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Inpatient management of high-risk acute coronary syndrome patients in a district hospital setting


European guidelines recommend that 'high-risk' acute coronary syndrome patients presenting to non-interventional centres should be transferred to a tertiary care centre for diagnostic coronary angiography ± coronary revascularisation within 72 hours of admission [1].

Aims and methods

To assess the contemporary management of non-ST elevation myocardial infarction (NSTEMI) patients in a district hospital setting. Over a 6-month period patients diagnosed with NSTEMI, identified via the hospital coding system, were identified and a retrospective review was performed.


Seventy-four patients were identified (age 70.4 ± 10.8 years), of which 46/74 (62%) were male. Male patients were younger 67.3 ± 10.6 vs 75.3 ± 9.4 years (P < 0.01) with a mean TIMI score 5.2 vs 5.4 (P = 0.3). The admission route was split 49%/51% between A&E and primary care. Patients were managed by cardiologists in 40% of cases; 53/74 (71%) were managed on CCU, median age 69.3 ± 10.7 vs 73.1 ± 11 years (P = 0.17) for patients not on CCU. Over 60% of patients had a positive smoking history and 7/74 (8%) had undergone previous revascularisation. At the time of admission 61/74 (82%) patients received aspirin, 41/74 (55%) received LMWH and only 51/74 (69%) received clopidogrel. Once the 12-hour troponin T result was available, LMWH and clopidogrel use increased to 45/74 (61%) and 54/74 (73%), respectively. Only 33/74 (45%) patients were transferred for further inpatient investigation, 11 from cardiologists and 22 from noncardiologists. Four patients underwent outpatient diagnostic angiography. Patients who were transferred were younger, 64.3 vs 75.2 years (P < 0.001), although had similar TIMI risk scores to those not transferred, 5.2 vs 5.3 (P = 0.56), and had 12-hour troponin T values, 0.7 vs 1 ng/ml (P = 0.29). Other than age there were no other significant differences in the specific TIMI risk score features. In the cohort, 15/23 (65%) <65 years, 16/23 (70%) 65–75 years and only 2/28 (7%) >75 years were transferred. Prior to transfer no patients received a GPIIb/IIIa receptor antagonist. In the 41/74 patients who were not transferred, four (10%) died during their inpatient stay (TIMI score 5.5 vs 5.3 for survivors, P = 0.5). Patients who died were older 76.5 vs 70 years (P = 0.25). Only 23/41 (56%) of patients not transferred were discharged on Clopidogrel with no significant difference in age.


The use of antiplatelet and anticoagulant therapies in the treatment of high-risk ACS patients is suboptimal. It might be more appropriate to start these therapies on admission and not once troponin results become available, with a view to discontinuing treatment subsequently in those deemed unlikely to benefit. The low rate of compliance with the guidelines might be partly explained by uncertainties about the management of the elderly.


  1. Task Force of the ESC: Eur Heart J. 2000, 21: 1406-1432. 10.1053/euhj.2000.2301

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Turley, A., de Belder, M., Smith, R. et al. Inpatient management of high-risk acute coronary syndrome patients in a district hospital setting. Crit Care 10 (Suppl 1), P368 (2006).

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