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Acute Coronary Syndromes (Heart Attack; Myocardial Infarction; Unstable Angina)

By

Ranya N. Sweis

, MD, MS, Northwestern University Feinberg School of Medicine;


Arif Jivan

, MD, PhD, Northwestern University Feinberg School of Medicine

Reviewed/Revised Feb 2024
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Acute coronary syndromes result from a sudden blockage in a coronary artery. This blockage causes unstable angina or a heart attack (myocardial infarction), depending on the location and amount of blockage. A heart attack is death of heart tissue due to lack of blood supply.

  • People who experience an acute coronary syndrome usually have chest pressure or ache, shortness of breath, and/or fatigue.

  • People who think they are experiencing an acute coronary syndrome should call for emergency help and then chew an aspirin tablet.

  • Doctors use electrocardiography and measure substances in the blood to determine whether a person is experiencing an acute coronary syndrome.

  • Treatment varies depending on the type of syndrome but usually includes attempts to increase blood flow to affected areas of the heart.

In the United States, about 1 million heart attacks or sudden cardiac deaths occur each year. And acute coronary syndromes cause almost 400,000 deaths each year.

Causes of Acute Coronary Syndromes

The heart muscle needs a constant supply of oxygen-rich blood. The coronary arteries Blood Supply of the Heart The heart and blood vessels constitute the cardiovascular (circulatory) system. The heart pumps the blood to the lungs so it can pick up oxygen and then pumps oxygen-rich blood to the body.... read more , which branch off the aorta just after it leaves the heart, deliver this blood. An acute coronary syndrome occurs when a sudden blockage in a coronary artery greatly reduces or cuts off the blood supply to an area of the heart muscle (myocardium). The lack of blood supply to any tissue is termed ischemia. If the blood supply is greatly reduced or cut off for more than a few minutes, heart tissue dies. A heart attack, also termed myocardial infarction (MI), is death of heart tissue due to ischemia.

A blood clot is the most common cause of a blocked coronary artery (see also Overview of Coronary Artery Disease Overview of Coronary Artery Disease (CAD) Coronary artery disease is a condition in which the blood supply to the heart muscle is partially or completely blocked. The heart muscle needs a constant supply of oxygen-rich blood. The coronary... read more Overview of Coronary Artery Disease (CAD) ). Usually, the artery is already partially narrowed by a buildup of cholesterol and other fatty materials in the artery wall Atherosclerosis Atherosclerosis is a condition in which patchy deposits of fatty material (atheromas or atherosclerotic plaques) develop in the walls of medium-sized and large arteries, leading to reduced or... read more Atherosclerosis (atheroma). An atheroma may rupture or tear, which releases substances that make platelets stickier, encouraging clots to form. In about two thirds of people, the blood clot dissolves on its own, typically within a day or so. However, by this time, some heart damage has usually occurred.

Uncommonly, a heart attack results when a clot forms in the heart itself, breaks away, and lodges in a coronary artery. Another uncommon cause is a spasm of a coronary artery that stops blood flow. Spasms may be caused by drugs such as cocaine. Sometimes the cause is unknown.

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Classification

Doctors classify acute coronary syndromes based on

  • The presence of substances in the blood (cardiac biomarkers) released by the damaged heart

  • Symptoms

  • Electrocardiography (ECG) results

The classification is important because treatments differ depending on the specific acute coronary syndrome. The classification consists of unstable angina and two types of heart attack.

Did You Know...

  • About one third of people who have a heart attack do not have chest pain.

Symptoms of Acute Coronary Syndromes

Symptoms of the acute coronary syndromes are similar, and it is usually impossible to distinguish the syndromes based on symptoms alone.

Symptoms of unstable angina are the same as those of angina pectoris Symptoms Angina is temporary chest pain or a sensation of pressure that occurs while the heart muscle is not receiving enough oxygen. A person with angina usually has discomfort or pressure beneath the... read more —people typically have intermittent pressure, or an ache beneath the breastbone (sternum). People often interpret the sensation as discomfort or heaviness rather than pain. Discomfort also may occur in either shoulder or down the inside of either arm, through the back, and in the throat, jaw, or teeth. However, in people with unstable angina, the pattern changes. People experience more frequent or more severe episodes of angina, or episodes occur at rest or after less physical exertion. About 2 of 3 people who have heart attacks experience unstable angina, shortness of breath, or fatigue a few days or weeks beforehand. Such a change in the pattern of chest pain discomfort may culminate in a heart attack.

