0521779407-C03 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:54
410 Coronary Syndromes, Acute➣Morphine IV if symptoms not relieved with nitroglycerin or if
pulmonary edema or severe agitation present
➣Beta blockade IV (metoprolol, atenolol)
➣Calcium blockade (non-dihydropyridine agents – Diltiazem or
Verapamil) if beta blocker contraindicated or ischemia persists
despite adequate beta blockade and V dysfunction or other con-
traindication not present
➣Consider ACE inhibitor therapy if pt remains hypertensive
despite beta blockade and adequate nitrate therapy
➣Consider intra-aortic balloon counterpulsation if patient refrac-
tory to medical therapy
■Anti-platelet, anticoagulation therapy
➣Aspirin po chewed STAT, then po qd (Clopidogrel if aspirin aller-
gic)
➣Clopidogrel, 300 or 600 mg po then 75 mg po qd after coronary
anatomy is shown to be “non-surgical” or if patient is not a CABG
candidate for other reasons; otherwise benefit of early use is con-
troversial (Clopidogrel use within 5–7 days of CABG increases
bleeding risk and may delay CABG)
➣Heparin, unfractionated to target PTT of 1.5–2.5X control (or
LMWH)
➣GPIIb/IIIa inhibitor added to Aspirin and Heparin if ischemia
persists or high risk features present. Eptifibatide or tirofiban
appropriate for ACS without definite plan for PCI, Reopro may
be used if PCI planned within 24 hours.Side Effects & Contraindications
■Nitrates
➣Side effects: head ache, hypotension, reflex tachycardia, tachy-
phylaxis
➣Contraindications
Absolute: recent (<24 h) Sildenafil citrate (Viagra) use
Relative: hypotension
■Beta blockers
➣Side effects: dizziness, tiredness, severe bradycardia, hypoten-
sion, rales, bronchospasm, heart block
➣Contraindications
Absolute: cardiogenic shock, severe COPD
Relative: heart rate <45, AV conduction defects, COPD
■Dihydropyridine Calcium channel blockers
➣Side effects: constipation, hypotension, heart block