pocket guide for nonstemi aha 2007
TRANSCRIPT
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ACC/AHA Pocket Guideline
Based on the ACC/AHA
2007 Guideline Revision
Management
Patients With
Unstable Angina/
Nn–ST-Elevatin
Mycardial
Inarctin
October 2007
Learn and LiveSM
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I n i t i a l E / M
H o s p i t a l C a r e
R e v a s c u l a r i z a t i o n
D i s c h a r g e / P o s t - D i s c h a r g e
© 2007 American College of Cardiology Foundation
and American Heart Association, Inc.
The following material was adapted from the ACC/AHA 2007 Guidelines for the Management of Patients With
Unstable Angina/Non–ST-Elevation Myocardial Infarction.
For a copy of the executive summary (J Am Coll Cardiol
2007;50:652–726; Circulation 2007;116:803–877) and
full report, visit our Web sites at http://www.acc.org or
http://www.americanheart.org or call the ACC Resource
Center at 1-800-253-4636, ext. 5603.
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I ni t i al E / M
H o s pi t al C ar e
R ev a s c ul ar i z a t i on
D i s c h ar g e
/ P o s t - D i s c h ar g e
Cntents
Intrductin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
I. Initial Evaluatin and Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
A. Clncal Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
B. Early Rsk Stratfcaton. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
C. Immedate Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
II. Early Hspital Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
A. Ant-Ischemc Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
B. Intal Conservatve Versus Intal Invasve Strateges . . . . . . . . . . . . . . . . . 15
C. Antplatelet and Antcoagulant Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
D. Rsk Stratfcaton . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
III. Crnary Revasculariatin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
IV. Hspital Discharge and Pst-Hspital Discharge Care . . . . . . . . 34
A. Post-Dscharge Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
B. Long-Term Medcal Therapy and Secondary Preventon. . . . . . . . . . . . . . . 36
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Intrductin
Coronary artery dsease (CAD) s the leadng cause of death
n the Unted States. Unstable angna (UA) and the closely relat-
ed condton non–ST-segment elevaton myocardal nfarcton
(NSTEMI) are very common manfestatons of ths dsease and
are responsble for approxmately 1.5 mllon hosptalzatons n
the Unted States each year. UA and NSTEMI are examples of
acute coronary syndrome (ACS), whch s characterzed by an
mbalance between myocardal oxygen supply and demand. Themost common cause s the reduced myocardal perfuson that
results from coronary artery narrowng caused by a nonocclu-
sve thrombus that has developed on a dsrupted atherosclerotc
plaque. UA and NSTEMI are consdered to be closely related
condtons whose pathogeness and clncal presentatons are
smlar but of dfferng severty; they dffer prmarly n whetherthe schema s severe enough to cause suffcent myocardal
damage to release detectable quanttes of a marker of myocar-
dal njury.
The customary Amercan College of Cardology/Amercan Heart
Assocaton (ACC/AHA) classfcaton of recommendatons and
levels of evdence s used and dsplayed n Table 1.
D i s c h ar g e
/ P o s t - d i s c h ar g e
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H o s p i t a l C a r e
Table 1. Applying Classiicatin
Recmmendatins and Level Evidence†
LeveL A
Mltipl (3-5) pplti
rik trt vlt*
Grl citc
ircti mgit
ct
LeveL B
Limit (2-3) pplti
rik trt vlt*
LeveL C
Vr limit (1-2)
pplti rik trt
vlt*
CLAss I
Beneft >>> Risk
Prcr/Trtmt
shouLd prrm/
miitr
n Rcmmti tt
prcr r trtmt
i l/ctiv
n scit vic rm
mltipl rmiz tril
r mt-l
n Rcmmti tt
prcr r trtmt
i l/ctiv
n Limit vic rm
igl rmiz tril r
rmiz ti
n Rcmmti tt
prcr r trtmt i
l/ctiv
n ol xprt pii, c
ti, r tr--cr
CLAss IIA
Beneft >> Risk
Additional studies with
ocused objectives needed
IT Is ReasonabLe t pr-
rm prcr/miitr
trtmt
n Rcmmti i vr
trtmt r prcr
ig l/ctiv
n sm cfictig vic
rm mltipl rmiz
tril r mt-l
n Rcmmti i vr
trtmt r prcr
ig l/ctiv
n sm cfictig vic
rm igl rmiz tril
r rmiz ti
n Rcmmti i vr
trtmt r prcr
ig l/ctiv
n ol ivrgig xprt
pii, c ti,
r tr--cr
should
is recommended
is indicated
is useul/eective/benefcial
sggt pr r
writig rcmmti
is reasonable
can be useul/eective/benefcial
is probably recommended or indicated
S I z E o f T R E A T M E N T E f f E C T
E s t i m
A t E
O f
C E R t A i n t y
( P R E C i s i O n ) O f
t R
E A t m
E n t
E f f E C t
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* Data available rom clinical trials
or registries about the useulness/
eicacy in dierent subpopulations,
such as gender, age, history o
diabetes, history o prior myo-
cardial inarction, history o heart
ailure, and prior aspirin use.
† A recommendation with Level oEvidence B or C does not imply
that the recommendation is weak.
Many important clinical questions
addressed in the guidelines do not
lend themselves to clinical trials.
Even though randomized trials are
not available, there may be a very
clear clinical consensus that a
particular test or therapy is useul
or eective.
I n t r o d u c t i on
Cl II
Beneft ≥ Risk
Additional studies with broad
objectives needed; additional
registry data would be helpul
Prcr/Trtmt
May be ConsIdeRed
n Rcmmti’
l/cc l
wll tli
n Grtr cfictig
vic rm mltipl
rmiz tril r
mt-l
n Rcmmti’
l/cc l
wll tli
n Grtr cfictig
vic rm igl
rmiz tril r
rmiz ti
n Rcmmti’
l/cc l
wll tli
n ol ivrgig xprt
pii, c ti, r
tr--cr
Cl III
Risk ≥ Beneft
No additional studies needed
Prcr/Trtmt l
noT prrm/mii-
tr sInCe IT Is noT heLP-
uL and May be haRMuL
n Rcmmti tt
prcr r trtmt i
t l/ctiv
m rml
n scit vic rm
mltipl rmiz tril
r mt-l
n Rcmmti tt
prcr r trtmt i
t l/ctiv
m rml
n Limit vic rm
igl rmiz tril r
rmiz ti
n Rcmmti tt
prcr r trtmt i
t l/ctiv
m rml
n ol xprt pii, c
ti, r tr--cr
may/might be considered
may/might be reasonable
useulness/eectiveness is
unknown /unclear/uncertain or
not well established
is not recommended
is not indicated
should not
is not useul/eective/benefcial
may be harmul
D i s c h ar g e / P o s t - D I s c h ar g e C ar e
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I. Initial Evaluatin and Management
A. Clinical Assessment
Recmmendatins r Initial Triage
Class I 1. Patents wth symptoms of ACS (chest dscomfort
wth or wthout radaton to the arm[s], back, neck,
jaw or epgastrum; shortness of breath; weakness;
daphoress; nausea; lghtheadedness) should be
nstructed to call 9-1-1 and should be transported to
the hosptal by ambulance rather than by frends or
relatves. (Level of Evidence: B)
2. Prehosptal EMS provders should admnster 162
to 325 mg of asprn (ASA; chewed) to chest pan pa-
tents suspected of havng ACS unless contrandcat-
ed or already taken by the patent. (Level of Evidence: C)
3. Health care provders should nstruct patents
wth suspected ACS for whom ntroglycern (NTG)
has been prescrbed prevously to take not more
than 1 dose of NTG sublngually n response to chest
dscomfort/pan. If chest dscomfort/pan s unm-
proved or s worsenng 5 mn after 1 NTG dose has
been taken, t s recommended that the patent or
famly member/frend/caregver call 9-1-1 mmed-
ately to access emergency medcal servce (EMS)
before takng addtonal NTG. In patents wth
chronc stable angna, f symptoms are sgnfcantlymproved by 1 NTG, t s approprate to nstruct the
patent or famly member/frend/caregver to repeat
I n i t i a l E / M
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NTG every 5 mn for a maxmum of 3 doses and call
9-1-1 f symptoms have not resolved completely.
