1.  Immediate reperfusion:  thrombolytics or PCI

2.  ASA

3.  heparin

4.  NTG

5.  BB

6.  morphine

7.  clopidogrel

8.  ACE-I (ant infarction or decreased ejection fraction)

NSTEMI and unstable angina tx

how to tell if one or other

enzymes rise >6h with NSTEMI

1.  NO lytics; perhaps PCI (invasive or conservative strategy)

2.  ASA

3.  heparin

4.  NTG

5.  BB

6.  morphine

7.  clopidogrel

8.  ACE-i

-hemorrhagic hx

-active bleeding

-known brain lesion

-known brain neoplasm

-suspect aortic dissection

-ischemic stroke w/in 3mo

-serious allergic reactions

-recent, severe GI bleed

-recent intracranial bleed

when is clopidogrel used

why are clinicians hesitant to add clopidogrel before an angiogram

-w/ PCI or stent, given prior to and for 12mo after

-during ACS/NSTEMI w/ASA

in case pt requires emergent CABG surgery (would delay), if CABG not indicated start asap

-nitroglycerin

-ASA

-ACE-I

-BB

-venodilator decreases blood return to heart- decreases preload-->decreased wall tension-->decreased O2 demand

-dilates coronary arteries, improving blood flow

-treats vasospasms causing chest pains

-treats ongoing ischemic discomfort, controls HTN, minimizes pulm congestion

HA and hypotension

STOP USE if SBP < 90, suspect RV infarct or phosphodiesterase inhibitor w/in 24-48hrs

thought to minimize ventricular remodeling via:

-vasodilatory--> decreases afterload

can be used for CAD but lack outcome evidence of BB and ACE-I

used when BB can not be used

nifedipine contraindicated

stop heparin and nitroglycerin when pain free and stable- add oral nitrates

cont. ASA, BB, ACE-I

address and treat risk factors:  smoking cessation, treat hyperlipidemia, treat HTN, manage DM