Tell me what all drugs to give in case of Stemi

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Drugs in STEMI - Complete Management

Based on The Washington Manual of Medical Therapeutics and standard ACC/AHA guidelines, here is the full drug regimen for STEMI, organized by category and timing.

1. IMMEDIATE / INITIAL DRUGS (given to ALL STEMI patients on arrival)

Antiplatelet Therapy - DAPT (Dual Antiplatelet Therapy)

Aspirin (ASA)

Dose: 162-325 mg orally (chewed) or rectally IMMEDIATELY
325 mg preferred for ASA-naive patients
Maintenance: 81 mg/day indefinitely after PCI

P2Y12 Inhibitor (add one - as soon as possible after presentation)

Drug	Loading Dose	Maintenance	Notes
Ticagrelor (preferred)	180 mg PO	90 mg twice daily x 12 months	Preferred - mortality benefit over clopidogrel. ASA maintenance must be <100 mg/day
Prasugrel	60 mg PO	10 mg daily x 12 months	Only give AFTER diagnostic angiography or within 1 hour of PCI. Contraindicated in prior CVA/TIA, weight <60 kg, age >75 yrs
Clopidogrel	600 mg PO (PCI) or 300 mg (fibrinolysis, first 24h)	75 mg daily x 12 months	If fibrinolysis patient >75 yrs - NO loading dose

2. ANTICOAGULANT THERAPY (ALL patients, regardless of reperfusion strategy)

Drug	Dose	Context
UFH (Unfractionated Heparin)	60 units/kg IV bolus (max 4000 units), then 12 units/kg/h	Preferred for primary PCI - real-time monitoring with ACTs
Enoxaparin (LMWH)	30 mg IV bolus, then 1 mg/kg SC q12h (age >75: no bolus, 0.75 mg/kg SC)	Validated with thrombolysis and rescue PCI. Give extra 0.3 mg/kg if last dose was >8h before PCI
Bivalirudin	0.75 mg/kg IV bolus, then 1.75 mg/kg/h	PCI patients already on ASA + clopidogrel. Lower bleeding vs UFH. Administer a heparin bolus first to reduce stent thrombosis
Fondaparinux	2.5 mg IV bolus, then 2.5 mg SC daily	Preferred with thrombolysis (lower bleeding vs UFH). NOT for primary PCI (risk of catheter thrombosis)

3. REPERFUSION DRUGS (Fibrinolytics - when primary PCI is unavailable or delayed >120 min)

Choose ONE fibrinolytic agent:

Drug	Dose	Notes
Alteplase (tPA)	15 mg IV bolus, then 0.75 mg/kg over 30 min (max 50 mg), then 0.5 mg/kg over 60 min (max 35 mg)	Fibrin-specific
Tenecteplase (TNK-tPA)	Single weight-based IV bolus (30-50 mg)	Easiest to administer - single bolus. Reduce dose by 50% in age >75 yrs
Reteplase (rPA)	10 units IV over 2 min, repeat in 30 min	Double bolus
Streptokinase	1.5 million units over 60 min	Non-fibrin-specific, antigenic - do NOT repeat after 5 days. No heparin needed

Use fibrinolytics within 12 hours of symptom onset. Door-to-needle target: <30 minutes.

4. ADJUNCT / SUPPORTIVE DRUGS

Nitrates

Nitroglycerin: 0.4 mg SL or aerosol q5 min x 3 doses for chest discomfort
IV nitroglycerin: 10-200 mcg/min for uncontrolled pain
Avoid in: hypotension (SBP <90), right ventricular infarction, recent PDE-5 inhibitor use

Beta-Blockers

Metoprolol: 25 mg PO q6h (titrate), or metoprolol succinate 25-50 mg
IV metoprolol (5 mg q5 min x 3 doses) if hemodynamically stable and tachycardic
Avoid in: acute heart failure, hemodynamic instability, AV block (significant), bronchospasm
Reduces infarct size, limits arrhythmias, reduces mortality

Oxygen

Give if SpO2 <90% or respiratory distress. Routine oxygen in normoxic patients is NOT recommended.

