Does timing matter? Upstream or downstream administration of antiplatelet therapy
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Fig. 1
Algorithm for patients with unstable angina and non–ST-segment-elevation myocardial infarction managed by an initial invasive strategy [2] (adapted from Anderson et al [2] , with permission from the American College of Cardiology). 
Evidence exists that glycoprotein IIb-IIIa inhibitors may not be necessary if the patient received a preloading dose of >300 mg clopidogrel at least 6 hours earlier, and bivalirudin has been selected as the anticoagulant. ASA indicates aspirin; GP, glycoprotein; IV, intravenous; US/NSTEMI, unstable angina/non–ST-elevation myocardial infarction.
Fig. 2
Algorithm for patients with unstable angina and non–ST-segment-elevation myocardial infarction managed by an initial conservative strategy [2] (adapted from Anderson et al [2] , with permission from the American College of Cardiology). Abbreviations are explained in Fig. 1 .
Fig. 3
Non–ST-elevation myocardial infarction risk score of NRMI. In-hospital mortality for patients receiving early glycoprotein IIb-IIIa inhibitor treatment vs those not treated, by the non–ST-elevation myocardial infarction risk score of NRMI. Among all risk strata, in-hospital mortality rates were lower in patients treated with a GP IIb-IIIa inhibitor than in those not so treated. In particular, the absolute treatment differences tended to be widest among those with intermediate to high baseline risk [36] (reprinted from Peterson et al [36] , with permission from the American College of Cardiology). Abbreviations are explained in Fig. 1 .
Fig. 4
Ischemic end points in the CURE trial were reduced within 24 hours of randomization [40] (adapted from Yusuf et al [40] ). RR, relative risk; RRR, relative risk reduction.
Abstract
Current treatment guidelines recommend an early, aggressive strategy in patients with non–ST-elevation acute coronary syndromes. Administration of antiplatelet therapy—a glycoprotein IIb-IIIa inhibitor with or without clopidogrel—before catheterization in patients with high-risk features confers substantially reduced risk of ischemic events while potentially increasing bleeding risk. Strategies for risk stratification are therefore important in the emergency department, with appropriate pharmacotherapy. This review will examine implications of the new guidelines for management of patients with unstable angina/non–ST-elevation myocardial infarction for emergency physicians, review current risk stratification paradigms, and evaluate appropriate use and timing of administration of glycoprotein IIb-IIIa inhibitors and clopidogrel for patients at varying levels of risk. We will also examine mechanisms for generating institutional care pathways that can enhance consistency and quality of care as well as communication among members of the medical team responsible for caring the patient with acute coronary syndrome.
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