acute coronary syndrome (acs) - kc: … coronary syndrome (acs) care pathway includes: all patients...

Patient’s name………………………..

NHS No………………………………

Hospital No…………………………..

Date of Birth…………………………

ACUTE CORONARY SYNDROME (ACS)

CARE PATHWAY

Includes: All patients with cardiac sounding chest pain to be included in this pathway Excludes: Patients NOT managed as ACS ALL STAFF Each professional making an entry in this CP must complete the sample signature section on this page. You can then use your initials when recording care. When activities are completed you should initial in the space provided and enter the time. If the activity is not completed or you need to vary the care outlined in the pathway, then you must record this as a variance next to the activity, and include the time and your initials. It may be necessary to record N/A against some activities outlined in the CP. Any extra care provided for the patients can be entered in the multidisciplinary notes. This CP is a multi-disciplinary plan of care based on evidence from research, and incorporates national and local guidelines for patients who present with Acute Chest Pain. It does not replace clinical judgement.

NAME (PRINT) DESIGNATION SIGNATURE INITIALS DATE

If you have any queries regarding this CP, please contact your line manager and/or the Cardiac Specialist

Nurses on EXT 4489 Lister Hospital or Bleep 0190 QEII

Date of admission……………….

Time…………………………….

Consultant………………………

ACS

Authors: Kylie Murray & Dr Neville Kukreja Updated May 2010 incorporating NICE clinical guideline 94 (March 2010)

Review Due May 2012

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CONCOMITANT TREATMENTS ASPIRIN

All patients should receive aspirin 300mg on onset of symptoms, unless contraindicated, followed by 75mg daily indefinitely (avoid higher doses to minimise risk of gastrointestinal side effects).

CLOPIDOGREL Treatment for PPCI patients should receive a loading dose 600mg clopidogrel Treatment for patients with all other ACS and mini GRACE score low risk or above (≥71: see page 8): loading dose clopidogrel 300mg. If already on clopidogrel, give 75mg clopidogrel (NICE Guidelines 2004). Clopidogrel 75mg should continue for 12 months.

OXYGEN All patients to receive supplemental oxygen unless contraindicated. Please refer to local guidelines on oxygen therapy.

NITRATES 2 metered doses of GTN s/l spray to those with pain due to ischaemia or infarction except if hypotensive. Isosorbide dinitrate 0.05% (Isoket 25mg/50ml) 4-20ml/hr or GTN (50mg/50mls) 1-10ml/hr should be initiated if continuing pain or left ventricular failure. Use with caution if blood pressure <100 systolic. Stop if blood pressure <90 systolic.

BETA BLOCKERS Treatment with oral metoprolol 12.5mg-25mg should be considered in all haemodynamically stable patients who present within 12 h of the onset of symptoms of acute MI and who are free of contraindications. Start with metoprolol and change to oral atenolol once daily or bisoprolol once daily once stable. For haemodynamically stable ACS patients without ST elevation, start atenolol 25 mg or bisoprolol 2.5 mg once daily

ACE INHIBITORS The drug of choice is ramipril 2.5mg once daily titrated up to 10 mg. Where hypotension or heart failure is a problem, consider using divided doses (1.25mg twice a day). This is given orally to everyone, starting on day 2 unless contra-indicated. Routine ACE is contra-indicated in pregnancy. Only use under specialist supervision when BP<100mmHg systolic, K+≥5mmols or poor renal function (Creatinine ≥180 µmol/l).

STATINS Start on Day 1 for everyone. The drug of choice is simvastatin 40mg-80mg once daily Caution if alcoholic or liver disease, check baseline liver function tests.

INSULIN Insulin infusion should be started on all patients who have random Blood glucose

10mmols. Aim for blood glucose between 4-8mmols. See protocol on page 23. The insulin infusion should be stopped with great care following the instructions given. Consideration of continuation of s/c insulin therapy after discharge should be decided by the Diabetic Specialist Team in all patients with elevated blood glucose. Please refer to the diabetes team as early as possible.

FONDAPARINUX Give dose 2.5mg once daily s/c for all ACS patients. Use in caution in patients with a high bleeding risk. Consider unfractionated heparin, with dose adjusted to clotting function for patients with creatinine > 265mmols/l (NICE clinical guideline 94, March 2010).

