Myocardial Infarction - STEMI

#STEMI, Type I NSTEMI, or Unstable Angina

Coronary evaluation:
-EKG, trop, TTE WMA, Stress, LHC.

Antithrombotic:
-ASA: Cont. ASA 81mg PO QD x life.
-P2Y12:-Clopidogrel (Plavix) load 600mg PO x 1 then 75mg qD (some resistance particular in East Asian and Pacific Islander).
-Ticagrelor (Brilinta) load 180mg PO x 1 then 90mg BID (may cause bradycardia and/or SOB).
-Prasugrel (Efient, Effient) load 60mg PO x 1 then 10mg PO qD (contraindicated if h/o CVA).
-IIb/IIIa:
--Eptifibatide (Integrilin): Can be given “up front” prior to cath.
--Abciximab (ReoPro): Okay in ESRD, can be given only after cath

Anticoagulation:
-Heparin bolus and gtt.

Demand reduction:
-Nitrates: (SLNTG, nitro paste, nitro gtt).
-BB: (within 24 hours of MI).
-ACE/ARB: (within 24 hours of MI).
-CCB: (if intolerant to BB).
-Pain medication: (Morphine a/w increased mortality in retrospective studies, if possible maximize above and use fentanyl).
-Advanced meds: Ranolazine (Renexa) for intractable UA, avoid in renal/liver failure and with long QTC.

Antiinflammatory/Antilipid:
-Start Atorva 80mg QHS.
-If admitted for ACS on high intensity statin and LDL > 50, consider adding Zetia 10mg PO QHS.
-If familial hyperlipidemia or cannot tolerate statin, consider PCSK9.
-In acute MI, avoid NSAIDs & steroids if at all possible.
-Defer screening and management of DM2 and inflammatory dz to PCP.