Unstable angina non ST elevation myocardial infarction long-term medical therapy and secondary prevention

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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ACC / AHA Guidelines- Antiplatelet Therapy (DO NOT EDIT)

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Class I 1. For UA/NSTEMI patients treated medically without stenting, aspirin (75 to 162 mg per day) should be prescribed indefinitely (Level of Evidence: A) clopidogrel (75 mg per day) should be prescribed for at least 1 month (Level of Evidence: A) and ideally for up to 1 year. (Level of Evidence: B) 2. For UA/NSTEMI patients treated with bare-metal stents, aspirin 162 to 325 mg per day should be prescribed for at least 1 month (Level of Evidence: B), then continued indefinitely at a dose of 75 to 162 mg per day (Level of Evidence: A); clopidogrel should be prescribed at a dose of 75 mg per day for a minimum of 1 month and ideally for up to 1 year (unless the patient is at increased risk of bleeding, then it should be given for a minimum of 2 weeks). (Level of Evidence: B) 3. For UA/NSTEMI patients treated with DES, aspirin 162 to 325 mg per day should be prescribed for at least 3 months after sirolimus-eluting stent implantation and 6 months after paclitaxel-eluting stent implantation then continued indefinitely at a dose of 75 to 162 mg per day. (Level of Evidence: B) Clopidogrel 75 mg daily should be given for at least 12 months to all post-PCI patients receiving DES. (Level of Evidence: B) 4. Clopidogrel 75 mg daily (preferred) or ticlopidine (in the absence of contraindications) should be given to patients recovering from UA/NSTEMI when ASA is contraindicated or not tolerated because of hypersensitivity or gastrointestinal intolerance (but with gastroprotective agents such as proton-pump inhibitors). (Level of Evidence: A) Class IIa 1. For UA/NSTEMI patients in whom the physician is concerned about the risk of bleeding, a lower initial aspirin dose after PCI of 75 to 162 mg per day is reasonable. (Level of Evidence: C) Class IIb 1. For UA/NSTEMI patients who have an indication for anticoagulation, add warfarin to maintain an international normalization ratio of 2.0 to 3.0. (Level of Evidence: B) Class III 1. Dipyridamole is not recommended as an antiplatelet agent in post-UA/NSTEMI patients because it has not been shown to be effective. (Level of Evidence: A)

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ACC / AHA Guidelines- Beta Blockers (DO NOT EDIT)

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Class I 1. Beta blockers are indicated for all patients recovering from UA / NSTEMI unless contraindicated. Treatment should begin within a few days of the event, if not initiated acutely, and should be continued indefinitely. (Level of Evidence: B) 2. Patients recovering from UA / NSTEMI with moderate or severe LV failure should receive beta blocker therapy with a gradual titration scheme. (Level of Evidence: B) Class IIa 1. It is reasonable to prescribe beta blockers to low-risk patients (i.e., normal LV function, revascularized, no high risk features) recovering from UA / NSTEMI in the absence of absolute contraindications. (Level of Evidence: B)

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ACC / AHA Guidelines- Inhibition Of The Renin-Angiotensin-Aldosterone System (DO NOT EDIT)

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Class I 1. Angiotensin-converting enzyme inhibitors should be given and continued indefinitely for patients recovering from UA / NSTEMI with HF, LV dysfunction (LVEF <40%), hypertension, or diabetes mellitus, unless contraindicated. (Level of Evidence: A) 2. An angiotensin receptor blocker should be prescribed at discharge to those UA / NSTEMI patients who are intolerant of an ACE inhibitor and who have either clinical or radiological signs of HF and LVEF <40%. (Level of Evidence: A) 3. Long term Aldosterone Receptor Blockade should be prescribed for UA / NSTEMI patients without significant renal dysfunction (estimated creatinine clearance should be >30 mL/min) or hyperkalemia (potassium should be ≤5 mEq/liter) who are already receiving therapeutic doses of an ACE inhibitor, have an LVEF ≤40%, and have either symptomatic heart failure or diabetes mellitus. (Level of Evidence: A) Class IIa 1. Angiotensin-converting enzyme inhibitors are reasonable for patients recovering from UA / NSTEMI in the absence of LV dysfunction, hypertension, or diabetes mellitus unless contraindicated. (Level of Evidence: A) 2. Angiotensin-converting enzyme inhibitors are reasonable for patients with HF and LVEF >40%. (Level of Evidence: A) 3. In UA / NSTEMI patients who do not tolerate ACE inhibitors, an angiotensin receptor blocker can be useful as an alternative to ACE inhibitors in long term management provided there are either clinical or radiological signs of HF and LVEF <40%. (Level of Evidence: B) Class IIb 1. The combination of an ACE inhibitor and an angiotensin receptor blocker may be considered in the long-term management of patients recovering from UA / NSTEMI with persistent symptomatic HF and LVEF <40% despite conventional therapy including an ACE inhibitor or an angiotensin receptor blocker alone. (Level of Evidence: B)