(Level of Evidence: C)
4. Patents wth a suspected ACS wth chest dscom-
fort or other schemc symptoms at rest for greater
than 20 mn, hemodynamc nstablty, or recent syn-
cope or presyncope should be referred mmedately
to an emergency department (ED). (Level of Evidence: C)
B. Early Risk Stratiicatin
Recmmendatins
Class I 1. Patents who present wth chest dscomfort or
other schemc symptoms should undergo early rsk
stratfcaton for the rsk of cardovascular events
(e.g., death or re-myocardal nfarcton [MI]) that fo-
cuses on hstory, ncludng angnal symptoms, phys-
cal fndngs, electrocardogram (ECG) fndngs, and
bomarkers of cardac njury (see Table 2). (Level of
Evidence: C)
2. A 12-lead ECG should be performed and shownto an experenced emergency physcan as soon as
possble after ED arrval, wth a goal of wthn 10
mn for all patents wth symptoms suggestve of
ACS. (Level of Evidence: B)
3. If the ntal ECG s not dagnostc but the patent
remans symptomatc and there s hgh clncal sus-pcon for ACS, seral ECGs, ntally at 15- to 30-mn
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I n i t i a l E / M
ntervals, should be performed to detect the poten-
tal for development of ST-segment elevaton or
depresson. (Level of Evidence: B)
4. Cardac bomarkers should be measured n all
patents who present wth chest dscomfort conss-
tent wth ACS. A cardac-specfc troponn s the
preferred bomarker. Patents wth negatve cardac
bomarkers wthn 6 h of the onset of symptoms
consstent wth ACS should have bomarkers remea-
sured n the tme frame of 8 to 12 h after symptom
onset. (Level of Evidence: B)
5. The ntal evaluaton of the patent wth sus-
pected ACS should nclude the consderaton of
noncoronary causes for the development of
unexplaned symptoms. (Level of Evidence: C)
Class IIa 1. Use of rsk stratfcaton models, such as the TIMI
or GRACE rsk score or PURSUIT rsk model, can be
useful to assst n decson makng regardng treat-
ment optons n patents wth suspected ACS. (Level
of Evidence: B) (See Table 2 and Figure 1.)
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Table 2. TIMI Risk Scre r
Unstable Angina/Nn–ST Elevatin MI
all-C Mrtlit, nw r Rcrrt MI,
r svr Rcrrt Icmi Rqirig
urgt Rvclrizti Trg 14
TIMI Rik scr atr Rmizti, %
0–1 4.7
2 8.3
3 13.2
4 19.9
5 26.2
6–7 40.9
The TIMI risk score is determined by the sum o the presence o 7 variables at admission;
1 point is given or each o the ollowing variables:
n age 65 y or older;
n at least 3 risk actors or CAD;
n prior coronary stenosis o 50% or more;
n
ST-segment deviation on ECG presentation;n at least 2 anginal events in prior 24 h;
n use o aspirin in prior 7 d;
n elevated serum cardiac biomarkers.
Prior coronary stenosis o 50% or more remained relatively insensitive to missing inormation
and remained a signiicant predictor o events.
Reprinted with permission rom Antman EM, Cohen M, Bernink PJ, et al. The TIMI risk score or unstable angina/
non-ST elevation MI: A method or prognostication and therapeutic decision making. JAMA 2000; 284:835-42.
Copyright © 2000 American Medical Association.
Cad= coronary artery disease; = day; eCG = electrocardiogram; = hour;
MI = myocardial inarction; = year.
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figure 1. GRACE Predictin Scre Card and Nmgram
r All-Cause Mrtality frm Discharge t 6 Mnths
iigdrig hpitlizti
Initial Serum PointsCreatinine, mg/dL
0-0.39 .............................. 1
0.4-0.79 ........................... 3
0.8-1.19 ........................... 5
1.2-1.59 ...........................7
1.6-1.99 ...........................9
2-3.99 ............................ 15≥4 .................................. 20
Elevated CardiacEnzymes ........................ 15
No In-HospitalPercutaneous
Coronary Intervention ..... 14
7
8
9
Micl hitr
Age in Years Points
≤29 ..................................... 0
30-39 .................................. 0
40-49 ................................ 18
50-59 ................................ 36
60-69 ................................ 55
70-79 ................................ 73
80-89 ................................ 91
≥90 ................................. 100
History o CongestiveHeart Failure ...................... 24
History oMyocardial Inarction ......... 12
2
1
3
iig t Iitilhpitl Prtti
Resting Heart ........... PointsRate, beats/min
≤49.9 ................................ 0
50-69.9 .............................3
70-89.9 .............................9
90-109.9 .........................14
110-149.9 .......................23
150-199.9 .......................35≥200 ...............................43
Systolic Blood Pressure,mm HG
≤79.9 .............................. 24
80-99.9 ........................... 22
100-119.9 .......................18120-139.9 .......................14
140-159.9 .......................10
160-199.9 .........................4≥200 .................................0
ST-Segment Depression ..11
4
5
6
1
23
4
Pit
5
6
7
8
9
Ttl Rik scr
Mrtlit Rik
(sm Pit)
(rm Plt)
Prict all-C Mrtlit rm hpitl dicrg t 6 Mt
0.50
0.45
0.40
0.35
0.30
0.25
0.20
0.15
0.10
0.05
0
P r o
b a
b i l i t y
Ttl Rik scr70 90 110 130 150 170 190 210
Eagle KA, Lim MJ, Dabbous OH, et al. A validated prediction model or all orms o acute coronary syndrome: estimating the risk o 6-month post-discharge death in an international registry. JAMA 2004; 291:2727-33. ©Copyright 2004 AmericanMedical Association.
