Unstable Angina and Non-STEMI: Risk Assessment and Management Case 3

A 69-year-old man presents to the ED with a 45 minute history of retrosternal chest pain which was relieved whilst in transit to the ED. The paramedics administered aspirin and GTN. The pain was onset whilst he was washing his car. He is normally fit and well; he reports occasional dyspepsia and only receives treatment for hypertension. He has no past medical history of ischaemic heart disease but does have a positive family history. He is a smoker.

On examination he is pain-free; Pulse is 80; BP is 140/85; RR is 16 and SaO2 is 96% on air. Heart sounds are normal and his chest is clear. His ECG is initially normal. Whilst you are considering whether to place him in a “rule-out” ACS pathway he develops further pain and his ECG is shown below. Click on the ECG to enlarge.

His renal function is normal and his initial troponin is negative; you use the GRACE Score to calculate his 6 month mortality and it is 4%.

Which one of the following would be the appropriate risk category for him according to NICE Guidelines?

Which of the following interventions are recommended by NICE for this gentleman based on his GRACE risk score (choose as many as you consider appropriate)?