Unstable angina non ST elevation myocardial infarction medical regimen and use of medications
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Differentiating Unstable Angina/Non-ST Elevation Myocardial Infarction from other Disorders |
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Antitplatelet Therapy |
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Additional Management Considerations for Antiplatelet and Anticoagulant Therapy |
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Risk Stratification Before Discharge for Patients With an Ischemia-Guided Strategy of NSTE-ACS |
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Unstable angina non ST elevation myocardial infarction medical regimen and use of medications On the Web |
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FDA on Unstable angina non ST elevation myocardial infarction medical regimen and use of medications |
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CDC onUnstable angina non ST elevation myocardial infarction medical regimen and use of medications |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
In most cases, the inpatient anti-ischemic medical regimen used in the nonintensive phase should be continued after discharge, and the antiplatelet/anticoagulant medications should be changed to an outpatient/oral regimen. The selection of a medical regimen should be individualized to the specific needs of each patient based on the in-hospital findings and events, the risk factors for CAD, drug tolerability, and recent procedural interventions.
Medical Regimen and Use of Medications in Unstable Angina/NSTEMI
An easy way to remember the checklist of interventions at the time of discharge is by mnemonic (ABCDE):
- A - ASA, antianginal and ACE inhibitors
- B - Beta blockers and blood pressure
- C - Cholesterol and cigarettes
- D - Diet and diabetes
- E - Exercise and education
Both the patient and family should be informed about symptoms of worsening myocardial ischemia and MI and should be instructed in how and when to seek emergency care and assistance if such symptoms occur. Enrollment in a cardiac rehabilitation (see Cardiac Rehabilitation) program after discharge can enhance patient education and compliance with the medical regimen.
2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes (DO NOT EDIT) [1]
Medical Regimen and Use of Medications at Discharge
| Class I |
| "1. Medications required in the hospital to control ischemia should be continued after hospital discharge in patients with NSTE-ACS who do not undergo coronary revascularization, patients with incomplete or unsuccessful revascularization, and patients with recurrent symptoms after revascularization. Titration of the doses may be required. (Level of Evidence: C)" |
| "2. All patients who are post–NSTE-ACS should be given sublingual or spray nitroglycerin with verbal and written instructions for its use. (Level of Evidence: C)" |
| "3. Before hospital discharge, patients with NSTE-ACS should be informed about symptoms of worsening myocardial ischemia and MI and should be given verbal and written instructions about how and when to seek emergency care for such symptoms. (Level of Evidence: C)" |
| "4. Before hospital discharge, patients who are post–NSTE-ACS and/or designated responsible caregivers should be provided with easily understood and culturally sensitive verbal and written instructions about medication type, purpose, dose, frequency, side effects, and duration of use. (Level of Evidence: C)" |
| "5. For patients who are post–NSTE-ACS and have initial angina lasting more than 1 minute, nitroglycerin (1 dose sublingual or spray) is recommended if angina does not subside within 3 to 5 minutes; call 9-1-1 immediately to access emergency medical services. (Level of Evidence: C)" |
| "6. If the pattern or severity of angina changes, suggesting worsening myocardial ischemia (e.g., pain is more frequent or severe or is precipitated by less effort or occurs at rest), patients should contact their clinician without delay to assess the need for additional treatment or testing. (Level of Evidence: C)" |
| "7. Before discharge, patients should be educated about modification of cardiovascular risk factors. (Level of Evidence: C)" |
Late Hospital and Posthospital Oral Antiplatelet Therapy
| Class I |
| "1. Aspirin should be continued indefinitely. The maintenance dose should be 81 mg daily in patients treated with ticagrelor and 81 mg to 325 mg daily in all other patients. (Level of Evidence: A)" |
"2. In addition to aspirin, a P2Y12 inhibitor (either clopidogrel or ticagrelor) should be continued for up to 12 months in all patients with NSTE-ACS without contraindications who are treated with an ischemia-guided strategy. Options include:
