UA vs NSTEMI vs STEMI
| |
UA |
NSTEMI |
STEMI |
| Pain Duration |
Rest, >20 min |
Rest, >20 min |
Rest, >20 min |
| Pain Relieved by NTG |
Maybe |
No |
No |
| ST Elevation |
No |
No |
Yes |
| Q Waves Present |
No |
Uncommon |
Yes |
| Troponin |
Negative |
Positive |
Positive |
Shared Exam Findings
- SSx of Ventricular Dysfunction
- Variable HR
- Elevated RR
- Abnormal Heart Sounds
Universal Management of ACS
MONA Therapy
- Morphine 2-4mg IV q5-30min in increments of 2-8mg PRN
- BP and RR after each bolus
- Can consider meperidine or other opiod
- D/C all NSAIDs and avoid all NSAIDs during admission
- O2 to sat of 95% if < 90% on presentation
- SL NTG 0.4mg q5min x3, if non-responsive start IV NTG 5-10mcg/min to 75-100mcg/min (Max 200, consider 1-2min bolus of 400mcg/min to load)
- Verify NO PDEIs w/i 24-36hr
- IV Contraindicated w/ SBP < 90; > 30 mmHg change from baseline; Bradycardia or Tachycardia; Suspected RV Infarction
- Monitor BP and HR q2h while on IV
- ASA 325mg Chewed and Swallowed on presentation
- Consider anxiolytics to decrease HR and demand
- Consider Stool Softeners: Constipation and straining w/ BM can lead to subsequent MI
STEMI
If PCI is available w/i 90min at facility, or the pt can be transferred to a PCI facility w/i 120min, initiate PCI
PCI Managment
- PCI w/i 90min
- DAPT w/ ASA and Clopidogrel, Ticagrelor, or Prasugrel +/- GPIs
- Consider GPIs if Other antiplatelets are not used or during bailout for thrombotic complications
- Anticoagulate w/ UFH or IV Bivalirudin
Dosing
Antiplatelets
- ASA
- 325mg chewed and swallowed (MONA)
- 81mg QD forever
- Clopidogrel
- 600mg before PCI then 75mg QD for at least 1yr
- D/C 5d before elective CABG
- D/C 24hr before emergent CABG
- Ticagrelor
- 180mg before PCI then 90mg BID for at least 12mo
- No more than 100mg ASA QD
- D/C 5d before elective CABG
- D/C 24hr before emergent CABG
- Contraindicated in Hx of Hemorrhagic Stroke, Ischemic Stroke, PO Anticoagulant Use, Mod-Severe Liver Disease
- Reversible inhibitor, so effects are gone 12hr after D/C
- Prasugrel
- 60mg PO load then 10mg QD (5mg if ≤ 60kg) for at least 12mo
- D/C 7d before elective CABG
- Extreme caution in pts ≥ 75yo or ≤ 60kg
- Contraindicated in Hx of Hemorrhagic Stroke, Ischemic Stroke, PO Anticoagulant Use, Mod-Severe Liver Disease
- Cangrelor
- 30mcg/kg IVPB then 4mcg/kg/min for 2hr or duration of PCI (whichever is longer)
- Higher bleeding risk than Clopidogrel
- Not for use w/ PO P2Y12 Inhibitors or GPI
GPIs
- Abciximab
- 0.25 mg/kg bolus then 0.125 mcg/kg.min (Max 10) for up to 12hr after PCI
- Eptifibitide
- 180 mcg/kg/min IV bolus q10min x2 then 2 mcg/kg/min for up to 18hr after PCI
- 1 mcg/kg/min if CrCl < 50 mL/min
- Tirofiban
- 25 mcg/kg bolus then 0.15 mcg/kg/min for up to 18hr after PCI
- Reduce infusion by 50% if CrCl < 30 mL/min
Contraindications
- Active Internal Bleed, major surgery, stroke < 30d
- Hx of Hemorrhagic Stroke
- Intracranial Neoplasm
- AV Malformation
- Acute PEricarditis
- SBP > 180 or DBP > 110
- Plt < 100k
Monitoring
- SSx of Hemorrhage
- CBC: Baseline and QD
- SCr: Baseline and QD
- Plt: Baseline, 2-4hr post initiation, and QD
Anticoagulation
