Acute Coronary Syndrome Adjunctive Therapy

Aka: Acute Coronary Syndrome Adjunctive Therapy, MI Adjunctive Therapy

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II. Indications: Based on Immediate MI Management Protocol

  1. High Risk: Myocardial Infarction Protocol
  2. Moderate Risk: Myocardial Ischemia Protocol

III. Management

  1. Heparin
    1. Preparations
      1. Weight based Heparin Nomogram
        1. Standard management in Acute Coronary Syndrome
      2. Low Molecular Weight Heparin
        1. As effective as Heparin in non-ST Elevation ACS
        2. Do NOT use if acute Angioplasty (PCI) is planned (discuss with cardiology first)
        3. Petersen (2004) JAMA 292:89-96 [PubMed]
    2. Continue Heparin until... (usually 24-48 hours):
      1. Definitive evaluation procedure or
      2. Revascularization performed
    3. Efficacy
      1. Heparin does not decrease overall mortality in ACS
      2. Heparin decreases the short-term (first 7-10 days) Myocardial Infarction rate by 3% (NNT 33)
        1. No difference in Myocardial Infarction rate at 30, 60 and 90 days
        2. Heparin appears to delay Myocardial Infarction to the longterm in these 3% of patients
      3. Low Molecular Weight Heparin and Unfractionated Heparin both have a 4% risk of major bleeding
        1. Major bleeding includes serious complications (Intracranial Hemorrhage, transfusion required)
      4. References
        1. Magee (2008) Cochrane Database Syst Rev (2):CD003462 [PubMed]
        2. Petersen (2004) JAMA 292(1):89-96 [PubMed]
  2. Nitroglycerin Drip (IV)
    1. High efficacy circumstances
      1. Recurrent ischemia
      2. Large anterior Myocardial Infarction
      3. Congestive Heart Failure
      4. Labile Blood Pressure or Hypertension
    2. Switch after 24 hours symptom free period
      1. Oral Nitroglycerin
      2. Transdermal Nitroglycerin
        1. Allow 6-8 hour drug free period
  3. Beta Blocker
    1. Start within 24 hours of STEMI or NSTE-ACS onset if not contraindicated
    2. Continued for 3 years after Myocardial Infarction
    3. Contraindication
      1. Overt Congestive Heart Failure, Cardiogenic Shock or low output state
      2. Second or third degree AV Block
      3. Hypotension
    4. Metoprolol (Lopressor)
      1. Titrate: 2.5-5 mg IV every 5 minutes
        1. Max dose of 15 mg OR
        2. Pulse under 60 OR
        3. Systolic Blood Pressure under 100
      2. Convert to Oral dose
        1. Step 1: Metoprolol Tartrate (Lopressor) 25-50 mg orally every 6 hours for 48 hours
        2. Step 2: Metoprolol Succinate (Toprol XL) 50-100 mg orally once daily
    5. Carvedilol (Coreg)
      1. Start: 3.125 mg orally twice daily
      2. Increase: 6.25 mg twice daily
      3. Longterm plan to titrate up to 25 mg orally twice daily
  4. ACE Inhibitor
    1. Start when stable or 6 hours after event (within first 24 hours) if not contraindicated
    2. Specific Indications
      1. Heart Failure (esp. ejection fraction <40%)
      2. Anterior STEMI
    3. Lisinopril 2.5 to 5 mg orally daily (titrating up to 10 mg orally daily)
      1. Alternative: Valsartan (Diovan) 20 mg orally twice daily (titrating up to 160 mg orally twice daily)
    4. Contraindications
      1. Systolic Blood Pressure below 100 mmHg
    5. High efficacy circumstances
      1. Large anterior Myocardial Infarction
      2. Congestive Heart Failure
      3. Prior Myocardial Infarction
  5. Platelet ADP Receptor Antagonist (e.g. Clopidogrel or Ticagrelor) WITH Aspirin
    1. Start in all moderate to high risk patients
    2. Decreasing Aspirin dose to 81 mg lowers bleeding risk
    3. See Platelet ADP Receptor Antagonist for dosing
    4. Start at loading doses prior to PCI and continue at maintenance dose for 12 months after event or stenting
      1. Example: Load Plavix at 300-600 mg and then give 75 mg daily
    5. Avoid if CABG imminent (will delay procedure by days)
    6. Boden (2004) Am J Cardiol 93:69-72 [PubMed]
  6. Statin
    1. Atorvastatin (Lipitor) 40-80 mg orally daily
    2. High dose Statin dosing is recommended in all ACS patients (even those with LDL Cholesterol <70 mg/dl)

IV. Management: Other medications

  1. Glycoprotein IIB/IIIA Inhibitor Indications
    1. Consider in Moderate Risk Acute Coronary Syndrome Management
    2. Evolving Acute Coronary Syndrome
    3. Following coronary stent placement

V. Management: Limited use medications (use with caution)

  1. Lidocaine IV
    1. Indication: For specific Arrhythmias only
    2. Amiodarone replaces for Ventricular Tachycardia
  2. Magnesium IV (if indicated for Hypomagnesemia, esp. <1.2 mg/dl)
    1. Goal Serum Magnesium 2.0 or higher
    2. Magnesium 1-2 g IV
  3. Transfusion (pRBC)
    1. Transfusion increased mortality if Hematocrit >25%
      1. ACS patients developing Anemia while hospitalized
      2. Rao (2004) JAMA 292:1555-62 [PubMed]
    2. Initial study suggested benefit if Hematocrit <33%
      1. Transfusion decreased 30 day mortality
      2. Wu (2001) N Engl J Med 345:1230-6 [PubMed]

VI. Management: Avoid Medications that decrease survival

  1. Avoid Calcium Channel Blockers (esp. Dihydropyridines)
  2. Avoid Antiarrhythmics

VII. References

  1. (2000) Circulation 102(suppl I):I172-203 [PubMed]
  2. Stenestrand (2001) JAMA 285:430-6 [PubMed]

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