From the Guidelines
The first line of medicine for unstable angina is a combination of antiplatelet and anticoagulant therapy, including aspirin, a P2Y12 inhibitor such as clopidogrel, and anticoagulation with low molecular weight heparin, as recommended by the European Heart Journal in 2002 1. This approach is supported by the European Society of Cardiology's guidelines for the management of acute coronary syndromes without persistent ST-segment elevation, which emphasize the importance of early medical treatment, including aspirin, clopidogrel, and low molecular weight heparin, as well as the use of GP IIb/IIIa receptor blockers in high-risk patients 1. The treatment strategy should be based on risk assessment, with high-risk patients receiving more aggressive treatment, including coronary angiography and revascularization procedures such as percutaneous intervention or coronary bypass surgery, as recommended by the European Heart Journal in 2002 1. Key components of the treatment regimen include:
- Aspirin (325 mg loading dose followed by 81-325 mg daily)
- Clopidogrel (300-600 mg loading dose followed by 75 mg daily)
- Low molecular weight heparin, such as enoxaparin
- Nitrates (sublingual nitroglycerin 0.4 mg every 5 minutes for up to 3 doses) for immediate symptom relief
- Beta-blockers (such as metoprolol 25-50 mg orally every 6 hours) started within 24 hours if there are no contraindications
- High-intensity statins (atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily) initiated promptly These medications work together to stabilize the ruptured plaque, prevent further thrombosis, reduce myocardial oxygen demand, and relieve symptoms, ultimately improving morbidity, mortality, and quality of life for patients with unstable angina.
From the FDA Drug Label
Clopidogrel tablets are indicated to reduce the rate of myocardial infarction (MI) and stroke in patients with non–ST-segment elevation ACS (unstable angina [UA]/non–ST-elevation myocardial infarction [NSTEMI]), including patients who are to be managed medically and those who are to be managed with coronary revascularization Clopidogrel tablets should be administered in conjunction with aspirin.
The first line of medicine for unstable angina is clopidogrel in conjunction with aspirin 2.
- The recommended dose is a single 300 mg oral loading dose, followed by 75 mg once daily.
- It is essential to note that clopidogrel is a prodrug that requires conversion to an active metabolite by the cytochrome P450 system.
- Patients with impaired CYP2C19 function may have reduced antiplatelet activity.
From the Research
First Line of Medicine for Unstable Angina
The first line of medicine for unstable angina includes:
- Aspirin, which should be given as soon as possible and continued indefinitely 3, 4, 5, 6
- Oral isosorbide dinitrate, which should be started immediately after admission 3
- Beta-blockers and angiotensin-converting enzyme (ACE) inhibitors, which should be given and continued indefinitely 5, 7
- Ca antagonist, which should be added according to the symptoms 3
- Clopidogrel, which should be given for up to 9 months in patients in whom an early noninterventional approach is planned or in whom a percutaneous coronary intervention (PCI) is planned 5, 7
Additional Therapies
Additional therapies that may be considered include:
- Intravenous nitroglycerin, which should be started if ischemic symptoms continue after administration of oral medical treatments 3, 5, 7
- Heparin, which should be started if ischemic symptoms continue after administration of oral medical treatments 3, 4, 5, 7
- Glycoprotein IIb/IIIa inhibitors, which should be given in addition to aspirin, clopidogrel, and heparin in patients in whom cardiac catheterization and PCI are planned 4, 5, 7
- K channel opener (nicorandil), which may be effective to stabilize the symptom 3
- Statins, which should be used if the serum low-density lipoprotein (LDL) cholesterol is >or=100 mg/dl and continued indefinitely 5, 7