EPLERENONE Consider starting 25mg on Days 3-14 post-MI for patients with heart failure and LVEF≤40%. Avoid if hyperkalaemia or renal impairment (eGFR < 50 mls/min).Change to spironolactone after 12 months if ongoing therapy needed.

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Abbreviations used throughout this CP ACS Acute Coronary Syndrome NSTEMI Non-ST-elevation MI

BM Blood Sugar Monitoring O2 Sats Oxygen saturation

CABG Coronary Artery Bypass Graft prn Pro Re Nata (as required)

CAD Coronary Artery Disease PCI Percutaneous Coronary Intervention

CCU Coronary Care Unit PPCI Primary Percutaneous Coronary Intervention

EofE East of England s/c Sub-cutaneous

GTN Glyceryl Trinitrate s/l Sub-lingual

ISDN Isosorbide Dinitrate STEMI ST-elevation myocardial Infarction

iv Intravenous TIMI Thrombolysis in Myocardial Infarction

LBBB Left Bundle Branch Block TTO Medication To Take Out

MI Myocardial Infarction

Cardiac sounding chest pain Perform ECG and BM and show to most senior doctor available and contact

Cardiology Nurse on Bleep 0190 at QEII or Bleep 4489 at Lister

STEMI ST elevation or new onset LBBB

Acute MI

Consider PPCI Discuss contraindications P.6

MEETS PPCI Criteria P.6

Mon-Fri 0830-1700 call

Lister ext4668

Afterhours/bank holidays

EofE ambulance Ambulance

01234 272266

Give 300mg aspirin

& 600mg clopidogrel Discuss URGENTLYwith cardiology team or medical team after

hours regarding management

YES

PPCI Follow PPCI protocol

NO

PPCI

All Other ACS

Unstable Angina, NSTEMI (ST depression, T wave inversion, or Normal

ECG with convincing story)

Mini GRACE Score all ACS patients see p8 Consider s/l GTN or iv GTN / ISDN

Consider iv morphine

repeat ECG every 30 min until changes & pain resolved

See page 9 for complete

management algorithm

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Presenting Complaint:

History of presenting complaint:

Past Medical History

(include details of prior MI, PCI, CABG, heart failure, valve disease) }

Drug History:

Social History Drug Allergies

Risk factors

Smoker Current / Ex / N

Hypertension Y/N

Diabetes Y/N

Hyperlipidemia Y/N

Family History Y/N

Renal failure Y/N

DAY OF ADMISSION (DAY 1)

Date & Time of onset of pain:

Date & Time of call for medical assistance:

Date & Time of arrival in Hospital:

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Height (m) Weight (kg) BMI Ethnic origin

Temp °C O2 Sat% BM If >10 start sliding scale- see page 23

Cardiovascular System

Pulse (rate/rhythm) BP JVP Carotid Bruits?

Apex

Heart sounds

Ankle oedema Y/N

Peripheral pulses

Respiratory System

CNS

GCS Pupils Limb power Reflexes

Impression / Differential Diagnosis

Provisional diagnosis:

Plan:

Signed: __________________________Bleep:___________Date:___/___/___ Time______

Abdomen


12 lead ECG (describe):

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PATIENT PRESENTS WITH CARDIAC SOUNDING CHEST PAIN


PPCI Indicated

Load with Aspirin 300mg Clopidogrel 600mg, Oxygen. Do not give fondaparinux. Consider Morphine, Nitrates, Beta Blockers.

Out of hours/bank holidays

Call East of England Ambulance

Service

Category A transfer

01234 27 22 66

Monday-Friday 08:30-17:00hrs

Lister Cardiac suite

Ext 4668 (dedicated phone line)

From QEII 7934668

ECG meets criteria as below:

a) ST elevation 1mm in 2 or more contiguous limb leads

or b) ST elevation 2mm in 2 or more contiguous chest leads

or c) LBBB with cardiac sounding chest pain

or d) True posterior – ST depression V2-V3 and dominant R waves

If the answer is YES then PPCI is indicated. Now assess for absolute contra-indications to PPCI

1 Is the patient unconscious? Y/ N

2 Is the patient actively bleeding e.g. haematemesis, malaena Y/ N

3 Have cardiac arrest resuscitation attempts failed? Y/N

4 Has the patient been resuscitated from a cardiac arrest but the underlying diagnosis is uncertain? Y/ N

If there are no absolute contra-indications for PPCI then go on to assess for relative contra-indications

1 Does the history or ECG suggest pericarditis, e.g. ST elevation in all leads or pain worse on deep inspiration? Y/N

2 Has the patient been involved in an incident causing traumatic bodily injury (not CPR)? Y/N

3 Does the ECG show LBBB or paced rhythm without a clinical picture of AMI? Y/ N

If the answer to any of the above contra-indications is YES then the patient may not be suitable

for PPCI. Ask for expert help for further advice.