Rik Clcltr r 6-Mt Pt-dicrg Mrtlit atr hpitlizti r act Crr srm
Record the points or each variable at the bottom let and sum the points to calculate the total risk score.Find the total score on the x-axis o the nomogram plot. The corresponding probability on the y-axis is the
estimated probability o all-cause mortality rom hospital discharge to 6 months.
I n i t i a l E / M
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4. In low-rsk patents who are referred for outpa-
tent stress testng (see above), precautonary phar-
macotherapy (e.g., ASA, sublngual NTG, and/or
beta blockers) should be consdered whle awatng
results of the stress test. (Level of Evidence: C)
5. Patents wth defnte ACS and ongong schemc
symptoms, postve cardac bomarkers, new ST-seg-
ment devatons, new deep T-wave nversons, he-
modynamc abnormaltes, or a postve stress test
should be admtted to the hosptal for further man-
agement. Admsson to the crtcal care unt s rec-
ommended for those wth actve, ongong schema/
njury and hemodynamc or electrcal nstablty.
Otherwse, a telemetry step-down unt s reasonable.
(Level of Evidence: C)
5. Patents wth possble ACS and negatve cardac
bomarkers who are unable to exercse or who have
an abnormal restng ECG should undergo a pharma-
cologcal stress test. (Level of Evidence: B)
6. Patents dscharged from the ED or chest pan unt
should be gven specfc nstructons for actvty,
medcatons, addtonal testng, and follow-up wth a
personal physcan. (Level of Evidence: C)
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B. Initial Cnservative Versus Initial Invasive Strategies
Recmmendatins
Class I 1. An early nvasve strategy (.e., dagnostc angog-
raphy wth ntent to perform revascularzaton) s
ndcated n UA/NSTEMI patents who have refracto-
ry angna or hemodynamc or electrcal nstablty
(wthout serous comorbdtes or contrandcatons
to such procedures). (Level of Evidence: B)
2. An early nvasve strategy (.e., dagnostc angog-
raphy wth ntent to perform revascularzaton) s
ndcated n ntally stablzed UA/NSTEMI patents
(wthout serous comorbdtes or contrandcatons
to such procedures) who have an elevated rsk for
clncal events. (Level of Evidence: A) (See Table 3.) 3. In women wth low-rsk features, a conservatve
strategy s recommended. (Level of Evidence: B)
Class IIb 1. In ntally stablzed patents, an ntally conser-
vatve (.e., a selectvely nvasve) strategy may beconsdered as a treatment strategy for UA/NSTEMI
patents (wthout serous comorbdty or
H o s pi t al C ar e
D i s c h ar g e
/ P o s t - d i s c h ar g e
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H o s p i t a l C a r e
contrandcatons) who have an elevated rsk of
clncal events (see Table 4) ncludng those who are
troponn postve. (Level of Evidence B) The decson to
mplement an ntal conservatve strategy n these
patents may be made consderng physcan and
patent preference. (Level of Evidence: C)
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Table 3. Selectin Initial Treatment Strategy:
Invasive Versus Cnservative Strategy
Prrr strtg Ptit Crctritic
Iviv Recurrent angina or ischemia at rest or with
low-level activities despite intensive medical therapy
Elevated cardiac biomarkers (TnT or TnI)
New or presumably new ST-segment depression
Signs or symptoms o HF or new or worsening
mitral regurgitation
High-risk indings rom noninvasive testing
Hemodynamic instability
Sustained ventricular tachycardia
PCI within 6 months
Prior CABG
High risk score (e.g., TIMI, GRACE)
Reduced let ventricular unction (LVEF less than 40%)
Crvtiv Low risk score (e.g., TIMI, GRACE)
Patient or physician preerence in the absence o
high-risk eatures
CabG = coronary artery bypass grat surgery; GRaCe = Global Registry o Acute Coronary Events;
h = heart ailure; LVe = let ventricular ejection raction; PCI = percutaneous coronary intervention;
TIMI = Thrombolysis In Myocardial Inarction; TI = troponin I; TT = troponin T.
H o s pi t al C ar e
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H o s p i t a l C a r e
Table 4. Shrt-Term Risk Death r
Nnatal MI in Patients With UA/NSTEMI*
hig Rik
At least 1 of the following features
tr must be present:
hitr Accelerating tempo o ischemic symptoms
in preceding 48 h
Crctr pi Prolonged ongoing (greater than 20 min)
rest pain
Cliicl iig Pulmonary edema, most likely due to ischemia
New or worsening MR murmur
S3 or new/worsening rales
Hypotension, bradycardia, tachycardia
Age greater than 75 years
eCG Angina at rest with transient ST-segment
changes greater than 0.5 mm
Bundle-branch block, new or presumed newSustained ventricular tachycardia
Cric mrkr Elevated cardiac TnT, TnI, or CK-MB
(e.g., TnT or TnI greater than 0.1 ng per mL)
*Estimation o the short-term risks o death and nonatal cardiac ischemic events in UA (or NSTEMI) is a com-
plex multivariable problem that cannot be ully speciied in a table such as this; thereore, this table is meant to
oer general guidance and illustration rather than rigid algorithms.
Adapted rom AHCPR Clinical Practice Guidelines No.10, Unstable Angina: Diagnosis and Management, May 1994.
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H o s p i t a l C a r e
C. Antiplatelet and Anticagulatin Therapy
A number of antplatelet and antthrombotc agents are now
avalable for use n ACS. The decson of whch agents to use,
when to admnster them and at what doses s complex. Please
see Figures 2, 3, 4 and 5 and Table 5 for gudance.
figure 2. Algrithm r Patients With UA/NSTEMI
Managed by an Initial Invasive Strategy
Diagnosis o UA/NSTEMI is Likely or Deinite
ASA (Class I, LOE: A)*
Clopidogrel i ASA intolerant (Class I, LOE: A)
Select Management Strategy†
Invasive Strategy
Initiate anticoagulant therapy (Class I, LOE: A)
Acceptable options*: enoxaparin or UFH (Class I, LOE: A)
bivalirudin or ondaparinux (Class I, LOE: B)
Prior to Angiography
Initiate at least one (Class I, LOE: A) or
both (Class IIa, LOE: B) o the ollowing:
Clopidogrel*‡
IV GP IIb/IIIa inhibitor*‡
Factors avoring administration o both
clopidogrel and GP IIb/IIIa inhibitor include:
Delay to Angiography
High Risk Features
Early recurrent ischemic discomort
Diagnostic Angiography (See Figure 4)
For an InitialConservative Strategy
see Figure 3.
When multiple drugs are
listed, they are in alphabe-
tical order and not in order
o preerence (e.g., Boxes
B1 and B2).
* See Dosing Table 5.
