1. The treating physician decided to start the
patient on medical management for NSTEMI.
State the required pre- and in hospital
pharmacological agents to manage the
patients
The goals of management are:
• Immediate relief of ongoing ischemia and angina
• Prevention of recurrent ischemia and angina
• Prevention of serious adverse cardiac events
2. Pre hospital management
History
suggestive of
ACS
Aspirin 300mg
stat
Sublingual GTN
• Pain management
ECG and
Biomarker
suggestive of ACS
Clopidogrel
300mg stat
• Anti-platelet,
reduce
thrombosis
ECG & cardiac
biomarker
inconclusive
Low risk pt.
• Referred as
outpatient
Intermediate
• Admitted to ward
3. Morphine
• IV 2-5mg together
with concomitant
intravenous anti-
emetic
• For pain relief
Oxygen
• Maintain SPO2 >
90%
• Increase myocardial
oxygenation
Beta Blocker
• First 24 hours - ORAL
• Metroprolol 25mg BD
Aspirin
• 300mg loading dose of
solube/chewable
aspirin
• Maintenance dose:
100mg daily enteric
coated aspirin
In hospital
management
(MOBA)
Early treatment
4. In hospital treatment
Oral Antiplatelet
agent
• Adenosine Diphosphate Receptor Antagonist
• Prasugrel – loading dose 60mg, maintenance
10mg/day
• More effective for patient with diabetes, but cannot
be given if patients weight <60kg
• Alternative, give clopidogrel 300-600mg (loading
dose), 75mg/day (maintenance dose)
Anticoagulant
• Unfractionated heparin
• IV bolus 60IU/kg (no adjustment)
• Low molecular weight heparin – Enoxaparin
• 30mg IV bolus, sc 1.0mg/kg/hour for every 12 hour
• Anti Xa inhibitor – Fondaparinux
• 2.5mg sc daily
• Anti 2a inhibitor – Bivalirudin
• 0.1mg/kg bolus & 0.25mg/kg/hour infusion
5. Anti-
ischemic
• Nitrates
• Sublingual for ongoing chest pain
• IV
• Beta-blocker
• Calcium channel blocker
• Verapamil/Diiltazem
• For patient intolerance to Beta
blocker
ACE
inhibitor/
ARB
• Not to be given to this patient
(worsening renal function)
**Our patient is classified in red box
The patient came with chest pain. The ECG and cardiac biomarker also showed the sign of ACS. Thus, a loading dose of aspirin or clopidogrel is given to patient to prevent platelet aggregation (thrombus formation).
Enteric coated not recommended for initial dosing because slow onset of action
The patient had history of DM type 2. It is best to give prasugrel according to CPG Malaysia 2011. However, the patients weight is 58kg. So need to opt. for another type of antiplatelet, clopidogrel
The patient has high creatinine clearance, indicating kidney problem (CKD). Some anticoagulant need dose adjustment according to CPG. Bivalirudin and fondaparinux seemto be associated with less bleedingthan heparin or enoxaparin.
The patient has high creatinine clearance. Thus cannot give ACE/ARB because it worsen renal function.