1. Medications used in acute coronary syndrome include antiplatelet drugs like aspirin and clopidogrel to prevent clotting, high-dose statins to lower cholesterol, and anticoagulants like heparin. 2. For treatment, anti-angina drugs like nitrates provide pain relief while beta-blockers and calcium channel blockers lower blood pressure and oxygen demand. 3. In STEMI patients presenting within 12 hours, fibrinolytic therapy can be used to dissolve clots when immediate PCI is not available. Congestive heart failure is treated with diuretics, inotropes, and vasodilators to reduce preload and afterload.

1. Discuss and describe the medications used in
patients with acute coronary syndrome based on
the clinical presentation

2. 1.Prevention
a. Antiplatelet therapy
b. Anticoagulation
c. Statins
2.Treatment
a. Anti angina treatment
Nitrates
Morphine
Calcium channel blockers
Betablockers
ACEI/ARB

3. C Acute cardiac failure management
d fibrinolytic treatment
e. Anti LV remodeling drugs

4. Antiplatelet therapy.
Aspirin
• cyclooxygenase inhibitor
• Initial treatment should begin with aspirin
• loading dose of at least 162 mg (162-325)
• Lower doses (75–100 mg/d) maintenance dose
• Contraindications are severe active bleeding or aspirin allergy.

6. • In the absence of a high risk for bleeding
• also should receive a platelet P2Y12 receptor blocker to inhibit platelet activation..
• clopidogrel is an inactive prodrug that irreversibly block the platelet P2Y12 receptor.
• The loading dose of clopidogrel is 600 or 300 mg while the maintenance dose is 75 mg daily.
• When clopidogrel is added to aspirin, so-called dual antiplatelet therapy (DAPT),
• 20% relative reduction in cardiovascular death, MI, or stroke, compared to aspirin alone, but to be
associated with a moderate (absolute 1%) increase in major bleeding.

7. • DAPT should continue for at least 1 year in patients , especially those with a drug-eluting stent, to
prevent stent thrombosis.

9. Statins
High dose statin
HMG CoA reductase inhibitor (synthesis of cholesterol)
Maximum at night –enzyme action
Atorvastatin 40-80mg
Rosuvastatin 20-40 mg
Side effects –myopathy, hepatotoxic

10. Anticoagulation
• Four options are available for anticoagulant therapy to be added to antiplatelet agents:
• (1) unfractionated heparin (UFH)
• (2) the low-molecular-weight heparin (LMWH), enoxaparin
• which has been shown to be superior to UFH in reducing recurrent cardiac events, especially in
patients managed by a conservative strategy.
• However, it is accompanied by a slight increase in bleeding compared to UFH
• (3) bivalirudin direct thrombin inhibitor
• (4) fondaparinux the indirect factor Xa inhibitor,
• UFH 60 U/Kg (max 4000U)12 U/Kg/hr(max1 000U/hr)

11. Absolute contraindications

13. ANTI-ANGINA TREATMENT
• To provide relief and prevention of recurrence of ischemic discomfort
• initial treatment should include bed rest, nitrates, beta adrenergic blockers
• inhaled oxygen in patients with arterial O2 saturation (<90%) and/or in those with heart failure and
rales

14. Nitrates
• Release NO cGMP increase vasodilatation
• Patients should be encouraged to use the drug prophylactically before taking exercise
that is liable to provoke symptoms
• .Sublingual GTN has a short duration
• GTN can be given transcutaneously as a patch (5–10 mg daily), or as a slow-release
buccal
tablet (1–5 mg 4 times daily).
• GTN undergoes extensive first-pass metabolism in the liver and is ineffective when
swallowed.
Other nitrates, such as isosorbide dinitrate (10–20 mg 3 times daily) and isosorbide
mononitrate
(20–60 mg once or twice daily), can be given by mouth.

15. Beta-blockers
• These lower myocardial oxygen demand by reducing heart rate, BP and myocardial contractility,
• Contraindicated in Variant angina
• Decrease the incidence of arrhythmias
Calcium channel antagonists
• These drugs inhibit the slow inward current caused by the entry of extracellular calcium through the
cell membrane of excitable cells, particularly cardiac and arteriolar smooth muscle
• lower myocardial oxygen demand by reducing BP and myocardial contractility.

16. • Dihydropyridine calcium antagonists, such as nifedipine and nicardipine, often cause a
reflex tachycardia ,best to use them in combination with a β-blocker
• Calcium channel antagonists reduce myocardial contractility and can aggravate
or precipitate heart failure.
Other unwanted effects include peripheral oedema, flushing, headache and dizziness

18. • Nicorandil
• Potassium channel activators
• These have arterial and venous dilating properties
• but do not exhibit the tolerance seen with nitrates.

19. • Ivabradine
• If channel antagonist
• Ivabradine is the first of this class of drug.
• It induces bradycardia by modulating If ion channels in the sinus node.
• It appears to be safe to use in patients with heart failure
• Side effect –visual disturbances

20. • Ranolazine
Block late sodium channelhence calcium entry (NCX)
pFOX inhibition
Chronic angina
Side effect QT prolongation
Trimetazidine
pFOX inhibition

22. Thrombolysis /fibrinolytic therapy
Not indicated in NSTEMI
STEMI who present within 12 hr of onset of chest pain to a hospital not capable of primary PCI
Optimal results should be administrated as early as possible,preferably within 1st 3 to 6 hrs and
potentially upto 12 hr after the onset of symptoms
Alteplase, reteplase Tenecteplase -used

24. Acute heart failure treatment drugs
a. Diuretics
Loop diuretics
Decrease preload
Venodialation prior to diuresis
b.Inotropic drugs
1.Dobutamin/Dopamine
2.Digoxin
3.Inodilators
milrinone ,Levosimendan

25. c.Nersitide
d.Vasodilators  nitrate ,minoxidil, CCB

26. • Drugs used to prevent LV remodelling
• ACEI/ARBs
• Betablockers
• Aldosterone antagonists
• Isosorbide dinitride plus hydralazine

27. • Thank you