Thursday, September 25, 2014

2014 AMA/ACC guidelines for the NSTE-ACS

This is a super short summary of the guidelines published on-line a couple of days ago. It basically contains what we need to know in the ED to treat these patients. There are dozens of pages on what to do after the patient leaves the department. If you are interested in that, go ahead and download the free PDF and get cozy with it. Here is the link:

You will notice that the guidelines are very similar to prior the prior edition. There are only few changes with regards with anti platelet agent choices, the elimination of CK-MB as diagnostic test, oxygen is only for those with hypoxia and a more liberal approach to coronary imaging and interventions.

OK.. now to the super condensed summary.

Class I
1. ECG within 10 mins or arrival.
2. Repeat ECG q 15-20 mins in patient who remain symptomatic and initial EKG was non-diagnostic.
3. Serial cardiac troponin I or T levels at presentation and 3 to 6 hours after symptom onset
4. Additional troponin levels should be obtained beyond 6 hours after symptom onset in patients with normal troponin levels on serial examination when changes on ECG and/or clinical presentation confer an intermediate or high index of suspicion for ACS
5. Risk scores (like GRACE score) should be used to assess prognosis in patients with NSTE-ACS
Class IIa
1. Risk-stratification models can be useful in management (like TIMI).
2. Get ECG leads V7 to V9 in patients whose 
initial ECG is nondiagnostic and who are at intermediate/high risk of ACS looking for posterior MI.
Class IIb
1. Continuous monitoring with 12-lead ECG
2. Measurement of B-type natriuretic peptide or N-terminal pro–B-type natriuretic peptide may be considered to assess risk in patients with suspected ACS

Biomarkers: Diagnosis
Class I
1. If the time of symptom onset is ambiguous, the time of presentation should be considered the time of onset for assessing troponin values
Class III: No Benefit

1. If you have troponins in your lab, forget about creatine kinase myocardial isoenzyme (CK-MB) and myoglobin are not useful for diagnosis of ACS

Biomarkers: Prognosis
Class I

1. The presence and magnitude of troponin elevations are useful for short- and long-term prognosis

Discharge from the ED
Class IIa
1. OK to admit at risk patients to chest pain units for repeat ECG's an trops at 3- to 6-hour intervals
2. Patients with normal serial ECGs and cardiac troponins can have a treadmill ECG, stress myocardial perfusion imaging, or stress echocardiography before discharge or within 72 hours after discharge.
3. Reasonable alternatives are coronary computed tomography angiography to assess coronary artery anatomy or rest myocardial perfusion imaging with a technetium-99m radiopharmaceutical to exclude myocardial ischemia.
4. Those who go home, get daily aspirin, short-acting nitroglycerin, and other medication if appropriate (e.g., beta blockers), with instructions about activity level and clinician follow-up.

Early Hospital Care
Class I

1. Supplemental oxygen should be administered to patients with NSTE-ACS with arterial oxygen saturation less than 90%, respiratory distress, or other high-risk features of hypoxemia.
Class I
1. Patients with NSTE-ACS with continuing ischemic pain should receive sublingual nitroglycerin 
(0.3 mg–0.4 mg) every 5 minutes for up to 3 doses, after which an assessment should be made about the need for intravenous nitroglycerin if not contraindicated
2. Intravenous nitroglycerin is indicated for patients with NSTE-ACS for the treatment of persistent ischemia, heart failure (HF), or hypertension.
Analgesic Therapy
Class IIb

1. If no contrainfications, Morphine for non-controlled ischemic pain is just fine.
Class III:

1. Don’t use NSAID’s and if they are taking NSAID’s for other reasons, stop it.
Beta-Adrenergic Blockers
Class I
1. Oral beta-blocker therapy should be initiated within the first 24 hours in patients who do not have any of the following: 1) signs of HF, 2) evidence of low-output state, 3) increased risk for cardiogenic shock, or 4) other contraindications to beta blockade (e.g., PR interval >0.24 second, second- or third-degree heart block without a cardiac pacemaker, active asthma, or reactive airway disease)
2. In patients with concomitant NSTE-ACS, stabilized HF, and reduced systolic function, it is recommended to continue beta-blocker therapy with 1 of the 3 drugs proven to reduce mortality in patients with HF: sustained-release metoprolol succinate, carvedilol, or bisoprolol.
3. Patients with documented contraindications to beta blockers in the first 24 hours of NSTE-ACS should be reevaluated to determine their subsequent eligibility. 

