Acute Coronary Syndrome Adjunctive Therapy

Aka: Acute Coronary Syndrome Adjunctive Therapy, MI Adjunctive Therapy

1. Indications based on Immediate MI Management Protocol
   1. High Risk: Myocardial Infarction Protocol
   2. Moderate Risk: Myocardial Ischemia Protocol
2. Management
   1. Heparin
      1. Preparations
         1. Weight based Heparin Nomogram
         2. Low Molecular Weight Heparin
            1. As effective as Heparin in non-ST Elevation ACS
            2. Petersen (2004) JAMA 292:89-96
      2. Continue Heparin until... (usually 24-48 hours):
         1. Definitive evaluation procedure or
         2. Revascularization performed
   2. Nitroglycerin Drip (IV)
      1. High efficacy circumstances
         1. Recurrent ischemia
         2. Large anterior Myocardial Infarction
         3. Congestive Heart Failure
         4. Hypertension
      2. Switch after 24 hours symptom free period
         1. Oral Nitroglycerin
         2. Transdermal Nitroglycerin
      3. Allow 6-8 hour drug free period
   3. Beta Blocker IV
      1. Contraindication
         1. Overt Congestive Heart Failure
         2. Second or third degree AV Block
         3. Hypotension
      2. Metoprolol (Lopressor)
         1. Titrate: 2.5-5 mg IV every 5 minutes
            1. Max dose of 15 mg OR
            2. Pulse under 60 OR
            3. Systolic Blood Pressure under 100
         2. Convert to Oral dose
            1. Step 1: 25-50 mg PO q6 hours for 48 hours
            2. Step 2: 50-100 mg PO bid
   4. ACE Inhibitor
      1. Contraindications
         1. Systolic Blood Pressure below 100 mmHg
      2. High efficacy circumstances
         1. Large anterior Myocardial Infarction
         2. Congestive Heart Failure
         3. Prior Myocardial Infarction
      3. Start when stable or 6 hours after event
   5. Glycoprotein IIB/IIIA Inhibitor Indications
      1. Moderate Risk Acute Coronary Syndrome Management
      2. Evolving Acute Coronary Syndrome
      3. Following coronary stent placement
   6. Clopidogrel (Plavix) with Aspirin
      1. Start in all moderate to high risk patients
      2. Decreasing Aspirin dose to 81 mg lowers bleeding risk
      3. Load Plavix at 300-600 mg and then give 75 mg daily
      4. Continue for 9-12 months after event
      5. Beneficial before Angioplasty
      6. Avoid if CABG imminent
      7. Boden (2004) Am J Cardiol 93:69-72
3. Management: Limited use medications (use with caution)
   1. Lidocaine IV
      1. Indication: For specific arrhythmias only
      2. Amiodarone replaces for Ventricular Tachycardia
   2. Magnesium IV (if indicated for Hypomagnesemia)
      1. Bolus: 8 mmol IV over 5 minutes
      2. Maintenance: 65 mmol over 24 hours
   3. Transfusion (pRBC)
      1. Transfusion increased mortality if Hematocrit >25%
         1. ACS patients developing Anemia while hospitalized
         2. Rao (2004) JAMA 292:1555-62
      2. Initial study suggested benefit if Hematocrit <33%
         1. Transfusion decreased 30 day mortality
         2. Wu (2001) N Engl J Med 345:1230-6
4. Management: Avoid Medications that decrease survival
   1. Avoid Calcium Channel Blockers (esp. Dihydropyridines)
   2. Avoid Antiarrhythmics
5. References
   1. (2000) Circulation 102(suppl I):I-172 to I-203
   2. Stenestrand (2001) JAMA 285:430-6