For the clinician who meets an acute coronary syndrome or a new arrhythmia a few times a year: NICE NG185, NG196, NG238, DG40 and CG95 against the AHA/ACC 2025 ACS guideline, the 2023 AHA/ACC AF guideline and the 2024 ESC AF guideline, by question; the doses; the device criteria; and the DVLA table. Doses should be confirmed against the BNF and the local protocol.
1. Acute coronary syndrome
| Question | UK | US 2025 |
|---|---|---|
| ECG | Within 10 min of first medical contact; repeat; posterior/right leads when indicated | Same; EMS transmission |
| STEMI reperfusion | PPCI if within 12 h and deliverable within 120 min of when fibrinolysis could be given; else fibrinolysis (tenecteplase) within 30 min and angiography within 24 h; PPCI beyond 12 h if ongoing ischaemia, instability or arrhythmia (NG185) | FMC-to-device ≤90 min; door-in-door-out ≤30 min for transfer; fibrinolysis if >120 min; pharmaco-invasive angiography 2–24 h |
| NSTE-ACS timing | GRACE 6-month mortality >3% → angiography within 72 h; immediate if unstable (NG185) | Intermediate/high risk → invasive during the admission; immediate for very high risk; low risk → non-invasive first or selective invasive |
| Access; imaging; completeness | Radial; complete revascularisation in multivessel STEMI without shock during the admission; culprit-only in shock | Radial; intracoronary imaging for complex lesions; complete revascularisation STEMI and NSTE-ACS; culprit-only in shock |
| Antiplatelets | Aspirin 300 then 75; ticagrelor for most, prasugrel with PCI, clopidogrel with high bleeding risk or OAC; DAPT 12 months (NG185) | DAPT loaded on arrival; prasugrel or ticagrelor preferred with PCI; 12 months, or 1–3 months then P2Y12 monotherapy with high bleeding risk (drop aspirin); with OAC, clopidogrel and early aspirin withdrawal |
| Anticoagulant | Fondaparinux 2.5 mg sc od for NSTE-ACS unless angiography <24 h or high bleeding risk; UFH in the laboratory; enoxaparin as alternative | UFH, enoxaparin or bivalirudin; continue to revascularisation |
| Oxygen; analgesia | O2 if SpO2 <94% (88–92% COPD); GTN; morphine for persisting pain | No routine O2 if SpO2 ≥90%; morphine sparingly (delays P2Y12 absorption) |
| Lipids | Atorvastatin 80 mg; NG238 target LDL ≤2.0 mmol/L or non-HDL ≤2.6; ezetimibe then PCSK9i (TA393/394) or inclisiran (TA733) by NHS thresholds; recheck 2–3 months | High-intensity statin, ezetimibe concurrently as an option; non-statin at LDL ≥1.8, reasonable 1.4–1.8; fasting panel 4–8 weeks |
| ACE inhibitor / ARB | Indefinitely; titrate; monitor U&E | Same; strongest for LVEF ≤40%, diabetes, hypertension, CKD, anterior MI |
| Beta-blocker | 12 months if LVEF preserved; indefinitely if reduced (NG185) | Within 24 h if stable; long-term with LVEF ≤40%; "may be considered" with preserved LVEF. The November 2025 IPD meta-analysis (n = 17,801): no benefit at LVEF ≥50%; benefit at 40–49% |
| MRA; SGLT2i | Eplerenone if LVEF ≤40% with HF or diabetes; SGLT2i per HF guidance | Same; EMPACT-MI and DAPA-MI neutral for routine post-MI SGLT2i |
| Colchicine | Not in NG185 | May be considered (COLCOT, LoDoCo2; CLEAR SYNERGY neutral) |
| Cardiogenic shock | Culprit PCI; inotropes/vasopressors; MCS by centre; IABP not routine | Culprit PCI; microaxial flow pump reasonable in selected AMI-CS (DanGer Shock); IABP not routine; shock team |
| Echo; monitoring; rehab | Echo before discharge; monitoring ≥24 h; cardiac rehabilitation offered to all, first contact within days | Same |
| ICD after MI | LVEF ≤35% at ≥4 weeks post-MI on OMT (TA314); ≥90 days post-revascularisation; wearable defibrillator to bridge selected patients | ≥40 days post-MI, ≥90 days post-revascularisation, LVEF ≤35%, NYHA II–III (or ≤30% NYHA I) |
