Nstemi initial dosing guide (Referenced Version)

NSTEMI INITIAL DOSING GUIDE

(Referenced Version)

This dosing guide lists initial drugs and doses that should be highly considered based upon recent clinical practice guidelines, medication package inserts, and emerging evidence.

WEIGHT AND CREATININE CLEARANCE

Determine patient’s weight (kg)

Determine CrCl ml/min = (140 – age) X weight (kg)/(serum creatinine X 72) multiply by 0.85 if female

ORAL ANTIPLATELET AGENTS

 Aspirin: 162 mg to 325 mg non-enteric chewed initially then 81 mg to 162 mg daily (or 162 mg to 325 mg daily after stent implantation).¹

 Clopidogrel: Loading dose 300 mg to 600 mg orally, then daily dose of 75 mg orally²

(Withhold for 5 days if CABG is planned; for BMS and DES ideally continue for at one year)³

ANTICOAGULANT THERAPY

 Unfractionated Heparin:

Bolus: 60 U/kg IV (not to exceed 4000 U)

Infusion: 12 U/kg/hr IV (not to exceed 1000U/hr) to goal aPTT 1.5 to 2.0 times local reference standard; check PTT in 6 hours and adjust heparin as below. ⁴

(Continue for 48 hours or until PCI)
If PTT < 1x control: re-bolus 60 U/kg (max 4000 U) and increase infusion by 2 U/kg/hr

PTT 1 to 1.5x control: increase infusion by 2 U/kg/hr

PTT 1.5 to 2x control (approx 50-70 sec): no change (therapeutic range)

PTT 2 to 3x control: decrease infusion rate by 2 U/kg/hr

PTT > 3x control: stop infusion, recheck PTT in 1 hour, follow algorithm based on repeat PTT
 Enoxaparin: 1 mg/kg subcutaneous every 12 hours (if CrCl < 30mL/min, give 1 mg/kg every 24 hours)

(Continue for the shorter of the duration of hospitalization, 8 days, or until PCI)⁵

 Bivalirudin: Bolus: 0.1 mg/kg IV

Infusion: 0.25 mg/kg/hr IV (caution if CrCl < 30 mL/min)⁶

(Continue for the shorter of the duration of hospitalization, 8 days, or until PCI)
 Fondaparinux: 2.5 mg subcutaneously once daily (avoid if CrCl < 30mL/min)⁷

(Continue for the shorter of the duration of hospitalization, 8 days, or until PCI)

GLYCOPROTEIN IIb/IIIa

 Eptifibatide: Loading: 180 mcg/kg IV bolus

Infusion: 2.0 mcg/kg/min (reduce to 1.0 mcg/kg/min if CrCl < 50mL/min)⁸

 Tirofiban: Loading: 0.4 mcg/kg/min for 30 minutes (reduce to 0.2 mcg/kg/min for CrCl ≤ 30mL/min)

Infusion: 0.1 mcg/kg/min, reduce to 0.05 mcg/kg/min if CrCl ≤ 30mL/min)⁹
 Abciximab: Loading: 0.25 mcg/kg IV bolus (reserve for patients with planned PCI within 12 hours)

Infusion: 0.125 mcg/kg/min IV¹⁰

(Continue for the shorter of the duration of hospitalization, 8 days, or until PCI)


EndNotes

1 Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. J Am Coll Cardiol. 2007;50:e1-e157

2 Anderson JL, Adams CD, Antman EM, et al, 2007, e 37.48.

3 Anderson JL, Adams CD, Antman EM, et al, 2007, e 37.48.

4 Anderson JL, Adams CD, Antman EM, et al, 2007, e 37.

5 Anderson JL, Adams CD, Antman EM, et al, 2007, e 37.

6 Anderson JL, Adams CD, Antman EM, et al, 2007, e 37.

7 Anderson JL, Adams CD, Antman EM, et al, 2007, e 37. 

8 Anderson JL, Adams CD, Antman EM, et al, 2007, e 38.

9 Anderson JL, Adams CD, Antman EM, et al, 2007, e38.

10 Anderson JL, Adams CD, Antman EM, et al, 2007, e38.




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