Unstable angina/ NSTEMI resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Andrea Tamayo Soto [2]; Rim Halaby, M.D. [3]

Unstable angina/ NSTEMI Resident Survival Guide Microchapters
Overview
Causes
FIRE
Diagnosis
Treatment Management Following Angiography
Pre-Discharge Care
Long Term Management
Do's
Don'ts

Overview

Unstable angina and non ST elevation myocardial infarction (NSTEMI) belong to two different ends of the spectrum of acute coronary syndrome. These conditions have a similar clinical presentation characterized by an acute onset of chest pain that starts on minimal exertion, rest or sleep, lasts at least 20 minutes (but usually less that half an hour) and, is not relieved by medications or rest. NSTEMI is differentiated from unstable angina by the presence of elevated cardiac biomarkers secondary to myocardial injury. Unstabel angina and NSTEMI might not be differentiated early following the occurrence of symptoms because cardiac biomarkers may require a few hours to rise.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Unstable angina and NSTEMI are life-threatening conditions and must be treated as such irrespective of the causes.

Common Causes

Myocardial Infarction

• Atherosclerotic plaque rupture and subsequent coronary thrombus (most common cause)
• Coronary artery spasm
• Arrhythmia
• Post-myocardial infarction
• Post-percutaneous coronary intervention
  • Abrupt closure
  • Loss of side branch
  • Distal embolization
  • Restenosis
  • Stent thrombosis
• Post-coronary artery bypass graft
  • Graft closure
  • New lesion in the graft

For a complete list of causes, click here for unstable angina and here for NSTEMI.

Ischemia-guided Strategy vs. Invasive Strategy

Invasive	Immediate invasive (within 2 hours)	Refractory angina
		Sign or symptoms of either heart failure or new/worsening mitral regurgitation
		Hemodynamic instability
		Recurrent angina or ischemia at rest or with low-level activities despite intensive pharmacologic therapy
	Early invasive (within 24 hours)	None of the requirements for immediate invasive strategy were met
		Grace score > 140
		Temporal changes in troponin level
		New/presumably new ST-segment depression
	Delayed invasive (within 25-72 hours)	None of the requirements for immediate/early invasive strategies was met
		Known history of diabetes mellitus
		Known history of renal insufficiency (defined as eGFR < 60 ml/min/1.73 m2)
		Reduced LV systolic function (LVEF < 40%)
		Early post-infarct angina
		PCI within 6 months
		History of prior CABG
		GRACE risk score 109-140 or TIMI risk score ≥ 2
Ischemia-guided strategy		None of the requirements for any of the invasive (either immediate, early, or delayed) strategies was met
		Low-risk score (e.g., TIMI [0 or 1], GRACE [<109])
		Low-risk Tn-negative female patients
		Patient or clinician preference in the absence of high-risk features

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention. The following algorithm is derived from the 2014 AHA/ACC guideline for the management of patients with Non-ST-elevation acute coronary syndromes (either unstable angina or non-ST-elevation myocardial infarction).

Boxes in the red color signify that an urgent management is needed.

Identify cardinal findings of unstable angina/ NSTEMI : ❑ Chest pain or chest discomfort ❑ Sudden-onset ❑ Located in retrosternal region ❑ Sensation of heaviness, tightness, pressure, or squeezing ❑ Duration> 10 minutes (but usually less than half an hour) ❑ Radiation to both arms, jaw, neck, back or epigastrium ❑ No relief with medications ❑ No relief with rest ❑ Progressively worsening ❑ Worse with exertion ❑ Associated symptoms of palpitations, nausea, vomiting, diaphoresis, dyspnea, abdominal pain,lightheadedness, or syncope ❑ Known personal history of CAD ❑ Family history of early CAD ❑ Known risk factors for CAD (dyslipidemia, HTN, diabetes, smoking, peripheral vascular disease) ❑ Perform a thorough cardiovascular physical examination and search for signs of myocardial ischemia, signs of HF, and signs of other non-ischemic causes of the patient's symptoms that might suggestive alternative diagnoses: ❑ Presence of S4 during cardiac auscultation ❑ Paradoxical splitting of S2 ❑ New-onset murmur suggestive of mitral regurgitation (late systolic murmur heard in mitral region) style="color:white;">NSTEMI]]