Morphine

2-4 mg IV for pain refractory to nitrates - use cautiously (may reduce efficacy of oral antiplatelets)

ACE Inhibitor / ARB (start within 24 hours)

Ramipril or Lisinopril or Captopril - start low, titrate up
Especially indicated with EF <40%, anterior MI, hypertension, or diabetes
ARB (Valsartan) if ACE inhibitor not tolerated

Statin (High-Intensity - start immediately)

Atorvastatin 80 mg or Rosuvastatin 40 mg - start as early as possible
Reduces mortality, plaque stabilization, anti-inflammatory effects
Do NOT withhold in the acute setting

Aldosterone Antagonist (within 3-14 days if EF <40% + heart failure or diabetes)

Eplerenone 25-50 mg/day or Spironolactone 25-50 mg/day
Avoid if serum Cr >2.5 mg/dL (men) or >2.0 mg/dL (women), or K+ >5 mEq/L

QUICK MNEMONIC - "MONABASH"

Letter	Drug
M	Morphine (pain control)
O	Oxygen (if SpO2 <90%)
N	Nitrates
A	Aspirin
B	Beta-blocker
A	Anticoagulant (heparin/LMWH)
S	Statin
H	Heparin + P2Y12 (DAPT)

Summary Table by Timeline

Phase	Drugs
Immediately (0-10 min)	Aspirin 325 mg, P2Y12 inhibitor, Heparin/anticoagulant, Nitrates, Oxygen, Morphine
Reperfusion	Fibrinolytic (if no PCI) OR PCI with anticoagulant + DAPT
Within 24 hours	Beta-blocker, ACE inhibitor, High-intensity statin
3-14 days (if indicated)	Aldosterone antagonist (if EF <40% + HF/DM)
Indefinite (post-discharge)	Aspirin 81 mg, P2Y12 x 12 months, Beta-blocker, ACE-I/ARB, Statin

Source: The Washington Manual of Medical Therapeutics, Acute Coronary Reperfusion section; ACC/AHA STEMI Guidelines

And for nstemj?

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Drugs in NSTEMI (UA/NSTEMI) - Complete Management

Source: The Washington Manual of Medical Therapeutics, UA/NSTEMI section

The key difference from STEMI: NO fibrinolytics are used in NSTEMI. Management centers on antithrombotic therapy, symptom control, and a risk-stratified invasive strategy.

1. ANTIPLATELET THERAPY - DAPT

Aspirin (ASA) - given to ALL patients immediately

Dose: 162-325 mg (chewed) initially, then 75-100 mg/day maintenance
If on ticagrelor, maintenance ASA must not exceed 100 mg/day

P2Y12 Inhibitor (add one - as early as possible)

Drug	Loading Dose	Maintenance	Notes
Ticagrelor (preferred)	180 mg PO	90 mg twice daily x 12 months	Reduced vascular death/MI/CVA vs clopidogrel (9.8% vs 11%). Higher non-CABG bleeding
Clopidogrel	300-600 mg PO	75 mg daily x 12 months	Reduces CV death/MI/stroke by 18-30% combined with ASA
Prasugrel	60 mg PO	10 mg daily	Higher potency. Avoid in prior CVA/TIA, age >75, weight <60 kg. Give only after diagnostic angiography
Cangrelor	30 mcg/kg IV bolus	4 mcg/kg/min infusion	IV only - FDA approved for PCI only. Reserved for those unable to take oral agents

GPIIb/IIIa Inhibitors (selective use - mainly at time of PCI or high-risk features)

Drug	Dose	Notes
Eptifibatide	180 mcg/kg IV bolus, then 2 mcg/kg/min	Most commonly used. Reduces death or MI in invasive + conservative strategies
Tirofiban	0.4 mcg/kg IV bolus, then 0.1 mcg/kg/min	Alternative to eptifibatide
Abciximab	0.25 mg/kg IV bolus, then 10 mcg/min	Reduces death/MI in ACS undergoing PCI. Long platelet binding duration

GPIIb/IIIa inhibitors are NOT used routinely upfront - reserved for high-risk patients (troponin-positive, refractory ischemia) or at time of PCI.

2. ANTICOAGULANT THERAPY (ALL patients, regardless of strategy)

Drug	Dose	Notes
UFH	60 units/kg IV bolus (max 4000 units), then 12-14 units/kg/h	aPTT target 1.5-2.0x control. Reduces death/MI by up to 60% with ASA. Easily reversible. Risk of HIT
Enoxaparin (LMWH)	1 mg/kg SC twice daily	At least as efficacious as UFH, possibly superior. No monitoring needed. Reduce to 50% if CrCl <30 or Cr >2 mg/dL. Cannot be fully reversed
Fondaparinux	2.5 mg SC daily	Similar efficacy to LMWH with possibly lower bleeding rates. Preferred in conservative (ischemia-driven) strategy. Do NOT use alone during PCI (catheter thrombosis risk)
Bivalirudin	0.75 mg/kg IV bolus, then 1.75 mg/kg/h	At PCI: as effective as UFH + GPIIb/IIIa, with less bleeding. Risk of stent thrombosis. Dose-adjust if GFR <30

