Should I give this patient with unstable angina heparin?

One of the tenets of treatment of ACS (unstable angina, NSTEMI, STEMI) is treatment with an anticoagulant like heparin or enoxaparin. The “heparin vs. enoxaparin” issue is a totally different discussion. What this post addresses is a gray area: does every patient with unstable angina need to be started on a heparin drip?

Heparin is a medication that has potential side effects (bleeding, immune reaction) and takes time and resources (maintaining a patient on a drip, PTT draws).

I think that if a patient has had chest pain within the past 24 hours, then it would be prudent to start a heparin drip, as unstable angina can escalate into an NSTEMI on short notice. There are several high-risk features that should prompt a heparin drip (reference):

  • history of MI
  • EKG changes
  • abnormal stress test
  • a strong history suggestive of UA

What about aspirin? EVERY patient with suspected unstable angina should get 324 mg of aspirin. There is virtually no harm to giving a single dose of aspirin, so you might as well give it.

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