Dual antiplatelet therapy and antithrombotic therapy is mainstay of treatment
Medical management vs cath determined by level of risk for future cardiovascular events
Aspirin
Recommended dose is 325 mg chewed
Reduces death from MI by 12.5 → 6.4%
Should be used in all ACS unless contraindicated (eg Anaphylaxis)
In pts with true ASA allergies, substitute Clopidogrel
Clopidogrel (see drug link for specific age and indication-related dosages)
Give in addition to ASA
Mortality benefit with<unk>  (CURE trial: Decrease in cardiovascular death, MI, or<unk> roke by 9.3-11.5%)
Main risk and contraindication is bleeding
GPIIb/IIIa Inhibitors
Eptifibatide, abciximab, tirofiban
Benefit only for patients undergoing PCI
Administer at time of PCI, not in the ED
Recommended dose is 325 mg chewed
Reduces death from MI by 12.5 → 6.4%
Should be used in all ACS unless contraindicated (eg Anaphylaxis)
In pts with true ASA allergies, substitute Clopidogrel
Give in addition to ASA
Mortality benefit with<unk>  (CURE trial: Decrease in cardiovascular death, MI, or<unk> roke by 9.3-11.5%)
Main risk and contraindication is bleeding
Eptifibatide, abciximab, tirofiban
Benefit only for patients undergoing PCI
Administer at time of PCI, not in the ED
Give heparin or enoxaparin along with ASA (Class 1A evidence)
Enoxaparin (Lovenox)
1mg/kg subq BID
AHA recommends for moderate & high risk Unstable angina/NSTEMI unless CABG within 24hr
Safer than UFH
ESSENCE trial showed 20% decrease in death, MI or urgent revascularization with LMWH
Adjust for CrCl<30ml and extremes of weight
No need to monitor labs
Unfractionated Heparin
Bolus 60-70u/kg (max 5000) followed by infusion of 12-15u/kg/hr (max 1000/hr), goal ptt 45-75s
Consider if patient likely to undergo PCI/CABG within 24hr of admission or in setting of renal failure
Hirudins
Approved only for patients with HIT
1mg/kg subq BID
AHA recommends for moderate & high risk Unstable angina/NSTEMI unless CABG within 24hr
Safer than UFH
ESSENCE trial showed 20% decrease in death, MI or urgent revascularization with LMWH
Adjust for CrCl<30ml and extremes of weight
No need to monitor labs
Bolus 60-70u/kg (max 5000) followed by infusion of 12-15u/kg/hr (max 1000/hr), goal ptt 45-75s
Consider if patient likely to undergo PCI/CABG within 24hr of admission or in setting of renal failure
Approved only for patients with HIT
Oxygen
Use only if SpO2 <90%
Nitrates (decrease preload)
Administer sublingual nitroglycerin every 5 min x3 for continuing ischemic pain and then assess need for IV nitroglycerin (AHA ACA Level I)
Use cautiously in inferior MI or if on sildenafil
Not shown to decrease MACE
Analgesia
Morphine, Fentanyl, or other opioid (AHA ACA Level IIb)
Do not use NSAIDs other than ASA (AHA ACA Level III: Harm)
Complete absence of pain is likely not feasible - aim for pain level <5
β-blockers<unk> art PO dose within 24 hours (Do not give IV β-blocker in ED (AHA ACA Level III: Harm))
Goal HR is 50-60
Contraindicated if HR<50 or SBP<90, acute CHF, low flow<unk> ate, or PR>240ms
Decreases inotropic and chronotropic response to catecholamines
Use diltiazem if cannot use beta-blocker (nifedipine clearly harmful)
ACE inhibitor<unk> art short-acting (captopril) within 24 hours of admission
Reduces RR of 30 day mortality by 7%
Those with recent MI (especially anterior) and LV dysfunction benefit most
Transfusion
Transfuse to keep hemoglobin >10
Thrombolytics
Not indicated (only useful for<unk> 
Use only if SpO2 <90%
Administer sublingual nitroglycerin every 5 min x3 for continuing ischemic pain and then assess need for IV nitroglycerin (AHA ACA Level I)
Use cautiously in inferior MI or if on sildenafil
Not shown to decrease MACE
Morphine, Fentanyl, or other opioid (AHA ACA Level IIb)
Do not use NSAIDs other than ASA (AHA ACA Level III: Harm)
Complete absence of pain is likely not feasible - aim for pain level <5<unk> art PO dose within 24 hours (Do not give IV β-blocker in ED (AHA ACA Level III: Harm))
Goal HR is 50-60
Contraindicated if HR<50 or SBP<90, acute CHF, low flow<unk> ate, or PR>240ms
Decreases inotropic and chronotropic response to catecholamines
Use diltiazem if cannot use beta-blocker (nifedipine clearly harmful)<unk> art short-acting (captopril) within 24 hours of admission
Reduces RR of 30 day mortality by 7%
Those with recent MI (especially anterior) and LV dysfunction benefit most
Transfuse to keep hemoglobin >10
Not indicated (only useful for<unk> 
Aspirin should be initiated as soon as possible and continued indefinitely in patients who tolerate it. (Level A)
Clopidogrel loading dose should be initiated as soon as possible in patients unable to tolerate aspirin.  (Level B)
Medium/High risk patients in whom initial invasive<unk> rategy is planned should receive dual therapy (Level A) including aspirin (Level A) and:
Before PCI one of the following:
Clopidogrel (Level B)
An IV GP IIb/IIIa inhibitor (Level A) preferably eptifibatide or tirofiban.
