Acute management of acute coronary syndrome

(STEMI, NSTEMI, or unstable angina)

Nitrates

• Rapid chest pain relief
• Caution with hypotension (eg, RV infarction)

Beta blocker

• Cardioselective (eg, metoprolol, atenolol)
• Decreases myocardial O₂ demand to limit infarct size
• Contraindicated in cardiogenic shock & bradycardia

Antiplatelet therapy

• Aspirin + P2Y₁₂ inhibitor (eg, prasugrel, clopidogrel)*
• Reduces platelet activity

Anticoagulation

• Unfractionated heparin, bivalirudin, or enoxaparin
• Limits thrombus expansion

Statin therapy

• High potency (eg, atorvastatin, rosuvastatin)
• Stabilizes atherosclerotic plaque

Coronary reperfusion

STEMI

• PCI <90 min from first medical contact
• Fibrinolytics (eg, alteplase) if PCI is unavailable

NSTEMI or unstable angina

• Coronary angiography often within 24 hr

*In patients with NSTEMI or unstable angina, P2Y₁₂ inhibitor therapy is often held until after coronary angiography in case the atherosclerotic coronary anatomy indicates the need for coronary artery bypass grafting.

NSTEMI = non–ST-segment elevation myocardial infarction; PCI = percutaneous coronary intervention; RV = right ventricular; STEMI = ST-segment elevation myocardial infarction.