† See Table 11 in ull text
guideline or selection o
management strategy.‡ Evidence exists that GP
IIb/IIIa inhibitors may not
be necessary i the patient
received a preloading
dose o at least 300 mg
o clopidogrel at least 6 h
earlier (Class I, LOE: B or
clopidogrel administration)
and bivalirudin is selected
as anticoagulant (Class IIa,
LOE: B).
a
b1
b2
asa = aspirin; GP = glycoprotein; IV = intravenous; Loe = level o evidence; ua/nsTeMI =
unstable angina/non–ST-elevation myocardial inarction; uh = unractionated heparin.
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figure 3. Algrithm r Patients With UA/NSTEMI
Managed by an Initial Cnservative Strategy
Diagnosis o UA/NSTEMI is Likely or Deinite
ASA (Class I, LOE: A)*
Clopidogrel i ASA intolerant (Class I, LOE: A)
Select Management Strategy†
Conservative Strategy
Initiate anticoagulant therapy (Class I, LOE: A);
Acceptable options: enoxaparin or UFH* (Class I, LOE: A)
or ondaparinux (Class I, LOE: B), but enoxaparin or
ondaparinux are preerable (Class IIa, LOE: B)
Initiate clopidogrel therapy (Class I, LOE: A)*
Consider adding IV eptiibatide or tiroiban (Class IIb, LOE: B)*
Any subsequent events necessitating angiography?‡
Yes No
Diagnostic
Angiography,
See Figure 4
EF 0.40or less EF greater than 0.40
Evaluate LVEF
StressTest
NotLow Risk
Low Risk
Continue ASA Indeinitely (Class I, LOE: A)*
Continue clopidogrel or at least 1 month (Class I, LOE: A)
and ideally up to 1 year (Class I, LOE: B)
Discontinue IV GP IIb/IIIa i started previously (Class I, LOE: A)
Discontinue anticoagulant therapy (Class I, LOE: A)
(Class I, LOE: B)
(Class I,LOE: B)
(Class IIa,LOE: B)
(Class IIa, LOE: B)
(Class I, LOE: A)(Class I, LOE: A)
For an Invasive
Strategy
see Figure 2.
When multiple drugs
are listed, they are
in alphabetical order
and not in order o
preerence (e.g.,
Boxes C1 and C2).
* See Dosing Table 5.
† See Table 11 in ull textguideline or selection o
management strategy.
‡ Recurrent symptoms/
ischemia, heart ailure,
serious arrhythmia.
a
C1
C2
d
L
M n
o
e1 e2
K
H o s pi t al C ar e
asa = aspirin; e = ejection raction; GP = glycoprotein; IV = intravenous; Loe = level o evidence;
LVe = let ventricular ejection raction; ua/nsTeMI = unstable angina/non–ST-elevation myocardial inarction;
uh = unractionated heparin.
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H o s p i t a l C a r e
figure 4. Management Ater Diagnstic Angigraphy
in Patients With UA/NSTEMI
J
Diagnostic Angiography
* See Dosing Table 5.
† Evidence exists that GP IIb/IIIa inhibitors may not be necessary i the patient
received a preloading dose o at least 300 mg o clopidogrel at least 6 h earlier (Class I, LOE: B or clopidogrel
administration) and bivalidrudin is selected as antithrombin (Class IIa, LOE: B).
‡ Additional bolus o UFH is recommended i ondaparinux is selected as antithrombin (see Dosing Table 5).
§ For patients in whom the clinician believes coronary atherosclerosis is present, albeit without any signiicant,low-limiting stenosis, long-term treatment with antiplatelet agents and other secondary prevention measures
should be considered.
asa = aspirin; CabG = coronary artery bypass grat; Cad = coronary artery disease; GP = glycoprotein;
IV = intravenous; Ld = loading dose; PCI = percutaneous coronary intervention; pr gi = beore angiography;
ua/nsTeMI = unstable angina/non–ST-elevation myocardial inarction; uh = unractionated heparin.
Select Post-Angiography Management Strategy
CABG PCI Medical therapy
Continue ASA
(Class I, LOE: A)
Discontinue clopidogrel 5 to
7 d prior to elective CABG
(Class I, LOE: B)
Discontinue IV GP IIb/IIIa
4 h prior to CABG(Class I, LOE: B)
Continue UFH (Class I, LOE:
B); discontinue enoxaparin
12 to 24 h prior to CABG;
discontinue ondaparinux
24 h prior to CABG;
Discontinue bivalirudin 3 h
prior to CABG. Dose with
UFH per institutional
practice (Class I, LOE: B)
Continue ASA*
(Class I, LOE: A)
Loading dose o
clopidogrel i not
given pre angio
(Class I, LOE: A)*
and
IV GP IIb/IIa i not
started pre angio
(Class I, LOE: A)*†
Discontinue anti-
coagulant ater PCI
or uncomplicated
cases
(Class I, LOE: B)‡
Continue ASA*
(Class I, LOE: A)
LD o clopidogrel i not
given pre angio
(Class I, LOE: A)
*
Discontinue IV GP IIb/IIIa
ater at least 12 h i started
pre angio (Class I, LOE: B)
Continue IV UFH or at
least 48 h (Class I, LOE: A)
or enoxaparin or
ondaparinux or duration
o hospitalization (Class I,
LOE: A); either discontinue
bivalirudin or continue at a
dose o 0.25 mg/kg/hr or
up to 72 h at physician’s
discretion (Class I, LOE: B)
No
signiicant
obstructive
CAD on
angiography
CAD on angiography
Antiplatelet andanticoagulant
therapy at
physician’s
discretion§
(Class I, LOE: C)
G
h
I
J
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figure 5. Lng-Term Antithrmbtic Therapy
at Hspital Discharge Ater UA/NSTEMI
UA/NSTEMI Patient
Groups at Discharge
* For aspirin (ASA) allergic patients, use clopidogrel alone (indeinitely), or try aspirin desensitization.
† For clopidogrel allergic patients, use ticlopidine, 250 mg by mouth twice daily.
‡ Continue ASA indeinitely and wararin longer term as indicated or speciic conditions such as atrial ibrillation;LV thrombus, cerebral, venous or pulmonary emboli.
§ When wararin is added to aspirin plus clopidogrel, an INR o 2.0 to 2.5 is recommended.
InR=international normalized ratio; Loe=Level o Evidence; LV=let ventricular,
ua/nsTeMI=unstable angina/non–ST-elevation myocardial inarction.
Medical TherapyWithout Stent Bare-Metal StentGroup Drug-Eluting StentGroup
ASA* 75 to 162 mg/d indei-
nitely (Class I, LOE: A)
&
Clopidogrel† 75 mg/d or at
least 1 month (Class I, LOE: A)
and ideally up to 1 year(Class I, LOE: B)
ASA* 162 to 325 mg/d or
at least 3 to 6 months, then
75 to 162 mg/d indeinitely
(Class I, LOE: A)
&
Clopidogrel
†
75 mg/d orat least 1 year (Class I,
LOE: B)
Indication or Anticoagulation?