Perform diagnostic tests ❑ Perform ECG within 10 minutes of patient arrival to the ED (LOE: IC) ❑ No electrocardiographic changes. If high suspicion of ACS and normal ECG, repeat ECG every 15-30 minutes during the first hour (LOE: IC) ❑ ST-segment depression (carries the poorest prognosis) - If patient has anterior ST-segment depression indicative of true posterior MI, manage patient according to STEMI guidelines. ❑ Non specific ST / T wave changes ❑ T wave inversions ❑ Transient ST-segment elevation ❑ Findings on ECG that may mask signs of ischemia. If ANY of the following findings is present, use the Sgarbossa's criteria for the diagnosis of MI: ❑ LBBB ❑ Ventricular pacing ❑ Consider supplemental ECG leads V7 to V9 in patients whose initial ECG is non-diagnostic and who are at intermediate/high risk of ACS (LOE: IIB) ❑ Consider continuous ECG monitoring in patients whose initial ECG is non-diagnostic and who are at intermediate/high risk of ACS (LOE: IIB) ❑ Biomarkers of myocardial necrosis (either sensitive cardiac troponin assay or high-sensitivity cardiac troponin assay). Positive troponin is defined as either 1) troponin > 99th percentile of upper reference level, 2) serial increase or decrease ≥ 20% if initial value is elevated, or 3) change ≥ 3 standard deviations of variation around initial value if troponin below or close to 99th percentile ❑ Perform serial cardiac troponin (either I or T) at presentation and 3-6 hours after onset of symptoms (LOE: IA) ❑ Obtain an additional set of troponin levels if the patient had normal troponin levels on serial exam when there is an intermediate/high index of suspicion for ACS based on clinical presentation or ECG changes (LOE: IA) ❑ Consider an additional set of troponin levels on day 3-4 as a surrogate marker for infarct size and dynamics of necrosis (LOE: IIB) ❑ Biomarkers of heart failure ❑ Consider measurement of BNP or N-terminal pro-BNP to assess risk in patients with suspected ACS (LOE: IIB)

Rule out alternative life threatening diseases ❑ Aortic dissection (classical findings: back pain, interscapular pain, murmur of aortic regurgitation, pulsus paradoxus, hypotension, blood pressure discrepancy between the arms, classically > 15 mm Hg difference of SBP) ❑ Pulmonary embolism (classical findings: acute onset of dyspnea, tachycardia, tachypnea, hemoptysis, history of prior coagulopathies, such as DVT) ❑ Cardiac tamponade (classical findings: hypotension, jugular venous distention, muffled heart sounds, pulsus paradoxus) ❑ Tension pneumothorax (classical findings: sudden dyspnea, tachycardia, tachypnea,, recent history of chest trauma, unilateral absence of breath sound) ❑ Esophageal rupture (classical findings: vomiting, subcutaneous emphysema)

Assess the Patient's Prognosis ❑ Apply ANY one of the following risk scores to evaluate the patient's prognosis (LOE: IA) ❑ TIMI risk score, OR ❑ The GRACE risk score

Does the patient have any of the following (at least one is sufficient to determine that the patient has high-risk features)? ❑ High risk score (defined as either TIMI > 1 OR GRACE score > 109) ❑ Signs or symptoms of HF or new/worsening mitral regurgitation ❑ Hemodynamic instability ❑ Sustained VT or VF ❑ New or presumably new ST-segment depression ❑ Known history of diabetes mellitus ❑ Known history of renal insufficiency (defined as eGFR < 60 min/min/1.72 m2) ❑ Reduced LV systolic function (LVEF < 40%) ❑ Recent PCI within 6 months ❑ History of prior CABG

No. The patient does NOT have ANY of the above high risk features.

