Management of NSTEMI according to CPG Malaysia
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How to manage NSTEMI cases? this slides include pre management and in hospital management of NSTEMI cases according to CPG Malaysia 2011 guideline
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Management of NSTEMI according to CPG Malaysia
- 1. The treating physician decided to start the patient on medical management for NSTEMI. State the required pre- and in hospital pharmacological agents to manage the patients The goals of management are: • Immediate relief of ongoing ischemia and angina • Prevention of recurrent ischemia and angina • Prevention of serious adverse cardiac events
- 2. Pre hospital management History suggestive of ACS Aspirin 300mg stat Sublingual GTN • Pain management ECG and Biomarker suggestive of ACS Clopidogrel 300mg stat • Anti-platelet, reduce thrombosis ECG & cardiac biomarker inconclusive Low risk pt. • Referred as outpatient Intermediate • Admitted to ward
- 3. Morphine • IV 2-5mg together with concomitant intravenous anti- emetic • For pain relief Oxygen • Maintain SPO2 > 90% • Increase myocardial oxygenation Beta Blocker • First 24 hours - ORAL • Metroprolol 25mg BD Aspirin • 300mg loading dose of solube/chewable aspirin • Maintenance dose: 100mg daily enteric coated aspirin In hospital management (MOBA) Early treatment
- 4. In hospital treatment Oral Antiplatelet agent • Adenosine Diphosphate Receptor Antagonist • Prasugrel – loading dose 60mg, maintenance 10mg/day • More effective for patient with diabetes, but cannot be given if patients weight <60kg • Alternative, give clopidogrel 300-600mg (loading dose), 75mg/day (maintenance dose) Anticoagulant • Unfractionated heparin • IV bolus 60IU/kg (no adjustment) • Low molecular weight heparin – Enoxaparin • 30mg IV bolus, sc 1.0mg/kg/hour for every 12 hour • Anti Xa inhibitor – Fondaparinux • 2.5mg sc daily • Anti 2a inhibitor – Bivalirudin • 0.1mg/kg bolus & 0.25mg/kg/hour infusion
- 5. Anti- ischemic • Nitrates • Sublingual for ongoing chest pain • IV • Beta-blocker • Calcium channel blocker • Verapamil/Diiltazem • For patient intolerance to Beta blocker ACE inhibitor/ ARB • Not to be given to this patient (worsening renal function)
- 6. Reference • Clinical Practice Guideline UA/NSTEMI Malaysia (2011) page 23-36
Editor's Notes
- https://www.slideshare.net/SAMAslides/acute-coronary-syndromes-by-seema-nour
- **Our patient is classified in red box The patient came with chest pain. The ECG and cardiac biomarker also showed the sign of ACS. Thus, a loading dose of aspirin or clopidogrel is given to patient to prevent platelet aggregation (thrombus formation).
- Enteric coated not recommended for initial dosing because slow onset of action
- The patient had history of DM type 2. It is best to give prasugrel according to CPG Malaysia 2011. However, the patients weight is 58kg. So need to opt. for another type of antiplatelet, clopidogrel The patient has high creatinine clearance, indicating kidney problem (CKD). Some anticoagulant need dose adjustment according to CPG. Bivalirudin and fondaparinux seemto be associated with less bleedingthan heparin or enoxaparin.
- The patient has high creatinine clearance. Thus cannot give ACE/ARB because it worsen renal function.