ASA* 162 to 325 mg/d or
at least 1 month, then 75 to
162 mg/d indeinitely
(Class I, LOE: A)
&
Clopidogrel† 75 mg/d or at
least 1 month (Class I, LOE: A)and ideally up to 1 year
(Class I, LOE: B)
Add: Wararin‡§ (Class IIb, LOE: B)Continue with dual antiplatelet
therapy as above
Yes No
H o s pi t al C ar e
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H o s p i t a l C a r e
drig
Ptit Rciv Iitil
drg* Iitil Micl Trtmt Micl Trtmt
orl tipltlt trp
Aspirin 162 to 325 mg nonenteric No additional treatment
ormulation, orally or chewed
Clopidogrel LD o 300 to 600 mg orally A second LD o 300 mg orally
MD o 75 mg orally per day may be given to supplement a
prior LD o 300 mg
Ticlopidine LD o 500 mg orally No additional treatment
MD o 250 mg orally twice daily
aticglt
Bivalirudin 0.1 mg per kg bolus, 0.25 mg 0.5 mg per kg bolus, increase
per kg per h inusion inusion to 1.75 mg per kg per h
Dalteparin 120 IU per kg SC every 12 h IV GP IIb/IIIa planned: target
(maximum 10,000 IU twice ACT 200 s using UFH
daily)‡ No IV GP IIb/IIIa planned: target ACT
250 to 300 s or HemoTec; 300 to
350 s or Hemochron using UFH
Enoxaparin LD o 30 mg IV bolus may be given║ Last SC dose less than 8 h:
MD=1 mg per kg SC every 12 h║; no additional treatment
extend dosing interval to 1 mg per Last SC dose greater than 8 h:
kg every 24 h i estimated creatinine 0.3 mg per kg IV bolus
clearance less than 30 ml per min║
Fondaparinux 2.5 mg SC once daily. Avoid or 50 to 60 U per kg IV bolus o
creatinine clearance less than UFH is recommended by the
30 mL per min║ OASIS 5 Investigators ¶
Table 5. Dsing Table r Antiplatelet and Anticagulant
Therapy in Patients With UA/NSTEMI
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H o s pi t al C
ar e
PCI
Ptit di nt Rciv Iitil
Micl Trtmt atr PCI at hpitl dicrg
162 to 325 mg nonenteric 162 to 325 mg daily should 162 to 325 mg daily should
ormulation orally or chewed be given† or at least 1 month be given† or at least 1 month
ater BMS implantation, 3 ater BMS implantation, 3
months ater SES implantation, months ater SES implantation,
and 6 months ater PES and 6 months ater PES
implantation, ater which daily implantation, ater which daily
chronic aspirin should be chronic aspirin should be
continued indeinitely at a dose continued indeinitely at a dose
o 75 to 162 mg o 75 to 162 mg
LD o 300 to 600 mg orally For BMS: 75 mg daily or at For BMS: 75 mg daily or at
least 1 month and ideally up to least 1 month and ideally up to
1 year. For DES, 75 mg daily 1 year. For DES, 75 mg daily
or at least 1 year (in patients or at least 1 year (in patients
who are not at high risk o who are not at high risk o
bleeding) (See Figure 5) bleeding) (See Figure 5)
LD o 500 mg orally MD o 250 mg orally twice daily MD o 250 mg orally twice daily
(duration same as clopidogrel) (duration same as clopidogrel)
0.75 mg per kg bolus, 1.75 No additional treatment or con-
mg per kg per h inusion tinue inusion or up to 4 hours
IV GP IIb/IIIa planned: No additional treatment
60 to 70 U per kg§ o UFH
No IV GP IIb/IIIa planned:
100 to 140 U per kg o UFH
0.5 to 0.75 mg per kg No additional treatment
IV bolus
50 to 60 U per kg IV bolus o No additional treatment
UFH is recommended by the
OASIS 5 Investigators¶ continued next page
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H o s p i t a l C a r e
aticglt ct’
Unractionated heparin LD o 60 U per kg (max 4,000 U) IV GP IIb/IIIa planned: target
as IV bolus║ ACT 200 s
MD o IV inusion o 12 U per kg No IV GP IIb/IIIa planned:
per h (max 1000 U per h) to maintain target ACT 250 to 300 s or
aPTT at 1.5 to 2.0 times control HemoTec; 300 to 350 s(approximately 50 to 70 s)║ or Hemochron
Itrv tipltlt trp
Abciximab Not applicable Not applicable
Eptiibatide LD o IV bolus o 180 mcg per kg Continue inusion
MD o IV inusion o 2.0 mcg per kgper min; reduce inusion by 50% in
patients with estimated creatinine
clearance less than 50 mL per min
Tiroiban LD o IV inusion o 0.4 mcg per kg Continue inusion
per min or 30 min
MD o IV inusion o 0.1 mcg per kg
per min; reduce rate o inusionby 50% in patients with estimated
creatinine clearance less than
30 mL per min
Table 5. Dsing Table r Antiplatelet and Anticagulant
Therapy in Patients With UA/NSTEMI continued from previous page
drig
Ptit Rciv Iitil
drg* Iitil Micl Trtmt Micl Trtmt
Additional considerations include the possibility that a conservatively managed patient may develop a need or PCI, in
which case an intravenous bolus o 50 to 60 U per kg o UFH is recommended i ondaparinux was given or initial medical
treatment; the saety o this drug combination is not well established. For conservatively managed patients in whom enoxa-
parin was the initial medical treatment, as noted in the table, additional intravenous enoxaparin is an acceptable option.
*This list is in alphabetical order and is not meant to indicate a particular therapy preerence † In patients in whom the phy-sician is concerned about the risk o bleeding, a lower initial ASA dose ater PCI o 75 to 162 mg/d is reasonable (Class
IIa, LOE: C) ‡ Dalteparin was evaluated or management o patients with UA/NSTEMI in an era beore the widespread use o
important therapies such as stents, clopidogrel, and GP IIb/IIIa inhibitors. Its relative eicacy and saety in the contempo-
rary management era is not well established. § Some operators use less than 60 U per kg o UFH with GP IIb/IIIa blockade,
although no clinical trial data exist to demonstrate the eicacy o doses below 60 U per kg in this setting. ║ For patients
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IV GP IIb/IIIa planned: 60 to 70 No additional treatment
U per kg§
No IV GP IIb/IIIa planned: 100
to 140 U per kg
LD o 0.25 mg per kg IV bolus Continue MD inusion
MD o 0.125 mcg per kg per min or 12 h
(max 10 mcg per min)
LD o IV bolus o 180 mcg per kg Continue MD inusion
ollowed 10 min later by second or 18 to 24 hIV bolus o 180 mcg per kg
MD o 2.0 mcg per kg per min;
reduce inusion by 50% in patients
with estimated creatinine clearance
less than 50 mL per min
LD o IV inusion o 0.4 mcg per Continue MD inusion
kg per min or 30 min or 18 to 24 h
MD o IV inusion o 0.1 mcg per
kg per min; reduce rate o inusionby 50% in patients with estimated
creatinine clearance less than
30 mL per min
PCI
Ptit di nt Rciv Iitil
Micl Trtmt atr PCI at hpitl dicrg
managed by an initial conservative strategy, agents such as enoxaparin and ondaparinux oer the convenience advantage
o SC administration compared with an intravenous inusion o UFH. They are also less likely to provoke heparin-induced
thrombocytopenia than UFH. Available data suggest ondaparinux is associated with less bleeding than enoxaparin in con-
servatively managed patients using the regimens listed. ¶ Personal communication, OASIS 5 Investigators, July 7, 2006.