In working hours, bleep cardio spr or call Cardiac suite Lister ext 4668

Out of hours, contact on call cardiology spr at Harefield hospital (01895 824278 bleep 108).

ACUTE ST-elevation MI (Write any comments below)

MONDAY TO FRIDAY Primary PCI AT LISTER 0830-1700 HRS ext 4468

AFTER HOURS, WEEKENDS & BANK HOLIDAYS E of E number 01234 27 22 66

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ACS: Immediate Prescription CHECKLIST for STEMI (ECG: ST Elevation or LBBB)

(This does NOT replace the drug chart!)

ALLERGIES:

Correct name bracelet applied (Please tick one)

YES NO N/A Initials…….

DRUG Dr’s

signature

Time If variance, state reason and action

taken

Aspirin 300 mg po (loading dose)

Clopidogrel 600 mg po (loading dose)

Oxygen

Morphine 2.5-10mg iv

Metoclopramide 10 mg iv prn up to

three times a day

GTN 1-2 puffs s/l prn

Consider beta-blocker

Consider iv GTN/ISDN

Insulin sliding scale (if BM>10 or

diabetic, target BM 4-8 mmols)

Paracetamol prn

Bloods taken:

FBC

Group & Save

U&E

LFTs

Lipids

Glucose

BM

Troponin ≥12h

HbA1c

TFTs

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Mini GRACE risk score Age

(y)

Score Heart

rate

(bpm)

Score Systolic

BP

(mmHg)

Score

≤30 0 ≤50 0 ≤80 58

30-39 8 50-69 3 80-99 53

40-49 25 70-89 9 100-119 43

50-59 41 90-109 15 120-139 34

60-69 58 110-149 24 140-159 24

70-79 76 150-199 38 160-199 10

80-89 91 ≥200 46 ≥200 0

≥90 100

Other variables Score

Cardiac Arrest on admission 39

ST-segment deviation 28

Elevated cardiac enzymes 14

Calculate Total Risk Score:

Score 6-month mortality Risk group

≤70 <1.6% Lowest

71-87 1.6%-3.1% Low

88-100 3.1%-5.5% Intermediate

101-111 5.5%-9.4% High

≥112 >9.5% Highest NICE clinical guideline 94, March 2010

All other ACS treatment pathway Unstable Angina, Troponin –ve ACS, NSTEMI

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risk score

≤70

risk score

71-87

risk score

88-100

risk score

101-111

Lowest Risk 6 month mortality

<1.6%

Low Risk 6 month mortality

1.6-3.1%

Intermediate Risk 6 month mortality

3.1-5.5%

High Risk 6 month mortality

5.5-9.4%

Give loading dose aspirin 300mg, then 75mg indefinitely

Give loading dose clopidogrel 300mg, then 75mg for 12 months

Give Fondaparinux 2.5mg sc od

Consider inpatient coronary angiography +/-

revascularization

Initial conservative

management

Consider inpatient coronary

angiography +/- revascularization if

ongoing ischaemia or positive ETT

risk score

≥112

Highest Risk 6 month mortality

≥ 9.5%

All other ACS treatment pathway Unstable Angina, Troponin –ve ACS, NSTEMI

ACS


Review Due May 2012

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All Other ACS Immediate Prescription CHECKLIST for Unstable Angina, NSTEMI

(This does NOT replace the drug chart!)

ECG

T wave inversion ST depression Minor ST abnormalities Normal ECG

ALLERGIES:

Correct name bracelet applied (Please tick one)

YES NO N/A Initials…….

