Antiplatelet Therapy

been shown to be equally eective with fewer bleeding

Begin immediate treatment with pirin (ASA) in paents complications as compared with standard
treatment with

with presentations concerning for ACS. Give 16 2 mg of a UFH or LMWH in select patient populations.

non-enteric-coated version. The rst dose should be

� Beta-Blockers

crushed or chewed to improve absorption and more

quickly reach therapeutic blood levels. Aspirin alone Beta-blockers exhibit antiarrhythmic, anti-ischemic,
and

reduces mortality by 23 in STEM! patients. Minor con antihypertensive properties. They reduce
myocardial 0 2

traindications (remote history of peptic ulcer disease, demand via decreasing the heart rate, cardiac
aerload,

vague allergy, etc) should not preclude its use. and ventricular contractility. Current guidelines recom
Clopidogrel, prasugrel, and ticagrelor all nction to mend the initiation of treatment in all ACS patients
with

ibit platelet activation via blockade of the adenosine no contraindications (decompensated CHF,
hypotension, diphosphate (ADP) receptors and therefore work in har heart blocks, and reactive airway
disease). Metoprolol can

mony with aspirin therapy. Clopidogrel has been the most be given in 5-mg N doses every 5 minutes for
a total of extensively researched of the 3 and, therefore, is the most 3 doses or as a single 50-mg oral
dose N treatment is not commonly used. A loading dose of 600 mg is recommended required.

for patients with STEM! undergoing emergent PCI, whereas

a 300-mg load is recommended for patients undergoing � Reperfusion Therapy

repersion with thrombolytics and those with UNNSTEMI.

No loading dose is recommended patients older than Patients with STEM! require immediate repersion

75 years because of a concern for increased bleedg compli therapy with either PCI or thrombolysis. The
American College of Cardiology guidelines recommend a duration

cations. Both prasugrel and ticagrelor produce a more

intense platelet inhibition, but do so at e eense of an of no more than 90 minutes between patient
presenta

increase in major bleeding complicaons. Although there is tion and balloon ination in those undergoing
PCI and a

a legitimate concern for excessive bleedg in patients given duration of no tion and treatment more in
than those 30 minutes between presentaundergoing thrombolysis.

AD nary artery bypass graing P-receptor antagonists who subsequently undergo coro(CABG), the denite
benet of PCI is the preferred modality owing to a decreased risk of

platelet inhibition in patients with ACS far outweighs the bleeding complications, lower incidence of
recurrent

potential concern for bleeding in the very low number of ability. ischemia and infarction, and improved
rates of survivFor patients with UA or NSTEMI, an early inva

patients who actually require emergent CABG.

Glycoprotein lib/Ilia inhibitors represent the third class sive approach (within 24-48 hours) utilizing PCI
reduces

of antiplatelet medications and nction by inhibiting plate the risk of death, AMI, and recurrent ACS.
Thrombolysis is not recommended for patients with either UA or

let aggregation via blockade of the surce binding sites for

activated brin. There are currently 3 avaable agents in this NSTEMI.

class (abcimab, eptibatide, and tiroban ), and their use in

DISPOSITION

patients with ACS has been extensively researched. These

agents have been associated with an increase in major bleed

Admission

ing complications, and current guidelines recommend their

use only for patients with ACS undergoing PCI. Admit all patients with suspected ACS to a monitored bed

for serial ECG testing and cardiac marker analysis. High

� Anticoagulation
risk patients including those with elevated cardiac markers,

ischemic ECG changes, and reactive symptoms warrant

Administer either unactionated molecular-weight heparin (LMWH) heparin (UFH) or lowin all patients
with admission to a critical care setting for early PCI. STEM!

ACS and no known conaindicat ions. ( enoxap) patients require admission to a critical care setting aer

is generally preferred given its more predictable weight appropriate repersion therapy (PCI or
thrombolysis).

based onset of activity, reduced tendency for immune

� Discharge

mediated thrombocytopenia, and lack of requirement for

laboratory monitoring. That said, the longer half-life and Patients at a very low risk for ACS (young
healthy patient,

lack of easy reversibity of LMWH is problematic in atypical history, normal ECG, and negative serial
cardiac

patients for whom invasive interventions are planned. markers) who remain symptom ee during an
emergency

UFH is typically recommended for patients undergoing department observation period of several hours
can be

PCI, whereas LMWH is preferred for patients with UA/ safely discharged home with early stress testing
arranged in

NSTEMI who are not undergoing emergent repersi on. the outpatient sett g.