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"3. In patients receiving a stent (bare-metal stent or DES) during PCI for NSTE-ACS, P2Y12 inhibitor therapy should be given for at least 12 months (330). Options include:
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| Class IIa |
| "1. It is reasonable to use an aspirin maintenance dose of 81 mg per day in preference to higher maintenance doses in patients with NSTE-ACS treated either invasively or with coronary stent implantation. (Level of Evidence: B)" |
| "2. It is reasonable to choose ticagrelor over clopidogrel for maintenance P2Y12 treatment in patients with NSTE-ACS treated with an early invasive strategy and/or PCI. (Level of Evidence: B)" |
| "3. It is reasonable to choose prasugrel over clopidogrel for maintenance P2Y12 treatment in patients with NSTE-ACS who undergo PCI who are not at high risk for bleeding complications. (Level of Evidence: B)" |
| "4. If the risk of morbidity from bleeding outweighs the anticipated benefit of a recommended duration of P2Y12 inhibitor therapy after stent implantation, earlier discontinuation (e.g., <12 months) of P2Y12 inhibitor therapy is reasonable. (Level of Evidence: C)" |
| Class IIb |
| "1. Continuation of DAPT beyond 12 months may be considered in patients undergoing stent implantation. (Level of Evidence: C)" |
Combined Oral Anticoagulant Therapy and Antiplatelet Therapy in Patients With NSTEACS
| Class I |
| "1. The duration of triple antithrombotic therapy with a vitamin K antagonist, aspirin, and a P2Y12 receptor inhibitor in patients with NSTE-ACS should be minimized to the extent possible to limit the risk of bleeding. (Level of Evidence: C)" |
| "2. Proton pump inhibitors should be prescribed in patients with NSTE-ACS with a history of gastrointestinal bleeding who require triple antithrombotic therapy with a vitamin K antagonist, aspirin, and a P2Y12 receptor inhibitor. (Level of Evidence: C)" |
| Class IIa |
| "1. Proton pump inhibitor use is reasonable in patients with NSTE-ACS without a known history of gastrointestinal bleeding who require triple antithrombotic therapy with a vitamin K antagonist, aspirin, and a P2Y12 receptor inhibitor. (Level of Evidence: C)" |
| Class IIb |
| "1. Targeting oral anticoagulant therapy to a lower international normalized ratio (INR) (e.g., 2.0 to 2.5) may be reasonable in patients with NSTE-ACS managed with aspirin and a P2Y12 inhibitor. (Level of Evidence: C)" |
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)[2]
Medical Regimen and Use of Medications (DO NOT EDIT)[2]
| Class I |
| "1. Medications required in the hospital to control ischemia should be continued after hospital discharge in patients with UA / NSTEMI who do not undergo coronary revascularization, patients with unsuccessful revascularization, and patients with recurrent symptoms after revascularization. Upward or downward titration of the doses may be required. (Level of Evidence: C)" |
| "2. All post UA / NSTEMI patients should be given sublingual or spray NTG and instructed in its use. (Level of Evidence: C)" |
| "3. Before hospital discharge, patients with UA / NSTEMI should be informed about symptoms of worsening myocardial ischemia and MI and should be instructed in how and when to seek emergency care and assistance if such symptoms occur. (Level of Evidence: C)" |
| "4. Before hospital discharge, post UA / NSTEMI patients and/or designated responsible caregivers should be provided with supportable, easily understood, and culturally sensitive instructions with respect to medication type, purpose, dose, frequency, and pertinent side effects. (Level of Evidence: C)" |
| "5. In post UA / NSTEMI patients, anginal discomfort lasting more than 2 or 3 min should prompt the patient to discontinue physical activity or remove himself or herself from any stressful event. If pain does not subside immediately, the patient should be instructed to take 1 dose of NTG sublingually. If the chest discomfort/pain is unimproved or worsening 5 min after 1 NTG dose has been taken, it is recommended that the patient or a family member/friend call 911 immediately to access EMS. While activating EMS access, additional NTG (at 5-min intervals 2 times) may be taken while lying down or sitting. (Level of Evidence: C)" |
| "6. If the pattern or severity of anginal symptoms changes, which suggests worsening myocardial ischemia (e.g., pain is more frequent or severe or is precipitated by less effort or now occurs at rest), the patient should contact his or her physician without delay to assess the need for additional treatment or testing. (Level of Evidence: C)" |
References
- ↑ Ezra A. Amsterdam, MD, FACC; Nanette K. Wenger, MD et al.2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. JACC. September 2014 (ahead of print)
- ↑ 2.0 2.1 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.