Yes. The patient has at least one of the above high risk features

Follow an ischemia-guided strategy ❑ Administer dual antiplatelet therapy to all patients with NSTE ACS (aspirin plus only one P2Y12) ❑ Administer non-enteric-coated chewable aspirin PO 162-325 mg to all patients who have no contraindications to aspirin therapy as soon as possible following presentation (LOE: IA). Continue aspirin indefinitely at a maintenance dose of 81-162 mg daily (usually 81 mg preferred for maintenance dose, especially when co-administered with ticagrelor). Do not administer aspirin to patients who cannot tolerate aspirin (either hypersensitivity or GI distress). ❑ Administer a P2Y12 inhibitor (either clopidogrel or ticagrelor) for up to 12 months to NSTE ACS patients to patients with NSTE ACS (without contraindications) with either early invasive or ischemia-guided strategy. ❑ Ticagrelor: Loading dose of ticagrelor PO 180 mg followed by maintenance dose of ticagrelor 80 mg twice daily (LOE: IB) (preferred over clopidogrel for NSTE ACS patients who undergo early invasive or ischemia-guided strategy) (LOE: IIB) ❑ Clopidogrel: Loading dose of clopidogrel PO 300-600 mg followed by maintenance dose of clopidogrel 75 mg once daily (LOE: IB), OR ❑ Titrate oxygen via nasal cannula to SpO2 > 90% for patients with saturation <90%, respiratory distress, or other high-risk features of hypoxemia (LOE: IC) Caution in COPD patients: maintain an oxygen saturation between 88% and 92%. ❑ Administer nitroglycerin ❑ Administer sublingual nitroglycerin (0.3 to 0.4 mg, every 5 minutes for a total of 3 doses) then assess for further need to IV nitroglycerin (LOE: IC) ❑ Administer IV nitroglycerin in case of persistent chest pain despite PO nitroglycerin, heart failure, or hypertension (LOE: IB): 10 mcg/min, increase by 10 mcg/min every 3 to 5 minutes until symptom relief; in case no response at 20 mcg/min, increase by 10 microgram/minute and then by 20 microgram/minute ❑ Hold nitroglycerin is SBP < 100 mm Hg Contraindicated in suspected right ventricular MI, recent use of phosphodiesterase inhibitors (24 hours of sildenafil or vardenafil use or 48 hours of tadalafil use), decreased blood pressure 30 mmHg below baseline ❑ Administer ANY of the following PO beta-blockers (unless contraindicated) within 24 hours of ischemia and titrate to the heart rate and blood pressure (LOE: IA) Beta blocker is contraindicated in unstable/decompensated heart failure, low output states (bradycardia or hypotension), in patients at high risk of cardiogenic shock (defined as either old age > 70 years, HR > 110 bpm, SBP < 120 mm Hg, or late presentation), prolonged PR interval > 0.24 s, 2nd/3rd degree heart block without pacemaker, or active asthma/reactive airway disease. Reassess the patient's condition frequently to re-evaluate the eligibility of beta-blockage therapy (LOE: IC). ❑ Metoprolol succinate, OR PO: 50-200 mg twice daily ❑ Carvedilol, OR PO: 6.25 mg twice daily. Maximum dose 25 mg twice daily ❑ Bisoprolol PO: 5 mg once daily ❑ Consider PO non-dihydropyridine CCB (either verapamil or diltiazem) only if patients either cannot tolerate beta blockers, are allergic to beta blockers, or were administered beta blockers plus nitrates and have recurrent ischemia (LOE: IIC) ❑ Verapamil PO: 80-120 mg orally 3 times a day, OR ❑ Diltiazem PO: 30 to 60 mg orally 3 to 4 times a day ❑ Administer IV morphine if persistent symptoms (LOE: IIB) or pulmonary edema ❑ Initially, administer morphine IV 1-5 mg and monitor BP ❑ Add morphine IV 2-8 mg every 5 to 30 minutes, as needed ❑ Monitor for any adverse effects of morphine therapy, including hypotension, respiratory depression, nausea/vomiting. Administer naloxone o.4 mg to 2 mg IV if morphine therapy is associated with respiratory of circulatory depression ❑ Administer ANY of the following high-intensity statins to patients who have co contraindications to statin therapy (LOE: IA) ❑ Atorvastatin PO: 40-80 mg once daily ❑ Rosuvastatin PO: 20-40 mg once daily ❑ Administer ANY of the following anticoagulation therapies for all patients regardless of initial treatment strategy ❑ Enoxaparin 1 mg/kg subcutaneously twice daily from presentation until time of PCI or discharge (if no PCI is performed) (LOE: IA). Reduce the dose to 1 mg/kg subcutaneously once daily for patients with CrCl < 30 mL/min, OR ❑ Fondaparinux: 2.5 mg subcutaneously once daily continued for the duration of hospitalization or until PCI or discharge (if no PCI is performed) (LOE: IIB). If PCI is performed while the patient is on fondaparinux, add either UFH or bivalirudin to fondaparinux because of increased risk of catheter thrombosis (LOE: IB), OR ❑ Unfractionated hepatin (UFH) IV: Administer loading dose 60 IU/kg (maximum 4,000 IU) with initial infusion of 12 IU/kg/hour (maximum 1,000 IU/hour) adjusted per aPTT to maintain a therapeutic range per hospital protocol. Continue UFH for 48 hours or until PCI is performed (LOE: IB)

