American Journal of Emergency Medicine
Volume 29, Issue 4 , Pages 446-456, May 2011

Upstream treatment of acute coronary syndrome in the ED☆

  • J. Douglas Kirk, MD

      Affiliations

    • Department of Emergency Medicine, University of California, Davis, Medical Center, Sacramento, CA 95817, USA
    • Corresponding Author InformationCorresponding author. Department of Emergency Medicine, University of California, Davis, Medical Center, Sacramento, CA 95817, USA. Tel.: +1 916 734 5010; fax: +1 916 734 7950.
    • ,
  • Michael Kontos, MD

      Affiliations

    • Cardiology Division, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA 23298, USA
    • ,
  • Deborah B. Diercks, MD

      Affiliations

    • Department of Emergency Medicine, University of California, Davis, Medical Center, Sacramento, CA 95817, USA

Received 9 December 2009; received in revised form 22 January 2010; accepted 23 January 2010. published online 03 May 2010.

Abstract 

Rapid risk stratification, selection of downstream management options, and institution of initial pharmacotherapy are essential to ensure that patients admitted to the emergency department with acute coronary syndromes receive optimal care. A broad range of antiplatelet and antithrombotic medications is available that permits tailoring of initial pharmacotherapy to each patient's risk status. In the urgent setting, thienopyridines (clopidogrel and prasugrel) carry limitations including response variability and increased risk for bleeding in patients requiring subsequent coronary artery bypass graft surgery. Glycoprotein IIb-IIIa receptor inhibitors, although they are highly effective in preventing ischemic events, must be used with care to reduce bleeding risk. Bivalirudin, a relatively new direct thrombin inhibitor, represents another upstream option but is costly and does not have approval for this indication. Simplified institutional management paradigms can streamline the process of selecting appropriate pharmacotherapy and aid in care delivery that will optimize patient outcomes.

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☆ Editorial assistance for this article was provided by Rina Kleege, MS. This assistance was funded by Schering Corp, a division of Merck and Co., Whitehouse Station, NJ.

PII: S0735-6757(10)00025-2

doi:10.1016/j.ajem.2010.01.023

American Journal of Emergency Medicine
Volume 29, Issue 4 , Pages 446-456, May 2011

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