By Amy Sanghvi, MD
Please refer to EMRAP
Updated UA on NSTEMI guidelines.
Focused update from Guidelines from 2007.
Done to focus on new issues relative to antiplatelet medications:
Ticagralor and Prasugrel (Effient).
Many using Prasugrel instead of clopidogrel. P2Y12 receptor inhibitors.
Some patients have a genetic resistance to clopidogrel.
The new agents slightly better at preventing MI and maybe death. Also work faster than clopidogrel (Hours v 30 min.) However, slight increase in major bleeding.
Contraindications for new agents are those with prior intracranial bleed, and for Prasugrel, those with history of prior TIA or ischemic stroke.
Not to be given in the ED! Supposed to be given in the cath lab after the cardiologist decides that the patient is a candidate for a PCI and not a CABG.
Avoid using early because the guidelines do not support that!
Same benefit if given right before the PCI in the cath lab when patient is a candidate for the cath lab.
These are high risk patients in the studies, either STD or transient STE.
Everybody starts with ASA. Even if they say they have history of GI bleed or rash.
If a patient has true anaphylaxis to ASA, give clopidogrel/ticagralor.
Also, they should get a 2nd antiplatelet medication, should get clopidogrel/ticagralor. Have to decide is this patient going to get invasive or noninvasive therapy. If patient is getting invasive therapy, give 600 mg of clopidogrel or 180 mg of ticagalor. G2b3a inhibitors falling out of favor, but can give only if going to cath. If not going to cath, give 300 clopidogrel or ticagralor.
These medications do not need to be given in ED, can defer to cardiologist.
Also, give same class rating for unfractionated heparin v low molecular weight heparin v fondaparinux. Can use bivalirudin if patient is going to be treated invasively.
Both agree that unfractionated heparin may be preferable in case the patient needs a CABG.
Re: Invasive v conservative therapy. If you are at a place with no cath lab, usually you would treat and admit. Worth knowing that somebody with following criteria should be transferred to cath facility:
-NSTEMI w/ elevated troponin or new STD
-New heart failure or valvular regurgitation
-High TIMI/Grace score
Doses for these meds have not been studied for elderly patients (>70).
Clopidogrel interacts with PPIs, do not use these together, PPIs inhibit the antiplatelet effects. Use H2 blockers if patient has GI issues.
NO GOOD WAYS OF TELLING WHO WILL END UP NEEDING CABG. DO NOT FEEL PRESSURED TO GIVE THESE TO YOUR PATIENTS.