Table 6

Summary of Recommendations for Early Hospital Care

RecommendationsCORLOEReferences
Oxygen
Administer supplemental oxygen only with oxygen saturation <90%, respiratory distress, or other high-risk features for hypoxemiaICN/A
Nitrates
Administer sublingual NTG every 5 min × 3 for continuing ischemic pain and then assess need for IV NTGIC(216–218)
Administer IV NTG for persistent ischemia, HF, or hypertensionIB(219–224)
Nitrates are contraindicated with recent use of a phosphodiesterase inhibitorIII: HarmB(225–227)
Analgesic therapy
IV morphine sulfate may be reasonable for continued ischemic chest pain despite maximally tolerated anti-ischemic medicationsIIbB(232,233)
NSAIDs (except aspirin) should not be initiated and should be discontinued during hospitalization for NSTE-ACS because of the increased risk of MACE associated with their useIII: HarmB(234,35)
Beta-adrenergic blockers
Initiate oral beta blockers within the first 24 h in the absence of HF, low-output state, risk for cardiogenic shock, or other contraindications to beta blockadeIA(240–242)
Use of sustained-release metoprolol succinate, carvedilol, or bisoprolol is recommended for beta-blocker therapy with concomitant NSTE-ACS, stabilized HF, and reduced systolic functionICN/A
Re-evaluate to determine subsequent eligibility in patients with initial contraindications to beta blockersICN/A
It is reasonable to continue beta-blocker therapy in patients with normal LV function with NSTE-ACSIIaC(241,243)
IV beta blockers are potentially harmful when risk factors for shock are presentIII: HarmB(244)
CCBs
Administer initial therapy with nondihydropyridine CCBs with recurrent ischemia and contraindications to beta blockers in the absence of LV dysfunction, increased risk for cardiogenic shock, PR interval >0.24 s, or second- or third-degree atrioventricular block without a cardiac pacemakerIB(248–250)
Administer oral nondihydropyridine calcium antagonists with recurrent ischemia after use of beta blocker and nitrates in the absence of contraindicationsICN/A
CCBs are recommended for ischemic symptoms when beta blockers are not successful, are contraindicated, or cause unacceptable side effectsICN/A
Long-acting CCBs and nitrates are recommended for patients with coronary artery spasmICN/A
Immediate-release nifedipine is contraindicated in the absence of a beta blockerIII: HarmB(251,252)
Cholesterol management
Initiate or continue high-intensity statin therapy in patients with no contraindicationsIA(269–273)
Obtain a fasting lipid profile, preferably within 24 hIIaCN/A

CCB indicates calcium channel blocker; COR, Class of Recommendation; HF, heart failure; IV, intravenous; LOE, Level of Evidence; LV, left ventricular; MACE, major adverse cardiac event; N/A, not available; NSAIDs, nonsteroidal anti-inflammatory drugs; NSTE-ACS, non–ST-elevation acute coronary syndromes; and NTG, nitroglycerin.

  • Short-acting dihydropyridine calcium channel antagonists should be avoided.