Otherwise during PCI one of the following:
Clopidogrel (Level A) if not<unk> arted beforehand
An IV GP IIb/IIIa inhibitor (Level A) preferably eptifibatide or tirofiban.
Prasugrel (Level B)
If an initial conservative (i.e.<unk> invasive)<unk> rategy is selected, clopidogrel should be added to ASA and anticoagulant therapy as soon as possible after admission. (Level B)
If an initial conservative<unk> rategy is selected and recurrent symptoms/ischemia, heart failure, or serious arrhythmias subsequently appear, then diagnostic angiography should be performed. (Level A). Either an IV GP IIb/IIIa inhibitor (Level A) or clopidogrel (Level B) should be added to ASA and anticoagulant therapy before diagnostic angiography. (Level C)
Before PCI one of the following:
Clopidogrel (Level B)
An IV GP IIb/IIIa inhibitor (Level A) preferably eptifibatide or tirofiban.
Otherwise during PCI one of the following:
Clopidogrel (Level A) if not<unk> arted beforehand
An IV GP IIb/IIIa inhibitor (Level A) preferably eptifibatide or tirofiban.
Prasugrel (Level B)
Clopidogrel (Level B)
An IV GP IIb/IIIa inhibitor (Level A) preferably eptifibatide or tirofiban.
Clopidogrel (Level A) if not<unk> arted beforehand
An IV GP IIb/IIIa inhibitor (Level A) preferably eptifibatide or tirofiban.
Prasugrel (Level B)
If an initial conservative<unk> rategy is selected and patient has recurrent ischemic discomfort with clopidogrel, ASA, and anticoagulant therapy, it is reasonable to add a GP IIb/IIIa inhibitor before diagnostic angiography. (Level C)
If an initial invasive<unk> rategy is selected, it is reasonable to omit administration of an IV GP IIb/IIIa inhibitor if bivalirudin is selected as the anticoagulant and clopidogrel was administered at least 6 hours earlier than planned catheterization or PCI. (Level B)
If an initial conservative<unk> rategy is selected, it may be reasonable to add eptifibatide or tirofiban to anticoagulant and oral antiplatelet therapy.19,20 (Level B)
Prasugrel may be considered for administration promptly upon presentation if PCI is planned, before definition of coronary anatomy if both the risk for bleeding is low and the need for CABG is considered unlikely. (Level C)
The use of GP IIb/IIIa inhibitors may be considered in high-risk patients already receiving ASA and a thienopyridine who are selected for an invasive<unk> rategy, such as those with elevated troponin levels, diabetes, or significant<unk> -segment depression, and who are not otherwise at high risk for
bleeding. (Level B)
In patients with definite UA/NSTEMI undergoing PCI, the use of a loading dose of clopidogrel of 600mg, followed by a higher maintenance dose of 150mg daily for 6 days, then 75mg daily may be reasonable in patients not considered at high risk for bleeding. (Level B)
Abciximab should not be administered to patients in whom PCI is not planned. (Level A)
Low risk patients for ischemic events (TIMI risk score 2) or at high risk of bleeding and who are already receiving ASA and clopidogrel, upstream GP IIb/IIIa inhibitors are not recommended. (Level B)
In UA/NSTEMI patients with a prior history of<unk> roke or TIA for whom PCI is planned, prasugrel is potentially harmful as part of a dual-antiplatelet therapy regimen.(Level B)
Non-ST-elevation myocardial infarction
Acute coronary syndromes 
ST-segment elevation myocardial infarction
STEMI
Takotsubo cardiomyopathy
Non-STEMI
Unstable angina
Acute coronary syndrome 