Drug used in unstable angina & NSTMI -

Ref: R. Alagappan Manual for Medicine 4th Edition pg no:180 Management Immediately assess the following: * Clinical evaluation - history and physical exami- nation* 12 - lead ECG recording * Measurement of cardiac specific markers - troponin and CK-MB. All ACS patients should be placed on aspirin, b-blocker, nitrate and clopidogrel immediately. Low risk patients - On observation if the patient remains pain-free with normal ECG and normal levels of cardiac markers, submit them for stress ECG. If the stress test is negative, consider alternative diagnosis. If the stress test is positive, continue medication and invasive testing when required. Intermediate and high risk patients - Patient has to be admitted in the intensive care unit and to be managed with anti-ischaemia, antiplatelet and anticoagulant group of drugs. In the meantime coronary angiography is planned. Antiplatelet Therapy A. Aspirin (loading dose of 325 mg followed by 75-150 mg/day after lunch) reduces subsequent MI and cardiac death. B. Clopidogrel (loading dose 300 mg followed by 75 mg/day) in aspirin intolerant patients. Added benefit in reducing the motality is achieved by combining both aspirin and clopidogrel and can be used for a minimum of one month if PCI is planned or maximum of 9 months. C. Glycoprotein (GP) IIb/IIIa antagonists - abciximab (ReoPRO) or eptifibatide (Integrilin) or tirofiban (Aggrastat) should be considered for high risk patients. They should be used in conjunction with heparin. If early invasive strategy is planned any one of the molecule can be used. If early invasive strategy is not planned, one of the small molecule either eptifibatide or tirofiban can be used. Anticoagulant Therapy Dalteparin - (Fragmin) 120 IU/kg SC 12 hr (Maximum 10,000 IU bid) Enoxaparin - (Lovenox) 30 mg IV bolus followed by 1 mg/kg SC bid Heparin (unfractionated -UFH) 60-70 U/kg (maxi- mum 5000 U)IV followed by infusion 12-15 u/kg/hr (Initial maximum 1000 U/hr) titrated to achieve a PTT 1.5-2.5 times control. Compared with UFH, LMWH produces more predictable anticoagulant response because of the better bioavailability, longer half-life and dose independent clearance. Enoxaparin 1 mg/kg bid subcutaneously is the only LMWH found to confer greater cardiac benefit.