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Unstable Angina and NSTEMIs: Management Principles

Unstable Angina and NSTEMIs: Management Principles. Meira Louis Lisa Campfens. Outline. Pick your/ cardio’s strategy Initial therapy...for everyone? Pick an anti-platelet...or two...or three... Protect the stomach??? PPI controversy Pick the right anti-coagulant

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Unstable Angina and NSTEMIs: Management Principles

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  1. Unstable Angina and NSTEMIs:Management Principles Meira Louis Lisa Campfens

  2. Outline • Pick your/cardio’s strategy • Initial therapy...for everyone? • Pick an anti-platelet...or two...or three... • Protect the stomach??? PPI controversy • Pick the right anti-coagulant • Send home the lucky stable one

  3. Evidence? Says Who?

  4. First, conservative or invasive?

  5. ASA

  6. Nitrates

  7. Morphine

  8. Beta Blockers: the good

  9. Beta Blockers: the bad

  10. CCB

  11. CCB dosing

  12. Ace i

  13. Ace i: Is more better?

  14. Lets talk anti-platelets...

  15. Plavix

  16. Plavix: How much?

  17. Prasugrel?

  18. Ticagrelor?

  19. Plato Controversy

  20. Plavixvs GP IIb/IIIa inhibitor

  21. What about adding a PPI?

  22. Anti-Coagulants • Indirect inhibitors of coagulation (need antithrombin for their full action) • Indirect thrombin inhibitors: UFH; LMWHs • Indirect factor Xa inhibitors: LMWHs; fondaparinux • Direct inhibitors of coagulation • Direct factor Xa inhibitors: apixaban, rivaroxaban, otamixaban • Direct thrombin inhibitors (DTIs): bivalirudin, dabigatran

  23. Bleeding risks

  24. UFH

  25. LMWH

  26. Bivalirudin

  27. Fondaparaneux

  28. Discharge

  29. Take Home Points • Initial therapy for everyone • think ASA and nitrates • Be careful with BB, CCB, morphine • Consider ace inhibitors • Pick an anti-platelet...or two...or three... • Plavix in everyone at 300mg • Talk to cardio about prasugrel or ticagrelor • Leave the GPI until they go to PCI • Protect the stomach! • PPIs show more benefit than harm • Pick an anti-coagulant • UFH if high risk or going to CABG • Enox or Bivalirudin if going to PCI • Fonda if conservative strategy or high risk for bleeding • For the ones sent home... • ASA and Plavix for at least 1 month • Stress test within 72 hours

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