1. For patients in ST-elevation myocardial infarction, administration of aspirin 10 minutes prior to nitroglycerin led to greater pain reduction compared to simultaneous administration.
2. Patients receiving aspirin prior to nitroglycerin additionally required fewer additional doses of nitroglycerin and were less likely to require opioids for pain control.
Evidence Rating Level: 2 (Good)
Acute coronary syndrome (ACS) describes a range of conditions associated with sudden, reduced blood flow to the heart, including unstable angina, non-ST elevation myocardial infarction (NSTEMI), and ST-elevation myocardial infarction (STEMI). ACS is a cause of significant morbidity and mortality worldwide and early treatment is critical for reducing negative health outcomes. Current guidelines from the American College of Cardiology (ACC) and the American Heart Association (AHA) state that aspirin and nitroglycerin should be administered to patients with ACS. However, the order or timing of giving these medications is not recognized. This retrospective cohort study aimed to examine if there was any benefit to giving aspirin before or after nitroglycerin in cases of ACS. A total of 2594 patients with ACS who received aspirin plus nitroglycerin in prehospital settings were identified using the National Emergency Medical Services Information System (NEMSIS) database. The patients were separated into 2 groups based on which medication was administered first: an aspirin-first group and a nitroglycerin-first group. The 2246 patients in the aspirin-first group were further stratified based on the time between administration of aspirin and the first dose of nitroglycerin. The 348 patients in the nitroglycerin-first group were stratified in a similar way. The outcome measures included administration of additional doses of nitroglycerin following the first dose and the subjective feelings of the patients. It was found that in patients with STEMI ischemia, administering aspirin 10 minutes before nitroglycerin led to a >20% reduction in need for additional nitroglycerin, a >7% decrease in subjective pain experience, and a reduced need for additional opioids, compared with administering them simultaneously. Additionally, the aspirin-first group in total experienced a 39.6% decrease in subjective pain experience after giving additional nitroglycerin compared with the nitroglycerin-first group. Study results may have implications for how initial management is carried out for patients with ACS.
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