How to Treat Non St Elevation Myocardial Infarction And Unstable Angina?



Medical Treatment:
If clinically hypoxic:
  • Oxygen.
    • Aspirin, oral, 300 mg immediately as a single dose (chewed or disolved).
      • Followed with 75-150 mg daily.
PLUS
Anticoagulation:
For acute myocardial infarction without ST elevation:
  • Unfractionated heparin, IV bolus, 5 000 units.
    • Follow with 1 000-1 200 units hourly monitored by aPTT.
Continue infusion for 3-5 days.
OR
Low molecular weight heparin, e.g:
  • Enoxaparin, SC, 1 mg/kg 12 hourly for two days.
Note:
Thrombolysis is not indicated except if new left bundle branch block (LBBB).
PLUS
Thrombolytic therapy:
  • Streptokinase, IV 1.5 million units diluted in 100 mL sodium chloride 0.9%, infused over 30-60 minutes. Do not use heparin if streptokinase is given.
Indications Contra-indications
For acute myocardial infarction with ST elevation:
  • If history of onset is less than 6 hours. (Beyond 6 hours treat as NSTEMI (see below),
  • If on-going ischaemic pain, or
  • For new left bundle branch block.
Absolute:
  • Streptokinase used within the last year,
  • Previous allergy,
  • CVA within the last 3 months,
  • History of recent major trauma,
  • Bleeding within the last month,
  • Aneurysms,
  • Brain or spinal surgery or head injury within the preceding month, or
  • Active bleeding or known bleeding disorder.
Relative:
  • Refractory hypertension,
  • Warfarin therapy,
  • Recent retinal laser treatment,
  • Subclavian central venous catheter,
  • Pregnancy,
  • TIA in the preceding 6 months,
  • Traumatic resuscitation.
To relieve spasm and pain and to reduce preload:
  • Isosorbide dinitrate SL, 5 mg immediately as a single dose.
    • May be repeated at 5-minute intervals for 3 or 4 doses.
For persistent pain and if oral therapy is insufficient:
  • Glyceryl trinitrate, IV, 5-200 mcg/minute, titrated to response.
    • Start with 5 mcg/minute and increase by 5 mcg/minute every 5 minutes until response or until the rate is 20 mcg/minute.
    • If no response after 20 mcg/minute increase by 20 mcg/minute every 5 minutes until pain response or drug no longer tolerated.
    • Flush the PVC tube before administering to patient.
    • Monitor blood pressure carefully.
To relieve pain:
  • Morphine, IV, 1-2 mg/minute.
    • Dilute 10 mg up to 10 mL with sodium chloride 0.9%.
    • Total maximum dose: 10 mg.
    • If necessary, repeat after 4 hours.
    • Pain that does not respond to this dose may suggest continued unresolved ischaemia.
If there is cardiac failure or LV dysfunction:
ACE inhibitor, e.g:
  • Enalapril, oral, 10 mg 12 hourly.


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