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creatinine clearance is below 50 mL/min, the eptifibatide infusion should be cut in half to 1 mcg/kg/min Fibrinolytic therapy should be avoided in patients without ST-segment elevation since they generally have a patent culprit artery, and since the risk of such therapy appears to outweigh the benefit
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G Intra-aortic Balloon Counterpulsation
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Intra-aortic balloon pump (IABP) counterpulsation can both reduce myocardial energy requirements (systolic unloading) and improve diastolic coronary blood flow This approach is sometimes used to stabilize patients prior to angiography or revascularization, but with modern techniques it is rarely necessary
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The nitrates are first-line anti-ischemic therapy for acute coronary syndromes Nonparenteral therapy with sublingual or oral agents or nitroglycerin ointment is usually sufficient If pain persists or recurs, intravenous nitroglycerin should be started The usual initial dosage is 10 mcg/ min The dosage should be titrated upward by 10 20 mcg/ min (to a maximum of 200 mcg/min) until angina disappears or mean arterial pressure drops by 10% Careful usually continuous BP monitoring is required when intravenous nitroglycerin is used Avoid hypotension (systolic BP < 100 mm Hg) Tolerance to continuous nitrate infusion is common
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Prognosis & Indications for Revascularization
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Risk stratification is important for determining intensity of care Several therapies, including glycoprotein IIb/IIIa receptor antagonists, low-molecular-weight heparin, and early invasive catheterization, have been shown to have the greatest benefit in higher-risk patients As outlined in the ACC/AHA guidelines, patients with any high-risk feature (Table 10 5)
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Table 10 5 Indications for catheterization and percutaneous coronary intervention
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Acute coronary syndromes (unstable angina and non-ST elevation MI) Class I Early invasive strategy for any of the following high-risk indicators: Recurrent angina/ischemia at rest or with low-level activity Elevated troponin ST-segment depression Recurrent ischemia with evidence of CHF High-risk stress test result EF < 040 Hemodynamic instability Sustained ventricular tachycardia PCI within 6 months Prior CABG In the absence of these findings, either an early conservative or early invasive strategy Class IIa Class III Early invasive strategy for patients with repeated presentations for ACS despite therapy Extensive comorbidities in patients in whom benefits of revascularization are not likely to outweigh the risks Acute chest pain with low likelihood of ACS Acute MI after fibrinolytic therapy (2004 ACC/AHA AMI Guideline) Class I Recurrent ischemia (spontaneous or provoked) Recurrent MI Cardiogenic shock or hemodynamic instability Class IIa Class IIb LV EF 040, CHF (even transient), serious ventricular arrhythmias Routine PCI as part of invasive strategy after fibrinolytic therapy
-Blockers are an important part of the initial treatment of unstable angina unless otherwise contraindicated If the patient has no physical findings of heart failure, these agents can usually be started without measurements of LV function Patients with evidence of large or multiple old infarctions are an exception The pharmacology of these agents is discussed in 11 and summarized in Table 11 7 Use of agents with intrinsic sympathomimetic activity should be avoided in this setting The goal of acute treatment is to reduce the heart rate below 60 70 beats/ min Oral medication is adequate in most patients, but intravenous treatment with metoprolol, given as three 5mg doses 5 minutes apart as tolerated and in the absence of heart failure, achieves a more rapid effect Oral therapy should be aggressively titrated upward as BP permits
E Calcium Channel Blockers
Calcium channel blockers have not been shown to favorably affect outcome in unstable angina, and they should be used primarily as third-line therapy in patients with continuing symptoms on nitrates and -blockers or those who are not candidates for these drugs In the presence of nitrates and without accompanying -blockers, diltiazem or verapamil is preferred, since nifedipine and the other dihydropyridines are more likely to cause reflex tachycardia or hypotension The initial dosage should be low, but upward titration should proceed rapidly (see Table 11 9)