibitor	Standard dose	If high thrombus burden
6	Consider IABP	—	Mechanical support if refractory

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🛠️ Multivessel Disease Strategy

Clinical Scenario	Revascularization Strategy
Stable patient, MVD	Complete revascularization (staged or same sitting)
Cardiogenic shock	Culprit-only PCI (CULPRIT-SHOCK trial)
Left main disease	Heart Team discussion; consider CABG
High SYNTAX score (≥33)	CABG may be preferred

📊 SYNTAX Score Guidance

SYNTAX Score	Complexity	Recommendation
0-22	Low	PCI reasonable
23-32	Intermediate	Heart Team decision
≥ 33	High	CABG generally preferred

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🔟 NSTEMI – INVASIVE STRATEGY (SECONDARY CARE)

🚨 Risk-Based Timing of Angiography

Risk Category	Features	Timing of Angiography
🔴 Very High Risk	Cardiogenic shock	< 2 hours
	Refractory angina
	Life-threatening arrhythmias (VT/VF)
	Mechanical complications (acute MR, VSD)
	Acute heart failure clearly related to ACS
🟠 High Risk	Rise/fall in troponin	< 24 hours
	Dynamic ST or T-wave changes
	GRACE score > 140
	Diabetes mellitus
	CKD (eGFR < 60)
	LVEF < 40%
	Prior PCI/CABG
🟢 Low Risk	None of the above	Conservative approach
		Stress imaging → selective angiography

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📊 GRACE Score Quick Reference

GRACE Score	Risk Category	Recommended Timing
≤ 108	Low	Conservative or elective
109-140	Intermediate	< 72 hrs
> 140	High	< 24 hrs

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1️⃣1️⃣ UNSTABLE ANGINA MANAGEMENT (SECONDARY CARE)

📋 Treatment Protocol

Component	Details
DAPT	Aspirin + Clopidogrel
Anticoagulation	Enoxaparin or Fondaparinux
Anti-ischemic	Beta-blocker + Nitrates
Statin	High-intensity (Atorvastatin 80 mg)
Risk Assessment	TIMI / GRACE score
Angiography	Based on risk stratification and stress testing
⛔ Fibrinolysis	NEVER indicated in UA

📋 Risk Stratification in Unstable Angina

TIMI Risk Score	Risk Level	Approach
0-2	Low	Conservative, stress testing
3-4	Intermediate	Consider angiography
5-7	High	Early angiography

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1️⃣2️⃣ CARDIOGENIC SHOCK PROTOCOL

⚠️ Definition

Cardiogenic Shock:

• SBP < 90 mmHg for > 30 min OR vasopressors needed to maintain SBP ≥ 90 mmHg
• PLUS signs of end-organ hypoperfusion (altered mentation, cool extremities, oliguria, elevated lactate)

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💉 Vasoactive Drug Protocol

Drug	Dose Range	Primary Effect	Role
Noradrenaline	0.1-1 μg/kg/min	Vasoconstriction (α > β)	FIRST-LINE
Dobutamine	2-20 μg/kg/min	Inotropy (β1)	Add if low CI with adequate BP
Adrenaline	0.01-0.5 μg/kg/min	Mixed α and β	Refractory shock, post-arrest
Milrinone	0.375-0.75 μg/kg/min	PDE inhibitor (inodilator)	RV failure, pulmonary HTN
Dopamine	—	—	⛔ AVOID (increased arrhythmias)

Stepwise Approach

Step	Action	Target
1	Start Noradrenaline	MAP ≥ 65 mmHg
2	Add Dobutamine if CI low	CI > 2.2 L/min/m²
3	If refractory, add Adrenaline	Maintain perfusion
4	Consider MCS early	See below

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⚙️ Mechanical Circulatory Support Devices

Device	Mechanism	Flow Support	Best For	Limitations
IABP	Counterpulsation	0.5-1 L/min	Acute MR, VSD, bridge	Least support
Impella CP	LV → Aorta axial pump	3-4 L/min	LV unloading	Hemolysis, limb ischemia
Impella 5.0/5.5	LV → Aorta	5-6 L/min	Greater support	Surgical cutdown
VA-ECMO	RA → Femoral artery	4-7 L/min	Biventricular failure	LV distension, limb ischemia

