Overview:

The term “Acute Coronary Syndrome” or “ACS” is an umbrella term that describes cardiovascular conditions such as unstable angina (UA), non-ST-elevated myocardial infarction (NSTEMI), and ST-elevated myocardial infarction (STEMI). ACS and cardiovascular disease (CVD) are a prominent cause of death in the US. Based on 2022 data, someone in the US dies from cardiovascular disease every 34 seconds, which accounts for 2580 deaths each day.¹ Due to the high morbidity and mortality associated with ACS, prompt medical treatment is instrumental in survival for patients presenting to the hospital with myocardial infarction. This post will focus on NSTEMI and STEMI pharmacological management and the importance of the pharmacist’s role in the treatment of patients with these conditions.

STEMI/NSTEMI Pharmacotherapy

Analgesics

Patients presenting to the hospital with ACS often are experiencing a significant amount of chest pain due to the present ischemia and lack of oxygen flow to their heart. The most commonly used modes of treatment for pain in these situations are nitrates and opiates. Nitroglycerin is the first-line agent that is administered to patients presenting with chest pain and opiates are often used when the pain is not controlled with nitroglycerin.²

• Recommendation: use effective medications (nitrates and/or opiates) to manage chest pain associated with ACS.
• Nitroglycerin³
  • Dosing:
    • Oral: 0.3 mg or 0.4 mg SL every 5 minutes as needed, up to 3 doses
    • Intravenous: initiate if chest pain persists after max oral nitroglycerin
      • Initial infusion rate: 5-10 mcg/min
      • Do not exceed 400 mcg/min
  • Contraindications⁵:
    • Systolic BP <90 mmHg or ≥30 mmHg below baseline
    • Bradycardia: HR <50 bpm
    • Tachycardia: HR >100 bpm
    • Suspected or known right ventricular infarction
    • PDE5 within the last 24 hours (or 48 hours if tadalafil was used)
    • Hypertrophic cardiomyopathy
    • Severe aortic stenosis
• Morphine²
  • Dosing: 2-4 mg IV every 5-15 minutes as needed
    • Can consider doses up to 10 mg
  • Considerations
    • Reserved for use in patients whose pain is resistant to maximally tolerated nitroglycerin therapy
    • Potential to delay effects of oral PGY12 therapy

Antiplatelets

Antiplatelet therapy is an integral component of the treatment regimen for patients experiencing acute coronary events and reduces risk of death and major adverse cardiovascular events (MACE). The general mechanism by which antiplatelets work to reduce mortality in ACS events it to prevent further clotting by inhibiting platelet aggregation. This helps restore and maintain coronary blood flow and lowers the risk of recurrent ischemic events.²

• Recommendation: All patients with NSTEMI or STEMI should receive aspirin therapy and an oral PGY12 inhibitor (dual anti-platelet therapy or DAPT).
  • PGY12 choice based on clinical characteristics
• Aspirin
  • Dosing:
    • Loading: 162-325 mg PO once
    • Maintenance: 75-100 mg PO once daily
  • Considerations:
    • Loading dose should be administered as soon as possible in patients without an absolute contraindication
    • Chewable form is preferred

• PGY₁₂ Inhibitors (Oral)

Anticoagulation

Similar to antiplatelet therapy, anticoagulation therapy is a cornerstone treatment in patients experiencing ACS and further reduces risk of death and MACE. Anticoagulation therapy complements antiplatelet therapy by inhibiting the formation of fibrin; a protein in the coagulation cascade that is responsible for clot formation.²

• Recommendations:
  • Parenteral anticoagulation is recommended for all patients with NSTEMI or STEMI regardless of treatment strategy to treat the underlying cause of the infarction
  • STEMI patients treated with fibrinolytics should be continued on parenteral anticoagulation for the duration of the hospital stay (maximum of 8 days) or until revascularization

Fibrinolytics

Fibrinolytics, also known as thrombolytics, are powerful and high-risk medications that are used in STEMI, ischemic strokes, massive pulmonary embolisms and others. Fibrinolytic therapy has many risks associated with them such as major bleeding and intracranial hemorrhage. The decision to use these medications in STEMI relates to the availability for patients to have mechanical intervention within a given time frame.²

