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Begin immediate treatment with pirin (ASA) in paents complications as compared with standard
treatment with
with presentations concerning for ACS. Give 16 2 mg of a UFH or LMWH in select patient populations.
� Beta-Blockers
quickly reach therapeutic blood levels. Aspirin alone Beta-blockers exhibit antiarrhythmic, anti-ischemic,
and
reduces mortality by 23 in STEM! patients. Minor con antihypertensive properties. They reduce
myocardial 0 2
traindications (remote history of peptic ulcer disease, demand via decreasing the heart rate, cardiac
aerload,
vague allergy, etc) should not preclude its use. and ventricular contractility. Current guidelines recom
Clopidogrel, prasugrel, and ticagrelor all nction to mend the initiation of treatment in all ACS patients
with
ibit platelet activation via blockade of the adenosine no contraindications (decompensated CHF,
hypotension, diphosphate (ADP) receptors and therefore work in har heart blocks, and reactive airway
disease). Metoprolol can
mony with aspirin therapy. Clopidogrel has been the most be given in 5-mg N doses every 5 minutes for
a total of extensively researched of the 3 and, therefore, is the most 3 doses or as a single 50-mg oral
dose N treatment is not commonly used. A loading dose of 600 mg is recommended required.
No loading dose is recommended patients older than Patients with STEM! require immediate repersion
75 years because of a concern for increased bleedg compli therapy with either PCI or thrombolysis. The
American College of Cardiology guidelines recommend a duration
increase in major bleeding complicaons. Although there is tion and balloon ination in those undergoing
PCI and a
a legitimate concern for excessive bleedg in patients given duration of no tion and treatment more in
than those 30 minutes between presentaundergoing thrombolysis.
AD nary artery bypass graing P-receptor antagonists who subsequently undergo coro(CABG), the denite
benet of PCI is the preferred modality owing to a decreased risk of
platelet inhibition in patients with ACS far outweighs the bleeding complications, lower incidence of
recurrent
potential concern for bleeding in the very low number of ability. ischemia and infarction, and improved
rates of survivFor patients with UA or NSTEMI, an early inva
Glycoprotein lib/Ilia inhibitors represent the third class sive approach (within 24-48 hours) utilizing PCI
reduces
of antiplatelet medications and nction by inhibiting plate the risk of death, AMI, and recurrent ACS.
Thrombolysis is not recommended for patients with either UA or
DISPOSITION
Admission
use only for patients with ACS undergoing PCI. Admit all patients with suspected ACS to a monitored bed
� Anticoagulation
risk patients including those with elevated cardiac markers,
Administer either unactionated molecular-weight heparin (LMWH) heparin (UFH) or lowin all patients
with admission to a critical care setting for early PCI. STEM!
ACS and no known conaindicat ions. ( enoxap) patients require admission to a critical care setting aer
is generally preferred given its more predictable weight appropriate repersion therapy (PCI or
thrombolysis).
� Discharge
laboratory monitoring. That said, the longer half-life and Patients at a very low risk for ACS (young
healthy patient,
lack of easy reversibity of LMWH is problematic in atypical history, normal ECG, and negative serial
cardiac
patients for whom invasive interventions are planned. markers) who remain symptom ee during an
emergency
UFH is typically recommended for patients undergoing department observation period of several hours
can be
PCI, whereas LMWH is preferred for patients with UA/ safely discharged home with early stress testing
arranged in
NSTEMI who are not undergoing emergent repersi on. the outpatient sett g.