Topic Refresher: Acute Coronary Syndrome Medications

Knowmedge Topic Refreshers is a series of medical concept reviews that offer quick and comprehensive recaps of essential medical topics for the USMLE Step 3, Internal Medicine, Family Medicine, COMLEX, PANCE, PANRE, and Pediatrics Board Exams.

In this topic refresher, we review the medications commonly used for treating Acute Coronary Syndrome (ACS).

Although the initial management of the different types of acute coronary syndrome is similar, it is important to distinguish between whether the patient is having an episode of Unstable Angina, ST-elevation MI or a non–STEMI (NSTEMI), because definitive therapies differ between these three types. Particular considerations and differences involve the urgency of therapy and the degree of evidence regarding different pharmacologic options.

Acute Coronary Syndrome Medications

All ACS patients are initially managed with Oxygen, IV nitroglycerin, and a pain killer. However, none of these reduce mortality in a patient presenting with acute myocardial infarction.

Thus, it is essential to give Aspirin as soon as possible. Aspirin is an antiplatelet drug that changes the balance between prostacyclin (which inhibits platelet aggregation) and thromboxane (that promotes aggregation).

Additional antiplatelet medicines like Clopidogrel or Ticagrelor may also be given with aspirin. These medicines work in a different way to aspirin and add to the action of reducing platelet aggregation. Clopidogrel can also be used instead of aspirin if a patient is allergic to aspirin.

High risk patients are given glycoprotein llb/Illa receptor antagonist intravenously which helps to relieve pain and works to reduce the chances of blood clots. Gp IIb/IIIa inhibitors like Abciximab,Eptifibatide or Tirofiban are also given before angioplasty.

Beta-Blockers help decrease the rate and force of contraction by blocking adrenaline. Additionally, Beta blockers prevent cardiac arrhythmias from developing. Beta-Blockers also have long-term protective effect on the heart muscle and reduce risk of having myocardial infarction in the future. However, the role of Beta Blockers in decreasing mortality is not time dependent, hence there can be a delay in starting Beta Blockers , unlike Aspirin, which needs to be administered immediately.

Both angiotensin-converting enzyme (ACE) inhibitors and Statins reduce mortality in a patient suffering from myocardial infarction. ACE inhibitors have a number of actions, including having a protective effect on the heart. Statins lower blood cholesterol level and helps to prevent build-up of fatty plaques (called atheroma).

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