With a heart attack, the most recognizable symptom is usually pain in the middle of the chest that may spread to the back, jaw, or left arm. Less often, the pain spreads to the right arm. The pain may occur in one or more of these places and not in the chest at all. The pain of a heart attack is similar to the pain of angina but is generally more severe, lasts longer, and is not relieved by rest or nitroglycerin. Less often, pain is felt in the abdomen, where it may be mistaken for indigestion, especially because belching may bring partial or temporary relief. For unknown reasons, women often have different symptoms, sometimes described as atypical chest pain, that are less likely to be accurately diagnosed as a heart problem.

Other symptoms include a feeling of faintness or actually fainting, sudden heavy sweating, nausea, shortness of breath, and a heavy pounding of the heart (palpitations).

During a heart attack, a person may become restless, sweaty, and anxious and may experience a sense of impending doom. The lips, hands, or feet may turn slightly blue or grayish.

Older adults may have unusual symptoms. In many, the most obvious symptom is breathlessness. Symptoms may resemble those of a stomach upset or a stroke. Older adults may become disoriented. Nonetheless, about two thirds of older adults have chest pain, as do younger people. Older adults, especially women, often take longer than younger people to admit they are ill or to seek medical help.

Despite all the possible symptoms, as many as 1 of 5 people who have a heart attack have only mild symptoms or none at all. Such a silent heart attack may be recognized only when ECG is routinely done some time afterward.

During the early hours of a heart attack, heart murmurs Physical Examination Physical Examination and other abnormal heart sounds may be heard through a stethoscope.

Complications

People who have unstable angina or a heart attack may also have complications Complications of an Acute Coronary Syndrome The heart muscle needs a constant supply of oxygen-rich blood. The coronary arteries, which branch off the aorta just after it leaves the heart, deliver this blood. An acute coronary syndrome... read more that can be long-lasting. The complications depend on how much of the heart muscle is damaged, which is a direct result of where a coronary artery was blocked and how long this artery was blocked. If the blockage affects a large amount of heart muscle, the heart will not pump effectively and can become enlarged, possibly leading to heart failure Heart Failure (HF) Heart failure is a disorder in which the heart is unable to keep up with the demands of the body, leading to reduced blood flow, back-up (congestion) of blood in the veins and lungs, and/or... read more Heart Failure (HF) . If the blockage shuts off blood flow to the electrical system of the heart, the heart rhythm may be affected, possibly leading to arrhythmia Overview of Abnormal Heart Rhythms Abnormal heart rhythms (arrhythmias) are sequences of heartbeats that are irregular, too fast, too slow, or conducted via an abnormal electrical pathway through the heart. Heart disorders are... read more Overview of Abnormal Heart Rhythms and sudden death (cardiac arrest Cardiac Arrest and CPR Cardiac arrest is when the heart stops pumping blood and oxygen to the brain and other organs and tissues. Sometimes a person can be revived after cardiac arrest, particularly if treatment is... read more Cardiac Arrest and CPR ).

Diagnosis of Acute Coronary Syndromes

  • Symptoms

  • Electrocardiography (ECG)

  • Blood tests

Whenever a man over age about 30 years or a woman over age about 40 years reports chest pain Chest Pain Chest pain is a very common complaint. Pain may be sharp or dull, although some people with a chest disorder describe their sensation as discomfort, tightness, pressure, gas, burning, or aching... read more , doctors usually consider the possibility of an acute coronary syndrome. But several other conditions can cause similar pain, such as pneumonia Overview of Pneumonia Pneumonia is an infection of the small air sacs of the lungs (alveoli) and the tissues around them. Pneumonia is one of the most common causes of death worldwide. The most common symptom of... read more Overview of Pneumonia , a blood clot in the lung (pulmonary embolism Pulmonary Embolism (PE) Pulmonary embolism is the blocking of an artery of the lung (pulmonary artery) by a collection of solid material brought through the bloodstream (embolus)—usually a blood clot (thrombus) or... read more ), pericarditis Acute Pericarditis Acute pericarditis is inflammation of the pericardium (the flexible two-layered sac that envelops the heart) that begins suddenly, is often painful, and causes fluid and blood components such... read more Acute Pericarditis , a rib fracture Rib Fractures A rib fracture is a crack or break in the bones enclosing the chest. Rib fractures cause severe pain, particularly when a person breathes deeply. A chest x-ray is usually taken. People are given... read more Rib Fractures , spasm of the esophagus Esophageal Spasm Esophageal spasm is a disorder of the rhythmic waves of muscular contractions (peristalsis) of the esophagus. The cause of this disorder is not known. Symptoms include chest pain and difficulty... read more , indigestion Indigestion Indigestion is pain or discomfort in the upper abdomen. People may also describe the sensation as gassiness, a sense of fullness, or gnawing or burning. The sense of fullness may occur after... read more , or chest muscle tenderness after injury or exertion.