Follow an invasive strategy ❑ Administer dual antiplatelet therapy to all patients with NSTE ACS (aspirin plus only one P2Y12) ❑ Administer non-enteric-coated chewable aspirin PO 162-325 mg to all patients who have no contraindications to aspirin therapy as soon as possible following presentation (LOE: IA). Continue aspirin indefinitely at a maintenance dose of 81-162 mg daily (usually 81 mg preferred for maintenance dose, especially when co-administered with ticagrelor). Do not administer aspirin to patients who cannot tolerate aspirin (either hypersensitivity or GI distress). ❑ Administer a P2Y12 inhibitor (either clopidogrel or ticagrelor) for up to 12 months to NSTE ACS patients to patients with NSTE ACS (without contraindications) with either early invasive or ischemia-guided strategy. ❑ Ticagrelor: Loading dose of ticagrelor PO 180 mg followed by maintenance dose of ticagrelor 80 mg twice daily (LOE: IB) (preferred over clopidogrel for NSTE ACS patients who undergo early invasive or ischemia-guided strategy) (LOE: IIB) ❑ Clopidogrel: Loading dose of clopidogrel PO 300-600 mg followed by maintenance dose of clopidogrel 75 mg once daily (LOE: IB), OR ❑ Titrate oxygen via nasal cannula to SpO2 > 90% for patients with saturation <90%, respiratory distress, or other high-risk features of hypoxemia (LOE: IC) Caution in COPD patients: maintain an oxygen saturation between 88% and 92%. ❑ Administer nitroglycerin ❑ Administer sublingual nitroglycerin (0.3 to 0.4 mg, every 5 minutes for a total of 3 doses) then assess for further need to IV nitroglycerin (LOE: IC) ❑ Administer IV nitroglyerin in case of persistent chest pain despite PO nitroglycerin, heart failure, or hypertenion (LOE: IB): 10 mcg/min, increase by 10 mcg/min every 3 to 5 minutes until symptom relief; in case no response at 20 mcg/min, increase by 10 mcg/min and then by 20 mcg/min ❑ Hold nitroglycerin is SBP < 100 mm Hg Contraindicated in suspected right ventricular MI, recent use of phosphodiesterase inhibitors (24 hours of sildenafil or vardenafil use or 48 hours of tadalafil use), decreased blood pressure 30 mmHg below baseline ❑ Administer ANY of the following PO beta-blockers (unless contraindicated) within 24 hours of ischemia and titrate to the heart rate and blood pressure (LOE: IA) Beta blocker is contraindicated in unstable/decompensated heart failure, low output states (bradycardia or hypotension), in patients at high risk of cardiogenic shock (defined as either old age > 70 years, HR > 110 bpm, SBP < 120 mm Hg, or late presentation), prolonged PR interval > 0.24 s, 2nd/3rd degree heart block without pacemaker, or active asthma/reactive airway disease. Reassess the patient's condition