Note that this regimen has not been rigorously tested in prospective randomized trials.
aCT = activated clotting time; bMs = bare-metal stent; GP = glycoprotein; Iu = international unit; IV = intravenous;
Ld = loading dose; Md = maintenance dose; PCI = percutaneous coronary intervention; Pes = paclitaxel-eluting stent;
sC = subcutaneous; ses = sirolimus-eluting stent; u = units; ua/nsTeMI = unstable angina/non–ST-elevation myocar-
dial inarction; uh = unractionated heparin.
H o s pi t al C ar e
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H o s p i t a l C a r e
D. Risk Stratiicatin
Recmmendatins
Class I 1. Nonnvasve stress testng s recommended n low
and ntermedate-rsk patents who have been free
of schema at rest or wth low-level actvty and of
heart falure for a mnmum of 12 to 24 h. (Level of
Evidence: C)
2. Choce of stress test s based on the restng ECG,
ablty to perform exercse, local expertse, and tech-
nologes avalable. Treadmll exercse s useful n pa-
tents able to exercse n whom the ECG s free of
baselne ST-segment abnormaltes, bundle-branch
block, left ventrcular (LV) hypertrophy, ntraventrc-
ular conducton defect, paced rhythm, preexctaton,and dgoxn effect. (Level of Evidence: C)
3. An magng modalty should be added n patents
wth restng ST-segment depresson (greater than or
equal to 0.10 mV), LV hypertrophy, bundle-branch
block, ntraventrcular conducton defect, preexcta-
ton, or dgoxn who are able to exercse. In patentsundergong a low-level exercse test, an magng
modalty can add senstvty. (Level of Evidence: B)
4. Pharmacologcal stress testng wth magng
s recommended when physcal lmtatons (e.g.,
arthrts, amputaton, severe perpheral vascular
dsease, severe chronc obstructve pulmonary
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dsease, general deblty) preclude adequate exercse
stress. (Level of Evidence: B)
5. Prompt angography wthout nonnvasve rskstratfcaton should be performed for falure of sta-
blzaton wth ntensve medcal treatment. (Level of
Evidence: B)
6. A nonnvasve test (echocardogram or radonu-
clde angogram) s recommended to evaluate LV
functon n patents wth defnte ACS who are notscheduled for coronary angography and left ventrc-
ulography. (Level of Evidence: B)
H o s pi t al C ar e
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R e v a s c u l a r i z a t i o n
III. Crnary Revasculariatin
Recmmendatins r Revasculariatin With
PCI and CABG in Patients With UA/NSTEMI
Class I 1. An early nvasve percutaneous coronary nter-
venton (PCI) strategy s ndcated for patents wth
UA/NSTEMI who have no serous comorbdty and
who have coronary lesons amenable to PCI andwho have any of the hgh-rsk features lsted n
Table 3.
2. Coronary artery bypass graft (CABG) s recom-
mended for UA/NSTEMI patents wth sgnfcant left
man coronary artery dsease (CAD; greater than
50% stenoss). (Level of Evidence: A)
3. CABG s recommended for UA/NSTEMI patents
wth 3-vessel CAD; the survval beneft s greater n
patents wth abnormal LV functon (LVEF less than
0.50). (Level of Evidence: A)
4. CABG s recommended for UA/NSTEMI patents
wth 2-vessel CAD wth sgnfcant proxmal left an-
teror descendng CAD and ether abnormal LV func-
ton (LVEF less than 0.50) or schema on nonnva-
sve testng. (Level of Evidence: A)
5. CABG s recommended for UA/NSTEMI patents n
whom percutaneous revascularzaton s not optmal
or possble and who have ongong schema not re-
sponsve to maxmal nonsurgcal therapy. (Level of
Evidence: B)
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6. CABG (or PCI) s recommended for UA/NSTEMI
patents wth 1- or 2-vessel CAD wth or wthout
sgnfcant proxmal left anteror descendng CAD
but wth a large area of vable myocardum and
hgh-rsk crtera on nonnvasve testng. (Level of
Evidence: B)
7. CABG (or PCI) s recommended for UA/NSTEMI
patents wth multvessel coronary dsease wth
sutable coronary anatomy, normal LV functon,
and wthout dabetes melltus. (Level of Evidence: A)
8. An ntravenous platelet GP IIb/IIIa nhbtor s
generally recommended n UA/NSTEMI patents
undergong PCI. (Level of Evidence: A)
See Figures 2, 3, and 4.
Class IIa 1. PCI s reasonable for focal saphenous ven graft
lesons or multple stenoses n UA/NSTEMI patents
who are undergong medcal therapy and who are
poor canddates for reoperatve surgery. (Level of
Evidence: C)
2. PCI or CABG s reasonable for UA/NSTEMI
patents wth 1- or 2-vessel CAD wth or wthout sg-
nfcant proxmal left anteror descendng CAD but
wth a moderate area of vable myocardum and
schema on nonnvasve testng. ( Level of Evidence: B)
3. PCI or CABG can be benefcal compared wth
medcal therapy for patents wth 1-vessel dsease
R ev a s c ul ar i z a t i on
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Class III 1. CABG or PCI s not recommended for patents
wth 1- or 2-vessel CAD wthout sgnfcant
proxmal left anteror descendng CAD wth no
current symptoms or symptoms that are unlkely
due to myocardal schema and who have no sch-
ema on nonnvasve testng. (Level of Evidence: C)
2. In the absence of hgh-rsk features assocated
wth UA/NSTEMI, PCI s not recommended for pa-
tents wth UA/NSTEMI who have sngle-vessel or
multvessel CAD and no tral of medcal therapy,
or who have 1 or more of the followng:
a. Only a small area of myocardum at rsk. (Level
of Evidence: C)
b. All lesons or the culprt leson to be dlated
wth morphology that conveys a low lkelhoodof success. (Level of Evidence: C)
c. A hgh rsk of procedure-related morbdty or
mortalty. (Level of Evidence: C)
d. Insgnfcant dsease (less than 50% coronary
stenoss). (Level of Evidence: C)
e. Sgnfcant left man CAD and canddacy forCABG. (Level of Evidence: B)
R ev a s c ul ar i z a t i on
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D i s c h a r g e / P o s t - D i s c h a r g e
IV. Hspital Discharge and
Pst-Hspital Discharge Care
The acute phase of UA/NSTEMI s usually
over wthn 2 months. The rsk of progresson
to MI or the development of recurrent MI or death s hghest
durng ths perod. Most patents then resume a clncal course
smlar to that of patents wth chronc, stable CAD.
