■ May↓infarct size and mortality in MI
■ Titrate to 10% (if normotensive) or30% (if hypertensive) BP reduction
(notto chest pain resolution).
■ Contraindications:
■ SBP<100 mmHg
■ Presence of RV infarction or severe aortic stenosis
■ Use of medications for erectile dysfunction in prior 24 hours (48 hours
with tadalafil [Cialis])—may cause cardiovascular collapse
■ Commonly causes a headache
■ -Blockers
■ Giveas early as possible.
■ Blocks sympathetic stimulation, reducing heart rate
■ ↓Myocardial O 2 consumption
■ ↓Incidence of ventricular fibrillation
■ Relative contraindications include:
■ SBP<100 mmHg
■ HR< 60
■ Left ventricular failure with pulmonary edema
■ Second- and third-degree heart block
■ Severe reactive airway disease
■ ↓Long-term mortality by 23%
■ Morphine
■ Blocks sympathetic activity and relieves anxiety, decreasing myocardial
O 2 consumption
■ Mild vasodilator, decreasing preload
■ Analgesic for intractable chest pain
■ No proven ↓in mortality
■ Contraindicated in patients with SBP <100 mmHg
■ Heparin
■ Antithrombotic agent—binds antithrombin III →inactivates thrombin
and activated factor X, decreasing clot formation and propagation
■ Synergistic effect with aspirin to ↓mortality in patients with MI or severe
unstable angina
■ Low-molecular-weight heparin
■ Similar mechanism to heparin
■ Longer half-life and more reliable effect allows for subcutaneous dosing.
■ Preferred over unfractionated heparin in UA and NSTEMI
■ Glycoprotein (GP) inhibitors IIb/IIIa
■ Abciximab (ReoPro), eptifibatide (Integrilin), and tirofiban (Aggrastat)
■ Blocks final common pathway of platelet aggregation by inhibiting the
GP IIb/IIIa receptor on platelets
■ Used primarily for patients with ACS in whom percutaneous coronary
intervention (PCI) is planned
■ Contraindications:
■ Active internal bleeding
■ Bleeding disorder <30 days prior
■ Platelet count <150,000/mm^3
■ History of intracranial hemorrhage, AVM, aneurysm, or stroke < 30
days prior
■ Major surgical procedure or trauma <30 days prior
■ Angiotensin converting enzyme (ACE) inhibitors
■ Less commonly initiated in ED
■ Reduce adverse LV remodeling
■ Decrease incidence of CHF, sudden death, and subsequent MIs
■ Proven mortality benefit for MI patients with EF <40% when adminis-
tered orally within 24 hours
CARDIOVASCULAR EMERGENCIESMorphine has not been shown
to↓mortality in ACS.Low-molecular-weight heparin
is preferred over
unfractionated heparin in
unstable angina and NSTEMI.GP IIb/IIIa inhibitors are used
for patients with ACS who are
undergoing PCI.Always ask the patient about
use of Viagra or other
phosphodiesterase inhibitors
before administering
nitroglycerin.