Unstable Angina and NSTEMIs:

Management PrinciplesMeira 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