A. Medical Regimen
An effort of the entre staff (physcans, nurses, dettans,
pharmacsts, rehabltaton specalsts, and physcal and occu-
patonal therapsts) s often necessary to prepare the patent
for dscharge. Drect patent nstructon s mportant and should
be renforced and documented wth wrtten nstructon sheets.Enrollment n a cardac rehabltaton program after dscharge
may enhance patent educaton and complance wth the
medcal regmen.
Recmmendatins r Pst-Discharge Therapy
Class I 1. Medcatons requred n the hosptal to control
schema should be contnued after hosptal ds-
charge n patents wth UA/NSTEMI who do not un-
dergo coronary revascularzaton, patents wth un-
successful revascularzaton, and patents wth re-
current symptoms after revascularzaton. Upwardor downward ttraton of the doses may be requred.
(Level of Evidence: C)
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2. All post UA/NSTEMI patents should be gven
sublngual or spray NTG and nstructed n ts use.
(Level of Evidence: C)
3. Before hosptal dscharge, patents wth UA/
NSTEMI should be nformed about symptoms of
worsenng myocardal schema and MI and should
be nstructed n how and when to seek emergency
care and assstance f such symptoms occur. (Level
of Evidence: C)
4. Before hosptal dscharge, post UA/NSTEMI pa-
tents and/or desgnated responsble caregvers
should be provded wth supportable, easly under-
stood, and culturally senstve nstructons wth re-
spect to medcaton type, purpose, dose, frequency,
and pertnent sde effects. (Level of Evidence: C)
5. In post UA/NSTEMI patents, angnal dscomfort
lastng more than 2 or 3 mn should prompt the pa-
tent to dscontnue physcal actvty or remove hm-
self or herself from any stressful event. If pan does
not subsde mmedately, the patent should be n-
structed to take 1 dose of NTG sublngually. If the
chest dscomfort/pan s unmproved or worsenng
5 mn after 1 NTG dose has been taken, t s recom-
mended that the patent or a famly member/frend
call 9-1-1 mmedately to access EMS. Whle actvat-
ng EMS access, addtonal NTG (at 5-mn ntervals
2 tmes) may be taken whle lyng down or sttng.
(Level of Evidence: C)
D i s c h ar g e
/ P o s t - D i s c h ar g e
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D i s c h a r g e / P o s t - D i s c h a r g e
6. If the pattern or severty of angnal symptoms
changes, whch suggests worsenng myocardal
schema (e.g., pan s more frequent or severe or s
precptated by less effort or now occurs at rest), the
patent should contact hs or her physcan wthout
delay to assess the need for addtonal treatment or
testng. (Level of Evidence: C)
B. Lng-Term Medical Therapy and Secndary Preventin
i. Antiplatelet Therapy
Class I 1. Asprn 75 to 162 mg daly should be gven and
contnued ndefntely for medcally treated patents
recoverng from UA/NSTEMI. (Level of Evidence: A) Forpatents who have undergone PCI, ASA 162 to 325
mg daly should be gven for at least 1 month after
bare-metal stent mplantaton, 3 months after srol-
mus-elutng stent mplantaton, and 6 months after
pacltaxel-elutng stent mplantaton, after whch
daly chronc ASA use should be contnued ndef-
ntely at a dose of 75 to 162 mg. (Level of Evidence: B)
2. Clopdogrel 75 mg daly (preferred) or tclopdne
(n the absence of contrandcatons) should be gven
to patents recoverng from UA/NSTEMI when ASA
s contrandcated or not tolerated because of
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D i s c h a r g e / P o s t - D i s c h a r g e
iii. Inhibitin the Renin-Angitensin-
Aldsterne System
Class I 1. ACE nhbtors should be gven and contnued n-
defntely for patents recoverng from UA/NSTEMI
wth HF, LV dysfuncton (ejecton fracton less than
0.40), hypertenson, or dabetes melltus unless con-
trandcated. (Level of Evidence: A)
2. An angotensn receptor blocker should be pre-scrbed at dscharge to those patents who are ntol-
erant of an ACE nhbtor and who have ether cln-
cal or radologcal sgns of HF and LVEF less than
0.40 (Level of Evidence: A)
3. Long-term aldosterone receptor blockade should
be prescrbed for post-UA/NSTEMI patents wthoutsgnfcant renal dysfuncton (estmated creatnne
clearance should be greater than 30 mL per mn) or
hyperkalema (potassum should be less than or
equal to 5 mEq per L) who are already recevng
therapeutc doses of an ACE nhbtor, have an LVEF
less than or equal to 0.40, and have ether symptom-
atc HF or dabetes melltus. (Level of Evidence: A)
Class IIa 1. ACE nhbtors are reasonable for patents recov-
erng from UA/NSTEMI n the absence of LV dys-
functon, hypertenson, or dabetes melltus unless
contrandcated. (Level of Evidence: A)
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iv. NTG
Class I 1. NTG to treat schemc symptoms s recommended.(Level of Evidence: C)
v. Calcium Channel Blckers
Class I 1. Calcum channel blockers* are recommended for
schemc symptoms when beta blockers are not suc-
cessful. (Level of Evidence: B)
2. Calcum channel blockers* are recommended for
schemc symptoms when beta blockers are contra-
ndcated or cause unacceptable sde effects. (Level of
Evidence: C)
* Short-acting dihydropyridine calcium channel blockers should
be avoided.
vi. Wararin Therapy
Class I Use of warfarn n conjuncton wth ASA and/or
clopdogrel s assocated wth an ncreased rsk of bleedng and should be montored closely. (Level of
Evidence: A)
Class IIb Warfarn ether wthout (nternatonal normalzed
rato 2.5 to 3.5) or wth low-dose ASA (75 to 81 mg
per day; nternatonal normalzed rato 2.0 to 2.5)
continued next page
D i s c h ar g e
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D i s c h a r g e / P o s t - D i s c h a r g e
may be reasonable for patents at hgh CAD rsk and
low bleedng rsk who do not requre or are ntoler-
ant of clopdogrel. (Level of Evidence: B)
vii. Lipid Management
Class I 1. The followng lpd recommendatons are
benefcal:
a. Lpd management should nclude assessment of
a fastng lpd profle for all patents, wthn 24 h of
hosptalzaton. (Level of Evidence: C)
b. Hydroxymethyl glutaryl-coenzyme A reductase n-
hbtors (statns), n the absence of contra-ndca-
tons, regardless of baselne LDL-C and det modf-
caton, should be gven to post-UA/NSTEMI patents,
ncludng postrevascularzaton patents. (Level of
Evidence: A)
c. For patents wth elevated LDL-C (greater than or
equal to 100 mg per dL), cholesterol-lowerng thera-
py should be ntated or ntensfed to acheve an
LDL-C of less than 100 mg per dL (Level of Evidence: A).