DRUG Dr’s

signature Time If variance, state reason and action taken

Mini GRACE score calculated

Aspirin 300 mg po (loading dose)

Clopidogrel 300 mg po (loading

dose) if mini GRACE SCORE ≥ 71

Oxygen

Morphine 2.5-10mg iv

Metoclopramide 10 mg iv prn (max

three times a day)

GTN 1-2 puffs s/l (prn)

Fondaparinux 2.5mg s/c once daily

Aspirin 75 mg once daily maintenance

Clopidogrel 75 mg once daily

maintenance if mini GRACE SCORE

≥ 71

Statin

Beta-blocker

Consider iv GTN/ISDN

Insulin sliding scale (if >10 or

diabetic, target BM 4-8, see page 23)

Diamorphine/Morphine

Paracetamol prn

Bloods taken:

FBC

U&E

LFT

Lipids

Glucose

BM

Troponin ≥12h

HbA1c

TFTs


ACS


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Continuing Nursing Assessment

All categories

Initials and time If variance, state reason and

action taken

Initials

& time am pm Nocte

Take observations:

TPR, BP and O2 sats 15mins for 1

hour, ½ hourly for 2 hours then 4

hourly if stable

ECG performed on arrival to ward

Admit to CCU if bed available (STEMI and High Risk ACS)

Hourly blood glucose if on insulin

infusion

Cardiac monitoring commenced

Patient remains pain free (if recurrent pain then repeat ECG and

Analgesia)

Patient advised to report all episodes of

chest pain

Date Multidisciplinary Notes DAY 1 Initials

& time


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Date Multidisciplinary Notes Initials

& time

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DAY 2

Medical Activity (please tick as appropriate)

Time Initials If variance, state reason

and action taken

Initials

& time

Bloods: Fasting Blood glucose and Lipids Y/N

U&E Y/N

Troponin if not already done Y/N

APTT if on Heparin Y/N

HbA1c (if known diabetic or high glucose) Y/N

Medication Review:

ACE-inhibitor □ Beta-blockers □

Statins □ Insulin □

If lowest or low risk (mini GRACE risk score ≤ 87)

then consider inpatient ETT. ETT ordered Y/ N

If intermediate or higher risk (mini GRACE risk

score ≥88) or ongoing ischaemia then refer to

cardiology

Echo requested (If STEMI or CCF) Y/N

Discharge planning

Anticipated discharge date discussed with patient

and family

Potential problems and assistance required

assessed

If low-risk PPCI (Zwolle score ≤3) then aim for

discharge after 48 hrs.

Referrals

Inform diabetes/endocrinology of admission if

started on sliding scale or known diabetic

Appropriate referral made and detail on Nursing

Profile and assessment sheet

Cardiac Rehabilitation

Cardiac Rehabilitation referral


& time

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DAY 3

Medical Activity (please tick as appropriate)

Time Initials If variance, state

reason and action

taken

Initials

& time

Take bloods if appropriate

Review medication

Switch B-blocker to once daily e.g. atenolol or bisoprolol

ACE inhibitor dose: up-titration, aim for 10mg ramipril

once daily Consider eplerenone 25mg if LVEF ≤40% and heart

failure in MI patients

If lowest or low risk (mini GRACE risk score ≤ 87) then

consider inpatient ETT.

If intermediate or higher risk (mini GRACE risk score

≥88) or ongoing ischaemia then refer to cardiology

Refer to Endocrinologist/diabetes if newly diagnosed

diabetic or known diabetic not previously on Insulin

Cardiac Rehabilitation

Cardiac Rehabilitation continues

Discharge Planning

Anticipated discharge date discussed with

patient and family.

Referrals

Inform Diabetes Specialist Nurse of planned

discharge date

Seen by Diabetes Specialist Nurse

Referral made for specialist Diabetes follow

up


& time

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Date Multidisciplinary Notes DAY 4 Initials &

time

Medical Activity DAY 4 (please tick as appropriate)


and action taken

Initials

& time

Take bloods if appropriate

TTO’s written and sent to pharmacy

prn GTN aspirin Statin

ACE-inhibitor beta blocker Insulin

clopidogrel eplerenone

All to be kept on insulin post discharge unless

indicated by Diabetes Team.

Inpatient ETT ordered yes no

Echo ordered yes no

Patient mobilising around ward

Discharge Planning

Anticipated discharge date discussed with

patient and family.

