Therapy		Recommendations for STEMI	Recommendations for NSTE-ACS*
Antiplatelet agents
Aspirin		With PCI or fibrinolytic therapy: initial loading dose of 162 to 325 mg; maintenance dosage of 81 to 325 mg per day indefinitely after therapy	Initial loading dose of 162 to 325 mg; maintenance dosage of 81 to 325 mg per day
P2Y₁₂ receptor antagonists
	Clopidogrel (Plavix)	With PCI: initial loading dose of 600 mg; maintenance dosage of 75 mg per day for one year in patients who receive a stent	Initial loading dose of 300 or 600 mg, then 75 mg per day for up to 12 months in patients treated with an early invasive or ischemia-guided strategy
		With fibrinolytic therapy: initial loading dose of 300 mg for patients younger than 75 years and 75 mg for patients 75 years and older; continue for at least 14 days and up to one year	In patients unable to take aspirin: initial loading dose of 75 mg; maintenance dosage of 75 mg per day
	Prasugrel (Effient)	With PCI: initial loading dose of 60 mg; maintenance dosage of 10 mg per day for one year in patients who receive a stent	No specific recommendations
	Ticagrelor (Brilinta)	With PCI: initial loading dose of 180 mg; maintenance dosage of 90 mg twice per day for one year in patients who receive a stent	Initial loading dose of 180 mg; maintenance dosage of 90 mg twice per day
Anticoagulants
Bivalirudin (Angiomax)		With PCI: 0.75 mg per kg IV bolus, then 1.75 mg per kg per hour infusion, with or without previous treatment with unfractionated heparin; administer additional bolus of 0.3 mg per kg if needed If creatinine clearance < 30 mL per minute per 1.73 m² (0.50 mL per second per m²), reduce infusion to 1 mg per kg per hour with estimated creatinine clearance Preferred over unfractionated heparin with GP IIb/IIIa receptor antagonist if high risk of bleeding	Loading dose of 0.1 mg per kg, followed by 0.25 mg per kg per hour; only provisional use of GP IIb/IIIa inhibitor in patients also receiving dual antiplatelet therapy Not recommended in ischemia-guided treatment
Enoxaparin (Lovenox)		With fibrinolytic therapy: If younger than 75 years: 30 mg IV bolus, followed in 15 minutes by 1 mg per kg subcutaneously every 12 hours (maximum 100 mg for the first two doses) If 75 years or older: no bolus; 0.75 mg per kg subcutaneously every 12 hours (maximum 75 mg for the first two doses) Regardless of age, if creatinine clearance < 30 mL per minute per 1.73 m², 1 mg per kg subcutaneously every 24 hours For the index hospitalization, continue up to eight days or until revascularization	1 mg per kg subcutaneously every 12 hours (reduce dosage to 1 mg per kg subcutaneously every 24 hours in patients with creatinine clearance < 30 mL per minute per 1.73 m²) Initial loading dose of 30 mg IV in select patients
Fondaparinux (Arixtra)		With PCI: not recommended as sole anticoagulant	2.5 mg subcutaneously per day
		Initial dose of 2.5 mg IV, then 2.5 mg subcutaneously per day starting the following day; for the index hospitalization, continue up to eight days or until revascularization
		Contraindicated if creatinine clearance < 30 mL per minute per 1.73 m²
Unfractionated heparin		With PCI: dosing depends on whether GP IIb/IIIa receptor antagonist is administered and should be adjusted based on the activated clotting time (50 to 70 U per kg IV bolus with GP IIb/IIIa receptor antagonist vs. 70 to 100 U per kg without GP IIb/IIIa receptor antagonist)	Initial loading dose of 60 U per kg (maximum of 4,000 U) followed by an infusion of 12 U per kg per hour (maximum of 1,000 U per hour)
		With fibrinolytic therapy: IV bolus of 60 U per kg (maximumof 4,000 U) followed by an infusion of 12 U per kg per hour (maximum of 1,000 U per hour) initially, adjusted to maintain aPTT at 1.5 to 2.0 times normal (approximately 50 to 70 seconds) for 48 hours or until revascularization	Adjust to therapeutic aPTT range
Beta blockers
Carvedilol, oral (Coreg)		6.25 mg twice daily, titrate up to 25 mg as tolerated	Same dosing and contraindications as for STEMI with all beta blockers
Metoprolol, IV		5 mg every five minutes as tolerated, up to three doses
Metoprolol, oral (Lopressor)		25 to 50 mg every six to 12 hours, eventually transitioning to twice daily or daily
		Contraindications to beta-blocker therapy include signs of heart failure, low output state, and risk of cardiogenic shock
Angiotensin-converting enzyme inhibitors
Captopril		6.25 to 12.5 mg three times per day, titrate up to 25 to 50 mg as tolerated	Same dosing initiated as for STEMI if patient has left ventricular ejection fraction < 40%, hypertension, diabetes mellitus, or chronic kidney disease
Lisinopril		2.5 to 5 mg per day, titrate up to 10 mg as tolerated
Angiotensin receptor blocker
Valsartan (Diovan)		20 mg twice daily, titrate up to 160 mg twice daily as tolerated	May be used if patient cannot tolerate angiotensin-converting enzyme inhibitors
Additional treatment options
Atorvastatin (Lipitor)		40 to 80 mg per day	Same dosing as for STEMI, if no contraindications
Morphine		4 to 8 mg IV every five to 15 minutes as needed	Can be administered in same dose as for STEMI with persistent chest pain if all anti-ischemic medications have been maximized
Nitroglycerin		0.4 mg sublingually every five minutes, up to three doses as blood pressure allows	Same dosing as for STEMI
		10 mcg per minute IV	Intravenous nitroglycerin can be used for persistent ischemia, heart failure, or hypertension
			Do not give nitroglycerin if the patient received a phosphodiesterase type 5 inhibitor within the previous 24 to 48 hours
Oxygen		2 to 4 L per minute via nasal cannula, increase as needed	Use only in patients with oxygen saturation < 90%, respiratory distress, or high-risk hypoxemia