frequently to re-evaluate the eligibility of beta-blockage therapy (LOE: IC). ❑ Metoprolol succinate, OR PO: 50-200 mg twice daily ❑ Carvedilol, OR PO: 6.25 mg twice daily. Maximum dose 25 mg twice daily ❑ Bisoprolol PO: 5 mg once daily ❑ Consider PO non-dihydropyridine CCB (either verapamil or diltiazem) only if patients either cannot tolerate beta blockers, are allergic to beta blockers, or were administered beta blockers plus nitrates and have recurrent ischemia (LOE: IIC) ❑ Verapamil PO: 80-120 mg orally 3 times a day, OR ❑ Diltiazem PO: 30 to 60 mg orally 3 to 4 times a day ❑ Administer IV morphine if persistent symptoms (LOE: IIB) or pulmonary edema ❑ Initially, administer morphine IV 1-5 mg and monitor BP ❑ Add morphine IV 2-8 mg every 5 to 30 minutes, as needed ❑ Monitor for any adverse effects of morphine therapy, including hypotension, respiratory depression, nausea/vomiting. Administer naloxone o.4 mg to 2 mg IV if morphine therapy is associated with respiratory of circulatory depression ❑ Administer ANY of the following high-intensity statins to patients who have co contraindications to statin therapy (LOE: IA) ❑ Atorvastatin PO: 40-80 mg once daily ❑ Rosuvastatin PO: 20-40 mg once daily ❑ Administer ANY of the following anticoagulation therapies for all patients regardless of initial treatment strategy ❑ Enoxaparin 1 mg/kg subcutaneously twice daily from presentation until time of PCI or discharge (if no PCI is performed) (LOE: IA). Reduce the dose to 1 mg/kg subcutaneously once daily for patients with CrCl < 30 mL/min, OR ❑ Bivalirudin may only be used for patients with early invasive strategy. Loading dose bivalirudin 0.1 mg/kg loading followed by bivalirudin 0.25 mg/kg/hour until PCI (LOE: IB), OR ❑ Fondaparinux: 2.5 mg subcutaneously once daily continued for the duration of hospitalization or until PCI or discharge (if no PCI is performed) (LOE: IIB). If PCI is performed while the patient is on fondaparinux, add either UFH or bivalirudin to fondaparinux because of increased risk of catheter thrombosis (LOE: IB), OR ❑ Unfractionated hepatin (UFH) IV: Administer loading dose 60 IU/kg (maximum 4,000 IU) with initial infusion of 12 IU/kg/hour (maximum 1,000 IU/hour) adjusted per aPTT to maintain a therapeutic range per hospital protocol. Continue UFH for 48 hours or until PCI is performed (LOE: IB) ❑ Consider administration of GP IIb/IIIa in addition to dual antiplatelet therapy in high-risk (e.g. troponin positive) patients (LOE: IIB) ❑ Eptifibatide IV: Loading dose 180 microgram/kg bolus followed by a maintenance dose of 2 microgram/kg/minute ❑ Tirofiban IV: Loading dose 0.1 microgram/kg bolus followed by maintenance infusion of 0.1 microgram/kg/minute