1. It is reasonable to continue beta-blocker therapy in patients with normal left ventricular (LV) function with NSTE-ACS 
III: Harm
1. Administration of intravenous beta blockers is potentially harmful in patients with NSTE-ACS who have risk factors for shock (poor EF, tachycardic, know myocardiopathy)
Calcium Channel Blockers
Class I
1. In patients with NSTE-ACS, continuing or frequently recurring ischemia, and a contraindication to beta blockers, a nondihydropyridine calcium channel blocker (CCB) (e.g., verapamil or diltiazem) should be given as initial therapy in the absence of clinically significant LV dysfunction, increased risk for cardiogenic shock, PR interval greater than 0.24 second, or second- or third- degree atrioventricular block without a cardiac pacemaker
2. CCBs are recommended for ischemic symptoms when beta blockers are not successful, are contraindicated, or cause unacceptable side effects. 
Class III: Harm

1. Immediate-release nifedipine should not be administered to patients with NSTE-ACS in the absence of beta-blocker therapy
Antiplatelet Agents
Class I
1. If non-allergic, give Aspirin to everyone (162 mg to 325 mg) as soon as possible after presentation, and a maintenance dose of aspirin (81 mg/d to 162 mg/d) should be continued indefinitely
2. If Aspirin allergic, give clopidogrel followed by a daily maintenance dose should be administered
Class IIa

1. It is reasonable to use ticagrelor in preference to clopidogrel in patients with NSTE ACS who undergo an early invasive or ischemia-guided strategy.
Class IIb

1. In patients with NSTE-ACS treated with an early invasive strategy and dual anti platelet therap  (DAPT) with intermediate/high-risk features (e.g., positive troponin), a glycoprotein (GP) IIb/IIIa inhibitor may be considered as part of initial antiplatelet therapy. Preferred options are eptifibatide or tirofiban.


Class I
1. In patients with NSTE-ACS, anticoagulation, in addition to antiplatelet therapy, is recommended for all patients irrespective of initial treatment strategy. Treatment options include:
- Enoxaparin: 1 mg/kg subcutaneous (SC) every 12 hours (reduce dose to 1 mg/kg SC once daily in patients with creatinine clearance [CrCl] <30 mL/min), continued for the duration of hospitalization or until percutaneous coronary intervention (PCI) is performed. An initial intravenous loading dose is 30 mg

- Bivalirudin: 0.10 mg/kg loading dose followed by 0.25 mg/kg per hour (only in patients managed with an early invasive strategy), continued until diagnostic angiography or PCI, with only provisional use of GP IIb/IIIa inhibitor, provided the patient is also treated with DAPT

- Fondaparinux: 2.5 mg SC daily, continued for the duration of hospitalization or until PCI is performed

- If PCI is performed while the patient is on fondaparinux, an additional anticoagulant with anti-IIa activity (either UFH or bivalirudin) should be administered because of the risk of catheter thrombosis

- UFH IV: initial loading dose of 60 IU/kg (maximum 4,000 IU) with initial infusion of 12 IU/kg per hour (maximum 1,000 IU/h) adjusted per activated partial thromboplastin time to maintain therapeutic anticoagulation according to the specific hospital protocol, continued for 48 hours or until PCI is performed

Class III: Harm

1. In patients with NSTE-ACS (i.e., without ST elevation, true posterior MI, or left bundle-branch block not known to be old), intravenous fibrinolytic therapy should not be used.
Ischemia-Guided Strategy Versus Early Invasive Strategies

Early Invasive and Ischemia-Guided Strategies
Class I
1. An urgent/immediate invasive strategy (diagnostic angiography with intent to perform revascularization if appropriate based on coronary anatomy) is indicated in patients (men and women) with NSTE-ACS who have refractory angina or hemodynamic or electrical instability (without serious comorbidities or contraindications to such procedures).
2. An early invasive strategy (diagnostic angiography with intent to perform revascularization if appropriate based on coronary anatomy) is indicated in initially stabilized patients with NSTE- ACS (without serious comorbidities or contraindications to such procedures) who have an elevated risk for clinical events
Class IIa

1. It is reasonable to choose an early invasive strategy (within 24 hours of admission) over a delayed invasive strategy (within 24 to 72 hours) for initially stabilized high-risk patients with NSTE-ACS. For those not at high/intermediate risk, a delayed invasive approach is reasonable

1. In initially stabilized patients, an ischemia-guided strategy may be considered for patients with NSTE ACS (without serious comorbidities or contraindications to this approach) who have an elevated risk for clinical events  
2. The decision to implement an ischemia-guided strategy in initially stabilized patients (without serious comorbidities or contraindications to this approach) may be reasonable after considering clinician and patient preference.
III: No Benefit

1. An early invasive strategy (i.e., diagnostic angiography with intent to perform revascularization) is not recommended in patients with:
- Extensive comorbidities (e.g., hepatic, renal, pulmonary failure, cancer), in whom the risks of revascularization and comorbid conditions are likely to outweigh the benefits of revascularization.  
- Acute chest pain and a low likelihood of ACS who are troponin- negative, especially women.

Ufff. That was painful !  But not as painful as the 71 pages of the whole document. Now go and tell your friends that NSTE-ACS has new guidelines with just a few changes.