title: Upstream treatment of acute coronary syndrome in the ED.
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.
authors.affiliation: Department of Emergency Medicine, University of California, Davis, Medical Center, Sacramento, CA 95817, USA. jdkirk@ucdavis.edu
authors.forename: J Douglas
authors.initials: JD
authors.lastname: Kirk
authors.forename: Michael
authors.initials: M
authors.lastname: Kontos
authors.forename: Deborah B
authors.initials: DB
authors.lastname: Diercks
mesh_terms: D054058:Acute Coronary Syndrome / Q000175:diagnosis / Q000209:etiology / Q000628:therapy*; D000925:Anticoagulants / Q000627:therapeutic use; D004636:Emergency Service, Hospital; D006801:Humans; D009204:Myocardial Revascularization; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D019039:Platelet Glycoprotein GPIIb-IIIa Complex / Q000037:antagonists & inhibitors
chemical_list: D000925:Anticoagulants; D010975:Platelet Aggregation Inhibitors; D019039:Platelet Glycoprotein GPIIb-IIIa Complex