Electrocardiography

ECG Electrocardiography Electrocardiography (ECG) is a quick, simple, painless medical test that measures the heart’s electrical impulses. During an ECG, the heart's electrical impulses are measured, amplified, and... read more Electrocardiography is the most important initial diagnostic test when doctors suspect an acute coronary syndrome. This test provides a graphic representation of the electrical current producing each heartbeat. In many instances, it immediately shows that a person is having a heart attack. Abnormalities detected by ECG help doctors determine the type of treatment needed. The abnormalities on ECG also help show if and where the heart muscle was damaged. If a person has had previous heart problems, which can alter the ECG, the most recent damage may be harder for doctors to detect. Such people should carry a small copy of their ECG, so that if they have symptoms of an acute coronary syndrome, doctors can compare the previous ECG with the current ECG. If a few ECGs recorded over several hours are completely normal, doctors consider a heart attack unlikely.

Cardiac biomarkers

Measuring levels of certain substances (called cardiac biomarkers) in the blood also helps doctors diagnose acute coronary syndromes. These substances are normally found in heart muscle but are released into the blood only when heart muscle is damaged or dead. Most commonly measured are heart muscle proteins called troponin I and troponin T and an enzyme called CK-MB (creatinine kinase, myocardial band subunit). Levels in the blood are elevated within 6 hours of a heart attack and remain elevated for several days. Levels of cardiac markers are usually measured when the person is admitted to the hospital and at 6- to 12-hour intervals for the next 24 hours.

Other testing

Other tests may be done during or shortly after hospitalization. These tests are used to determine whether a person needs additional treatment or is likely to have more heart problems. For instance, a person may have to wear a Holter monitor Holter Monitor: Continuous ECG Readings Holter Monitor: Continuous ECG Readings , which records the heart’s electrical activity for 24 hours or more. This test enables doctors to detect whether the person has abnormal heart rhythms Overview of Abnormal Heart Rhythms Abnormal heart rhythms (arrhythmias) are sequences of heartbeats that are irregular, too fast, too slow, or conducted via an abnormal electrical pathway through the heart. Heart disorders are... read more Overview of Abnormal Heart Rhythms (arrhythmias) or episodes of inadequate blood supply without symptoms (silent ischemia). An exercise stress test Stress Testing Stress testing measures the heart's function with electrocardiography (ECG) while the heart is under stress, either from exercise or from a medication used to stress the heart. Stressing the... read more Stress Testing (electrocardiography done during exercise) before or shortly after discharge can help determine how well the person is doing after the heart attack and whether ischemia is continuing. If these tests detect abnormal heart rhythms or ischemia, medications Medications for Treatment of Coronary Artery Disease The heart muscle needs a constant supply of oxygen-rich blood. The coronary arteries, which branch off the aorta just after it leaves the heart, deliver this blood. Coronary artery disease that... read more may be recommended. If ischemia persists, doctors may recommend coronary angiography Cardiac Catheterization and Coronary Angiography Cardiac catheterization is a procedure that can measure heart function through a catheter inserted into a vein or artery and guided into the heart. Coronary angiography, which can be done during... read more Cardiac Catheterization and Coronary Angiography to evaluate the possibility of doing percutaneous coronary intervention Percutaneous Coronary Intervention Coronary artery disease is a condition in which the blood supply to the heart muscle is partially or completely blocked. The heart muscle needs a constant supply of oxygen-rich blood. The coronary... read more Percutaneous Coronary Intervention or coronary artery bypass grafting Coronary Artery Bypass Grafting Coronary artery disease is a condition in which the blood supply to the heart muscle is partially or completely blocked. The heart muscle needs a constant supply of oxygen-rich blood. The coronary... read more Coronary Artery Bypass Grafting to restore blood flow to the heart.

