Therapy

Treat symptoms rather than ECG changes ^d

Give

• oxygen ^d
• aspirin 75 to 325 mg long-term ^a and clopidogrel ^a (300 mg loading dose, followed by 75 mg daily for up to 12 months)

Less effective alternatives include ticlopidine ^a  

with ^a any of

• a low-molecular weight heparin (LMWH) ^a for up to 7 days (e.g. enoxaparin 1 mg/kg daily) ^a
• heparin ^d  
• hirudin ^a

Start a beta-blocker ^a or a calcium channel blocker (e.g. dilitazem ^a or verapamil) ^a  
For patients already on a beta-blocker, add a calcium channel blocker ^a
For patients already on calcium channel blockers, add a beta-blocker ^a if possible

Consider adding long-acting nitrates ^c

With ECG changes or elevated cardiac enzymes

• Add a platelet glycoprotein IIb/IIIa inhibitor ^a e.g. tirofiban or eptifibatide ^a
  Avoid using 
  • abciximab ^a
  • oral glycoprotein IIb/IIIa inhibitors. ^a

  There is no clear benefit from using 

  • a platelet glycoprotein IIb/ IIIa inhibitor alone. ^d  
  • lamifiban ^d
    

For patients with any of the following:

• new ST depression of at least 0.5 mm, transient (< 20 min) ST elevation of at least 1 mm, or T wave inversion of at least 3 mm in 2 or more leads
• elevated cardiac markers
• history of coronary disease from catheterisation, revascularisation or myocardial infarction

arrange for urgent angiography and revascularisation if required as soon as possible ^a

With severe refractory ischaemia

Consider

• adding a glycoprotein IIb/ IIIa inhibitor ^a  
• adding nicorandil ^a  
• thoracic epidural anaesthesia ^a  
• adding n-acetylcysteine to nitrates ^{a b}
• angiography and revascularisation

There is no clear benefit from thrombolysis ^a 

Avoid anticoagulation ^a

Angioplasty

Assess your patient for risk of complications ^a before deciding on angioplasty 

• Look for
  • aortic valve disease ^a  
  • shock ^a  
  • acute myocardial infarction within 24 hours of coronary angioplasty ^a
  • unstable angina ^{a b}  
  • complex lesion on coronary angioplasty ^{a b}
  • left main coronary artery lesions ^a  
  • multivessel disease ^{a b}

Arrange for angioplasty by an experienced physician in a busy centre. ^b 

Give a glycoprotein IIb/ IIIa antagonist ^a e.g. abciximab and heparin ^b   

Consider 

• giving probucol ^a
• intracoronary gamma radiation therapy following opening of stenosed coronary stents ^a

There is no clear benefit from:

• atherectomy ^a  
• multivitamins ^a  

Coronary artery bypass surgery

• multivessel disease or left main artery disease ^a
• poor left ventricular function ^a
• severe angina ^a
• an abnormal exercise tolerance test ^a

Consider giving acadesine perioperatively. ^a  

Refractory angina, but unfit for angioplasty or CABG

Offer any of 

• transmyocardial laser revascularisation ^a
• spinal cord stimulation surgery  ^a