0521779407-C03 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:54
Coronary Syndromes, Acute 411➣Contraindications
Absolute: cardiogenic shock, heart block without pacemaker,
pulmonary edema on CXR
Relative: combination therapy with beta blocker
Note: Immediate release dihydropyridine calcium antagonists
(e.g., nifedipine) are contraindicated in the absence of ade-
quate beta blockade
■Aspirin
➣Side effects: GI upset, bleeding
➣Contraindications
Absolute: significant aspirin allergy
■Clopidogrel
➣Side effects: bleeding, rash, rare neutropenia
➣Contraindications
Absolute: active pathological bleeding (ICH, PUD)
■Heparin
➣Side effects: bleeding, thrombocytopenia
➣Contraindications
Absolute: severe thrombocytopenia
■GPIIb/IIIa agents
➣Side effects: bleeding, thrombocytopenia
➣Contraindications
Absolute: severe hypertension, major surgery in past 6 weeks,
stroke within past month or any severe hemorrhagic stroke,
active significant bleeding
Relative: thrombocytopenia, renal impairment (adjust dose),
anticipated urgent major surgery
■Revascularization therapy for STEMI, immediate PCI preferred if
available immediately, otherwise consider thrombolytic therapy.
■(Thrombolytic therapy is contraindicated in the absence of STEMI,
a true posterior MI, or a presumed new LBBB)
➣For NSTEMI and UA, consider early conservative versus invasive
management
Any ACS pt without contraindication to coronary angiography
may optionally be managed invasively (within 12–24H) unless
not a candidate for revascularization
Any high risk feature should prompt strong consideration of
immediate or early invasive management
Early invasive approach is favored (TIMI-18), especially in
NSTEMI (Troponin+) or TIMI risk score >4 (www.timi.org/
files/riskscore/uacalculator.htm).