Early Pharmacotherapy for Nste Acss

In general, early pharmacotherapy of NSTE ACS (Fig. 8-3) is similar to that of STE ACS with three exceptions: (a) fibri-nolytic therapy is not administered; (b) glycopro-tein IIb/IIIa receptor inhibitors are administered to high-risk patients for medical therapy as well as to PCI patients; and (c) at this time, there are no standard quality performance measures for patients with NSTE ACS who are not diagnosed with MI.

According to the ACC/AHA NSTE ACS practice guidelines, in the absence of contraindications, early pharmacotherapy of NSTE ACS should include intranasal oxygen (if oxygen saturation is low), SL NTG followed by IVNTG in selected patients, ASA, clopidogrel, ft-blocker, and anticoagulant. High-risk patients should undergo early coronary angiography and revascularization with PCI or CABG. Administration of a glycoprotein IIb/IIIa receptor inhibitor may be considered in high-risk patients. Morphine is also administered to patients with refractory angina as described previously. These agents should be administered early, while the patient is still in the emergency department. Dosing and contraindications for SL and IV NTG (for selected patients), ASA, clopidogrel, P-blockers, and the anticoagulants UFH, LMWHs,

bivali-rudin, and fondaparinux are listed in Table 8-2. ' Fibrinolytic Therapy

Fibrinolytic therapy is not indicated in any patient with NSTE ACS, as increased mortality has been reported with fibrinolytics compared to controls in clinical trials in which fibrinolytics have been administered to patients with NSTE ACS (patients with normal or ST-segment depression ECGs).

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