NSTEMI/UA

Devin Welke
Mind Map by Devin Welke, updated more than 1 year ago
Devin Welke
Created by Devin Welke over 6 years ago
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Description

ACS

Resource summary

NSTEMI/UA
  1. Early Invasive
    1. Increased troponins and/or 3 TIMI risk factors
    2. Early Conservative (cath/revasc. only if ischemia recurs or is unresolved-->EI)
      1. MONA
        1. Morphine
          1. 1-4 mg IV q5-15 min prn
          2. Oxygen
            1. 4 L/min
            2. Nitrate
              1. Nitroglycerin 0.4 mg SL X 3 doses prn
                1. Alternative: 5 mcg/min infustion up to 200 mcg/min
              2. Aspirin
                1. 162-325 mg STAT (chew if not scheduled) then 75-162 mg daily FOR LIFE!
              3. Anticoagulation
                1. UFH
                  1. 60-70 units/kg bolus, then 12-15 units/kg/h infustion
                    1. aPTT q6h until therapeutic, then q12-24h
                      1. Monitor H/H and platelets
                      2. LMWH
                        1. no aPPTs
                          1. 1 mg/kg SQ q12h
                            1. q24h if CrCl <30 ml/min
                          2. Fondaparinux
                            1. no aPPTs
                              1. 2.5 mg IV then 2.5 mg SQ daily
                                1. Need supplemental UFH in PCI
                                2. Bivalirudin
                                  1. 0.75 mg/kg IV then 1.75 mg/kg/h
                                    1. 1mg/kg/h if CrCl <30 ml/min
                                    2. EI only NOT EC
                                    3. Start if + troponins or unrelieved chest pain
                                    4. Thienopyridines
                                      1. Ticlodipine
                                        1. Prasugrel
                                          1. 60 mg load then 10 mg daily
                                            1. No renal/hepatic adjustments
                                              1. Avoid concurrent NSAIDs and warfarin (if possible)
                                                1. Contraindicated if prior TIA/CVA
                                                  1. Not recommended if >75 unless diabetic or prior MI
                                                  2. Clopidogrel
                                                    1. 300-600 mg load >6 hours before PCI then 75 mg daily
                                                      1. >1 month for medically managed or BMS and >1 year for DES
                                                      2. Uses: in place of aspirin or in addition for EC/PCI (not used if CABG planned)
                                                        1. Reversible non-thienopyridine
                                                          1. Ticagrelor
                                                            1. 180 mg load then 90 mg BID
                                                              1. No hepatic activation
                                                                1. Contraindicated in intracranial bleeds, severe hepatic dysfunction, CYP 3A4 inducers, and ASA >100 mg
                                                            2. Glycoprotein IIb/IIIa Inhibitors
                                                              1. Addition to anticoagulation with EI (PCI planned)
                                                                1. If clopidogrel 300 mg load was given >6 hours prior to cath, GP not needed
                                                                2. Abciximab
                                                                  1. Irreversible
                                                                    1. PCI only
                                                                      1. Clearance: RES
                                                                      2. Eptifibatide
                                                                        1. UA/NSTEMI and elective PCI
                                                                          1. Reversible
                                                                            1. Renal (no dialysis pts.)
                                                                            2. Tirofiban
                                                                              1. Reversible
                                                                                1. UA/NSTEMI only
                                                                                  1. Renal (no dialysis pts.)
                                                                                2. Beta Blockers
                                                                                  1. Metoprolol 5 mg IV q5min X 3 doses then 25-50 mg po bid and increase as tolerated
                                                                                    1. Life long following UA/MI
                                                                                      1. Avoid acebutalol
                                                                                      2. ACEi
                                                                                        1. Use in pts. with diabetes, LVEF <40, HTN
                                                                                          1. May benefit all pts. after MI
                                                                                        2. Statins
                                                                                          1. See statin lecture
                                                                                          2. Aldosterone Blockers
                                                                                            1. Post MI with symptomatic HF, EF <40, and on ACEi and beta blocker
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