Acute Coronary Syndrome Management

Nitrate Administration

• The American College of Cardiology and American Heart Association recommend administering nitrates to patients with STEMI or NSTEMI for relief of ischemia, management of hypertension, or treatment of heart failure, with initial treatment starting with sublingual nitroglycerin (NTG) 0.4 mg every 5 minutes for a total of 3 doses, and assessment of the need for intravenous NTG after initial sublingual doses, but not to patients with systolic blood pressure <90 mmHg, severe bradycardia, tachycardia without heart failure, right ventricular infarction, or recent use of phosphodiesterase inhibitors 1, 2, 3, 4
• Nitrates are indicated in the first 48 hours after STEMI/NSTEMI for persistent ischemia, heart failure, and hypertension, and should not preclude therapy with other mortality-reducing interventions such as beta-blockers or ACE inhibitors 2, 3

Contraindications and Precautions

• Nitrates are contraindicated in patients with systolic blood pressure <90 mmHg or ≥30 mmHg below baseline, severe bradycardia (<50 beats per minute), tachycardia (>100 beats per minute) without symptomatic heart failure, right ventricular infarction, or recent use of phosphodiesterase-5 inhibitors (within 24 hours of sildenafil use, within 48 hours of tadalafil use) due to the risk of severe hypotension 1, 2, 3, 4

Other Medications

• Beta-blockers should be administered within 24 hours (via oral route) in patients without contraindications, according to the American College of Cardiology 2, 3
• Non-dihydropyridine calcium channel blockers (verapamil or diltiazem) can be considered in patients who are contraindicated for beta-blockers, in the absence of severe LV dysfunction 2, 3
• ACE inhibitors should be administered within 24 hours to patients with pulmonary congestion or LVEF ≤0.40, as recommended by the American Heart Association 2, 3
• The American College of Cardiology and Circulation guidelines recommend initiating intravenous nitroglycerin at a low dose (5-10 μg/min) and gradually increasing every 3-5 minutes until symptoms are relieved or a blood pressure response is achieved, with frequent hemodynamic monitoring to minimize the risk of hypotension 2