Pocket Guide for Nonstemi Aha 2007

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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







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.



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



2



3

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



4


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



5

* 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



6

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



7

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

I ni t i al E / M



8

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.)



9

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.

I ni t i al E / M



10

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





12

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.


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)

I n i t i a l E / M







15

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


D i s c h ar g e

/ P o s t - d i s c h ar g e



16


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)



17

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.




18


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.





20


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.



21

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 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


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.



22


figure 4. Management Ater Diagnstic Angigraphy

in Patients With UA/NSTEMI

J

Diagnostic Angiography


† 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



23

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




24


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



25

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



26


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



27

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.




28


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



29

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)




30

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)



31

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






33

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)




34


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.




35

2. All post UA/NSTEMI patents should be gven

sublngual or spray NTG and nstructed n ts use.


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.


D i s c h ar g e




36


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





38


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)



39

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




40


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)



41

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




42


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:



43

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)

D i s c h ar g e




44


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)



45

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)

D i s c h ar g e




46


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)





Documents

Pocket Guide for Nonstemi Aha 2007