TOC | Cardiology   
Angina - Unstable (ACS = Acute Coronary Syndrome) Rx :                       See Chest Pain  
See also  

1. Bed rest & Correct any underlying precipitating or contributing factors.

2. M-O-N-A  

  • Morphine sulfate 2-4 mg IV q 1-3 hours prn for pain & anxiety
  • Oxygen supplement
  • Nitroglycerin 0.4 mg tab sublingual prn, Nitropaste 1-2 inches q 6 hours, or IV Nitroglycerin infusion Rx            
  • Anti-platelets  and Anti-thrombin agents as
    a. Aspirin 325 mg or Plavix 75 mg/d (loading 375 mg) PO and
    b. Lovenox (Enoxaparin) 1 mg/kg Subc q 12 hours for unstable angina & non-Q Myocardial Infarction patients. or
    c. IV Heparin 5,000 u bolus, followed by 800-1,000 u/h infusion Rx.   
    d. Platelet Glycoprotein IIb/IIIa Receptor Antagonists
    * Integrilin /Eptifibatide  For acute coronary syndrome: 180 ug/kg IV bolus, then infusion of 2 ug/kg/min upto 72 hours, until discharge or CABG;  For percutaneous coronary interventions: 135 ug/kg bolus, then 0.5 ug/kg/min infusion for 24 h.

    * ReoPro /Abciximab 0.25 ug/kg bolus, then 0.125 ug/kg/min infusion for 12 hours for before & during percutaneous coronary interventions
    * Aggrastat /Tirofiban 0.4 ug/kg/min bolus for 30 min, then 0.1 ug/kg/min infusion for upto 72h for acute coronary synd.

    * Lamifiban - not approved yet.

    Direct Thrombin Inhibitor - IV Hirudin  or Angiomax/Hirulog (bivalirudin) infusion

    (Cleveland Clin J of Med  Feb.2000;67:131 - Matthew Roe, etc. )
    The EPILOG Investigators.
    Platelet glycoprotein IIb/IIIa receptor blockade and low-dose heparin during percutaneous coronary revascularization.   N Engl J Med. 1997;336:1689-1696
    The CAPTURE Investigators. Randomized, placebo-controlled trial of abciximab before and during coronary intervention in refractory unstable angina. Lancet. 1997;349:1429-1435.
    Beyond Heparin and Aspirin New Treatments for Unstable Angina and Non–Q-Wave MI - Jeffrey  
    Arch IM Mar.27, 2000:160:749      See Figure of Anti-Platelet Aggregation diagram .

3. Thrombolytic agents for acute Myocardial Infarction if no contraindication.  See MI Rx

4. Beta-blockers if no contraindication

  • IV Atenolol (Tenormin) 5 mg, repeated in 10 min prn & followed by PO 25-100 mg/day
  • IV Metoprolol (Lopressor) 2-5 mg q 5 min to total 15 mg total dose, & followed by PO 25-100 mg bid
  • IV Esmolol ,ultra-short acting, start 500 ug/kg bolus, followed by infusion of 50-200 ug/kg/min as needed.
  • PO Atenolol  (Tenormin) 25-100 mg daily or Metoprolol 25-100 mg bid

5. ACE-inhibitor if indicated for hypertensive, CHF or cardiomyopathy patients.

6. Intervention Rx: Angioplasty (PTCA) with or without stent, Coronary Bypass (CABG) as indicated.

Reduction of O2 Demand & Increase Oxygenation         

  1. Rest & O2 supplement
  2. Sedation & Pain control: IV morphine 3-4 mg prn
  3. Preload reduction & vasodilatation:
    -Nitroglycerin IV, sublingual, topical, PO
    -Diuretics if there is CHF
  4. Afterload reduction & vasodilatation:
    -ACE inhibitors: Lisinopril, etc.
    -Calcium blocker: Diltiazem (Cardizem), nifidipine (Procardia), verapamil (Calan), etc.
  5. Chronologic & inotropic reduction prn if no bradycardia or CHF:
    -Beta blockers: Propranolol (Inderal), metoprolol (Lopressor)
  6. Bradyarrhythmia & tachycarrhythmic Rx

Perfusion definitive Rx

  1. PTCA (angioplasty) with or without stent
  2. CABG (coronary artery bypass)

Unstable Angina - Current Concepts of Pathogenesis & Treatment - John A Ambrose & George Dangas
Arch IM Jan. 10, 2000;160:25