2. Atrial fibrillation
| Question | UK (NG196) | ESC 2024 / AHA 2023 |
|---|---|---|
| Stroke risk | CHA2DS2-VASc: offer OAC at ≥2, consider at 1 (men); ORBIT for bleeding, to modify risk factors not to withhold | ESC: CHA2DS2-VA (no sex point), OAC at ≥2, consider at 1; AHA: annual stroke risk ≥2%; HAS-BLED/other scores to address modifiable factors |
| Agent | DOAC first line (apixaban, dabigatran, edoxaban, rivaroxaban); warfarin if DOAC contraindicated or mechanical valve / moderate–severe mitral stenosis; no aspirin for stroke prevention | Same |
| Rate control | First line: beta-blocker or diltiazem/verapamil; digoxin if sedentary or HF; combination if needed | Same; lenient targets (<110 resting) acceptable |
| Rhythm control | If symptoms persist on rate control, new-onset, reversible cause, or HF; cardioversion (anticoagulated ≥3 weeks or TOE-guided if >48 h); flecainide/sotalol/dronedarone/amiodarone by structural disease | ESC: early rhythm control within a year improves outcomes (EAST-AFNET 4); cardioversion window 24 h; wait-and-see for spontaneous conversion; AHA: early rhythm control reasonable |
| Ablation | After a failed or unsuitable antiarrhythmic; first-line reasonable in selected paroxysmal AF per TA | ESC: first-line option for paroxysmal AF (class I); AHA: first-line reasonable; both: ablation in HFrEF with AF (CASTLE-AF); repeat ablation if the first improved symptoms; uninterrupted OAC through the procedure |
| Device-detected AF | Individualised | ESC: OAC may be considered with high stroke risk and AF burden; NOAH-AFNET 6 and ARTESIA (small stroke reduction, more bleeding) |
| LAA occlusion | If OAC contraindicated (IPG349 / TA) | Same; ESC adds surgical LAA exclusion at cardiac surgery as an adjunct to OAC |
| Comorbidities | Addressed | ESC: the C in AF-CARE — weight, alcohol (abstinence RCT), sleep apnoea, hypertension, diabetes, exercise |
| After ablation, OAC | Per stroke risk, not rhythm outcome | Same |
3. Other rhythms and conduction
- SVT: modified Valsalva (REVERT); adenosine 6 mg then 12 then 18 mg rapid IV push (avoid in asthma; caution in WPW); verapamil if adenosine fails; synchronised DC if unstable; ablation as definitive therapy (success >95%).
- VT with a pulse: synchronised DC if unstable; amiodarone 300 mg IV over 20–60 min then infusion if stable; correct K+ and Mg2+; ICD assessment if not an acute reversible cause. Polymorphic VT / torsades: magnesium 2 g IV, correct QT drugs, isoprenaline or pacing.
- Bradycardia and block: atropine 500 mcg IV repeated to 3 mg; isoprenaline or adrenaline infusion; transcutaneous then transvenous pacing; Mobitz II and complete block → permanent pacemaker unless a reversible cause (inferior MI, drugs, Lyme, hyperkalaemia, hypothyroidism) resolves it; anterior MI with block → pacemaker. CRT for LVEF ≤35% with QRS ≥130 ms and LBBB; conduction-system pacing as an alternative (ESC 2021).
- Post-arrest: targeted normothermia (TTM2), coronary angiography for STEMI or a coronary cause, CMR and the ICC workup for an arrest without an acute cause; ICD for secondary prevention. The arrest itself: the resuscitation chapter.
- Long QT: QTc >480 ms repeatedly, or a Schwartz score; beta-blocker (nadolol or propranolol), the QT-drugs list, ICD for events on treatment; genotype-specific advice. Brugada: type 1 pattern spontaneous or on ajmaline; ICD after events; avoid the drugs list; treat fever. CPVT: nadolol, flecainide, sympathectomy. ARVC: exercise restriction, ICD by risk. HCM: ESC or AHA risk score for ICD; mavacamten for obstructive symptoms.
