Yale: Acute Coronary Syndrome: Treatment Guidelines

CONTENTS

Yale University
School of Medicine
333 Cedar Street
New Haven, CT
06510 USA

(203) 432-1333

Yale

Treatment Guidelines:
Glycoprotein IIb/IIIa Inhibitors for
Acute Coronary Syndrome

INTRODUCTION
Glycoprotein IIb/IIIa receptor antagonists are a valuable adjunct to conventional therapy in moderate to high risk patients presenting with acute coronary syndrome.

Identification of Moderate to High-Risk Patients

1. EKG manifestations

ST-segment depression (>0.1mV)
Minimal ST-segment elevation (<0.1 mV)
Anterior T-wave inversion

2. Clinical Criteria

Prior aspirin therapy ("aspirin failure")
Post-infarctional angina, rest angina
History of diabetes
Age > 75 years

3. Serum markers

Positive troponin
Positive CPK-MB
Elevated C-reactive protein

Contraindication to Treatment

Active bleeding
Recent < 4 weeks) major surgery or trauma
Stroke within past 6 months
Uncontrolled hypertension (SBP > 180, DBP > 110)
Platelet count < 100,000 (relative risk)

TREATMENT
IV glycoprotein IIb/IIIa therapy is recommended in moderate to high-risk patients

I. Is the patient to receive medical management only or is cath lab treatment postponed for >12 hours?

IV heparin (5000 U bolus, then 800-1000 U/hr to maintain APTT between 50-60 secs)*
IV tirofiban (Aggrastat®) for up to 108 hours (0.4 ug/kg/min) for 30 minutes, then 0.1 ug/kg/min)
Beta blocker (to keep heart rate < 60 bpm); i.e., metroprolol 50mg bid
Aspirin 325 mg qd (chewable)
Nitrate therapy (IV, long acting oral, or topical)

*Note: Enoxaparin 1mg/kg s.c. bid may be considered instead of unfractionated IV heparin; however, the combination of an LMWH and a GP IIb/IIIa inhibitor has not been well studied.

*Note: If PCI is performed, continue Rx with IV Aggrastat for 12 hours after procedure.

II. Is cath lab treatment planned within 12 hours?

IV abciximab (Reopro® bolus therapy, 0.25mcg/kg, followed by maintenance weight-adjusted dose for 12 hours)
If tirofiban (Aggrastat®) used for PCI (agent selected by interventional attending): bolus infusion, 10mcg/kg x 3 minutes, then maintenance infusion (0.15 mcg/kg/min x 12-24 hours).
Aspirin 325 mg
Beta blocker to reduce HR less then or equal to 60
Nitrate therapy (I.V., long-acting oral, or topical)
IV heparin (800-1000 U/hr to maintain APTT between 50-60 sec); goal of ACT in lab less then or equal to 250 seconds.

*Note: If PCI is performed, add clopidogrel 300mg, then 75 mg qd.

MONITORING & ASSESSMENT

Since administration of IIb/IIIa antagonists may be associated with an increased frequency of thrombocytopenia and major bleeding complications, the following precautions should be taken:

Obtain CBC with platelets at baseline, 6 and 24 hours following administration, then qd.
Obtain troponin level at baseline and 8 hours after admission
Discontinue drug if platelets decrease to less than 100,000 or by 25% of pre-treatment value (assess peripheral smear to r/o pseudothrombocytopenia)
Assess for signs of bleeding:
- Observe for mental status changes
- Observe eyes for hemorrhage
- Assess mucous membranes of nose and mouth
- Monitor puncture and access sites
- Examine urine, stool, and emesis for signs of frank blood
- Guaiac stool and Hemastix for presence of occult blood
If significant bleeding occurs:
- Discontinue GP IIb/IIIa and heparin therapy
- Consider infusion of 12 units platelets (or PRBC/FFP) if clinically indicated
- Stat CBC and platelets
- Fem-stop or direct pressure for groin bleed.

Last modified: October 14, 1999 (PL)