Standard Medications and Dosages for Acute Coronary Syndrome (ACS) Treatment
All patients with ACS should receive aspirin 162-325 mg loading dose (chewed if non-enteric coated) immediately upon presentation, followed by 75-100 mg daily maintenance indefinitely, combined with a P2Y12 inhibitor (preferably ticagrelor or prasugrel over clopidogrel) and parenteral anticoagulation. 1
Antiplatelet Therapy
Aspirin
- Loading dose: 162-325 mg orally (non-enteric coated, chewed for faster onset) 1
- Maintenance dose: 75-100 mg daily (preferred) or up to 325 mg daily 1
- Continue indefinitely unless contraindicated 1
P2Y12 Inhibitors (Dual Antiplatelet Therapy)
For NSTE-ACS:
- Ticagrelor (preferred): 180 mg loading dose, then 90 mg twice daily 1
- Clopidogrel: 300-600 mg loading dose, then 75 mg daily 1, 3
- Continue for up to 12 months 1
For STEMI with Primary PCI:
- Prasugrel or ticagrelor (preferred): 1
- Clopidogrel: Use only when prasugrel/ticagrelor unavailable or contraindicated 1
For STEMI with Fibrinolytic Therapy:
- Clopidogrel: 300 mg loading dose if age ≤75 years; 75 mg (no loading dose) if age >75 years, then 75 mg daily 1
Parenteral Anticoagulation
Choose ONE of the following options 1:
Enoxaparin (Preferred for most patients)
- Dosing: 1 mg/kg subcutaneous every 12 hours 1
- Renal adjustment: 1 mg/kg once daily if creatinine clearance <30 mL/min 1
- Optional: 30 mg IV loading dose in selected patients 1
- Continue for duration of hospitalization or until PCI performed 1
Bivalirudin
- Dosing: 0.10 mg/kg IV loading dose, then 0.25 mg/kg/hour infusion 1
- Use for early invasive strategy only 1
- Allows provisional (not routine) use of GP IIb/IIIa inhibitors 1
Fondaparinux
- Dosing: 2.5 mg subcutaneous daily 1
- Continue for duration of hospitalization or until PCI 1
- Critical: Must add additional anticoagulant with anti-IIa activity during PCI 1
Unfractionated Heparin
- Dosing: 60 IU/kg IV bolus (maximum 4000 IU), then 12 IU/kg/hour infusion (maximum 1000 IU/hour) 1
- Adjust to therapeutic aPTT range 1
- Continue for 48 hours or until PCI 1
GP IIb/IIIa Inhibitors (Selective Use)
- Consider: Eptifibatide or tirofiban in high-risk patients (positive troponin) undergoing early invasive strategy with dual antiplatelet therapy 1
- Class IIb recommendation - may be reasonable but not routinely indicated 1
Additional Essential Medications
Beta-Blockers
- Recommended for all ACS patients without contraindications 1
- Particularly important for symptom control and mortality reduction 1
Statins
- High-intensity statin therapy recommended for all ACS patients 1, 4
- Atorvastatin 80 mg daily demonstrates superior outcomes 4
- Add ezetimibe if LDL goals not achieved on maximum statin dose 1
ACE Inhibitors
- Recommended for all ACS patients, especially with heart failure, hypertension, diabetes, or LV dysfunction 1
- ARBs are acceptable alternatives if ACE inhibitors not tolerated 1
Nitroglycerin
- Acute relief: Sublingual or spray for immediate symptom relief 1
- Dosing instruction: If angina persists >3-5 minutes after first dose, call emergency services 1
Gastrointestinal Protection
Proton Pump Inhibitors
- Mandatory: For patients with history of GI bleeding on triple antithrombotic therapy 1
- Reasonable: For all patients on dual antiplatelet therapy or anticoagulation at high GI bleeding risk 1
Critical Pitfalls to Avoid
- Never use enteric-coated aspirin initially - delayed and reduced absorption 1
- Never use NSAIDs for pain management - associated with increased MACE risk; use acetaminophen or short-acting opioids instead 1, 2
- Never use fibrinolytic therapy in NSTE-ACS - associated with harm 1
- Never use high-dose aspirin (≥160 mg) long-term - increases bleeding without improving outcomes 1
- Never combine ticagrelor or prasugrel with oral anticoagulation as triple therapy - use clopidogrel instead 1
- Never delay aspirin administration - should be given immediately upon ACS presentation 1, 2