D. Aspirin + fondaparinux – Explanation

The NICE guidelines would advocate the use of fondaparinux in this scenario. Given the clinical
details in this case it is unlikely that angiography will be performed in the next 24 hours and hence
unfractionated heparin is not required.

Acute coronary syndrome: management
NICE produced guidelines in 2010 on the management of unstable angina and non-ST elevation
myocardial infarction (NSTEMI). They advocate managing patients based on the early risk
assessment using a recognized scoring system such as GRACE (Global Registry of Acute Cardiac
Events) to calculate a predicted 6 month mortality.

All patients should receive
– aspirin 300mg
– nitrates or morphine to relieve chest pain if required

Whilst it is common that non-hypoxic patients receive oxygen therapy there is little evidence to
support this approach. The 2008 British Thoracic Society oxygen therapy guidelines advise not
giving oxygen unless the patient is hypoxic.

Antithrombin treatment. Fondaparinux should be offered to patients who are not at a high risk of
bleeding and

who are not having angiography within the next 24 hours. If angiography is likely within 24 hours or a
patients creatinine is > 265 μmol/l unfractionated heparin should be given.

Clopidogrel 300mg should be given to patients with a predicted 6 month mortality of more than
1.5% or patients who may undergo percutaneous coronary intervention within 24 hours of admission
to hospital. Clopidogrel should be continued for 12 months.

Intravenous glycoprotein IIb/IIIa receptor antagonists (eptifibatide or tirofiban) should be given to
patients who have an intermediate or higher risk of adverse cardiovascular events (predicted 6-
month mortality above 3.0%), and who are scheduled to undergo angiography within 96 hours of
hospital admission.

Coronary angiography should be considered within 96 hours of first admission
to hospital to patients who have a predicted 6-month mortality above 3.0%. It should also be
performed as soon as possible in patients who are clinically unstable.

The table below summaries the mechanism of action of drugs commonly used in the management of
acute coronary syndrome: