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Objectives
Objectives
Patient Case
NSTEMI
Defined as angina at rest for > 20 min without STsegment elevation, but with a rise in cardiac
markers
Pathophysiology
in myocardial oxygen supply
Thrombus formation on an atherosclerotic plaque
Abrupt
DiPiro, Joseph T. "Chapter 24. Acute Coronary Syndromes." Pharmacotherapy: A Pathophysiologic Approach. New
York, N.Y: McGraw-Hill Medical, 2011. Access Pharmacy.
http://www.accesspharmacy.com/content.aspx?aID=7972196
3.
4.
5.
6.
7.
Age 65 years
3 or more CHD risk factors: smoking, hypercholesterolemia,
hypertension, diabetes mellitus, family history of premature
CHD death/events
Known CAD (50% stenosis of at least one major coronary
artery on coronary angiogram)
Aspirin use within the past 7 days
2 or more episodes of chest discomfort within the past 24 hrs
ST-segment depression 0.5 mm
Positive biochemical marker for infarction
Antman, EM, et al. The TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication and
therapeutic decision making. JAMA. 2000 Aug 16; 284(7):835-42
Patient Case
Medium-risk
TIMI risk Score
34 points
Low-risk
TIMI risk score
02 points
DiPiro, Joseph T. "Chapter 24. Acute Coronary Syndromes." Pharmacotherapy: A Pathophysiologic Approach. New
York, N.Y: McGraw-Hill Medical, 2011. Access Pharmacy.
http://www.accesspharmacy.com/content.aspx?aID=7972196
Hoenig MR, Aroney CN, Scott IA. Early invasive versus conservative strategies for unstable angina and non-ST elevation
myocardial infarction in the stent era. Corchrane Database Syst review 2010; Mar 17; 3:CD004815.
Mahoney M, Jurkovitz CT, Chu H, et al. Cost and cost-effectiveness of an early invasive vs conservative strategy for the
treatment of unstable angina and non-ST-segment elevation myocardial infarction. JAMA 2002; 288: 1851
8185.
Kushner FG, Hand M, Smith SC Jr, et al. 2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients
with ST-Elevation Myocardial Infarction and ACC/AHA/SCAI Guidelines on Percutaneous Coronary
Intervention. 2009; 120: 22712306.
Pharmacologic Management of
NSTEMI
Antiplatelet therapy
Quantitative comparison of clopidogrel 600 mg, prasugrel and ticagrelor, against clopidogrel 300 mg on major
adverse cardiovascular events and bleeding in coronary stenting: synthesis of CURRENT-OASIS-7, TRITONTIMI-38 and PLATO. Int J Cardiol. 2012 Jul 12; 158(2): 181-5. Epub 2012 Jan 10.
Giugliano, Robert P. et al. Early versus Delayed, Provisional Eptifibatide in Acute Coronary Syndromes. N Engl J Med
2009; 360: 2176-2190
Pharmacologic Management of
NSTEMI
Anticoagulation
OR
OR
Enoxaparin vs Unfractionated Heparin in High-Risk Patients With NonST-Segment Elevation Acute Coronary
Syndromes Managed With an Intended Early Invasive Strategy. JAMA. 2004; 292(1): 45-54.
Stone GW, McLaurin BT, Cox DA, et al. Bivalirudin for patients with acute coronary syndromes. N Engl J Med 2006;
355: 2203-2216.
Pharmacologic Management of
NSTEMI
Beta blockers
Nitrates
Morphine Sulfate
DiPiro, Joseph T. "Chapter 24. Acute Coronary Syndromes." Pharmacotherapy: A Pathophysiologic Approach. New
York, N.Y: McGraw-Hill Medical, 2011. Access Pharmacy.
http://www.accesspharmacy.com/content.aspx?aID=7972196
Pharmacologic Management of
NSTEMI
ACE inhibitors
HOPE trial
o
o
Statins
BC received
Patient Case
Patient Case
Procedure
PCI
3000 units
NTG 600mcg initially, 400mcg after 30min
Bivalirudin 65mg, or 13 mL IV bolus (0.75mg/kg),
followed by continuous IV infusion of 30mL/hr
(1.75mg/kg/hr). DCd at end of procedure
STEMI
time is 90 minutes
DiPiro, Joseph T. "Chapter 24. Acute Coronary Syndromes." Pharmacotherapy: A Pathophysiologic Approach. New
York, N.Y: McGraw-Hill Medical, 2011. Access Pharmacy.
http://www.accesspharmacy.com/content.aspx?aID=7972196
(alteplase)
r-PA (retaplase)
TNK (tenecteplase)
Pharmacologic Management of
STEMI
Antiplatelet therapy
Aspirin 162-325mg chewed immediately and 81162mg continued indefinitely
Clopidogrel 300mg load for pts undergoing PCI or
receiving fibrinolytic and 75mg daily continued for at
least 14 days and up to12 months
Generally do not use GP IIb/IIIa inhibitors in the setting
of STEMI due to no improvement in outcomes and an
increased risk of bleeding
Pharmacologic Management of
NSTEMI
Anticoagulation
With
fibrinolytic
Heparin
Enoxaparin
Without
fibrinolytic
Heparin
Enoxaparin
1mg/kg Q12hrs
Pharmacologic Management of
STEMI
Beta blockers
Nitrates
Morphine Sulfate
ACE inhibitors
Statins
Dosing similar to
NSTEMI
References
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References (cont.)
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