We are proud to present CAPSULES module 6: Pharmacology of Acute Coronary Syndromes, now published on the Academic Life in EM University (ALiEMU) website. Here is a summary of the key points from this outstanding module by Drs. Paul Takamoto and Glen Oettinger.

Course Contributors

Role Team Member Background Authors Paul Takamoto, PharmD

@ptakpharm Emergency Medicine Pharmacist, University of California San Francisco Glenn Oettinger, PharmD, BCPS

@glennoettinger Emergency Medicine Pharmacist, Thomas Jefferson University PharmD Reviewer Craig Cocchio, PharmD, BCPS

@iEMPharmD Emergency Medicine Pharmacist, Trinity Mother Frances Hospital Physician Reviewer David Juurlink, BPharm, MD, PhD, FRCPC

@DavidJuurlink Professor of Medicine, University of Toronto Creator and Lead Editor Bryan Hayes, PharmD, FAACT

@pharmertoxguy Emergency Medicine Pharmacist, Clinical Associate Professor; University of Maryland Chief of Design and Development and Co-Founder of ALiEMU Chris Gaafary, MD

@cgaafary EM Chief Resident, University of Tennessee Chattanooga

Go to ALiEMU module

Summary: Pharmacology of Acute Coronary Syndromes

Primary Reperfusion Strategies

American Heart Association (AHA) and American College of Cardiology (ACC) recommend early-as-possible reperfusion strategies for acute STEMI management

Primary goal of first medical contact to device time <90 minutes; <2 hours if transporting patients from non-PCI capable site to a cardiac catheterization lab; strong consideration for fibrinolytics if potential delay anticipated (door-to-needle <30 minutes from arrival)

Prehospital fibrinolytic administration; consider in participating communities

Benefit of fibrinolytics weaker when administered beyond 12 hours of symptom onset

The appropriate and timely use of some form of reperfusion therapy (PCI or fibrinolysis) is likely more important than the choice of therapy

Morphine-Oxygen-Nitrates-Aspirin (MONA)

Each intervention can be beneficial and in certain cases potentially harmful

Morphine is primary analgesic recommended for nitrate-refractory chest pain during ACS

Supplemental oxygen should not be provided unless patient exhibits persistent dyspnea with evidence of hypoxia

Aspirin is only pharmacologic intervention of these 4 treatments with mortality benefit; rapid absorption occurs with chewable, non-enteric coated formulations; chew enteric coated tablets

Antiplatelet

As part of the overall treatment, an antithrombotic cocktail comprised of a P2Y12 inhibitor in addition to aspirin, is indicated for all patients with N-STEMI

Anticoagulation

All patients with NSTEMI, regardless of initial treatment strategy, should receive anticoagulation in addition to antiplatelet therapy

Most experts agree, patients undergoing primary PCI should receive UFH or bivalirudin, although enoxaparin is an acceptable alternative in some circumstances

GP IIb/IIIa inhibitors

For patients undergoing PCI who are also receiving heparin and clopidogrel, consider intravenous GP IIb/IIIa inhibitors like abciximab, high bolus dose tirofiban or double-bolus dose eptifibatide

GP IIb/IIIa inhibitor therapy may also be deferred until completion of cardiac catheterization to better determine appropriate therapy for diagnosis

Preparation for CABG

Regardless of initial treatment strategy, patients with NSTEMI should receive anticoagulation in addition to dual-antiplatelet therapy

For patients with high-risk features (i.e. positive troponin) scheduled for PCI who are also receiving heparin and clopidogrel, consider an intravenous GP IIb/IIIa inhibitor such as eptifibatide or tirofiban

Post-PCI drugs

Early administration of beta-blockers does not suggest short-term survival benefit; caution in low output states

After initial reperfusion strategy ACE/ARBS should be initiated in all ACS patients with hypertension, diabetes mellitus, stable CKD, and significant LV dysfunction

Statins are standard component of primary and secondary cardiovascular prevention and should be initiated (high-dose) after PCI

Aldosterone antagonists (eplerenone and spironolactone) may provide additional benefit for patients with new LV dysfunction or heart failure after ACS

What is the CAPSULES series?

The CAPSULES series is a free, online e-curriculum of high-quality, current, and practical pharmacology knowledge for the EM practitioner. About once a month a new course module is released, which has lessons to read about (or watch) and brief quizzes to complete. With each step, your personal dashboard will keep track of what you have completed. The CAPSULES series’ primary focus is bringing EM pharmacology education to the bedside. Our expert team distills complex pharmacology principles into easy-to-apply concepts. It’s our version of what-you-need-to-know as an EM practitioner.

