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ALiEMU CAPSULES Module 6: Pharmacology of Acute Coronary Syndromes

2017-10-01T20:25:28+00:00

We are proud to present CAPSULES module 6: Pharmacology of Acute Coronary Syndromes, now published on the Academic Life in EM University (ALiEMU) website. Here is a summary of the key points from this outstanding module by Drs. Paul Takamoto and Glen Oettinger.

Course Contributors

Role Team Member Background
Authors Paul Takamoto, PharmD
@ptakpharm
Emergency Medicine Pharmacist, University of California San Francisco
Glenn Oettinger, PharmD, BCPS
@glennoettinger
Emergency Medicine Pharmacist, Thomas Jefferson University
PharmD Reviewer Craig Cocchio, PharmD, BCPS
@iEMPharmD
Emergency Medicine Pharmacist, Trinity Mother Frances Hospital
Physician Reviewer David Juurlink, BPharm, MD, PhD, FRCPC
@DavidJuurlink
Professor of Medicine, University of Toronto
Creator and Lead Editor Bryan Hayes, PharmD, FAACT
@pharmertoxguy
Emergency Medicine Pharmacist, Clinical Associate Professor; University of Maryland
Chief of Design and Development and Co-Founder of ALiEMU Chris Gaafary, MD
@cgaafary
EM Chief Resident, University of Tennessee Chattanooga

Go to ALiEMU module

Summary: Pharmacology of Acute Coronary Syndromes

Primary Reperfusion Strategies

  • American Heart Association (AHA) and American College of Cardiology (ACC) recommend early-as-possible reperfusion strategies for acute STEMI management
  • Primary goal of first medical contact to device time <90 minutes; <2 hours if transporting patients from non-PCI capable site to a cardiac catheterization lab; strong consideration for fibrinolytics if potential delay anticipated (door-to-needle <30 minutes from arrival)
  • Prehospital fibrinolytic administration; consider in participating communities
  • Benefit of fibrinolytics weaker when administered beyond 12 hours of symptom onset
  • The appropriate and timely use of some form of reperfusion therapy (PCI or fibrinolysis) is likely more important than the choice of therapy

Morphine-Oxygen-Nitrates-Aspirin (MONA)

  • Each intervention can be beneficial and in certain cases potentially harmful
  • Morphine is primary analgesic recommended for nitrate-refractory chest pain during ACS
  • Supplemental oxygen should not be provided unless patient exhibits persistent dyspnea with evidence of hypoxia
  • Aspirin is only pharmacologic intervention of these 4 treatments with mortality benefit; rapid absorption occurs with chewable, non-enteric coated formulations; chew enteric coated tablets

Antiplatelet

  • As part of the overall treatment, an antithrombotic cocktail comprised of a P2Y12 inhibitor in addition to aspirin, is indicated for all patients with N-STEMI

Anticoagulation

  • All patients with NSTEMI, regardless of initial treatment strategy, should receive anticoagulation in addition to antiplatelet therapy
  • Most experts agree, patients undergoing primary PCI should receive UFH or bivalirudin, although enoxaparin is an acceptable alternative in some circumstances

GP IIb/IIIa inhibitors

  • For patients undergoing PCI who are also receiving heparin and clopidogrel, consider intravenous GP IIb/IIIa inhibitors like abciximab, high bolus dose tirofiban or double-bolus dose eptifibatide
  • GP IIb/IIIa inhibitor therapy may also be deferred until completion of cardiac catheterization to better determine appropriate therapy for diagnosis

Preparation for CABG

  • Regardless of initial treatment strategy, patients with NSTEMI should receive anticoagulation in addition to dual-antiplatelet therapy
  • For patients with high-risk features (i.e. positive troponin) scheduled for PCI who are also receiving heparin and clopidogrel, consider an intravenous GP IIb/IIIa inhibitor such as eptifibatide or tirofiban

Post-PCI drugs

  • Early administration of beta-blockers does not suggest short-term survival benefit; caution in low output states
  • After initial reperfusion strategy ACE/ARBS should be initiated in all ACS patients with hypertension, diabetes mellitus, stable CKD, and significant LV dysfunction
  • Statins are standard component of primary and secondary cardiovascular prevention and should be initiated (high-dose) after PCI
  • Aldosterone antagonists (eplerenone and spironolactone) may provide additional benefit for patients with new LV dysfunction or heart failure after ACS

What is the CAPSULES series?

The CAPSULES series is a free, online e-curriculum of high-quality, current, and practical pharmacology knowledge for the EM practitioner. About once a month a new course module is released, which has lessons to read about (or watch) and brief quizzes to complete. With each step, your personal dashboard will keep track of what you have completed. The CAPSULES series’ primary focus is bringing EM pharmacology education to the bedside. Our expert team distills complex pharmacology principles into easy-to-apply concepts. It’s our version of what-you-need-to-know as an EM practitioner.

Bryan D. Hayes, PharmD, FAACT, FASHP

Bryan D. Hayes, PharmD, FAACT, FASHP

Leadership Team, ALiEM
Creator and Lead Editor, Capsules series, ALiEMU
Attending Pharmacist, EM and Toxicology, MGH
Assistant Professor of EM, Harvard Medical School