NSTEMI/UA

NSTEMI/UA

Early Invasive
1. Increased troponins and/or 3 TIMI risk factors
Early Conservative (cath/revasc. only if ischemia recurs or is unresolved-->EI)
1. MONA
  1. Morphine
    1. 1-4 mg IV q5-15 min prn
  2. Oxygen
    1. 4 L/min
  3. Nitrate
    1. Nitroglycerin 0.4 mg SL X 3 doses prn
      1. Alternative: 5 mcg/min infustion up to 200 mcg/min
  4. Aspirin
    1. 162-325 mg STAT (chew if not scheduled) then 75-162 mg daily FOR LIFE!
2. Anticoagulation
  1. UFH
    1. 60-70 units/kg bolus, then 12-15 units/kg/h infustion
    2. aPTT q6h until therapeutic, then q12-24h
    3. Monitor H/H and platelets
  2. LMWH
    1. no aPPTs
    2. 1 mg/kg SQ q12h
      1. q24h if CrCl <30 ml/min
  3. Fondaparinux
    1. no aPPTs
    2. 2.5 mg IV then 2.5 mg SQ daily
    3. Need supplemental UFH in PCI
  4. Bivalirudin
    1. 0.75 mg/kg IV then 1.75 mg/kg/h
      1. 1mg/kg/h if CrCl <30 ml/min
    2. EI only NOT EC
  5. Start if + troponins or unrelieved chest pain
3. Thienopyridines
  1. Ticlodipine
  2. Prasugrel
    1. 60 mg load then 10 mg daily
    2. No renal/hepatic adjustments
    3. Avoid concurrent NSAIDs and warfarin (if possible)
    4. Contraindicated if prior TIA/CVA
    5. Not recommended if >75 unless diabetic or prior MI
  3. Clopidogrel
    1. 300-600 mg load >6 hours before PCI then 75 mg daily
    2. >1 month for medically managed or BMS and >1 year for DES
  4. Uses: in place of aspirin or in addition for EC/PCI (not used if CABG planned)
  5. Reversible non-thienopyridine
    1. Ticagrelor
      1. 180 mg load then 90 mg BID
      2. No hepatic activation
      3. Contraindicated in intracranial bleeds, severe hepatic dysfunction, CYP 3A4 inducers, and ASA >100 mg
4. Glycoprotein IIb/IIIa Inhibitors
  1. Addition to anticoagulation with EI (PCI planned)
    1. If clopidogrel 300 mg load was given >6 hours prior to cath, GP not needed
  2. Abciximab
    1. Irreversible
    2. PCI only
    3. Clearance: RES
  3. Eptifibatide
    1. UA/NSTEMI and elective PCI
    2. Reversible
    3. Renal (no dialysis pts.)
  4. Tirofiban
    1. Reversible
    2. UA/NSTEMI only
    3. Renal (no dialysis pts.)
5. Beta Blockers
  1. Metoprolol 5 mg IV q5min X 3 doses then 25-50 mg po bid and increase as tolerated
  2. Life long following UA/MI
  3. Avoid acebutalol
6. ACEi
  1. Use in pts. with diabetes, LVEF <40, HTN
    1. May benefit all pts. after MI
7. Statins
  1. See statin lecture
8. Aldosterone Blockers
  1. Post MI with symptomatic HF, EF <40, and on ACEi and beta blocker

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