Referrals

Inform Diabetes Specialist Nurse of planned

discharge date

Seen by Diabetes Specialist Nurse

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Medical /Multidisciplinary Activity DAY 5 (please tick as appropriate)


and action taken

Initials

& time

Ensure TTO is prepared and include prn GTN

Echo performed

Refer to cardiology if:

intermediate or higher risk (mini GRACE

risk score ≥88)

or ongoing ischaemia

or positive ETT

Other criteria for discharge:

Pain free for 48 hours

No heart murmurs on auscultation

No signs of heart failure

Seen by Cardiac Rehabilitation Nurse

Pre discharge ECG given to patient

Discharge Planning

Patient and relative aware

Book outpatient Echo if not done

Book nurse-led post MI/PCI clinic

Book outpatient diabetes follow up as indicated

by diabetes team

Discharge Yes No


& time

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& time

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TITAN-ACS

All patients presenting with cardiac sounding chest pain should have a BM measured AS SOON AS POSSIBLE (preferably in the ambulance, if not in A&E or Cath Lab)

IF BM 10 or higher start insulin sliding scale as follows (do NOT wait for the troponin):

50 units human soluble insulin in 49.5ml 0.9% sodium chloride

AND 5% Dextrose with 40mmol KCl at 30ml/hr via a non-reflow Y connector. If there is concern about

the volume of fluid this can be replaced by 10% dextrose with 20mmol KCL at 15ml/hr. Follow instructions on flow chart for the next 24 hours and contact DSN/Diabetes team ASAP Note1. If the patient is known diabetic on Lantus ( Glargine) or Levemir ( Detemir) Continue this background insulin AS WELL as starting insulin infusion Note2. If the patient is a known diabetic and their BM is <10 for 2 hours after admission Continue on their usual diabetes treatment regime EXCEPT

1. Stop Metformin 2. Ensure BM monitoring at least 4 hourly

Note 3. Stopping the Infusion Refer to the diabetes/endo team as soon as practically possible and they can advise on how to take down the sliding scale safely and follow up as appropriate If the infusion is due to end outside of their available times: If the patient is a known diabetic on insulin and is able to eat and drink normally they can be restarted on their usual regime until review by the diabetes team. Prescribe their usual regime and wait until their next usual dose would be due. Ensure that they receive their next due dose with that meal 1 hour BEFORE the IV insulin is switched off If the patient is NOT usually on insulin (whether previously diagnosed with diabetes or not) and is able to eat and drink normally:

1. Calculate the amount of insulin they have received in the previous 24 hours: this is TDD (total daily dose) eg 66 units

2. Divide the TDD into two separate doses and decrease by 10% eg 60 units: Dose A (0800 with breakfast ) = 60% of TDD eg 40 units

Dose B (1800 with evening meal) = 30% of TDD eg 20 units 3. Prescribe Novomix 30 as per your calculation. 4. Give the next dose subcut. with the next available meal and stop insulin /dextrose infusions one hour

LATER Other investigations required:

i) Serum K+ on admission and at 24 hours (iv insulin may lower serum K+ which may require replacement). If sustained arrhythmia K+ should be checked and recorded.

ii) HbA1c iii) Fasting glucose after an overnight fast- a minimum of 12 hours after discontinuation of the

insulin infusion

ACS

Authors: Kylie Murray & Dr Neville Kukreja, May 2010

Updated version with reference to NICE clinical guideline 94, March 2010 Review Due May 2012

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Blood Glucose Insulin infusion (mls/hr = Units/hr)

< 4 mmol 0ml: Treat hypoglycaemia according to local protocol

4.1-6.0 mmol 1ml

6.1-8.0 mmol 2ml

8.1-10.0 mmol 3ml

10.1-12.0 mmol 4ml

12.1-14.0 mmol 5ml

≥14.1 mmol 6ml: If BM ≥14.1 for 2 hours, then call doctor to increase insulin infusion rate

In obesity or known diabetic using >60 units per day: start at 3-4 ml/hr

Patient with suspected

ACS

Glucose 8 - 9.9 mmol

check glucose at 1 and 2 hours

glucose < 10 mmol

Patient excluded. If known

diabetes,See note 2.

Glucose >= 10 mmol, troponin

+ve glucose >= 10 mmol

Start insulin infusion and

fluids. Monitor

glucose hourly See Note 1.

Glucose >=

10mmol. troponin

-ve

Patient excluded from audit data but continue

infusion as per protocol.

Refer to diabetes

team

Glucose range 4-8 mmol for 2 h.

Reduce monitoring to 2 hourly

Glucose 4 - 8 mmol for 6

hours. Stop infusion. Record time.

glucose <4 mmol. Stop insulin, manage by

local protocol

Check glucose frequently until

stable 4 - 8 mmol

Check glucose at 1 and 2 h.

