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.
OK.. now to the super condensed summary.
Evaluation
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
Oxygen
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.
Nitrates
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:
Harm
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.
IIa
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.
Anticoagulation
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
IIb
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.
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.