3. ANTI-ISCHEMIC / SUPPORTIVE DRUGS

Nitrates

Nitroglycerin SL 0.4 mg q5 min x 3 doses for ongoing chest pain
IV nitroglycerin 10-200 mcg/min for refractory pain
Avoid if: SBP <90 mmHg, RV infarction, recent PDE-5 inhibitor use

Beta-Blockers (start within 24 hours if no contraindication)

Metoprolol 25-50 mg PO q6-8h, titrate to heart rate 50-60 bpm
IV metoprolol 5 mg q5 min x 3 doses if hemodynamically stable + tachycardic/hypertensive
Avoid in: decompensated heart failure, cardiogenic shock, high-degree AV block, severe bronchospasm
Reduces infarct size, limits arrhythmias

Oxygen

Only if SpO2 <90% or respiratory distress. Routine oxygen is NOT recommended and may be harmful.

Morphine

2-4 mg IV for pain refractory to nitrates. Use cautiously - may reduce absorption of oral P2Y12 inhibitors.

4. SECONDARY PREVENTION DRUGS (start in hospital, continue indefinitely)

High-Intensity Statin (start immediately)

Atorvastatin 80 mg or Rosuvastatin 40 mg daily
Plaque stabilization, anti-inflammatory, mortality benefit

ACE Inhibitor (start within 24 hours, especially if EF <40%, diabetes, or HTN)

Ramipril, Lisinopril, or Enalapril - start low, titrate
ARB (Valsartan, Losartan) if ACE-I not tolerated

Aldosterone Antagonist (if EF <40% + heart failure OR diabetes, after stabilization)

Eplerenone 25-50 mg/day or Spironolactone 25-50 mg/day
Avoid if K+ >5 mEq/L or significant renal impairment

PPI (if on DAPT with high GI bleeding risk)

Pantoprazole or Omeprazole - in elderly, known ulcers, H. pylori, or co-prescribed with NSAIDs/steroids/anticoagulants
Pharmacokinetic interaction between omeprazole and clopidogrel is not clinically significant per randomized data

KEY DIFFERENCE: NSTEMI vs STEMI Drug Approach

Feature	STEMI	NSTEMI
Fibrinolytics	YES (if no PCI available)	NEVER
GPIIb/IIIa inhibitors	Not routine	Selective use (high-risk/PCI)
P2Y12 timing	Immediately	Immediately (or after angiography for prasugrel)
Anticoagulant	UFH preferred for primary PCI	UFH / LMWH / Fondaparinux / Bivalirudin
Reperfusion urgency	Door-to-balloon <90 min	Risk-stratified (2h / 24h / 24-72h window)

NSTEMI Risk-Stratified Invasive Timing

Timing	Indication
Urgent (<2h) - like STEMI	Refractory angina, hemodynamic instability, cardiogenic shock, sustained VT/VF
Early invasive (<24h)	TIMI ≥3 or GRACE >140, new ST depressions, rapidly rising troponins
Delayed invasive (24-72h)	Diabetes, GFR <60, EF <40%, prior PCI within 6 months, prior CABG, TIMI ≥2
Ischemia-driven (conservative)	Low risk (TIMI ≤1, GRACE <109), low-risk biomarker-negative patients

Source: The Washington Manual of Medical Therapeutics, UA/NSTEMI Medications section

I am in emergency ward A patient comes with CVA How to manage What drugs What doses and in case of both ischemic and haemorrhagic

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CVA Emergency Management - Complete Drug Guide

Source: Rosen's Emergency Medicine, Chapter 87 (Stroke)

FIRST: IMMEDIATE STEPS FOR ALL CVA (Before Knowing the Type)

Action	Target Time
Doctor sees patient	<10 min
CT scan completed	<25 min
CT read	<45 min
Treatment decision	<60 min ("door-to-needle")

Initial stabilization (ALL stroke patients):

ABC - Airway, Breathing, Circulation
Oxygen - only if SpO2 <95%. Do NOT give routine oxygen to normoxic patients
IV access - use Normal Saline (NOT dextrose - hyperglycemia worsens ischemic deficit)
Blood glucose STAT - treat hypoglycemia immediately (it mimics stroke)
ECG - identify AF or arrhythmias
Non-contrast CT head STAT - to differentiate ischemic vs hemorrhagic

