Table 3. Drugs commonly used in intensive medical management of patients with unstable angina Drug category Clinical condition When to avoid[1] Dose _____________________________________________________________________________________________________________________________ Aspirin[2] Unstable angina * 324 mg (160-324) daily Hypersensitivity Active * Severe * Heparin Unstable angina in * Active bleeding * 80 units/kg intravenous (IV) bolus high-risk category * History of heparin- * Constant intravenous infusion at 18 induced thrombocytopenia units/kg/hr * Severe bleeding risk * Titrated to maintain aPTT between 1.5 to 2.5 * Recent stroke times control Nitrates Symptoms are not * Hypotension * 5 to 10 micro-g/min by continuous infusion fully three * Titrated up to 75 to 100 micro-g/min until sublingual relief of symptoms or limiting side-effects nitroglycerin (headach or hypotension with a systolic blood tablets and pressure <90 mmHg or more than 30 percent initiation of beta below starting mean arterial pressure levels blocker therapy if significant hypertension is present) * Topical, oral, or buccal nitrates are acceptable alternatives for patients without ongoing or refractory symptoms Beta blockers[3] Unstable angina * PR ECG segment >0.24 Metoprolol seconds * 5 mg increments by slow (over 1 to 2 minutes) * 2 degrees or 3 degrees intravenous administration atrio- ventricular (AV) * Repeated every 5 minutes for a total initial block dose of 15 mg * Heart rate <60 * Followed in 1 to 2 hours by 25 to 50 mg by * Blood pressure <90 mmHg mouth every 6 hours * Shock * If a very conservative regimen is desired, * Left ventricular failure initial doses can be reduced to 1 to 2 mg with congestive heart Propranolol failure * 0.5 to 1.0 mg intravenous dose * Severe reactive airway * Followed in 1 to 2 hours by 40 to 80 mg by disease mouth every 6 to 8 hours Esmolol * Starting maintenance dose of 0.1 mg/kg/min intravenously * Titration in increments of 0.05 mg/kg/min every 10 to 15 minutes as tolerated by blood pressure until the desired therapeutic response has been obtained, limiting symptoms develop, or a dose of 0.20 mg/kg/min is reached * Optional loading dose of 0.5 mg/kg may be given by slow intravenous administration (2 to 5 minutes) for more rapid onset of action Atenolol * 5 mg intravenous dose * Followed 5 minutes later by a second 5 mg intravenous dose and then 50 to 100 mg orally every day initiated 1 to 2 hours after the intravenous dose Calcium channel Patients already * Pulmonary edema * Dependent on specific agent blockers on adequate doses * Evidence of left of nitrates and ventricular dysfunction beta blockers or in patients unable to tolerate adequate doses of one or both of these agents or in patients with variant angina Morphine sulfate Patients whose * Hypotension * 2 to 5 mg intravenous dose symptoms are not * Respiratory depression * May be repeated every 5 to 30 minutes as relieved after * Confusion needed to relieve symptoms and maintain three sublingual * Obtundation patient comfort nitro-glycerin tablets or whose symptoms recur with anti-ischemic therapy [1]Allergy or prior intolerance contraindication for all categories of drugs listed in this chart. [2]Patients unable to take aspirin because of a history of hypersensitivity or major gastrointestinal intolerance should be started on ticlopidine 250 mg twice a day, as a substitute. [3]Choice of the specific agent is not as important as ensuring that appropriate candidates receive this therapy. If there are concerns about patient intolerance due to existing pulmonary disease, especially asthma, left ventricular dysfunction, or risk of hypotension or severe bradycardia, initial selection should favor a short-acting agent, such as propranolol or metoprolol or the ultra short-acting agent, esmolol. Mild wheezing or a history of chronic obstructive pulmonary disease should prompt a trial of a short-acting agent at a reduced dose (e.g., 2.5 mg intravenous metoprolol, 12.5 mg oral metoprolol, or 25 micro-g/kg/min esmolol as initial doses) rather than complete avoidance of beta-blocker therapy. Note: Some of the recommendations in this guide suggest the use of agents for purposes or in doses other than those specified by the Food and Drug Administration (FDA). Such recommendations are made after consideration of concerns regarding nonapproved indications. Where made, such recommendations are based on more recent clinical trials or expert consensus.