Table 9: Summary of drugs commonly used in the emergency department to treat patients with symptoms suggestive of unstable angina

Drug category     Clinical      When to avoid[1]     Usual dose
                  condition                          (low-high)
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Aspirin         Diagnosis of    Hypersensitivity,   324 mg (160-
                unstable        active bleeding,    324)
                angina or       severe bleeding
                acute MI        risk
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Heparin         Unstable        Active bleeding,    80 units/kg
                angina in       history of          IV bolus with
                high-risk       heparin-induced     constant IV
                category and    thrombocytopenia,   infusion at
                some            severe bleeding     18
                intermediate-   risk, recent        units/kg/hr
                risk patients   stroke              titrated to
                                                    maintain aPTT
                                                    between 46
                                                    and 70
                                                    seconds[2]
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Nitrates        Ongoing pain    Hypotension         Sublingual
                or ischemia                         (1-3
                                                    tablets)[3]
                                                    IV (5-100
                                                    micro-g/min)
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Beta Blockers   Diagnosis of    PR ECG segment      Oral dose
                unstable        >0.24 seconds, 2    appropriate
                angina          degrees or 3        for specific
                                degrees AV          drug
                                block, heart        IV metoprolol
                                rate <60,           (1-5 m slow
                                systolic blood      IV every 5
                                pressure <90        minutes to 15
                                mmHg shock, left    mg total)
                                ventricular                     
                                failure with        IV propranolol
                                CHF, severe         0.5 to 1.0 mg
                                reactive airway     
                                disease             IV atenolol 5
                                                    mg every
                                                    minutes to 10
                                                    mg total
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Narcotics       Persistent      Hypotension,        Morphine
                pain            respiratory         sulfate 2 to
                following       depression,         5 mg IV
                initial         confusion,
                therapy with    obtundation
                nitrates and
                beta blockers
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[1] Allergy or prior intolerance contraindication for all.
[2] Dose regimen assumes a mean control aPTT of 30 seconds and a
therapeutic goal of 1.5 to 2.5 times control.
[3] Patients with symptoms suggestive of unstable angina and
ongoing pain should be given sublingual NTG 0.3 to 0.4 every 5
minutes until discomfort is relieved, three tablets have been
given, or limiting symptoms or signs develop. If discomfort is
still present after three tablets, IV NTG should be started
promptly at a dose of 5 micro-/min and titrated up to 75 to 100
micro-g/min or limiting side effects.

Note: Some of the recommendations in this guideline 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.