8
Treatment
Table 6. Standard Medical Therapies
Recommendations
COR LOE
Oxygen
Supplemental oxygen should be administered to patients with
NSTE-ACS with arterial oxygen saturation <90%, respiratory
distress, or other high-risk features of hypoxemia.
I C
Nitrates
Patients with NSTE-ACS with continuing ischemic pain should
receive sublingual nitroglycerin (0.3-0.4 mg ) every 5 min for ≤3
doses, aer which an assessment should be made about the need for
intravenous nitroglycerin if not contraindicated.
I C
Intravenous nitroglycerin is indicated for patients with NSTE-ACS
for the treatment of persistent ischemia, HF, or hypertension.
I B
Nitrates should NOT be administered to patients with NSTE-ACS
who recently received a phosphodiesterase inhibitor, especially
within 24 h of sildenafil or vardenafil, or within 48 h of tadalafil.
III:
Harm
B
Analgesic therapy
In the absence of contraindications, it may be reasonable to
administer morphine sulfate intravenously to patients with NSTE-
ACS if there is continued ischemic chest pain despite treatment
with maximally tolerated anti-ischemic medications.
IIb B
NSAIDs (except ASA) should NOT be initiated and should be
discontinued during hospitalization for NSTE-ACS because of the
increased risk of MACE associated with their use.
III:
Harm
B
Beta-adrenergic blockers
Oral beta-blocker therapy should be initiated within the first 24 h
in patients who do not have any of the following : 1) signs of HF, 2)
evidence of low-output state, 3) increased risk for cardiogenic shock,
or 4) other contraindications to beta blockade (e.g., PR interval
>0.24 second, second- or third-degree heart block without a cardiac
pacemaker, active asthma, or reactive airway disease).
I A
In patients with concomitant NSTE-ACS, stabilized HF, and
reduced systolic function, it is recommended to continue beta-
blocker therapy with 1 of the 3 drugs proven to reduce mortality in
patients with HF: sustained-release metoprolol succinate, carvedilol,
or bisoprolol.
I C
Patients with documented contraindications to beta blockers in the
first 24 h of NSTE-ACS should be reevaluated to determine their
subsequent eligibility.
I C
It is reasonable to continue beta-blocker therapy in patients with
normal LV function with NSTE-ACS.
IIa C
Administration of intravenous beta blockers is potentially harmful
in patients with NSTE-ACS who have risk factors for shock.
III:
Harm
B
