http://www.fpnotebook.com/
Acute Coronary Syndrome Adjunctive TherapyAka: MI Adjunctive Therapy
- Indications based on Immediate MI Management Protocol
- High Risk: Myocardial Infarction Protocol
- Moderate Risk: Myocardial Ischemia Protocol
- Management
- Heparin
- Preparations
- Weight based Heparin Nomogram
- Low Molecular Weight Heparin
- As effective as Heparin in non-ST Elevation ACS
- Petersen (2004) JAMA 292:89
- Continue Heparin until... (usually 24-48 hours):
- Definitive evaluation procedure or
- Revascularization performed
- Nitroglycerin Drip (IV)
- High efficacy circumstances
- Recurrent ischemia
- Large anterior Myocardial Infarction
- Congestive Heart Failure
- Hypertension
- Switch after 24 hours symptom free period
- Oral Nitroglycerin
- Transdermal Nitroglycerin
- Allow 6-8 hour drug free period
- Beta Blocker IV
- Contraindication
- Overt Congestive Heart Failure
- Second or third degree AV Block
- Hypotension
- Metoprolol (Lopressor)
- Titrate: 2.5-5 mg IV every 5 minutes
- Max dose of 15 mg OR
- Pulse under 60 OR
- Systolic Blood Pressure under 100
- Convert to Oral dose
- Step 1: 25-50 mg PO q6 hours for 48 hours
- Step 2: 50-100 mg PO bid
- ACE Inhibitor
- Contraindications
- Systolic Blood Pressure below 100 mmHg
- High efficacy circumstances
- Large anterior Myocardial Infarction
- Congestive Heart Failure
- Prior Myocardial Infarction
- Start when stable or 6 hours after event
- Glycoprotein IIB/IIIA Inhibitor Indications
- Moderate Risk Acute Coronary Syndrome Management
- Evolving Acute Coronary Syndrome
- Following coronary stent placement
- Clopidogrel (Plavix) with Aspirin
- Start in all moderate to high risk patients
- Decreasing Aspirin dose to 81 mg lowers bleeding risk
- Load Plavix at 300-600 mg and then give 75 mg daily
- Continue for 9-12 months after event
- Beneficial before Angioplasty
- Avoid if CABG imminent
- Boden (2004) Am J Cardiol 93:69
- Management: Limited use medications (use with caution)
- Lidocaine IV
- Indication: For specific arrhythmias only
- Amiodarone replaces for Ventricular Tachycardia
- Magnesium IV (if indicated for Hypomagnesemia)
- Bolus: 8 mmol IV over 5 minutes
- Maintenance: 65 mmol over 24 hours
- Transfusion (pRBC)
- Transfusion increased mortality if Hematocrit >25%
- ACS patients developing Anemia while hospitalized
- Rao (2004) JAMA 292:1555
- Initial study suggested benefit if Hematocrit <33%
- Transfusion decreased 30 day mortality
- Wu (2001) N Engl J Med 345:1230
- Management: Avoid Medications that decrease survival
- Avoid Calcium Channel Blockers (esp. Dihydropyridines)
- Avoid Antiarrhythmics
- References
- (2000) Circulation 102(suppl I):I
- Stenestrand (2001) JAMA 285:430
Navigation Tree