unstable angina and nstemis: management principles meira louis lisa campfens
TRANSCRIPT
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Unstable Angina and NSTEMIs:
Management PrinciplesMeira Louis
Lisa Campfens
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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
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Evidence? Says Who?
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First, conservative or invasive?
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ASA
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Nitrates
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Morphine
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Beta Blockers: the good
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Beta Blockers: the bad
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CCB
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CCB dosing
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Ace i
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Ace i: Is more better?
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Lets talk anti-platelets...
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Plavix
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Plavix: How much?
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Prasugrel?
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Ticagrelor?
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Plato Controversy
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Plavix vs GP IIb/IIIa inhibitor
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What about adding a PPI?
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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
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Bleeding risks
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UFH
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LMWH
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Bivalirudin
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Fondaparaneux
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Discharge
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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