4. The unusual ones, in one table
| Condition | Deciding test | Acute management | Follow-up |
|---|---|---|---|
| Takotsubo | Angiogram without culprit; wall motion beyond one territory; CMR without LGE; InterTAK | Monitor; ACEi and beta-blocker while LVEF reduced; avoid catecholamines and QT-prolonging drugs; anticoagulate if apical thrombus | Echo 4–6 weeks; metanephrines; review drugs on recovery; rehab; recurrence 1–2%/yr |
| SCAD | Angiographic pattern; OCT/IVUS sparingly | Conservative unless unstable, LM or ongoing occlusion; aspirin; DAPT contested (DISCO); beta-blocker; no fibrinolysis; stop anticoagulation at diagnosis; observe 3–5 days | Head-to-pelvis CTA/MRA for FMD once; recurrence ~10% at 3 years; pre-conception planning; adapted rehab |
| MINOCA | CMR within weeks; intracoronary imaging; provocation testing | By cause | Statin and ACEi associated with benefit (SWEDEHEART); the cause named on the letter |
| Myocarditis | CMR (Lake Louise); EMB if severe or unexplained | Supportive; HF therapy; immunosuppression for specific forms; MCS for fulminant | No strenuous sport 3–6 months; echo 3–6 months; ICD if persistent low LVEF; ESC 2025 guideline |
| Pericarditis | Clinical + ECG + CRP + echo | NSAID or aspirin taper + colchicine 3 months; steroids only if NSAIDs contraindicated; drain tamponade | Exercise restriction until resolved; recurrence → colchicine 6 months, IL-1 blockade if refractory |
| Vasospasm / microvascular | Transient ST elevation during pain; provocation; CFR/IMR | CCB + long-acting nitrate; avoid beta-blockers in spasm; stop provocations | Rehab; risk-factor control; named diagnosis |
5. Doses
| Agent | Dose | Note |
|---|---|---|
| Aspirin | 300 mg chewed, then 75 mg od | Lifelong after type 1 MI |
| Ticagrelor | 180 mg load, 90 mg bd 12 months | Dyspnoea in ~15%; avoid with strong CYP3A4 inhibitors; not with prior ICH |
| Prasugrel | 60 mg load, 10 mg od (5 mg if <60 kg or ≥75 y) | Only with PCI; contraindicated after stroke/TIA |
| Clopidogrel | 300–600 mg load, 75 mg od | With OAC or high bleeding risk; CYP2C19 poor metabolisers respond less |
| Fondaparinux | 2.5 mg sc od | NSTE-ACS; not if CrCl <20; UFH bolus at PCI |
| Enoxaparin | 1 mg/kg sc bd (0.75 mg/kg if ≥75 y; od if CrCl <30) | With fibrinolysis: 30 mg IV bolus then 1 mg/kg (no bolus if ≥75) |
| UFH | 60–70 U/kg bolus (max 5,000) then 12–15 U/kg/h to APTT 1.5–2.5×; 70–100 U/kg at PCI | |
| Tenecteplase (STEMI) | Weight-banded single bolus: <60 kg 30 mg; 60–69 35 mg; 70–79 40 mg; 80–89 45 mg; ≥90 50 mg; half dose if ≥75 y | Not the 0.25 mg/kg stroke dose |
| Atorvastatin | 80 mg od | Ezetimibe 10 mg added if target not met |
| Ramipril | 2.5 mg → 10 mg od over weeks | U&E and K+ at each step |
| Bisoprolol | 1.25 mg → 10 mg od | Per LVEF, as section 1 |
| Eplerenone | 25 → 50 mg od | LVEF ≤40% with HF or diabetes; K+ monitoring |
| GTN | 400 mcg sublingual, two doses five minutes apart then 999; IV 1–10 mg/h | Not within 24–48 h of PDE5 inhibitors; not with RV infarction |
| Adenosine | 6 mg, then 12, then 18 mg rapid IV | Warn about the sensation; continuous ECG |
| Amiodarone | 300 mg IV over 20–60 min then 900 mg/24 h; arrest: 300 mg IV bolus after third shock | Central line preferred; oral loading for AF/VT per protocol |
| DOACs for AF | Apixaban 5 mg bd (2.5 if two of: ≥80 y, ≤60 kg, Cr ≥133); rivaroxaban 20 mg od (15 if CrCl 15–49); edoxaban 60 mg od (30 if CrCl 15–50, ≤60 kg, or P-gp inhibitor); dabigatran 150 mg bd (110 if ≥80 y or bleeding risk) | Warfarin INR 2–3 for mechanical valves, mitral stenosis, APS |
6. Driving: the DVLA table
| Event | Group 1 (car) | Group 2 (bus, lorry) |
|---|---|---|
| ACS with successful PCI, LVEF >40%, no further planned revascularisation | 1 week; no need to notify | 6 weeks, then exercise test and assessment |
| ACS otherwise, or LVEF ≤40% | 4 weeks; no need to notify unless persisting disability | 6 weeks minimum, with assessment |
| CABG | 4 weeks | 3 months |
| Elective PCI | 1 week | 6 weeks |
| Angina | Stop if symptoms at rest, with emotion or at the wheel; resume when controlled | Disqualified while symptomatic |
| Pacemaker | 1 week; notify | 6 weeks; notify |
| ICD, primary prevention | 1 month; notify | Permanent bar |
| ICD, secondary prevention / after a shock | 6 months; notify | Permanent bar |
| AF | May drive unless incapacitating symptoms; notify if so | Disqualified until controlled |
| Cardiac arrest survivor | 6 months (unless treated reversible cause) | Permanent bar, with rare exceptions |
| Syncope, unexplained | 6 months, or 12 if recurrent | 12 months |
Reference only. Local protocols, the SmPC and the BNF take precedence for dosing; the DVLA table is as the "Assessing fitness to drive" guidance read in September 2026 and changes; the class-of-recommendation labels are as the guideline summaries report them.