Page 17 - JSOM Fall 2021

2. Clopidogrel (Plavix) urgent PCI as it is considered the optimal treatment. This
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a. Age ≤ 75 years old: initial loading dose of 300mg PO should be achieved within 2 hours of patient arrival. In the
× 1 then 75mg PO daily event that door-to-balloon time cannot be achieved within 2
b. Age > 75 years old: initial dose of 75mg PO × 1 then hours, fibrinolytics should be given instead. In the deployed
75mg PO daily setting, PCI may be prohibitively far away, and thus rapid de-
livery of fibrinolytic therapy is the method of choice for re-
OR
vascularization. Fibrinolytic therapy should be administered
3. Ticagrelor (Brilinta) 180mg PO × 1 then 90mg twice daily. within 30 minutes of STEMI diagnosis. There are absolute
It is important to note that ticagrelor can cause dyspnea, and relative contraindications to administration of fibrino-
which is thought to be benign, though sometimes concern- lytics (listed in Appendix A). This list should be meticulously
ing to the patient/clinician. reviewed step by step prior to administration of these agents.
The two most common agents available are listed below with
Anticoagulant Therapy their dosing. Fibrinolytics should be offered to patients with
Systemic anticoagulation should be administered as soon as symptom duration of 12 hours or less. It is recommended that
the diagnosis of ACS is made if no contraindications exist. Op- expert consultation with the theater cardiology consultant be
tions for anticoagulants include unfractionated heparin and used prior to administering fibrinolytics in the 12- to 24-hour
low molecular weight heparin (LMWH) (i.e., enoxaparin), period.
which exert their anticoagulant properties by indirectly in-
hibiting thrombin. Another option is factor Xa inhibitor (i.e., Note: Dual antiplatelet therapy, systemic anticoagulation,
fondaparinux). Heparin is administered as a bolus followed β-blocker, and high-dose statins should still be given even
by a drip, and its effects are monitored by the activated partial when fibrinolytics are given.
thromboplastin time (aPTT). Currently, typical CCATT that
transports patients out of theater do not have the ability to 1. Tenecteplase (TNKase) – preferred agent
monitor aPTT for heparin drips. Thus, enoxaparin is preferred a. < 60 kg: 30mg IV bolus × 1
over a heparin drip when transport is required, given its ease b. 60–69 kg: 35mg IV bolus × 1
of use. If enoxaparin or another LMWH is not available, then c. 70–79 kg: 40mg IV bolus × 1
consideration of fondaparinux should be utilized if available. d. 80–89 kg: 45mg IV bolus × 1
If heparin is the only agent available, then it should be given. e. ≥ 90 kg: 50mg IV bolus × 1
Dosing consideration for transport would be decided based on OR
an aPTT immediately prior to the flight. For patients that have
a known or suspected history of heparin-induced thrombocy- 2. Alteplase (Activase)
topenia, fondaparinux should be used. Anticoagulation should a. ≤ 67 kg: 15mg IV bolus over 1–2 minutes, then infusion
continue for at least 48 hours or until revascularization. of 0.75mg/kg (maximum 50mg) over 30 minutes, then
infusion of 0.5mg/kg (maximum 35mg) over 60 minutes
The following are the dosings for each agent listed below: b. > 67 kg: 15mg IV bolus over 1–2 minutes, then infusion
of 50mg over 30 minutes, then infusion of 35mg over 60
1. Enoxaparin (Lovenox) – preferred agent minutes (maximum total dose 100mg)
a. STEMI dosing:
– Age < 75 years: single 30mg IV bolus plus 1mg/kg NOTE: In contrast to STEMI, fibrinolytics are contraindi-
SQ (maximum 100mg for the first 2 doses only) then cated in UA/NSTEMI patients.
1mg/kg SQ every 12 hours
– Age ≥ 75 years: 0.75mg/kg SQ every 12 hours Statin Therapy
b. NSTEMI dosing: 1mg/kg SQ every 12 hours Regardless of the patient’s blood lipid levels, high-dose statin
c. Consult pharmacy to adjust this dose if there is any re- therapy should also be administered during the initial presen-
nal injury (rise in creatinine). tation (within the first 2 hours) of ACS. The following are the
two therapy options to administer:
OR
2. Heparin sulfate 1. Atorvastatin (Lipitor) 80mg PO × 1 then 80mg nightly
a. STEMI dosing: 60U/kg initial bolus IV (4,000U maxi- OR
mum), then 12U/kg/hr (maximum 1,000U/hr) infusion
Maintain aPTT 1.5–2.0 times control (50–70 s) 2. Rosuvastatin (Crestor) 20–40mg PO × 1 then 20–40mg PO
b. NSTEMI dosing: 60 U/kg initial bolus IV (5,000U max- daily
imum), then 12U/kg/hr (maximum 1,000U/hr) infusion.
Maintain aPTT 1.5–2.0 times control (50–70 s)
Supportive Therapy
OR
Supplemental Oxygen
3. Fondaparinux (Arixtra) Administering oxygen in patients with ACS is recommended
a. STEMI dosing: 2.5mg IV × 1, then 2.5mg SQ daily only when oxygen saturation levels are < 90%, to avoid po-
b. NSTEMI dosing: 2.5mg SQ daily tential harm from oxygen free radicals and further hyperoxia
coronary vasoconstriction.
Reperfusion Therapy
Prompt reperfusion is the mainstay of STEMI care. Whenever Analgesia
possible, a patient presenting with STEMI should be transferred Decreasing the pain response can block sympathetic activ-
emergently to the nearest medical facility that can perform ity and relieve anxiety, which decreases myocardial oxygen

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