2. Treatment of trglycerdes and non–HDL-C s use-
ful, ncludng the followng:
a. If trglycerdes are 200 to 499 mg per dL, non–
HDL-C* should be less than 130 mg per dL. (Level of
Evidence: B)
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b. If trglycerdes are greater than or equal to 500 mg
per dL†, therapeutc optons to prevent pancreatts
are fbrate‡ or nacn‡ before LDL-lowerng therapy s
recommended. It s also recommended that LDL-C
be treated to goal after trglycerde-lowerng therapy.
Achevement of a non–HDL-C* less than 130 mg per
dL (.e., 30 mg per dL greater than LDL-C target) f
possble s recommended. (Level of Evidence: C)
Class IIa The followng lpd management strateges can be
benefcal:
a. Further reducton of LDL-C to less than 70 mg per
dL s reasonable. (Level of Evidence: A)
b. If baselne LDL cholesterol s 70 to 100 mg per dL,
t s reasonable to treat LDL-C to less than 70 mg per
dL. (Level of Evidence: B)
* Non–HDL-C = total cholesterol minus HDL-C.
† Patients with very high triglycerides should not consume alcohol.
The use of bile acid sequestrants is relatively contraindicated whentriglycerides are greater than 200 mg per dL.
‡ The combination of high-dose statin plus fibrate can increase risk
for severe myopathy. Statin doses should be kept relatively low with
this combination. Dietary supplement niacin must not be used as a
substitute for prescription niacin.
D i s c h ar g e
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D i s c h a r g e / P o s t - D i s c h a r g e
viii. Bld Pressure Cntrl
Class I Blood pressure control to less than 140/90 mm Hg(or less than 130/80 mm Hg f the patent has
dabetes melltus or chronc kdney dsease). (Level
of Evidence: A) Addtonal measures recommended to
treat and control blood pressure nclude the
followng:
a. Patents should ntate and/or mantan lfestylemodfcatons, ncludng weght control; ncreased
physcal actvty; alcohol moderaton; sodum reduc-
ton; and emphass on ncreased consumpton of
fresh fruts, vegetables, and low-fat dary products.
(Level of Evidence: B)
b. For patents wth blood pressure greater than orequal to 140/90 mm Hg (or greater than or equal to
130/80 mm Hg for ndvduals wth chronc kdney
dsease or dabetes melltus), t s useful to add blood
pressure medcaton as tolerated, treatng ntally
wth beta blockers and/or ACE nhbtors, wth add-
ton of other drugs such as thazdes as needed to
acheve target blood pressure. (Level of Evidence: A).
ix. Diabetes Mellitus
Class I Dabetes management should nclude lfestyle and
pharmacotherapy measures to acheve a near-nor-
mal hemoglobn A1c level of less than 7% (Level of
Evidence: B). Dabetes management should also n-
clude the followng:
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a. Vgorous modfcaton of other rsk factors (e.g.,
physcal actvty, weght management, blood pres-
sure control, and cholesterol management) as rec-
ommended should be ntated and mantaned. (Level
of Evidence: B)
b. It s useful to coordnate the patent’s dabetc care
wth the patent’s prmary care physcan or endocr-
nologst. (Level of Evidence: C)
x. Smking Cessatin
Class I Smokng cessaton and avodance of exposure to en-
vronmental tobacco smoke at work and home are
recommended. Follow-up, referral to specal pro-
grams, or pharmacotherapy (ncludng ncotne re-
placement) s useful, as s adoptng a stepwse strate-
gy amed at smokng cessaton (the 5 As: Ask, Advse,
Assess, Assst, and Arrange). (Level of Evidence: B)
xi. Weight Management
Class Ia Weght management, as measured by body mass n-
dex and/or wast crcumference, should be assessed
on each vst. A body mass ndex of 18.5 to 24.9 kg
per m2 and a wast crcumference (measured hor-
zontally at the lac crest) of less than 40 nches for
men and less than 35 nches for women s recom-
mended. (Level of Evidence: B)
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D i s c h a r g e / P o s t - D i s c h a r g e
xii. Physical Activity
Class I 1. The patent’s rsk after UA/NSTEMI should be as-sessed on the bass of an n-hosptal determnaton
of rsk. A physcal actvty hstory or an exercse test
to gude ntal prescrpton s benefcal. (Level of
Evidence: B)
2. Guded/modfed by an ndvdualzed exercse
prescrpton, patents recoverng from UA/NSTEMIgenerally should be encouraged to acheve physcal
actvty duraton of 30 to 60 mn per day, preferably
n the form of 7 (but at least 5) days per week of
moderate aerobc actvty, such as brsk walkng,
supplemented by an ncrease n daly lfestyle actv-
tes (e.g., walkng breaks at work, gardenng, and
household work). (Level of Evidence: B)
3. Cardac rehabltaton/secondary preventon pro-
grams are recommended for patents wth UA/
NSTEMI, partcularly those wth multple modfable
rsk factors and/or those moderate- to hgh-rsk pa-
tents n whom supervsed exercse tranng s par-
tcularly warranted. (Level of Evidence: B)
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xiii Patient Educatin
Class I Beyond the detaled nstructons for daly exercse,patents should be gven specfc nstructon on ac-
tvtes (eg, heavy lftng, clmbng stars, yard work,
and household actvtes) that are permssble and
those that should be avoded. Specfc menton
should be made regardng resumpton of drvng, re-
turn to work, and sexual actvty. (Level of Evidence: C)
xiv. Inluena
Class I An annual nfluenza vaccnaton s recommended
for patents wth cardovascular dsease. (Level of
Evidence: B)
xv. Depressin
Class IIa It s reasonable to consder screenng UA/NSTEMI
patents for depresson and refer treatment when
ndcated. (Level of Evidence: B)
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D i s c h a r g e / P o s t - D i s c h a r g e
xvi. Hrmne Therapy
Class III 1. Hormone therapy wth estrogen plus progestn, orestrogen alone, should not be gven de novo to post-
menopausal women after UA/NSTEMI for secondary
preventon of coronary events. (Level of Evidence: A)
2. Postmenopausal women who are already takng
estrogen plus progestn, or estrogen alone, at the
tme of UA/NSTEMI n general should not contnuehormone therapy. However, women who are more
than 1 to 2 years past the ntaton of hormone ther-
apy who wsh to contnue such therapy for another
compellng ndcaton should wegh the rsks and
benefts, recognzng the greater rsk of cardovascu-
lar events and breast cancer (combnaton therapy)
or stroke (estrogen). Hormone therapy should not be
contnued whle patents are on bedrest n the hosp-
tal. (Level of Evidence: B)
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