Treatment of Acute Coronary Syndromes

  • Medications

  • Reopening or bypassing blocked arteries

  • Lifestyle changes

Acute coronary syndromes are medical emergencies. Half of deaths due to a heart attack occur in the first 3 or 4 hours after symptoms begin. The sooner treatment begins, the better the chances of survival. Anyone having symptoms that might indicate an acute coronary syndrome should obtain prompt medical attention. Prompt transportation to a hospital’s emergency department by an ambulance with trained personnel may save the person’s life. Trying to contact the person’s doctor, relatives, friends, or neighbors is a dangerous waste of time.

Did You Know...

  • In a person who is having symptoms that might indicate a heart attack, prompt transportation to a hospital’s emergency department by an ambulance with trained personnel may save the person’s life. Trying to contact the person’s doctor, relatives, friends, or neighbors is a dangerous waste of time.

People who may be having a heart attack are usually admitted to a hospital that has a cardiac care unit. Heart rhythm, blood pressure, and the amount of oxygen in the blood are closely monitored so that heart damage can be assessed. Nurses in these units are specially trained to care for people with heart problems and to handle heart emergencies.

Often, oxygen is given through nasal prongs or a face mask. Providing more oxygen to the heart can help keep heart tissue damage to a minimum.

Medication treatment

The most important issue in the early part of treatment of a heart attack is to get to medical attention quickly so doctors can attempt to restore blood flow in the affected artery. People who think they may be having a heart attack should chew an aspirin tablet immediately after calling an ambulance. If aspirin is not taken at home or given by emergency personnel, it is immediately given at the hospital. This therapy improves the chances of survival by reducing the size of the clot (if present) in the coronary artery. People with an allergy to aspirin may be given clopidogrel, ticlopidine, or ticagrelor instead. Some people are given both aspirin and clopidogrel, ticlopidine, or ticagrelor.

People are given medications to prevent the formation of blood clots, to reduce anxiety, and to reduce the size of the heart. People may need to take these medications for some time after they have recovered from a heart attack. Medications are used to reduce the heart's workload during and after a heart attack.

Because decreasing the heart’s workload also helps limit tissue damage, a beta-blocker is usually given to slow the heart rate. Slowing the rate enables the heart to work less hard and reduces the area of damaged tissue.

Most people are also given an anticoagulant, such as heparin, to help prevent the formation of additional blood clots.

Most people are given nitroglycerin, which relieves pain by reducing the workload of the heart and possibly by dilating arteries. Usually, it is first given under the tongue, then intravenously. Occasionally, when nitroglycerin cannot be used or is ineffective, doctors give morphine to reduce discomfort and anxiety.

Angiotensin-converting enzyme (ACE) inhibitors Angiotensin-converting enzyme inhibitors High blood pressure is very common. It often does not cause symptoms; however, high blood pressure can increase the risk of stroke, heart attack, and heart failure. Therefore, it is important... read more can reduce heart enlargement and increase the chance of survival for many people. Therefore, these medications are usually given in the first few days after a heart attack and prescribed indefinitely.

Statins Treatment Dyslipidemia is a high level of cholesterol and/or triglycerides or a low level of high-density lipoprotein (HDL) cholesterol. Lifestyle, genetics, disorders (such as low thyroid hormone levels... read more Treatment have long been used to help prevent coronary artery disease, but doctors have found that they also have short-term benefit for people with an acute coronary syndrome. Doctors give a statin to people who are not already taking one.

More information on the medications used to treat heart attack can be found in the table .

Opening the arteries

The decision on the timing and method of opening a blocked coronary artery depends on the type of acute coronary syndrome and on how quickly the person got to the hospital. There are several ways to open blocked coronary arteries:

In people who have an ST-segment elevation MI, immediately clearing the coronary artery blockage saves heart tissue and improves survival. Doctors try to clear the blockage within 90 minutes after the person arrives at the hospital. Because the sooner the artery is cleared the better the outcome, the method of clearing is probably not as important as the timing.

Percutaneous coronary interventions Percutaneous Coronary Intervention Coronary artery disease is a condition in which the blood supply to the heart muscle is partially or completely blocked. The heart muscle needs a constant supply of oxygen-rich blood. The coronary... read more Percutaneous Coronary Intervention (PCI), such as angioplasty and stent placement, appear to be the best way to open blocked arteries during an ST-segment elevation MI if they can be done within 90 minutes of the time the person arrives at the hospital.