• Recommendations: Fibrinolytic therapy is indicated for ACS patients experiencing a STEMI, have a symptom onset of <12 hours, cannot receive a primary PCI within 120 minutes of first medical contact and do not have contraindications.
  • Administered in a non-PCI-capable hospital

Lipid Management

A large risk factor of infarction are high lipid levels as a high concentration of these molecules build plaques in blood vessels and increase the risk of occlusion. At the time of an ACS event, lipid management with the use of statins and other lipid lowering agents reduces the risk of recurrent ACS, stabilizes present atherosclerotic plaques, improves endothelial function, and supports secondary prevention. Lipid-lowering agents are often initiated upon hospitalization, continued indefinitely for secondary prevention, and used for long-term management.²

• Recommendations:
  • ACS patients are recommended to be initiated on high-intensity statin therapy
  • ACS patients already on maximally tolerated statin with LDL-C ≥70 mg/dL are recommended to be initiated on a non-statin lipid lowering therapy
  • ACS patients that are statin intolerant are recommended to be initiated on non-statin lipid lowering therapy
  • Lipid profile should be reassessed 4-8 weeks after hospital discharge and therapy should be adjusted as needed to achieve the targeted lipid levels
• Lipid Lowering Agents & LDL Reduction

Beta-Blockers

Beta-blockers play a crucial role in the management of ACS, and similar to lipid-lowering agents, are used both in the acute and long-term management setting post ACS event. These medications reduce the risk of reinfarction and lower early mortality by decreasing heart rate and contractility (lowers oxygen demand), decreasing blood pressure (reduces stress and ischemia), and decreases the risk for arrythmias which could lead to more issues.²

Recommendation: ACS patients are recommended to be initiated early (<24 hours) on oral beta-blocker therapy if not contraindicated.

Putting it All Together

Acute coronary events are prevalent causes of death in the US, and early and appropriate treatment is critical in ensuring patients have the best chance at survival; however, the fight does not end there. As pharmacists, we play critical roles in the treatment of patients post-ACS event. Such a role is ensuring patients are on appropriate therapy post-hospitalization to aid in preventing repeat events.

As discussed above, post-hospitalization, patients are likely to have new medications and therapy change. Common medication additions include aspirin, PGY12 inhibitors, beta-blockers, nitrates, statins, and others. It is our role as pharmacists to understand these medications, their use in a patient’s treatment plan, and, most importantly, be able to describe the importance of these medications to our patients to best be able to help prevent repeat ACS events and reduce morbidity and mortality.

Emily Heutmaker, APPE Student

References

1. Martin SS, Aday AW, Allen NB, Almarzooq ZI, Anderson CAM, Arora P, Avery CL, Baker-Smith CM, Bansal N, Beaton AZ, Commodore-Mensah Y, Currie ME, Elkind MSV, Fan W, Generoso G, Gibbs BB, Heard DG, Hiremath S, Johansen MC, Kazi DS, Ko D, Leppert MH, Magnani JW, Michos ED, Mussolino ME, Parikh NI, Perman SM, Rezk-Hanna M, Roth GA, Shah NS, Springer MV, St-Onge M-P, Thacker EL, Urbut SM, Van Spall HGC, Voeks JH, Whelton SP, Wong ND, Wong SS, Yaffe K, Palaniappan LP; on behalf of the American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Committee. 2025 Heart disease and stroke statistics: a report of US and global data from the American Heart Association. Circulation. Published online January 27, 2025.
2. Rao, S. V., O’Donoghue, M. L., Ruel, M., Rab, T., Tamis-Holland, J. E., Alexander, J. H., et al. (2025). 2025 ACC/AHA/ACEP/NAEMSP/SCAI guideline for the management of patients with acute coronary syndromes: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Journal of the American College of Cardiology. https://doi.org/10.1016/j.jacc.2024.11.009
3. Reeder, G. S., Kaski, J. C., & Dardas, T. F. (2023). Nitrates in the management of acute coronary syndrome. UpToDate. Wolters Kluwer. Available from https://www.uptodate.com/contents/nitrates-in-the-management-of-acute-coronary-syndrome?search=acute%20coronary%20syndrome&topicRef=66&source=see_link