For a patient with suspected acute coronary syndrome who has already received an antihypertensive, an anticoagulant, and IV glyceryl trinitrate (GTN) at 2.6 µg/min, what additional medications and interventions are recommended according to guidelines?

Additional Management for Suspected Acute Coronary Syndrome

Immediate Antiplatelet Therapy

You must add aspirin 162-325 mg immediately (chewed, non-enteric-coated) if not already given, followed by 75-100 mg daily maintenance indefinitely. 1, 2

• Add a P2Y12 inhibitor (clopidogrel, ticagrelor, or prasugrel) on top of aspirin for dual antiplatelet therapy 1
• Ticagrelor (180 mg loading, then 90 mg twice daily) is preferred over clopidogrel due to superior outcomes in reducing cardiovascular death, MI, and stroke 1, 3
• Clopidogrel 300-600 mg loading dose followed by 75 mg daily is an acceptable alternative if ticagrelor is unavailable or contraindicated 1, 3
• Prasugrel (60 mg loading, 10 mg daily) should only be given after coronary anatomy is known and PCI is planned, not as upstream therapy 1, 4

Beta-Blocker Therapy

Initiate oral beta-blockers within the first 24 hours in the absence of heart failure, low-output state, risk for cardiogenic shock, or other contraindications. 1

• Target heart rate 50-60 beats per minute to reduce myocardial oxygen demand 2
• Intravenous beta-blockers are potentially harmful when risk factors for shock are present 1
• Continue chronic beta-blocker therapy unless the patient is in overt heart failure 1

Risk Stratification and Invasive Strategy Timing

Perform immediate invasive strategy (<2 hours) if any very high-risk features are present: 1, 2

• Hemodynamic instability or cardiogenic shock
• Refractory or recurrent chest pain despite medical therapy
• Life-threatening arrhythmias or cardiac arrest
• Acute heart failure clearly related to ACS
• ST-segment depression >1 mm in ≥6 leads with ST elevation in aVR and/or V1

Perform early invasive strategy (<24 hours) if any high-risk features are present: 1, 2

• Elevated cardiac troponin with dynamic or presumably new ST/T-segment changes
• GRACE risk score >140
• Diabetes mellitus as a high-risk feature

Statin Therapy

Initiate or continue high-intensity statin therapy immediately with no contraindications, regardless of baseline LDL levels. 1, 2, 3

• Target LDL cholesterol reduction ≥50% 2
• Obtain fasting lipid profile preferably within 24 hours 1

Oxygen and Monitoring

• Administer supplemental oxygen only if arterial oxygen saturation <90%, respiratory distress, or other high-risk features of hypoxemia 1
• Admit to intensive care or coronary care unit with continuous telemetry monitoring for at least 24 hours 1, 3

Additional Anti-Ischemic Therapy

• Continue intravenous nitroglycerin for persistent ischemia, heart failure, or hypertension 1
• Morphine sulfate IV may be reasonable for continued ischemic chest pain despite maximally tolerated anti-ischemic medications 1

Critical Contraindications to Avoid

Do not administer nitrates if the patient has used phosphodiesterase inhibitors (sildenafil or vardenafil within 24 hours, tadalafil within 48 hours). 1

Discontinue NSAIDs (except aspirin) immediately during hospitalization due to increased risk of mortality, reinfarction, hypertension, heart failure, and myocardial rupture. 1, 3

Anticoagulation Duration and Management

• Continue unfractionated heparin for at least 48 hours or until discharge if given before diagnostic angiography 1
• Continue enoxaparin or fondaparinux for duration of hospitalization, up to 8 days, if given before diagnostic angiography 1
• Do not switch between anticoagulants as this increases bleeding risk 3

Common Pitfalls

• Do not use CK-MB or myoglobin for diagnosis with contemporary troponin assays available 1
• Remeasure troponin at 3-6 hour intervals if initial measurements are inconclusive 1, 2
• Obtain echocardiography to evaluate left ventricular function and rule out differential diagnoses 2
• Measure left ventricular ejection fraction in all patients; if LVEF ≤0.40, perform diagnostic angiography 1, 3