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. Plavix vs 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

25. UFH

26. LMWH

27. Bivalirudin

28. Fondaparaneux

29. Discharge

30. 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