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ACC / AHA Guidelines- Nitroglycerin (DO NOT EDIT)

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Class I 1. Nitroglycerin to treat ischemic symptoms is recommended. (Level of Evidence: C)

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ACC / AHA Guidelines- Calcium Channel Blockers (DO NOT EDIT)

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Class I 1. Calcium channel blockers are recommended for ischemic symptoms when beta blockers are not successful. (Level of Evidence: B) 2. Calcium channel blockers are recommended for ischemic symptoms when beta blockers are contraindicated or cause unacceptable side effects. (Level of Evidence: C)

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ACC / AHA Guidelines- Warfarin Therapy (DO NOT EDIT)

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Class I 1. Use of warfarin in conjunction with ASA and/or clopidogrel is associated with an increased risk of bleeding and should be monitored closely. (Level of Evidence: A) Class IIb 1. Warfarin either without (INR 2.5 to 3.5) or with low-dose ASA (75 to 81 mg per d; INR 2.0 to 2.5) may be reasonable for patients at high CAD risk and low bleeding risk who do not require or are intolerant of clopidogrel. (Level of Evidence: B)

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ACC / AHA Guidelines- Lipid Management (DO NOT EDIT)

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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 post revascularization 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 (≥100 mg/dL), cholesterol lowering therapy should be initiated or intensified to achieve an LDL-C of <100 mg/dL. (Level of Evidence: A) Further titration to <70 mg/dL is reasonable (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 <7% of total calories), cholesterol (to <200 mg/d), and trans fat (to <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 200-499 mg/dL, non HDL-C should be <130 mg/dL. (Level of Evidence: B) b. If triglycerides are ≥500 mg/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 <130 mg/dL (i.e., 30 mg/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 <70 mg/dL is reasonable. (Level of Evidence: A) b. If baseline LDL cholesterol is 70-100 mg/dL, it is reasonable to treat LDL-C to less than 70 mg/dL. (Level of Evidence: B) c. Further reduction of non HDL-C to <100 mg/dL is reasonable; if triglycerides are 200 to 499 mg/dL, non HDL-C target is <130 mg/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 <40 mg/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 >200 mg/dL. (Level of Evidence: B) g. The addition of plant stanol/sterols (2 g/day) and/or viscous fiber (>10 g/day) 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)

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ACC / AHA Guidelines- Blood Pressure Control (DO NOT EDIT)

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Class I 1. Blood pressure control according to JNC 7 guidelines is recommended (i.e., blood pressure <140/90 mmHg or <130/80 mmHg if the patient has diabetes mellitus or chronic kidney disease). (Level of Evidence: A) Additional measures recommended to treat and control blood pressure include the following: a. Patients should initiate and/or maintain lifestyle modifications, including weight control, increased physical activity, alcohol moderation, sodium reduction, and emphasis on increased consumption of fresh fruits, vegetables, and low-fat dairy products. (Level of Evidence: B) b. For patients with blood pressure ≥140/90 mmHg (or ≥130/80 mmHg for individuals with chronic kidney disease or diabetes mellitus), it is useful to add blood pressure medication as tolerated, treating initially with beta blockers and/or ACE inhibitors, with addition of other drugs such as thiazides as needed to achieve target blood pressure. (Level of Evidence: A)

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ACC / AHA Guidelines- Diabetes Mellitus (DO NOT EDIT)

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Class I 1. Diabetes management should include lifestyle and pharmacotherapy measures to achieve a near-normal HbA1c level of <7%. (Level of Evidence: B) Diabetes management should also include the following: a. Vigorous modification of other risk factors (e.g., physical activity, weight management, blood pressure control, and cholesterol management) as recommended should be initiated and maintained. (Level of Evidence: B) b. It is useful to coordinate the patient’s diabetic care with the patient’s primary care physician or endocrinologist. (Level of Evidence: C)

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ACC / AHA Guidelines- Smoking Cessation (DO NOT EDIT)

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Class I 1. Smoking cessation and avoidance of exposure to environmental tobacco smoke at work and home are recommended. Follow-up, referral to special programs, or pharmacotherapy (including nicotine replacement) is useful, as is adopting a stepwise strategy aimed at smoking cessation (the 5 A’s are: Ask, Advise, Assess, Assist, and Arrange). (Level of Evidence: B)

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ACC / AHA Guidelines- Weight Management (DO NOT EDIT)

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Class I 1. Weight management, as measured by body mass index and/or waist circumference, should be assessed on each visit. A body mass index of 18.5 to 24.9 kg/m² and a waist circumference (measured horizontally at the iliac crest) of <40 inches for men and <35 inches for women is recommended. (Level of Evidence: B) Additional weight management practices recommended include the following: a. On each patient visit, it is useful to consistently encourage weight maintenance / reduction through an appropriate balance of physical activity, caloric intake, and formal behavioral programs when indicated to maintain/achieve a body mass index between 18.5 and 24.9 kg/m². (Level of Evidence: B) b. If waist circumference is ≥35 inches in women or ≥40 inches in men, it is beneficial to initiate lifestyle changes and consider treatment strategies for metabolic syndrome as indicated. (Level of Evidence: B) c. The initial goal of weight loss therapy should be to reduce body weight by approximately 10% from baseline. With success, further weight loss can be attempted if indicated through further assessment. (Level of Evidence: B)

