How can I effectively manage a patient with ACS who has multiple comorbidities?

When managing a patient with acute coronary syndrome (ACS) who has multiple comorbidities, it is essential to tailor treatment strategies to their individual circumstances ¹.

• Informed Patient Choice and Risk Assessment:
  • Offer people with unstable angina or non-ST-segment elevation myocardial infarction (NSTEMI) clear information about the risks and benefits of treatments, ensuring it is appropriate to their underlying risk of future adverse cardiovascular events and any comorbidities ¹.
  • Formally assess the individual risk of future adverse cardiovascular events using an established risk scoring system (for example, Global Registry of Acute Cardiac Events [GRACE]) as soon as the diagnosis of unstable angina or NSTEMI is made ¹. This risk assessment should guide clinical management, balancing the benefit of a treatment against any risk of related adverse events in light of this assessment ¹.
• Revascularisation Strategy:
  • When advising people with unstable angina or NSTEMI about the choice of revascularisation strategy (percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]), take into account coronary angiographic findings, comorbidities, and the benefits and risks of each intervention ¹.
  • If the role of revascularisation or the revascularisation strategy is unclear, resolve this through discussion involving an interventional cardiologist, cardiac surgeon, and other healthcare professionals relevant to the needs of the person ¹. The choice of revascularisation strategy should be discussed with the person ¹.
  • Consider coronary angiography (with follow-on PCI if indicated) within 72 hours of first admission for people with unstable angina or NSTEMI who have an intermediate or higher risk of adverse cardiovascular events (predicted 6-month mortality above 3.0%) and no contraindications to angiography (such as active bleeding or comorbidity) ¹.
• Pharmacological Management:
  • Carefully consider the choice and dose of antithrombin therapy for people with unstable angina or NSTEMI who have a high risk of bleeding associated with factors such as advancing age, known bleeding complications, renal impairment, or low body weight ¹. For instance, unfractionated heparin may be considered as an alternative to fondaparinux for people with unstable angina or NSTEMI and significant renal impairment (creatinine above 265 micromoles per litre) ¹.
• Managing Hyperglycaemia:
  • For people admitted to hospital for an ACS, manage hyperglycaemia by keeping blood glucose levels below 11.0 mmol/litre while avoiding hypoglycaemia ¹. In the first instance, consider a dose-adjusted insulin infusion with regular monitoring of blood glucose levels ¹. Do not routinely offer intensive insulin therapy unless clinically indicated ¹.
  • For people with hyperglycaemia after ACS and without known diabetes, offer tests for HbA1c levels before discharge and fasting blood glucose levels no earlier than 4 days after the onset of ACS ¹. These tests should not delay discharge ¹.