Do not continue after procedure w/o other indication
- UFH
- 50-70 U/kg w/ GPI (ACT 250-350s)
- 70-100 U/kg w/o GPI (ACT 200-250s)
- Enoxaparin
- Bivalirudin
- 0.75 mg/kg IVPB then 1.75 mg/kg/hr until end of PCI, can continue at 0.25 mg/kg/hr if needed
- No mortality advantage, but lower bleed risk and higher stent thrombosis risk
- Use if high risk of bleed or HIT
- Monitor SSx of bleeding; Baseline and QD SCr and CBC; Baseline aPTT, INR, and Plt
Antiplatelet Selection
- High CV Risk Pts: Prasugrel or Ticagrelor
- Unknown Coronary Anatomy or High Likelihood of CABG: Ticagrelor
- < 60kg, ≥ 75yo, or Hx of TIA: Avoid Prasugrel
- High Bleed Risk: Clopidogrel
Medical Managment
- Fibrinolysis w/i 30min (hopefully w/i 12hr of pain onset)
- DAPT w/ ASA and Clopidogrel
- Anticoagulate w/ UFH, IV and SC Enoxaparin, or IV and SC Fondaparinux
Dosing
Fibrinolytics
- SK
- 1.5million U in 50mL D5W or NS over 60min
- Can cause allergic reactions, hypotension, hemostatic defects, and intracerebral bleeds
- Do not give to a person more than once in their life
- Can only use UFH as anticoagulant, start 3-4hr after beginning of SK
- tPA
- 15mg bolus then 0.75mg/kg (Max 50mg) over 30min then 0.5 mg/kg (Max 35mg) over 60min
- Hemostatic Defect and Intracerebral bleeds
- Reteplase
- 10 U IVPB then 10 U IVPB 30min later
- Hemostatic Defect and Intracerebral bleeds
- Tenecteplase
- ≤ 60kg: 30mg IVPB
- 60-69.9kg: 35mg IVPB
- 70-79.9kg: 40mg IVPB
- 80-89.9kg: 45mg IVPB
- ≥ 90kg: 50mg IVPB
- Hemostatic Defect and Intracerebral bleeds
- Absolute CIs
- Hx of Intracranial Hemorrhage
- Structural Cerebral Vascular Lesion
- Malignant IC Neoplasm
- Ischemic Stroke w/i 3mo
- Active Internal Bleeding
- Significant Facial Trauma w/i 3mo
- SK: Past Exposure w/i 6mo
- Severe HTN refractory to treatment
- Relative CIs
- Hx Poorly Controlled HTN
- Hx of Ischemic Stroke
- Traumatic or Prolonged CPR or Major Surgery (Surgery w/i 3wks)
- Internal Bleeding (<2-4wks)
- Pregnancy
- Active Ulcers
- Current Anticoagulant Use
- > 75yo
- Monitoring
- SSx of Reperfusion
- SSx of Bleeding
- CBC: Baseline and QD
- Plt: Baseline
- INR/aPTT: Baseline
- Mental Status Q2H
Antiplatelts
- ASA
- 325mg chewed and swallowed then 81mg QD forever
- Clopidogrel
- 300mg loading dose then 75mg QD
- Minimum of 14d, up to 1yr
- D/C 5d before elective CABG
- Do not load if > 75yo
Anticoagulation
Give for at least 48hr, preferably 8d or duration of hospital stay
- UFH
- 60 U/kg IVPB (Max 4000 U) the 12 U/kg/hr (Max 1000 U/hr)
- aPTT 50-70s (1.5-2x control)
- Not for more than 48hr
- Monitor SSx of Bleeding; Baseline and QD CBC; aPTT Baseline and q6h until stable then QD; Plt Baseline then q1-3d (preferably QD); Baseline INR
- Enoxaparin
- 30mg IVPB and 1mg/kg SC Q12H (Usually max 100mg for first 2 doses)
- CrCl [10,30) 1mg/kg SC Q24H
- > 75yo 0.75 mg/kg Q12H (Max of 75mg for first 2 doses)
- Monitor SSx of Bleeding; Baseline and QD SCr and CBC; Baseline Plt, aPTT, and INR (Plt only if UFH w/i ~3mo)
- Fondaparinux
- 2.5mg IVPB then 2.5mg SC QD for up to 8d or until CABG or PCI
- Caution if CrCl 30-50 mL/min
- CI if CrCl < 30 mL/min
- Monitor SSx of Bleeding; Baseline and QD CBC and SCr; Baseline aPTT, INR, and Plt