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ACC / AHA Guidelines- Physical Activity (DO NOT EDIT)

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Class I 1. The patient’s risk after UA / NSTEMI should be assessed on the basis of an in-hospital determination of risk. A physical activity history or an exercise test to guide initial prescription is beneficial. (Level of Evidence: B) 2. Guided/modified by an individualized exercise prescription, patients recovering from UA / NSTEMI generally should be encouraged to achieve physical activity duration of 30 to 60 min/day, preferably 7 (but at least 5) day/week of moderate aerobic activity, such as brisk walking, supplemented by an increase in daily lifestyle activities (e.g., walking breaks at work, gardening, and household work). (Level of Evidence: B) 3. Cardiac rehabilitation / secondary prevention programs are recommended for patients with UA / NSTEMI, particularly those with multiple modifiable risk factors and/or those moderate- to high-risk patients in whom supervised exercise training is particularly warranted. (Level of Evidence: B) Class IIb 1. The expansion of physical activity to include resistance training on 2 day per week may be reasonable. (Level of Evidence: C)

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ACC / AHA Guidelines- Patient Education (DO NOT EDIT)

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Class I 1. Beyond the detailed instructions for daily exercise, patients should be given specific instruction on activities (e.g., heavy lifting, climbing stairs, yard work, and household activities) that are permissible and those that should be avoided. Specific mention should be made regarding resumption of driving, return to work, and sexual activity. (Level of Evidence: C)

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ACC / AHA Guidelines- Influenza Vaccination (DO NOT EDIT)

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Class I 1. An annual influenza vaccination is recommended for patients with cardiovascular disease. (Level of Evidence: B)

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ACC / AHA Guidelines- Depression (DO NOT EDIT)

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Class IIa 1. It is reasonable to consider screening UA / NSTEMI patients for depression and refer/treat when indicated. (Level of Evidence: B)

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ACC / AHA Guidelines- Nonsteroidal Anti-Inflammatory Drugs (DO NOT EDIT)

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Class I 1. At the time of preparation for hospital discharge, the patient’s need for treatment of chronic musculoskeletal discomfort should be assessed, and a stepped-care approach to treatment should be used for selection of treatments. Pain relief should begin with acetaminophen, small doses of narcotics, or non acetylated salicylates. (Level of Evidence: C) Class IIa 1. It is reasonable to use nonselective NSAIDs, such as naproxen, if initial therapy with acetaminophen, small doses of narcotics, or non acetylated salicylates is insufficient. (Level of Evidence: C) Class IIb 1. Non steroidal anti inflammatory drugs with increasing degrees of relative COX-2 selectivity may be considered for pain relief only for situations in which intolerable discomfort persists despite attempts at stepped-care therapy with acetaminophen, small doses of narcotics, non acetylated salicylates, or non selective NSAIDs. In all cases, the lowest effective doses should be used for the shortest possible time. (Level of Evidence: C) Class III 1. Non steroidal anti inflammatory drugs with increasing degrees of relative COX-2 selectivity should not be administered to UA / NSTEMI patients with chronic musculoskeletal discomfort when therapy with acetaminophen, small doses of narcotics, non acetylated salicylates, or non selective NSAIDs provides acceptable levels of pain relief. (Level of Evidence: C)

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ACC / AHA Guidelines- Hormone Therapy (DO NOT EDIT)

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Class III 1. Hormone therapy with estrogen plus progestin, or estrogen alone, should not be given de novo to postmenopausal women after UA / NSTEMI for secondary prevention of coronary events. (Level of Evidence: A) 2. Postmenopausal women who are already taking estrogen plus progestin, or estrogen alone, at the time of UA / NSTEMI in general should not continue hormone therapy. However, women who are more than 1 to 2 years past the initiation of hormone therapy who wish to continue such therapy for another compelling indication should weigh the risks and benefits, recognizing the greater risk of cardiovascular events and breast cancer (combination therapy) or stroke (estrogen). Hormone therapy should not be continued while patients are on bed rest in the hospital. (Level of Evidence: B)

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ACC / AHA Guidelines- Antioxidant Vitamins and Folic Acid (DO NOT EDIT)

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Class III 1. Antioxidant vitamin supplements (e.g., vitamin E, vitamin C, or beta carotene) should not be used for secondary prevention in UA / NSTEMI patients. (Level of Evidence: A) 2. Folic acid, with or without vitamin B6 and vitamin B12, should not be used for secondary prevention in UA / NSTEMI patients. (Level of Evidence: A)

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See Also

• The UA / NSTEMI Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines

Sources

• The ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction