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Chapter 2

Amal Mattu Gets Peppered

Amal Mattu, MD and Rob Orman, MD
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Amal Mattu breaks down his approach to using NTG in STEMI patients; LMWH in NSTEMI; and workup of PVCs. 

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David G. -

I'm not sure I can sign on to your conclusion, "In the setting of an ACS, as long as beta-blockers are given in the first 24 hours, patients will get the maximum benefit. There is no advantage to giving them earlier in the ED."

I suspect this conclusion is based on Bugiardini, et al's 2015 study, "COMPARISON OF EARLY VERSUS DELAYED ORAL Β BLOCKERS IN ACUTE CORONARY SYNDROMES AND EFFECT ON OUTCOMES", which looked at "early" (</= 24hr) vs "late" (> 24 hr) administration of PO b-blocker in a large ACS population. This was a registry study (so causation can't be concluded), but it found early b-blocker administration in ACS patients was significantly associated with reduced in-hospital mortality and reduced incidence of severe LV dysfunction.

So, two objections to your above conclusion:
1. No one has examined giving PO b-blocker in the ED for those with ACS vs giving it later on (but within 24 hr) in the admission, so you can' say we know there's "no advantage to giving them earlier in the ED".
2. If you don't give it in the ED, there's no guarantee the in-hospital team will give it.

My take is that (as the paper says) as long at the pt is not presenting with pulmonary edema or cardiogenic shock, I try to give a single oral dose (say, metoprolol 25mg). I don't see a likely down side.

David Glaser, Denver

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2.25 AMA PRA Category 1 Credits™ certified by Hippo Education (2020)