Acute Coronary Syndrome (ACS)
Warning
What's new / Latest updates
12/01/2023 Please note that the Raigmore and Rural pathways have now been combined into one pathway.
22/06/2022 Please note change of dose of UFH. Following ECS guidelines UFH is 4000 units IV bolus.
Emergency Department Acute Coronary Syndrome (ACS) Management Pathway - click here.
This is the combined pathway for both Raigmore and Rural use.
| Drug administration for tenecteplase thrombolysis | Age under 75 years | Age 75 years or older |
| Step 1 | Aspirin 300mg oral (ideally soluble or chewed), if not already given | Aspirin 300mg oral (ideally soluble or chewed), if not already given |
| Step 2 | Tenecteplase (TNK) full dose 0.5mg per kg IV (see below) | Tenecteplase (TNK) half dose 0.25mg per kg IV (see below) |
| Step 3 | Unfractionated heparin (UFH) 4000 units IV bolus | No UFH bolus |
| Step 4 | Clopidogrel 300mg oral | Clopidogrel 75mg oral |
| Step 5 | Enoxaparin 1mg/kg bd s.c. (max 100mg per injection for the first two doses) | Enoxaparin 0.75mg/kg bd s.c. (max 75mg per injection for the first two doses) |
Special considerations:
- If enoxaparin is unavailable and long or delayed transfer, consider UFH 1000 unit i.v. bolus after 2 hours
- If eGFR <30, regardless of age, the enoxaparin s.c. doses are given once daily
- If eGFR <15, enoxaparin is not recommended, UFH IV infusion is preferred with aPTT monitoring
- If patient is taking warfarin, check INR immediately and omit UFH/enoxaparin until INR,2
- If patient is taking DOAC (e.g. edoxaban), omit UFH/enoxaparin until >12hours since last DOAC dose
- If fondaparinux has already been given, administer UFH IV bolus if age <75yrs, omit enoxaparin for 24 hours
- If tenecteplase is unavailable, it can be substituted by alteplase (requires infusion pump, no half-dosing)
|
Tenecteplase (TNK) dosing regimen |
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Age < 75 yrs |
Age ≥ 75 yrs |
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|
Weight (kg) |
TNK (units) |
TNK (mg) |
Vol (ml) |
TNK (units) |
TNK (mg) |
Vol (ml) |
|
< 60 |
6,000 |
30 |
6 |
3,000 |
15 |
3 |
|
60 - < 70 |
7,000 |
35 |
7 |
3,500 |
17.5 |
3.5 |
|
70 - < 80 |
8,000 |
40 |
8 |
4,000 |
20 |
4 |
|
80 - < 90 |
9,000 |
45 |
9 |
4,500 |
22.5 |
4.5 |
|
≥ 90 |
10,000 |
50 |
10 |
5,000 |
25 |
5 |
Unfractionated heparin IV infusion (only if eGFR < 15)
Following IV UFH bolus, start IV UFH infusion of 12 units per kg, up to a maximum of 1,000 units/h for 24 to 48 hours. Target aPTT: 50-70 s, or 1.5 to 2.0 times control at 3, 6, 12 and 24 h
For further more detailed information please see Europeon Society of Cardiology (ESC) guidance:
Management of Acute Myocardial Infarction in patients presenting with ST-segment elevation
| Abbreviation | Meaning |
| GTN | Glyceryl trinitrate |
| ECG | Electrocardiogram |
| CCU | Coronary care unit |
| STEMI | ST-Elevation Myocardial Infarction |
| AV | Atrioventricular block |
| SBP | Systolic blood pressure |
| DBP | Diastolic blood pressure |
| LBBB | Left bundle branch block |
| eGFR | Estimated glomerular filtration rate |
| DOAC | Direct oral anticoagulants |
| UFH | Unfractionated heparin |
| aPTT | Activated partial thromboplastin time |
| PCI | Percutaneous Coronary Intervention |