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● To reverse thrombus formation aspirin is given in the recently lowered dosage of 150-300 mg p.o. or 80-150 mg i.v. The oral route is preferred, to achieve a preferential inhibition of the thrombocytic COX1 over endothelial COX2. Furthermore, low molecular weight heparin is given at a brand-specific dosage or, if not available, unfractionated heparin. The third antithrombotic drug is determined by the subsequent treatment: if percutaneous intervention is available, patients receive an ADP receptor antagonist. Currently, the prodrug clopidogrel (2 activation steps) is being replaced by prasugrel (1 activation step; approved for STEMI) and ticagrelor (active substance; approved for NSTEMI).
● If percutaneous intervention is not available, you treat with fibrinolytics instead of ADP antagonists. The drug of choice is tenecteplase, as it can be given as an i.v. bolus owing to a longer half-life. Fibrinolysis is less efficient and more toxic (bleedings!) than percutaneous intervention, but it is independent from high-cost infrastructure. "Lysed" patients still profit and should undergo percutaneous intervention, if available.
● Besides resting, reduce ischaemia by applying oxygen (only to hypoxic patients, to minimize the risk of oxidative myocardial damage), beta blockers, and glyceryl trinitrate. The latter two drugs are given in the absence of hypotension and (beta blockers only) bradycardia. Morphine alleviates pain and metoclopramide nausea and vomiting.