Does the patient meet ANY of the following criteria to transfer to invasive strategy? ❑ Refractory angina, OR ❑ Angina at rest or with minimal activity, OR ❑ Objective evidence of ischemia (dynamic ECG changes or myocardial perfusion defect) by non-invasive testing, OR ❑ Presence of high prognostic risk (high TIMI or high GRACE score)

No

Yes

Proceed to complete diagnostic approach

Proceed to revascularization therapy

Complete Diagnostic Approach

A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.

Abbreviations: CABG: coronary artery bypass graft; ECG: electrocardiogram; LAD: left anterior descending; LBBB: left bundle branch block; MI: myocardial infarction; PCI: percutaneous coronary intervention; S3: third heart sound; S4: fourth heart sound; VSD: ventricular septal defect

Characterize the symptoms: ❑ Chest pain or chest discomfort ❑ Sudden onset ❑ Sensation of heaviness, tightness, pressure, or squeezing ❑ Duration> 20 minutes ❑ Radiation to the left arm, jaw, neck, right arm, back or epigastrium ❑ No relief with rest ❑ Worse with time ❑ Worse with exertion ❑ Dyspnea ❑ Weakness ❑ Palpitations ❑ Nausea ❑ Vomiting ❑ Sweating ❑ Loss of consciousness ❑ Fatigue
Obtain a detailed history: ❑ Age ❑ Baseline blood pressure ❑ Previous episodes of chest pain ❑ Previous PCI or CABG ❑ Cardiac risk factors ❑ Hypertension ❑ Diabetes ❑ Hypercholesterolemia ❑ Smoking ❑ Obesity ❑ List of medications ❑ Family history of premature coronary artery disease Identify possible triggers: ❑ Physical exertion ❑ Air pollution or fine particulate matter ❑ Antecedant infection ❑ Heavy meal ❑ Cocaine ❑ Marijuana
Examine the patient: Vital signs ❑ Blood pressure ❑ Blood pressure lower than baseline, suggestive of: ❑ Discrepancy between arms (suggestive of aortic dissection) ❑ Narrow pulse pressure (suggestive of heart failure) ❑ Heart rate ❑ Tachycardia (suggestive of heart failure) ❑ Bradycardia (suggestive of heart block or bradyarrhythmias) Pulses ❑ Femoral pulse (if a patient is to undergo PCI) ❑ Strength ❑ Bruits Skin ❑ Xanthelasma (suggestive of dyslipidemia) ❑ Xanthoma (suggestive of dyslipidemia) ❑ Edema (suggestive of heart failure) ❑ Cyanotic and cold skin, lips, nail bed (suggestive of cardiogenic shock) Heart ❑ Heart sounds ❑ S3 (suggestive of heart failure) ❑ S4 (associated with conditions that increase the stiffness of the ventricle) ❑ Murmurs ❑ Aortic regurgitation: early diastolic high-pitched sound best heard at the left sternal border (suggestive of aortic dissection with propagation to the aortic arch) ❑ Pericardial friction rub (suggestive of pericarditis) Lungs ❑ Rales (suggestive of heart failure)
Order labs and tests: ❑ EKG ❑ Biomarkers ❑ Troponin I ❑ CK-MB ❑ Echocardiography ❑ Creatinine ❑ Glucose ❑ Hemoglobin ❑ Multislice CT coronary imaging (rule out CAD as cause of pain in patients with low to intermediate likelihood of CAD and when troponin and ECG are inconclusive) ❑ MRI (integrate imaging of function, perfusion and necrosis)

Revascularization Therapy

Confirmed NSTE ACS (either unstable angina or NSTEMI)

Ischemia-guided strategy

Early invasive strategy

Was pharmacologic therapy for ischemia-guided strategy effective? If the patient has ANY of the following findings, pharmacologic therapy is considered ineffective: ❑ Refractory angina, OR ❑ Angina at rest or with minimal activity, OR ❑ Objective evidence of ischemia (dynamic ECG changes or myocardial perfusion defect) by non-invasive testing, OR ❑ Presence of high prognostic risk (either high TIMI risk score > 1 or high GRACE score > 109)

Yes. Pharmacologic therapy was effective

No. Pharmacologic therapy was not effective

Proceed to pre-discharge care

PCI with stenting

CABG

Continue the following drugs ❑ Continue aspirin (LOE: IA) ❑ Continue P2Y12 inhibitor (either clopidogrel or ticagrelor) in addition to aspirin (LOE: IB) ❑ Continue anticoagulant (either UFH (LOE: IB), enoxaparin (LOE: IA), or fondaparinux (LOE: IB)) ❑ Continue GPIIb/IIIa only among patients with high risk features (with adequate clopidogrel pretreatment (LOE: IA) or without adequate clopidogrel pretreatment (LOE: IIB) who were not treated with bivalirudin at the time of PCI

Continue the following drugs ❑ Continue aspirin (LOE: IA)

Discontinue the following drugs ❑ Discontinue P2Y12 inhibitor (either clopidogrel or ticagrelor) 5 days before elective CABG / up to 24 hours in case of urgent CABG (LOE: IB) ❑ Discontinue prasugrel 7 days before elective CABG / before 7 days in case of urgent CABG ❑ Discontinue eptifibatide/tirofiban at least 2-4 hours before CABG (LOE: IB) ❑ Discontinue abciximab at least 12 hours before CABG (LOE: IB)

Proceed to pre-discharge care

Pre-Discharge Care

Abbreviations: ACE: angiotensin converting enzyme; LVEF: left ventricular ejection fraction; PCI: percutaneous coronary intervention; PO: per os; VF: ventricular fibrillation; VT: ventricular tachycardia