Clot-dissolving medications (also called thrombolytic or fibrinolytic medications—see table ) are given by vein (intravenously) to open the arteries if PCI procedures are not available within the 90-minute time frame. Thrombolytic medications include streptokinase, tenecteplase (TNK-tPA), alteplase, and reteplase. Although better if given immediately, these medications can work well within 3 hours and may be of some benefit for up to 12 hours after the person arrives at the hospital. In some areas, thrombolytic medications are given before hospital arrival by specially trained paramedics. Most people who are given a thrombolytic medication still need to have PCI before they leave the hospital.

Because thrombolytic medications can cause bleeding, they are not usually given to people who have bleeding in the digestive tract, who have severe high blood pressure, who have recently had a stroke, or who have had surgery during the month before the heart attack.

People who have a non–ST-segment elevation MI or unstable angina do not usually benefit from immediate PCI or thrombolytic medications. However, doctors usually do PCI within the first day or two of hospitalization. If the person’s symptoms worsen or certain complications develop, doctors may do PCI earlier.

In some people, coronary artery bypass grafting Coronary Artery Bypass Grafting Coronary artery disease is a condition in which the blood supply to the heart muscle is partially or completely blocked. The heart muscle needs a constant supply of oxygen-rich blood. The coronary... read more Coronary Artery Bypass Grafting (CABG) is done during an acute coronary syndrome instead of using PCI or a thrombolytic medication. For example, CABG may be used for people who cannot be given a thrombolytic medication (for example, because they have a bleeding disorder or have had a recent stroke or recent major surgery). CABG may also be used for people who cannot undergo PCI because of the severity of their arterial disease (for example, because there are many areas of blockage or heart function is poor, especially if the person also has diabetes).

General measures

Stool softeners and gentle laxatives may be used to prevent constipation, so that the person does not have to strain. If the person cannot pass urine or if the doctors and nurses need to keep track of the precise amount of urine produced, a urinary catheter is used.

For severe anxiety or stress (which can stress the heart), a mild antianxiety medication (for example, a benzodiazepine such as lorazepam) may be prescribed. To deal with mild depression and denial of illness, which are common after acute coronary syndromes, people are encouraged to talk about their feelings with doctors, nurses, social workers, and their family members and friends. Some people require an antidepressant.

Discharge

After about 1 to 3 days in the hospital, people who have had an uncomplicated heart attack and successful PCI are usually discharged. Other people may require a longer stay.

Nitroglycerin, aspirin, and sometimes clopidogrel, a beta-blocker, an angiotensin-converting enzyme (ACE) inhibitor, and a lipid-lowering drug Lipid-lowering drugs Dyslipidemia is a high level of cholesterol and/or triglycerides or a low level of high-density lipoprotein (HDL) cholesterol. Lifestyle, genetics, disorders (such as low thyroid hormone levels... read more Lipid-lowering drugs (most often, a statin) are usually prescribed.

Rehabilitation

Cardiac rehabilitation Rehabilitation for Heart Disorders Cardiac rehabilitation is useful for some people who have had a recent heart attack, have heart failure or coronary artery disease that has recently developed or suddenly worsened, or had heart... read more , an important part of recovery, begins in the hospital. Remaining in bed for longer than 2 or 3 days leads to physical deconditioning and sometimes to depression and a sense of helplessness. Barring complications, people who have had a heart attack can usually progress to sitting in a chair, passive exercise, use of a commode chair, and reading on the first day. By the second or third day, people are encouraged to walk to the bathroom and engage in nonstressful activities, and they can do more activities each day. If everything goes well, people are usually back to their normal activities within about 6 weeks. Participation in a regular exercise program consistent with the person’s age and heart health is beneficial.

Prognosis for Acute Coronary Syndromes

Many people who have unstable angina go on to have a heart attack within about 3 months.

The most dangerous time for someone who is having a heart attack is during the first few hours, particularly before they arrive at the hospital. Thus, it is critical to seek medical attention immediately when people suspect they are having a heart attack. Most people who survive for a few days after a heart attack can expect a full recovery, but about 10% die within a year. Most deaths occur in the first 3 or 4 months, typically in people who continue to have angina, abnormal heart rhythms Overview of Abnormal Heart Rhythms Abnormal heart rhythms (arrhythmias) are sequences of heartbeats that are irregular, too fast, too slow, or conducted via an abnormal electrical pathway through the heart. Heart disorders are... read more Overview of Abnormal Heart Rhythms originating in the ventricles (ventricular arrhythmias), or heart failure Heart Failure (HF) Heart failure is a disorder in which the heart is unable to keep up with the demands of the body, leading to reduced blood flow, back-up (congestion) of blood in the veins and lungs, and/or... read more Heart Failure (HF) . The prognosis is worse if the heart has enlarged after a heart attack.