Restart infusion if

glucose >8 mmol

Continue infusion to 24h;

further management See note 3.

TITAN – ACS FLOWCHART

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Venous Thromboembolism (VTE) Risk Assessment for all Adult Medical Patients

ALL adult medical patients must be:

1) Risk assessed and considered for thromboprophylaxis

2) If at risk, checked for contraindications

3) Prescribed appropriate thromboprophylaxis on drug chart

NB Patients outside the given criteria should be assessed on a case-by-case basis

Please tick all appropriate boxes and assign a Risk Category. Then sign, date and file sheet in patient’s Medical Record.

Risk Factors

Age >40 years Acute infectious disease

History of VTE/thrombophilia Pregnancy and the post partum period

Inflammatory bowel disease Hormone therapy eg HRT/COCP

Active cancer or treatment Obesity (BMI≥ 30kg/m2)

Acute exacerbation of heart failure Nephrotic syndrome

Acute myocardial infarction Dehydration

Ischaemic stroke Myeloproliferative disorders

Acute on chronic respiratory disease Paraplegia

Rheumatic disease Prolonged immobility

Contraindications to Enoxaparin 40mg Contraindications to TEDS

Creatinine >150µmol/(eGFR<30ml/min)

– use Enoxaparin 20mg daily

Severe peripheral vascular disease

Active bleeding Severe dermatitis/ulceration of leg

Thrombocytopenia (platelet count <50) Leg oedema

Known bleeding disorder Gross leg deformity

Previous HIT or allergy to Enoxaparin Peripheral neuropathy

On therapeutic anticoagulation Recent skin graft

Risk Category

(1) Patient NOT at risk of VTE

Tick

(2) Patient > 40 years, hospitalised with an acute medical illness or other risk factors

and with NO contraindications to low molecular weight heparin

Recommended Prophylaxis:

Enoxaparin 40mg per day + TED stockings (if no contraindications) + Early mobilisation

Timing: Enoxaparin should be given once daily subcutaneously

Duration: Enoxaparin should be given for at least 6 days with a maximum of 14 days. Where therapy is long term (>14 days) for high risk patients the platelet count should be monitored fortnightly for Heparin Induced Thrombocytopenia (HIT)

Obesity: Use Enoxaparin: 40mg twice daily if body weight > 100kg 60mg twice daily if body weight > 150kg

(3) Patient unable to receive low molecular weight heparin due to contraindications

Recommended Prophylaxis:

TED stockings (if no contraindications) + Early mobilisation

Risk Assessment carried out by: Name: …………………………………..…….… Signature: …………....……………..…… Date: …………..……

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Date

Time

U & E’s Sodium 133-145 mmol/l

Potassium 3.6-5.2 mmol/l

Urea 3.5-10 mmol/l

Creatinine 59-104 µmol/l

eGFR

LFT Bilirubin 0-17 µmol/l

Alk Phos 30-115 IU/l

GGT 12-43 IU/l

ALT 5-55 IU/l

Albumin 35-52 g/l

Cardiac Enzymes Troponin I < 0.08

CK 24-195 IU/L

Other Calcium 2.20-2.65 mmol/l

Corrected Ca 2.0-2.65 mmol/l

Inorg Phos 0.75-1.36 mmol/l

Magnesium 0.74-1.0 mmol/l

CRP 0-5 mg/l

Amylase 12-100 IU/L

Glucose 3.5-8.0 mmol/l

HbA1c

Lactate 1.0-1.8 mmol/l

TSH 0.3-5.6 mlU/l

Free T4 7.8-14.4 pmol/l

Lipids Total Cholesterol <5.0mmols

Triglycerides 0.3-1.8 mmol/l

HDL >1.0-2.0mmols

LDL <3.0mmols

FBC WBC 4.0-11.0 10˄9/L

RBC 3.8-4.8 10˄9/L

HB 12.0-15.0 g/dL

Hct 0.36-0.46 L/L

MCV 78-101 fl

MCH 27-32 pg

MCHC 31.5-34.5 %

Platelets 150-400 10˄9/L

Coagulation Prothrombin Time 9-12 secs

APTT 23-31 secs

APTT Ratio

Fibrinogen 2.0-4.0 g/L

acute coronary syndrome (acs) - kc: … coronary syndrome (acs) care pathway includes: all patients...

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