Administer the following medications in patients without contraindications: ❑ Aspirin 81-325 mg (indefinitely) (I-A) Among patients with either GI intolerance or hypersensitivity to aspirin, administer a loading dose followed by maintenance dose of either clopidogrel 75 mg OD (I-B), OR prasugrel 10 mg OD (only in PCI patients) (I-C), OR ticagrelor 90 mg BID (I-C) ❑ Beta blockers Contraindicated in heart failure, prolonged or high degree AV block, reactive airway disease, high risk of cardiogenic shock and low cardiac output state :❑ Metoprolol tartrate ❑ Begin with 25 to 50 mg PO every 6 to 12 hour ❑ Then, metoprolol tartrate twice daily or metoprolol succinate once daily for 2-3 days ❑ Titate to 200 mg daily, OR ❑ Carvedilol ❑ Begin with 6.25 mg twice daily ❑ Titrate to 25 mg twice daily ❑ Calcium channel blockers are used as anti-ischemic or antihypertensive drugs and also in atrial fibrillation when beta blockers are contraindicated Contraindicated in heart failure and left ventricular dysfunction ❑ ACE inhibitors and ARBs may also be considered in selected patients (no enough information) Contraindicated in hypotension, renal failure and hyperkalemia ❑ Atorvastatin 80 mg daily Administer ONE of the following antiplatelet therapy for a duration of: Up to 12 months in medically treated with no stenting (I-B) Up to 12 months in BMS (I-B) At least 12 months in DES (I-B) ❑ Clopidogrel 75 mg daily, OR ❑ Ticagrelor 90 mg twice a day, OR ❑ Prasugrel 10 mg daily only for patients who underwent PCI Consider earlier discontinuation in case bleeding risk exceeds benefit of the antiplatelet therapy (I-C). Assess the patient for ischemia: ❑ Perform non invasive testing before discharge for the evaluation of ischemia among patients who did not undergo coronary angiography and in whom coronary angiography is not warranted due to the absence of high risk features (Class I, level of evidence B) ❑ Assess the LVEF (Class I, level of evidence C)

Abbreviations: ACE: angiotensin converting enzyme; ARB: angiotensin receptor blocker;

❑ Prepare a list of all the home medications and educate the patient about compliance ❑ Aspirin 81-325 mg (indefinitely) ❑ Antiplatelet therapy ❑ Beta blockers ❑ ACE inhibitors or ARB (only in selected patients ❑ Atorvastatin 80 mg daily ❑ Encourage lifestyle modification ❑ Smoking cessation ❑ Physical activity ❑ Dietary changes ❑ Ensure the initiation of the management of comorbidities ❑ Obesity ❑ Dyslipidemia ❑ Hypertension ❑ Diabetes ❑ Heart failure ❑ Educate the patient about the early recognition of symptoms of acute coronary syndrome ❑ Educate the patient about the use of nitroglycerin 0.4 mg, sublingually, up to 3 doses every 5 minutes

Do's

• Administer a loading dose followed by a maintenance dose of clopidogrel, ticagrelor or prasugrel (if PCI is planned) as initial treatment instead of aspirin among patients with gastrointestinal intolerance or hypersensitivity reaction to aspirin.

• Administer sublingual nitroglycerin in patients with ischemic chest pain; however, administer IV nitroglycerin among patients with persistent chest pain after three sublingual nitroglycerin.

• Discontinue NSAID drugs immediately.

• If fondaparinux is chosen to be administered ad the anticoagulant therapy during PCI, co-administer another antocoagulant with factor IIa activity such as UFH.

Don'ts

• Do not administer IV GP IIb/IIIa inhibitors to patients with low risk of ischemic events or at high risk of bleeding and who are already on aspirin and P2Y12 receptor inhibitors therapy.

• Do not administer prasugrel among patients with prior history of strokes or TIAs.

• Do not administer IV beta-blockers among hemodynamically unstable patients.

• Do not administer a complete dose of prasugrel among patients under 60kg (132lbs) due to high exposure to the active metabolite. They should receive half the dose of prasugrel although there is no evidence that half the dose is as effective as a complete dose.

• Do not administer fibrinolytic therapy to patients with unstable angina.

• Do not administer abciximab for patients not scheduled for PCI.

• Do not administer 2 P2Y12 receptor inhibitors, even in the presence of hypersensitivity or GI interoperability to aspirin.

References

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