Includes unstable angina and non-ST elevation myocardial infarction (NSTEMI)  

1. Start on continuous telemonitoring and supplemental O2 as needed to maintain SpO2 >90%  

2. Give Aspirin 162 to 325 mg to be chewed and swallowed. If unable to take PO give as rectal suppository  

3. Obtain serial EKG’s and trend troponins (every 4 to 6 hrs)  

3. Give sublingual Nitroglycerin tablets (0.4 mg) every five minutes for maximum of three doses except in patients with hypotension or those using phosphodiesterase inhibitors. In patients with persistent symptoms, start on Nitroglycerin drip at 10 mcg/min and increase the drip rate by 10 mcg/min every 5 minutes until pain resolves or systolic BP falls below 100 mmHg  

4. Clopidogrel loading dose of 300 mg once, and then continue with 75 mg daily  

5. Give IV Heparin (UFH) bolus of 60 units/kg (maximum of 4000 units), followed by a continuous IV infusion of 12 units/kg/hour (maximum 1000 units/hour) adjusted per pharmacy protocol to achieve a goal aPTT of approximately 50 to 70 seconds. Heparin infusion is typically continued for 48 hours  

6. IV Morphine as needed for persistent chest pain or severe anxiety related to ischemia  

7. Check electrolytes, Keep K > 4 and Mg > 2  Start on high intensity statin therapy such as Atorvastatin 80 mg daily and check lipid panel  

8. Consider beta blockers such as metoprolol 12.5 mg BID in all patients except those with hypotension, bradycardia, or heart failure  

9. Order ECHO and consult Cardiology  

10. For patients managed conservatively with noninvasive approach (No left heart catheterization),

Rafiq, Amil. Current Hospital Medicine 2023: Quick guide for management of common medical conditions in acute care setting (pp. 70-72). Kindle Edition. 

 

Patients with NSTE-ACS and high-risk factors, such as ongoing chest pain, hemodynamic instability, ventricular arrhythmias, or heart failure, should undergo urgent coronary arteriography.