Aspirin unstable angina

There has been a rebirth of interest in a spirin between the 1970s and 1990s as evidence accumulated from a number of clinical trials that aspirin ingestion lowers the incidence of myocardial infarction (39,40), unstable angina (41,42), and stroke (43). 

Reduction of the risk of myocardial infarction in those with unstable angina or previous myocardial infarction (aspirin only) and... 

Neri Semeri G. G., Gensini G. F., Poggessi L. Effect of heparin, aspirin oralteplase in reduction of myocardial ischaemia in refractory unstable angina. Lancet 1990 335,615-8. 

Coronary artery disease Due to the vasodilatory effect of dipyridamole, use with caution in patients with severe coronary artery disease (eg, unstable angina, recently sustained Ml). Chest pain may be aggravated in patients with underlying coronary artery disease who are receiving dipyridamole. For stroke or transient ischemic attack patients for whom aspirin is indicated to prevent recurrent Ml or angina pectoris, the aspirin in this product may not provide adequate treatment for the cardiac indications. 

Acute coronary syndrome For patients with acute coronary syndrome (unstable angina/non-Q-wave Ml), initiate clopidogrel with a single 300 mg loading dose and then continue at 75 mg once daily. Initiate and continue aspirin (75 to 325 mg once daily) in combination with clopidogrel. 

Unstable angina/Non-Q-wave Ml - The recommended dose is 120 units/kg of body weight (but not more than 10,000 units) subcutaneously every 12 hours with concurrent oral aspirin (75 to 165 mg/day) therapy. Concurrent aspirin therapy is recommended except when contraindicated. Continue treatment until the patient is clinically stabilized. The usual duration of treatment is 5 to 8 days. 

Prophylaxis of ischemic complications of unstable angina and non-Q-wave Ml, when concurrently administered with aspirin 1 mg/kg subcutaneously once daily... 

Drug therapy of acute coronary syndromes including unstable angina and non-Q-wave myocardial infarction includes use of aspirin, heparin and anti-ischaemic drugs and is similar in older patients to other age groups. Activation of platelet thromboxane production in the coronary circulation has been demonstrated in unstable angina. The risk of myocardial infarction or death is reduced by approximately 50% by early aspirin therapy in recommended doses of 160-325 mg per day and continued... 

The main indications for aspirin as a platelet aggregation inhibitor are prevention of stroke in patients with cerebrovascular disease, prevention of myocardial infarct in patients with unstable angina or after myocardial infarction. For the prevention of myocardial infarction in someone with documented or suspected coronary artery disease, doses as low as 75 mg daily (or possibly even lower) are sufflcient. 

Tirofiban is a synthetic, nonpeptide inhibitor of glycoprotein-(GP)-receptors. Tirofiban has a rapid onset and short duration of action after intravenous administration. Coagulation parameters turn to normal 4-8 hours after the drug is withdrawn. Tirofiban in combination with heparin and aspirin is indicated in the management of patients with unstable angina or non-Q-wave myocardial infarction. 

Holdright D, Patel D, Cunningham D, Thomas R, Hubbard W, Hendry G et al. Comparison of the effect of heparin and aspirin versus aspirin alone on transient myocardial ischemia and in-hospital prognosis in patients with unstable angina. J Am Coll Cardiol 1994 24(1) 39-45. 

Anticoagulant in patients with unstable angina who are undergoing percutaneous transluminal coronary angioplasty (PTCA) in conjunction with aspirin IV 0 75 mg/kg as IV bolus followed by IV infusion at rate of 1.75 mg/kg/hr for duration of procedure. After initial 4-hr infusion is completed, may give additional IV infusion at rate of 0.2 mg/ kg/hr for 20 hr or less, if necessary. 

Unstable angina, non -wave MI Subcutaneous 120 international units/kg ql2h (maximum 10,000 international units/dose) given with aspirin until clinically stable. Prevention of deep vein thrombosis (DVT) or pulmonary edema in the acutely ill patient Subcutaneous 5000 international units once a day. 

B. Indications and use Angiomax is indicated when given with aspirin for the prevention of ischemic complications in unstable angina patients during coronary angioplasty. It has been used successfully as a substitute for heparin. The efficacy of Angiomax appears to be similar to heparin with fewer bleeding complications. 

Aspirin decreases the incidence of transient ischemic attacks, unstable angina, coronary artery thrombosis with myocardial infarction, and thrombosis after coronary artery bypass grafting (see Chapter 34). 

However, in a second study, data on 1857 women from the Coumadin Aspirin Reinfarction Study were used to assess the incidence of cardiac deaths or unstable angina as related to the use of HRT. Of the population studied, 524 (28%) had used HRT at some point and 111 of the latter (21%) had started HRT after suffering a myocardial infarct ( new users ). Women who began HRT after their first myocardial infarct had a significantly higher subsequent incidence of unstable angina than women who had never used hormones (39 versus 20%) however, these new hormone users suffered death or recurrence of myocardial infarct at a much lower rate than never-users (4 versus 15%). These differences are striking. Prior/current users had no excess risk of the composite end-point after... 

Activation of platelets is considered an essential process for arterial thrombosis. Thus, treatment with platelet-inhibiting drugs such as aspirin and ticlopidine or clopidogrel is indicated in patients with transient ischemic attacks and strokes or unstable angina and acute myocardial infarction. In angina and infarction, these drugs are often used in conjunction with -blockers, calcium channel blockers, and fibrinolytic drugs. 

The PRISM Investigators. A comparison of aspirin plus tirofiban with aspirin plus heparin for unstable angina. N Engl J Med 1998 338 1498-1505. 

Theroux B Ouimet H, McCans J, et al. Aspirin, Heparin or both to treat unstable angina. New Engl J Med 1988 319 1 105-1 III. 

Theroux B Waters D.Qiu S, et al. Aspirin versus heparin to preventmyocardial infarction during the acute phase of unstable angina. Circulation 1993 88 2045-2048. 

I The Clopidogrel in Unstable angina to prevent Recurrent Events (CURE) Trial Investigators. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation, N Engl J Med 2001 345 494-502. 

Oler A, Whooley MA, Oler J, et al, Adding heparin to aspirin reduces the incidence of myocardial infarction and death in patients with unstable angina. A meta-analysis. JAMA 1996 276 81 1-815. 

Tirofiban (Aggrastat) is a nonpeptide antagonist of the GPIIb/llla receptor. It is administered intravenously. Its properties are shown in Table I. It is used in ACS for unstable angina and in PCI along with aspirin and heparin. 

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