Management for UA/NSTEMI

General measure

Admit for observation. Monitor cardiac rhythm for 24-48 hr. Patient
encouraged to report any recurrence of pain
Bed rest, sedation, and analgesics should be administered as in
acute myocardial infarct. IV morphine is recommended for patient
with persistent or recurrent symptoms despite anti-ischemic
therapy. IV morphine is given as bolus 2-5mg with IV anti-emetic eg
IV metoclopramide (Maxolon) 10mg.
BP every 15-30 min for few hour, then every 1-2 hour.
IV line for drug administration
Oxygen via nasal prongs.
Serial ECG and cardiac enzymes to detect AMI and silent recurrence
of ischaemia.
Other coronary risk factors (eg diabetes melliatus,
hypercholesterolaemia) and precipating factors (anemia,
hypertension, infections or hypoxaemia) should be treated/corrected

Pharmacological

1. Anti-thrombotic theraphy
- Combination of aspirin (ASA), clopidogrel, unfractioned heparin
(UFH) or low molecular weight heparin (LMWH) or fondaparinux,
with or without a platelet GP IIb/IIIa receptor antagonist is the
optimal therapy.
- Anti platlet Tablet aspirin, clopidrogel, ticlopidine, prasurgel
- Anticoagulations - IV UFH, LMWH, Fondaparinux (Factor Xa
inhibitor)
- Platelet glycoprotienn IIb/IIIa receptor antagonists IV abciximab,
eftifibatide, tirofiban.
2. Beta-blockers
- if not contraindicated (in severe heart failure, history of
bronchospasm, av nodal block, severe peripheral vascular disease.
- can reduce myocardial oxygen demand by inhibiting increase in
heart rate and myocardial contractility caused by adrenergic
activity.
3. Nitrates
- first-line agent for treatment of angina
- sublingual nitroglycerin 0.3-05mg for rapid relief of pain. Repeated
at 5-min interval to maximum of 3 tablets.
-IV nitrates should be instituted in patient who do not get
symptomatic relief with three 0.5mg sublingual nitrates tablet, have
 ECG evidence of myocardial ischemia or have concomitant heart
failure
4. Calcium channel blockers
- 3rd line agents. Added if the BP allows them to be safely used.
- drug preferred dialtiazem , verapamil, amlodipine
- cause variable degree of coronary and peripheral artery
vasodilatation, and have negative inotropic effects. Decreased
cardiac afterload hence, preserve or increase cardiac output despite
negative inotrophic effects.
5. Statin theraphy
- beneficial irrespective of serum lipid level and should be started
early
6. ACEi and ARB
- Benefit patient with LV dysfunction (EF < 40%).

Invasive Therapy

Urgent cardiac catheterization if:

i) chest pain with objective evidence of ischemia that persist for .
24-48h after aggressive medical therapy
ii) recurrent ischemic episodes despite optimal medical theraphy,
and
iii) hypotension or severe heart failure
Not indicated if patient refuse further intervention (PCI/CABG)
Elective cardiac catheterization if patient has any of the following
risk factors:
Prior angioplasty or bypass surgery, congestive heart failure or
depressed left ventricular failure, life-threatening ventricular
arrhythmias, recurrence low threshold ischemia, ECG changes
during pain, or a non-invasive exercise or pharmacological stress
test indicating a high likehood of severe coronary artery disease
If cardiac catheterization is not immediately available, patient with
high risk ACS should be considered for upstreamm Gp IIb/IIIa
antagonists.