OBJECTIVE
Provide antithrombotic therapy to modify the disease process and its progression to death, MI, or recurrent MI ANNOTATION
ANNOTATION
Patients with NSTE-ACS who are at short-term intermediate- or high-risk of death or MI should be given appropriate antiplatelet therapy. The specific antiplatelet therapy recommended depends on whether the patient is to undergo prompt revascularization and whether the revascularization is via percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG).
A combination of ASA, heparin, and a platelet GP IIb/IIIa receptor antagonist represents the most comprehensive therapy. The intensity of treatment should be tailored to individual risk. Triple antithrombotic treatment (a GP IIb/IIIa inhibitor, in addition to aspirin and heparin or low molecular weight heparin) should be used in patients with continuing ischemia or with other high-risk features and in patients in whom an early invasive strategy is planned. (see Table 8) The GP IIb/IIIa antagonist may also be administered just prior to PCI. If intervention is not planned, clopidogrel should be added to aspirin, heparin and GP IIb/IIIa.
|
Low Risk Possible ACS |
Moderate
Risk |
High Risk Continuing Ischemia or Other High-Risk Features |
|||
|---|---|---|---|---|---|
No Planned Intervention |
Planned
Intervention |
||||
PCI |
CABG |
||||
| 1 | Aspirin | Aspirin | Aspirin | Aspirin | Aspirin |
| 2 | Clopidogrel | Clopidogrel | Clopidogrel |
family history of CAD |
|
| 3 | -
|
LMWH Or UFH |
LMWH Or UFH |
LMWH Or UFH |
UFH |
| 4 | -
|
- |
Platelet
GP IIb/IIIa antagonist: |
Platelet
GP IIb/IIIa antagonist: |
Platelet
GP IIb/IIIa antagonist: |
If LMWH is used during the period of initial stabilization,
the dose can be withheld on the morning of the procedure; and if an intervention
is required and more than 8 hours has elapsed since the last dose of LMWH,
UFH can be used for PCI according to usual practice patterns. Because the
anticoagulant effect of UFH can be more readily reversed than that of LMWH,
UFH is preferred in patients likely to undergo CABG within 24 h.
Aspirin |
160 mg to 325 mg. No trial has directly compared the efficacy of different doses of ASA in patients who present with UA/NSTEMI. However, trials in secondary prevention of stroke, MI, death, and graft occlusion have not shown an added benefit for ASA doses of greater than 80 and 160 mg per day but have shown a higher risk of bleeding. |
Clopidogrel |
Loading dose of 300 mg followed by 75 mg daily. In patients in whom an early noninterventional approach is planned, clopidogrel should be added to ASA as soon as possible on admission and administered for at least 1 month ) and for up to 9 months |
Abciximab |
Abciximab is bolused at 0.25 mg/kg, then infused at 0.125 mcg/kg/min (maximum of 10 mcg/min) for 18 to 24 hours, or 12 hours post-PCI. |
Enoxaparin |
Eenoxaparin is given as 1 mg/kg sq bid. A bolus of enoxaparin 30 mg IV may be given initially. Enoxaparin is preferable to UFH as an anticoagulant in patients with UA/NSTEMI, in the absence of renal failure and unless CABG is planned within 24 hours. |
UFH |
Because the anticoagulant effect of UFH can be more readily reversed than that of LMWH, UFH is preferred in patients likely to undergo CABG within 24 h. UFH is also preferred in patients with renal failure. |
Eptifibatide |
Eptifibatide is bolused at 180 mcg/kg (maximum 22.6 mg) and then infused at 2 mcg/kg/min (maximum of 15mg/hr) for up to 72 hours If a PCI is performed, the infusion is decreased to 0.5 mcg/kg/min and continued for 20 to 24 hours post-procedure. If serum creatinine is > 2.0, but <4.0 mg/dL, the bolus should be reduced to 135 mcg/kg and the infusion to 0.5 mcg/kg/min. If the serum creatinine is > 4.0, this agent should not be used. |
Tirofiban |
Tirofiban is given at 0.4 mcg/kg/min for 30 minutes, then 0.1 mcg/kg/min for 48 to 96 hours, or 12 to 24 hours post-PCI |