⚠️ You CANNOT give tPA until CT rules out hemorrhage

PART 1: ISCHEMIC STROKE

A. Blood Pressure Management

Situation	Target BP	Drug
tPA candidate (before thrombolysis)	Must be <185/110 mmHg	Labetalol 10-20 mg IV over 1-2 min (repeat x1) OR Nicardipine 5 mg/h IV (titrate up by 2.5 mg/h q5-15 min, max 15 mg/h)
tPA candidate (after thrombolysis)	Maintain <180/105 mmHg	Same agents
NOT a tPA candidate	Do NOT lower BP unless >220/120 mmHg	Lower by only 15-20% in first 24h

Rationale: Permissive hypertension maintains perfusion to ischemic penumbra. Aggressive BP lowering worsens outcomes.

Avoid in ischemic stroke: Sublingual nifedipine, aggressive IV nitroprusside

B. Thrombolysis - IV Alteplase (tPA)

ELIGIBILITY: Within 4.5 hours of symptom onset (or last seen normal)

Dose: Alteplase 0.9 mg/kg IV (maximum 90 mg total)

10% of total dose as IV bolus over 1 minute
Remaining 90% as IV infusion over 60 minutes

Example: 70 kg patient = 63 mg total → 6.3 mg bolus + 56.7 mg over 60 min

Absolute Contraindications to tPA:

Hemorrhage on CT
Symptom onset >4.5 hours (or unknown onset)
Prior intracranial hemorrhage ever
Active internal bleeding
Intracranial/spinal surgery in past 3 months
Head trauma in past 3 months
BP >185/110 mmHg (uncontrolled)
Blood glucose <50 or >400 mg/dL
INR >1.7, aPTT >40 sec, platelets <100,000
NIHSS >25 (severe stroke - relative)

After tPA:

No anticoagulants or antiplatelets for 24 hours
Monitor BP every 15 min for 2 hours, then every 30 min for 6 hours, then every hour x 16 hours
Watch for angioedema, symptomatic intracranial hemorrhage

C. Antiplatelet Therapy (if NOT a tPA candidate, or after 24h post-tPA)

Drug	Dose	Notes
Aspirin	325 mg orally within 24-48h of onset	First-line. Do NOT give within 24h of tPA
Aspirin + Clopidogrel (DAPT)	ASA 325 mg + Clopidogrel 75 mg	For minor stroke (NIHSS ≤3) or high-risk TIA - give within 24h, continue x 21 days
Clopidogrel	75 mg daily	Alternative to aspirin if intolerant

D. Anticoagulation (selected cases)

Indication	Drug	Notes
Cardioembolic stroke (AF)	Heparin IV or LMWH	Typically delayed 24-48h to avoid hemorrhagic transformation
Cerebral venous sinus thrombosis (CVST)	UFH or LMWH	Even if hemorrhagic infarct present
Hypercoagulable state	Heparin	Individualized

Routine heparin for all ischemic strokes is NOT recommended.

E. Glucose Management

Treat hypoglycemia immediately: Dextrose 50% (D50W) 25-50 mL IV (if glucose <60 mg/dL)
Treat hyperglycemia: Insulin sliding scale, keep glucose <180 mg/dL
Avoid dextrose-containing IV fluids

F. Temperature

Acetaminophen (Paracetamol) 650 mg PO/IV q6h for fever (target normothermia)
Even minor hyperthermia worsens neurologic injury

G. Seizure (if occurs)

Lorazepam 0.1 mg/kg IV (or Diazepam 0.15 mg/kg IV) for active seizure
Prophylactic antiepileptics NOT recommended routinely in ischemic stroke

PART 2: HEMORRHAGIC STROKE (ICH / SAH)

Key Principle: The goals are OPPOSITE to ischemic stroke

STOP the bleeding - reverse anticoagulation, lower BP aggressively
NO tPA, NO anticoagulants, NO antiplatelets

A. Blood Pressure Management in ICH

Target	Drug	Dose
SBP <140 mmHg (AHA/ASA guideline for most ICH)	Labetalol	10-20 mg IV bolus q10-20 min, OR 2-8 mg/min IV infusion
	Nicardipine	5 mg/h IV, titrate by 2.5 mg/h q5-15 min, max 15 mg/h
	Clevidipine	1-2 mg/h IV, double q90 sec, max 21 mg/h
	Enalaprilat	1.25-5 mg IV q6h (use if LV dysfunction)
	Hydralazine	10-20 mg IV q4-6h (alternative)

