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Non-ST Elevation ACS Medical Therapy Algorithm

Non-ST Elevation ACS Medical Therapy Algorithm - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Cardiovascular, Related

UW Health Non-STE ACS Medical Therapy Algorithm
Patient with Definite or Likely Non-ST Elevation ACS
Postadmission Medical Therapy (Floor- CVM)
1. Continue pharmacotherapy initiated in ED
ξ Anticoagulation (enoxaparin or IV heparin) should be continued for
duration of hospitalization or until PCI is performed
ξ Anticoagulation does not need to be held on the morning of
planned coronary angiogram
2. Administer additional pharmacotherapy:
ξ Beta Blocker (AHA Class I, LOE A)
ξ ACE-I (or ARB if intolerant) if EF < 40%, hypertension, diabetes , or
stable CKD (AHA Class I, LOE A)
ξ Aldosterone blockade (i.e., spirlactone or eplereone) if EF < 40%,

diabetes, or heart failure and no significant renal dysfunction (Cr >
2.5 mg/dL in men or > 2.0 mg/dL in women) or hyperkalemia (K >
5.0 mEq/L) (AHA Class I, LOE A)
ξ Atorvastain (80 mg daily) (AHA Class I, LOE A)

Administer supplemental oxygen if saturations < 90% or in
respiratory distress (AHA Class I, LOE C)
4. Maintain nutrition status of NPO (expect medications)
5. Repeat ECG with any new symptoms
6. Complete laboratory tests (if not completed in ED):
ξ Troponin (every 6 hours until peak or 3 negative results)(AHA Class I,
ξ Lipid Profile (AHA Class Iia, LOE C)
ξ CBC without differential
ξ BMP (Na, K, Cl, total CO2, glucose, BUN, Cr, Ca)
ξ A1c
ξ PT/INR (if patient on coumadin)

Obtain transthoracic echocardiogram (TTE) for EF assessment to aid
risk stratification (AHA Class I, LOE C)
8. Consult Cardiac Rehabilitation
Risk Stratification to determine initial therapy strategy using TIMI
risk score and/or Grace risk model
Last Revised: 06/2015 | Contact CCKM for revisions.
UW Health Management of Non-ST Elevation Acute Coronary Syndromes – Adult – Inpatient/Ambulatory Guideline
NOTE: Invasive strategy is not recommended in patients with extensive co-
morbidities (hepatic, renal (CKD stage > 4), pulmonary failure, or cancer) in whom
the risks likely outweigh the benefits of revascularization.
Confirm clopidogrel
loading dose (600 mg)
Perform PCI
Anticoagulation during
procedure to be determined by
Interventional Cardiology, with
preference for unfractionated
heparin (AHA Class I, LOE B) if low
bleed risk and bivalirudin(AHA
Class I, LOE B) if high bleed risk.
Perform CABG

Initiate or continue aspirin
therapy (AHA Class I, LOE B)

Hold ACE-I or ARB on day of

Refer to guideline for timing of
other antiplatelet therapy
cessation before surgery
(AHA Class I, LOE B)
1. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes:
A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130(25):e344-426.
Initial Medical Therapy (ED Initiation)

Administer initial pharmacotherapy:

ξAspirin(325 mg STAT; 81 mg daily) (AHA Class I, LOE A)
Avoid all other NSAIDs (AHA Class III, LOE B)
ξClopidogrel (600 mg loading; 75 mg daily) (AHA Class I, LOE B)
ξEnoxaparin (1 mg/kg subcutaneous Q12 hrs) (AHA Class I, LOE A)
If CKD, administer heparin instead (60 IU/kg initial dose; 12 IU/
kg/hr infusion) (AHA Class I, LOE B)
ξNitroglycerin (0.4 mg Q5 min up to 3 doses) (AHA Class I, LOE C)

If HTN, heart failure or pain persists, consider IV. (AHA Class I, LOE

Do not administer if recent use of PDE-5 inhibitors (i.e., 24
hrs. since sildenafil/vardenafil dose, or 48 hrs. since tadalfil
dose) (AHA Class III, LOE B)
ξMorphine (if ischemic pain persists despite max. tolerated
nitrates) (AHA Class Iib, LOE B)
2. Administer supplemental oxygen if saturation < 90% or
patient is in respiratory distress. (AHA Class I, LOE C)
Risk stratification using
noninvasive imaging
Perform diagnostic cardiac cath
normal or mildly
Refer to NSTE-ACS Discharge Checklist
Medical Management
Continue medications required to
control ischemia after discharge in
patients who do not undergo
coronary revascularization, patients
with incomplete/unsuccessful
revascularization, or those with
recurrent symptoms after
revascularization (AHA Class I, LOE C)
Yes No
Yes No
Copyright © 201 5 University of Wisconsin Hospital s and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2015CCKM@uwhealth.org