1. Acute Coronary Syndromes SIGN 93

2. MINAP Mortality after Acute Coronary Syndromes Cumulative: 13.6% Blue 10.6% Green 11.6% Red

3. C In patients with suspected ACS, serum Troponin should be measured on arrival at hospital to guide appropriate management and treatment. C Patients with an acute coronary syndrome should be managed within a specialist cardiology service.  Patients with persisting bundle branch block or ST segment change should be given a copy of their ECG to assist future clinical management.

4. Rate of PCI in Scotland 2002-4 by hospital facility after 1st ever admission with ACS

5. Risk stratification and non-invasive testing C Risk stratification using clinical scores should be conducted to identify those patients with an acute coronary syndrome who are most likely to benefit from early therapeutic intervention.  Greater generalisability and accuracy favours the use of the GRACE score for risk stratification in acute coronary syndromes.

6. Advantages of primary percutaneous coronary intervention over thrombolysis. 81 Clinical indices Event Rate Absolute RR Relative RR NNT ThrombolysisPCI Short term mortality (4-6weeks) 8%5%3%36%33 Long term mortality (6-18months) 8%5%3%38%33 D When this cannot be achieved within 90 minutes of diagnosis patients should receive immediate thrombolytic therapy A Patients with an ST elevation acute coronary syndrome should be treated immediately with 1y percutaneous coronary intervention B Those presenting < 6hours who fail to reperfuse should be considered for rescue PCI

7. Thrombolysis Time is of the essence! Each minute of delay in the first 3 hours confers 10 lost days of survival

8. A In the presence of ischaemic ECG changes or elevation of cardiac markers, patients with an acute coronary syndrome should be treated immediately with fondaparinux or low molecular weight heparin. B Patients with an ST elevation acute coronary syndrome who do not receive reperfusion therapy should be treated immediately with fondaparinux.

9. Clinical Benefits of Clopidogrel Therapy with Time (Table 3) Time Interval (months) Primary end point event rates * =(NS) Clopidogrel (%) Placebo (%) Absolute RR (%) Relative RR (%) NNT (per interval) 0-14.35.51.22284 >1-31.82.70.832120 >3-61.71.80.03*1725 >6-91.31.40.17*1057 >9-121.11.30.215*533 0-1210.312.62.41942

10. B In addition to long term aspirin, clopidogrel therapy should be continued for three months in patients with non-ST elevation acute coronary syndromes.

11. D Physicians should be involved in providing information to patients.