Avoid nitroprusside in increased ICP (increases cerebral vasodilation)

B. Reversal of Anticoagulation (URGENT in ICH)

Anticoagulant	Reversal Agent	Dose
Warfarin (elevated INR)	Vitamin K + 4-Factor PCC (Kcentra)	Vitamin K 10 mg IV slow + PCC 25-50 units/kg IV (target INR <1.4). FFP 10-15 mL/kg if PCC unavailable
Heparin (UFH)	Protamine sulfate	1 mg per 100 units of heparin given in last 2 hours (max 50 mg IV slow)
Enoxaparin (LMWH)	Protamine sulfate (partial reversal)	1 mg per 1 mg enoxaparin if given <8h ago
Dabigatran	Idarucizumab (Praxbind)	5 g IV (two 2.5 g vials)
Apixaban / Rivaroxaban	Andexanet alfa	Low dose: 400 mg bolus + 480 mg infusion; High dose: 800 mg bolus + 960 mg infusion
Antiplatelet agents (aspirin/clopidogrel)	Platelet transfusion (controversial)	1 apheresis unit - only if going to surgery/life-threatening

C. Intracranial Pressure (ICP) Management

Drug	Dose	Indication
Mannitol	0.5-1 g/kg IV over 20-30 min (20% solution)	Cerebral edema, herniation signs. Repeat q6-8h. Check serum osmolarity (stop if >320 mOsm)
Hypertonic Saline (3% NaCl)	150-250 mL IV over 15-30 min	Alternative to mannitol, preferred if hypotension present. Target serum Na 145-155 mEq/L
Dexamethasone	NOT recommended in ICH	No benefit, increases infection risk

D. Seizure Prophylaxis / Treatment in ICH

Situation	Drug	Dose
Active seizure	Lorazepam	0.1 mg/kg IV (max 4 mg), repeat once
Status epilepticus	Levetiracetam (preferred) OR Phenytoin	Levetiracetam: 1000-3000 mg IV loading dose
Prophylaxis (lobar ICH only, controversial)	Levetiracetam	500-1000 mg IV/PO twice daily x 7 days

Prophylactic phenytoin is NOT recommended in ICH (associated with worse outcomes)

E. Glucose and Temperature (same as ischemic stroke)

Treat hypoglycemia: D50W IV
Treat hyperglycemia: Insulin, keep glucose <180 mg/dL
Treat fever: Acetaminophen 650 mg q6h. Active cooling if needed

F. Subarachnoid Hemorrhage (SAH) - Additional Drugs

Drug	Dose	Purpose
Nimodipine	60 mg PO q4h x 21 days	Prevents cerebral vasospasm (does NOT reverse it - only prevention). Do NOT give IV - causes severe hypotension
Dexamethasone	4 mg IV q6h	Reduce meningeal irritation (controversial)
Levetiracetam	1000 mg IV/PO twice daily	Seizure prophylaxis
Stool softeners (Docusate)	100 mg PO twice daily	Prevent Valsalva / straining

SUMMARY COMPARISON TABLE

Feature	Ischemic Stroke	Hemorrhagic Stroke
CT appearance	Hypodense (after 6-12h)	Hyperdense (bright white) immediately
tPA	YES (if eligible, <4.5h)	ABSOLUTELY CONTRAINDICATED
Aspirin	Yes (after 24h)	NO (at least first 24h)
Anticoagulation	Selected cases only	Reverse it if on anticoagulants
BP target	Permissive (allow up to 220/120 if no tPA)	Aggressive (<140 systolic)
Mannitol/HTS	If edema/herniation	Yes for ICP control
Nimodipine	No	Yes in SAH only
Steroids	No benefit	No (harmful)

QUICK EMERGENCY DRUG CHECKLIST

Ischemic: D50W (if hypoglycemic) → CT → tPA 0.9 mg/kg (if eligible) → Aspirin 325 mg (after 24h) → BP control if needed (Labetalol/Nicardipine to keep <185/110 for tPA) → Normal saline fluids → Treat fever (Paracetamol)

Hemorrhagic: CT → STOP all anticoagulants → Reverse anticoagulation (PCC/Vitamin K/Idarucizumab) → BP control aggressively (SBP <140) → Mannitol/HTS if herniation → Nimodipine (SAH only) → Levetiracetam (seizures)

Source: Rosen's Emergency Medicine, 9th Ed., Chapter 87 - Stroke

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