Secondary Prevention
-
Non-ISA β-Blockers
- Metoprolol 25-50mg PO q6h or 5mg IVPB q5min x3 then PO
- Propranolol 40-80mg PO q6-8hr
- Atenolol 50-100mg PO QD or 5mg IVPB q5min x2 then PO
- Carvedilol 25-50mg PO BID
- Monitoring for PO: BP, HR, RR, 12 lead ECG, and SSx of HF q shift
- Monitoring for IV: BP, HR, RR, 12 lead ECG, and SSx of HF q5min
-
RAAS Inhibitors
| Drug |
Initial Dose |
Target Dose |
| Captopril |
6.25-12.5 mg |
50mg BID-TID |
| Lisinopril |
2.5-5mg |
10-20mg QD |
| Enalapril |
2.5-5mg |
10mg BID |
| Ramipril |
1.25-2.5mg |
5mg BID or 10mg QD |
| Trandolapril |
1mg |
4mg QD |
| Candesartan |
4-8mg |
32mg QD |
| Valsartan |
40mg |
160mg BID |
| Losartan |
12.5-25mg |
150mg QD |
| Eplerenone |
25mg |
50mg QD |
| Spironolactone |
12.5mg |
25-50mg QD |
- ACEIs to all pts w/ LVEF < 40%, DM or CKD w/o hypotension
- ACEIs / ARBs CI in Pregnancy, BRAS, hypotension
- ACEIs CI in previous angioedema
- Start ACEI or ARB w/i 24hr w/ stable BP
- Do not give IV ACEI w/i 24hr of MI
- Aldosterone Antagonists should be considered in patients w/ LVEF < 40% w/ HF SSx OR DM
- Aldosterone Antagonists should be started w/i 3-14d post MI
- Aldosterone Antagonists should not be used w/ SCr > 2.5 in men or > 2 in women (or CrCl < 30 mL/min), or w/ [K] > 5 or who are receiving a K sparing diuretic
- Aldosterone Antagonists do not require K supplementation if K > 4
- Appropriate Statin
- Magnesium if low (to prevent hypokalemia)
- Glycemic Control PRN
- DHP CCB if angina is refractory to NTG and β-blockers
NSTEMI
Ischemia Strategy vs Early Invasive
Medical therapy unless
- Failure of medical therapy
- High TIMI risk
- Myocardial ischemia on non-invasive test
- Require diagnostic coronary angiography anyway
TIMI Risk Score for NSTE-ACS
One point for each of the following:
- Age ≥ 65
- ≥ 3 risk factors
- SSx of HF
- Low SBP
- Tachycardia
- Old Age
- Elevated SCr
- Arrest on Admission
- ST-Deviation
- Elevated Troponin
- CAD
- ≥ 2 episodes of chest pain in the last 24hr
- ≥ 0.5mm ST-segment depression
- (+) Biochemical Markers
Score Evaluation
- 0-2: Low risk (Can Treat Outpatient)
- 3-4: Medium Risk (Treat Inpatient)
- 5-7: High Risk (Treat Inpatient)
Risk of Events:
- 0-1: 4.6%
- 2: 8.3%
- 3: 13.2%
- 4: 19.9%
- 5: 26.2%
- 6-7: 40.9%
Ischemia Guided Therapy
- DAPT w/ ASA and Clopidogrel or Ticagrelor
- Anticoagulation w/ UFH, SC Enoxaparin, or SC Fondaparinux
- Secondary Prevention as w/ STEMI
Dosing
- UFH
- Enoxaparin
- 1 mg/kg SC Q12H w/ typical dose adjustments
- Fondaparinux
- 2.5mg SC QD for ups to 8d
- Avoid if CrCl < 30 mL/min
Early Invasive Therapy
- DAPT w/ ASA and Clopidogrel and Ticagrelor +/- GPIs
- Anticoagulation w/ UFH, SC Enoxaparin, SC Fondaparinux, or IV Bivalirudin
- Angiography determines PCI, CABG, or medical management
Dosing
- UFH
- Enoxaparin
- 0.3 mg/kg IVPB if last dose was > 8-12hr or if less than 2 doses have been received
- Treat for 24-48hr or until end of PCI
- Bivalirudin
- 0.1 mg/kg IVPB followed by 0.25 mg/kg/hr
- For PCI second bolus of 0.5 mg/kg IVPB followed by 1.75 mg/kg/hr
- Reduce to 1 mg/kg/hr (CrCl < 30 mL/min) or 1.4 mg/kg/hr (CrCl (30,60))
- Continue PRN after PCI at 0.25 mg/kg/hr
Guidelines