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CHAPTER 1
ACUTE CORONARY SYNDROME
ANTIPLATELET/ANTICOAGULANT STRATEGIES
All patients receive aspirin, P2Y12 inhibitor, and anticoagulant
ASA 162–325 mg initially / 75–100 mg daily
●Plavix 300–600 mg load / 75 mg daily
●Ticagrelor 180 mg load / 90 mg bid
•ASA maintenance dose should be no greater than 81 mg daily with ticagrelor
●Prasugrel 60 mg load / 10 mg bid
•Only given in the cath lab after decision made for PCI
•Contraindicated age > 75 or Hx CVA / TIA
●Heparin 60–80 U/kg bolus / 18 U/kg gtt goal aPTT 50–70
●Enoxaparin 1 mg/kg
●Bivalirudin
●Only used for patients not pretreated with P2Y12 inhibitor
●Eptifibatide 180 mcg/kg IV bolus over 1–2 min / 2 mcg/kg/min gtt
UA/NSTEMI—INVASIVE VS. CONSERVATIVE APPROACH
●Age > 65
●3+ cardiac RFs
•Family history of premature CAD
⚬< 55-year-old male / < 65-year-old female
•HTN
•Hyperlipidemia
•DM
•Tobacco abuse
●Known CAD (any lesion > 50%)
●ASA use in the last 7 days
●2 or more anginal episodes in preceding 24 hours
●ST segment deviation
●Elevated troponin
●≥ 3 = high risk
•Invasive strategy preferred (cath 4–24 hours after admission)
●0–2 = low risk
•Consider conservative management
UA/NSTEMI – Invasive strategy
●Coronary angiography should be 4–24 hours after admission → no difference in outcomes first 24 hours
UA/NSTEMI – Conservative strategy
●NOTE: Only difference in anticoagulation / antiplatelet strategy between invasive and conservative strategy is that prasugrel and bivalirudin are not indicated for a conservative approach
●Fondaparinux can be used as an anticoagulant (contraindicated for invasive strategy due to increased risk of catheter thrombosis)
●Duration of therapy in conservative strategy
•Heparin × 48 hours
•2B/3A inhibitor × 48 hours
•Enoxaparin / fondaparinux used duration of hospit...