Older adults are more likely to die after a heart attack and to have complications, such as heart failure. Women and people with diabetes, hypertension, or overweight are also more likely to have a worse prognosis.

Did You Know...

  • Half of deaths due to a heart attack occur in the first 3 or 4 hours after symptoms begin.

Prevention of Acute Coronary Syndromes

For people who have had a heart attack, doctors recommend taking one baby aspirin, one half of an adult aspirin, or one full adult aspirin daily. Because aspirin prevents platelets from forming clots, it reduces the risk of death and the risk of a second heart attack by 15 to 30%. People with an allergy to aspirin may take clopidogrel instead. Aspirin is not generally recommended for prevention of acute coronary syndrome in people who have not already had a heart attack.

Usually, doctors also prescribe a beta-blocker (such as metoprolol) for people who have had a heart attack because these medications reduce the risk of death by about 25%. The more serious the heart attack, the more benefit beta-blockers provide. However, some people cannot tolerate the side effects (such as wheezing, tiredness, erectile dysfunction Erectile Dysfunction (ED) Erectile dysfunction (ED) is the inability to attain or sustain an erection satisfactory for sexual intercourse. (See also Overview of Sexual Dysfunction in Men.) Every man occasionally has... read more , and cold limbs), and not everyone benefits.

Taking lipid-lowering medications will reduce the risk of death after a heart attack.

Angiotensin-converting enzyme (ACE) inhibitors, such as captopril, enalapril, perindopril erbumine, trandolapril, lisinopril, and ramipril, are often prescribed after a heart attack. These medications help prevent death and the development of heart failure Heart Failure (HF) Heart failure is a disorder in which the heart is unable to keep up with the demands of the body, leading to reduced blood flow, back-up (congestion) of blood in the veins and lungs, and/or... read more Heart Failure (HF) , particularly in people who have had a massive heart attack or who develop heart failure.

People should also make changes in their lifestyle. They should eat a low-fat diet and increase the amount of exercise they get. People who have high blood pressure or diabetes should try to keep those disorders under control. People who smoke should quit.

Drugs Mentioned In This Article

Generic Name Select Brand Names
Anacin Adult Low Strength, Aspergum, Aspir-Low, Aspirtab , Aspir-Trin , Bayer Advanced Aspirin, Bayer Aspirin, Bayer Aspirin Extra Strength, Bayer Aspirin Plus, Bayer Aspirin Regimen, Bayer Children's Aspirin, Bayer Extra Strength, Bayer Extra Strength Plus, Bayer Genuine Aspirin, Bayer Low Dose Aspirin Regimen, Bayer Womens Aspirin , BeneHealth Aspirin, Bufferin, Bufferin Extra Strength, Bufferin Low Dose, DURLAZA, Easprin , Ecotrin, Ecotrin Low Strength, Genacote, Halfprin, MiniPrin, St. Joseph Adult Low Strength, St. Joseph Aspirin, VAZALORE, Zero Order Release Aspirin, ZORprin
Deponit, GONITRO , Minitran, Nitrek, Nitro Bid, Nitrodisc, Nitro-Dur, Nitrogard , Nitrol, Nitrolingual, NitroMist , Nitronal, Nitroquick, Nitrostat, Nitrotab, Nitro-Time, RECTIV, Transdermal-NTG, Tridil
Plavix
Ticlid
BRILINTA
Hepflush-10 , Hep-Lock, Hep-Lock U/P, Monoject Prefill Advanced Heparin Lock Flush, SASH Normal Saline and Heparin
ARYMO ER, Astramorph PF, Avinza, DepoDur, Duramorph PF, Infumorph, Kadian, MITIGO, MORPHABOND, MS Contin, MSIR, Opium Tincture, Oramorph SR, RMS, Roxanol, Roxanol-T
TNKase
Activase, Cathflo Activase
Ativan, Loreev XR
KAPSPARGO, Lopressor, Toprol XL
Capoten
Epaned, Vasotec
Aceon
Mavik
Prinivil, QBRELIS, Zestril
Altace
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