🎯 Device Selection Guide

Clinical Scenario	Preferred Device
Acute severe MR / VSD	IABP (bridge to surgery)
Isolated LV failure	Impella CP or 5.0
Biventricular failure	VA-ECMO
Refractory VT/VF	VA-ECMO
Bridge to decision/recovery	ECMO or Impella

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1️⃣3️⃣ DISCHARGE MEDICATION PROTOCOL

💊 Mandatory Discharge Medications

Drug Class	Drug	Dose	Duration
Aspirin	Aspirin	75-150 mg OD	Lifelong
P2Y12 Inhibitor	Ticagrelor	90 mg BD	12 months
	OR Prasugrel	10 mg OD	12 months
	OR Clopidogrel	75 mg OD	12 months
High-intensity Statin	Atorvastatin	80 mg OD	Lifelong
Beta-blocker	Metoprolol / Carvedilol / Bisoprolol	Titrate to max tolerated	≥3 years (indefinite if EF <40%)
ACE-I / ARB / ARNI	Ramipril / Telmisartan / Sacubitril-Valsartan	Titrate to max tolerated	Lifelong
MRA	Spironolactone / Eplerenone	25-50 mg OD	If EF ≤ 40% + symptoms
SGLT2-I	Dapagliflozin / Empagliflozin	10 mg OD	If DM or HF

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📋 Discharge Checklist

Category	Item	☑️
Medications	All medications explained	☐
	Written prescription provided	☐
	Drug interactions reviewed	☐
Education	Warning signs explained	☐
	Activity restrictions explained	☐
	Dietary advice	☐
	Smoking cessation counseling	☐
Follow-up	Cardiology appointment scheduled	☐
	Cardiac rehabilitation referral	☐
Documentation	Discharge summary completed	☐
	ECG and procedure notes provided	☐

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🚭 Lifestyle Modification Targets

Modification	Target
Smoking	Complete cessation
Diet	Mediterranean diet; sodium < 2g/day
Exercise	150 min/week moderate activity
Weight	BMI 18.5-24.9
BP	< 130/80 mmHg
LDL-C	< 55 mg/dL
HbA1c (if DM)	< 7%

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1️⃣4️⃣ FOLLOW-UP & RISK STRATIFICATION

📅 Follow-Up Schedule

Time Point	Focus	Tests
1-2 weeks	Wound check, medication tolerance	BP, HR, basic labs
4-6 weeks	Titrate medications, functional status	Echo if not done
3 months	Device evaluation if indicated	Echo, ICD assessment if EF ≤ 35%
6 months	Lipid and glycemic control	Lipid profile, HbA1c
12 months	Complete reassessment	Echo, stress test if indicated
Annually	Secondary prevention review	Lipids, BP, lifestyle

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🔴 High-Risk Features Requiring Close Follow-Up

High-Risk Feature	Action Required
EF < 40%	Serial Echo, GDMT optimization, ICD evaluation at 3 months
Persistent elevated NT-proBNP	HF management
Residual ischemia	Consider repeat angiography
Recurrent symptoms	Urgent evaluation
Uncontrolled risk factors	Intensive management

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🔋 ICD Evaluation Criteria (at ≥40 days post-MI and ≥3 months of GDMT)

Indication	Criteria
Primary Prevention ICD	EF ≤ 35% despite optimal medical therapy
	NYHA Class II-III
	Life expectancy > 1 year
CRT-D Consideration	EF ≤ 35% + LBBB with QRS ≥ 150 ms

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📌 QUICK REFERENCE SUMMARY TABLES

🔴 STEMI Quick Reference (Primary Care)

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🔵 NSTEMI/UA Quick Reference (Primary Care)

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⚠️ CRITICAL WARNINGS

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📚 ABBREVIATIONS

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• ✅ Fibrinolysis moved exclusively to Secondary Care
• ✅ STEMI ECG criteria corrected to include complete definition (ST elevation ≥1 mm in ≥2 contiguous leads OR New LBBB)
• ✅ Primary Care pathway simplified to: Recognise → Stabilise → Medicate → Transfer