Unstable Angina and NSTEMIs: Management Principles Meira Louis Lisa Campfens

Outline Pick your/cardio’s strategy Initial therapy...for everyone? Pick an anti-platelet...or two...or three... Protect the stomach??? PPI controversy Pick the right anti-coagulant Send home the lucky stable one

Evidence? Says Who?

First, conservative or invasive?

ASA

Nitrates

Morphine

Beta Blockers: the good

Beta Blockers: the bad

CCB

CCB dosing

Ace i

Ace i: Is more better?

Lets talk anti- platelets...

Plavix

Plavix: How much?

Prasugrel?

Ticagrelor?

Plato Controversy

Plavix vs GP IIb/IIIa inhibitor

What about adding a PPI?

Anti-Coagulants Indirect inhibitors of coagulation (need antithrombin for their full action) – Indirect thrombin inhibitors: UFH; LMWHs – Indirect factor Xa inhibitors: LMWHs; fondaparinux Direct inhibitors of coagulation – Direct factor Xa inhibitors: apixaban, rivaroxaban, otamixaban – Direct thrombin inhibitors (DTIs): bivalirudin, dabigatran

Bleeding risks

UFH

LMWH

Bivalirudin

Fondaparaneux

Discharge

Take Home Points Initial therapy for everyone – think ASA and nitrates – Be careful with BB, CCB, morphine – Consider ace inhibitors Pick an anti-platelet...or two...or three... – Plavix in everyone at 300mg – Talk to cardio about prasugrel or ticagrelor – Leave the GPI until they go to PCI Protect the stomach! – PPIs show more benefit than harm Pick an anti-coagulant – UFH if high risk or going to CABG – Enox or Bivalirudin if going to PCI – Fonda if conservative strategy or high risk for bleeding For the ones sent home... – ASA and Plavix for at least 1 month – Stress test within 72 hours