Unstable angina non ST elevation myocardial infarction long-term medical therapy and secondary prevention ACC/AHA guidelines for lipid management
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Unstable angina non ST elevation myocardial infarction long-term medical therapy and secondary prevention ACC/AHA guidelines for lipid management On the Web |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-in-Chief: Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.; Maheep Sangha, M.B.B.S..
Overview
Evaluation of lipid profiles and initiation of lipid-lowering therapy is recommended for patients who are hospitalized with unstable angina/ NSTEMI. Promoting weight reduction, increased physical activity, and dietary modification should be recommended for the appropriate patients. Further management of lipids may be employed depending on a patients individual lipid status.
2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non -ST-Elevation Myocardial Infarction (DO NOT EDIT)[1][2]
Lipid Management (DO NOT EDIT)[1][2]
| Class I |
| "1. The following lipid recommendations are beneficial: |
| a) Lipid management should include assessment of a fasting lipid profile for all patients, within 24 h of hospitalization. (Level of Evidence: C) |
| b) Hydroxymethyl glutaryl-coenzyme A reductase inhibitors (statins), in the absence of contraindications, regardless of baseline LDL-C and diet modification, should be given to post-UA/NSTEMI patients, including postrevascularization patients. (Level of Evidence: A) |
| c) For hospitalized patients, lipid-lowering medications should be initiated before discharge. (Level of Evidence: A) |
| d) For UA/NSTEMI patients with elevated LDL-C (greater than or equal to 100 mg per dL), cholesterol-lowering therapy should be initiated or intensified to achieve an LDL-C of less than 100 mg per dL. (Level of Evidence: A) Further titration to less than 70 mg per dL is reasonable. (Class IIa, Level of Evidence: A) |
| e) Therapeutic options to reduce non–HDL-C* are recommended, including more intense LDL-C–lowering therapy. (Level of Evidence: B) |
| f) Dietary therapy for all patients should include reduced intake of saturated fats (to less than 7% of total calories), cholesterol (to less than 200 mg per d), and trans fat (to less than 1% of energy). (Level of Evidence: B) |
| g) Promoting daily physical activity and weight management are recommended. (Level of Evidence: B)" |
| "2. Treatment of triglycerides and non-HDL-C is useful, including the following: |
| a) If triglycerides are 200 to 499 mg per dL, non-HDL-C* should be less than 130 mg per dL. (Level of Evidence: B) |
| b) If triglycerides are greater than or equal to 500 mg per dL, therapeutic options to prevent pancreatitis are fibrate† or niacin† before LDL-lowering therapy is recommended. It is also recommended that LDL-C be treated to goal after triglyceride-lowering therapy. Achievement of a non-HDL-C* less than 130 mg per dL (i.e., 30 mg per dL greater than LDL-C target) if possible is recommended. (Level of Evidence: C)" |
| Class IIa |
| "1. The following lipid management strategies can be beneficial: |
| a) Further reduction of LDL-C to less than 70 mg per dL is reasonable. (Level of Evidence: A) |
| b) If baseline LDL cholesterol is 70 to 100 mg per dL, it is reasonable to treat LDL-C to less than 70 mg per dL. (Level of Evidence: B) |
| c) Further reduction of non-HDL-C* to less than 100 mg per dL is reasonable; if triglycerides are 200 to 499 mg per dL, non-HDL-C target is less than 130 mg per dL. (Level of Evidence: B) |
| d) Therapeutic options to reduce non-HDL-C* (after LDL-C lowering) include niacin† or fibrate therapy. |
| e) Nicotinic acid (niacin)† and fibric acid derivatives (fenofibrate, gemfibrozil)**< can be useful as therapeutic options (after LDL-C–lowering therapy) for HDL-C less than 40 mg per dL. (Level of Evidence: B) |
| f) Nicotinic acid (niacin)† and fibric acid derivatives (fenofibrate, gemfibrozil)**< can be useful as therapeutic options (after LDL-C–lowering therapy) for triglycerides greater than 200 mg per dL. (Level of Evidence: B) |
| g) The addition of plant stanol/sterols (2 g per d) and viscous fiber (more than 10 g per d) is reasonable to further lower LDL-C. (Level of Evidence: A)" |
| Class IIb |
| "1. Encouraging consumption of omega-3 fatty acids in the form of fish*** or in capsule form (1 g per d) for risk reduction may be reasonable. For treatment of elevated triglycerides, higher doses (2 to 4 g per d) may be used for risk reduction. (Level of Evidence: B)" |
* Non-HDL-C = total cholesterol minus HDL-C.
† 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.
** Patients with very high triglycerides should not consume alcohol. The use of bile acid sequestrants is relatively contraindicated when triglycerides are greater than 200 mg per dL.
*** Pregnant and lactating women should limit their intake of fish to minimize exposure to methylmercury.
References
- ↑ 1.0 1.1 Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE; et al. (2011). "2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". Circulation. 123 (18): e426–579. doi:10.1161/CIR.0b013e318212bb8b. PMID 21444888.
- ↑ 2.0 2.1 Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B (2007). "ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine". Journal of the American College of Cardiology. 50 (7): e1–e157. doi:10.1016/j.jacc.2007.02.013. PMID 17692738. Retrieved 2011-04-12. Unknown parameter
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