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