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| {{Infobox_Disease | | __NOTOC__ |
| | Name = Unstable angina pectoris | | {| class="infobox" style="float:right;" |
| | Image = Coronary thrombosis 3.jpg | | |- |
| | Caption = Plaque rupture in a coronary artery at arrows yielding obstructive thrombus in red. <br> <small> [http://www.peir.net Image courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology] </small> | | | [[File:Siren.gif|30px|link=Unstable angina/ NSTEMI resident survival guide]]|| <br> || <br> |
| | DiseasesDB = 8695 | | | [[Unstable angina/ NSTEMI resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']] |
| | ICD10 = {{ICD10|I|20||i|20}}
| | |} |
| | ICD9 = {{ICD9|413}}
| | {{Unstable angina / NSTEMI}} |
| | ICDO =
| | {{CMG}}; {{MWT}}; {{CZ}}; [[Varun Kumar]], M.B.B.S.; [[Lakshmi Gopalakrishnan]], M.B.B.S. |
| | OMIM =
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| | MedlinePlus =
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| | eMedicineSubj = med
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| | eMedicineTopic = 133
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| | MeshID = D000787
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| }} | |
| {{Search infobox}} | |
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| {{CMG}}
| | ==Overview== |
| | Advancements in the efficacy and increased utilization of synergistic [[anti-platelet]] agents, [[anticoagulant]] therapies, and invasive risk stratification in high-risk patients with [[unstable angina]] and non-ST-segment elevation myocardial infarction ([[NSTEMI]]) has led to a 40% decrease in mortality from [[coronary artery disease]] (CAD) over the preceding 20 years.<ref name="Anderson"> Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey WE II, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS. 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).'' Circulation 2007 116: e148 – e304. PMID 17679616</ref><ref name="Anderson2"> Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey WE II, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS. Correction of 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).'' J Am Coll Cardiol. 2008 Mar 4; 51(9): 974. PMID 17692738 </ref> The advanced management of [[NSTEMI]] minimizes [[ischemic]] events; however the paradigm is that it also increases the risk of bleeding and necessitation for blood transfusion.<ref>Boersma E, Harrington RA, Moliterno DJ, White H, Théroux P, Van de Werf F, de Torbal A, Armstrong PW, Wallentin LC, Wilcox RG, Simes J, Califf RM, Topol EJ, Simoons ML. Platelet glycoproteinIIb/IIIa inhibitors in acute coronary syndromes: a meta-analysis of all major randomised clinical trials. Lancet. 2002;359:189-98</ref><ref>James S, Armstrong P, Califf R, Husted S, Kontny F, Niemminen M, Pfisterer M, Simoons ML, Wallentin L. Safety and efficacy of abciximab combined with dalteparin in treatment of acute coronary syndromes. Eur Heart J. 2002;23:1538–45.</ref><ref name="Anderson"> Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey WE II, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS. 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).'' Circulation 2007 116: e148 – e304. PMID 17679616</ref><ref name="Anderson2"> Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey WE II, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS. Correction of 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).'' J Am Coll Cardiol. 2008 Mar 4; 51(9): 974. PMID 17692738 </ref> Recent analyses and randomized controlled trials demonstrate an independent association between bleeding complications, [[blood transfusion]]s, and poor outcomes among [[NSTEMI]] patients.<ref>Rao SV, O'Grady K, Pieper KS, Granger CB, Newby LK, Mahaffey KW, Moliterno DJ, Lincoff AM, Armstrong PW, Van de Werf F, Califf RM, Harrington RA. A comparison of the clinical impact of bleeding measured by two different classifications among patients with acute coronary syndromes. J Am Coll Cardiol. 2006;47:809–16.</ref><ref>Eikelboom JW, Mehta SR, Anand SS, Xie C, Fox KAA, Yusuf S. Adverse impact of bleeding on prognosis in patients with acute coronary syndromes. Circulation. 2006;114:774–82.</ref><ref name="Anderson"> Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey WE II, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS. 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).'' Circulation 2007 116: e148 – e304. PMID 17679616</ref><ref name="Anderson2"> Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey WE II, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS. Correction of 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).'' J Am Coll Cardiol. 2008 Mar 4; 51(9): 974. PMID 17692738 </ref> Clinical trials of [[antithrombotic]] therapies associated with decreased bleeding complications have demonstrated improvements in short-term and long-term survival. |
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| {{MWT}}; {{CZ}}; [[Varun Kumar]], M.B.B.S.; [[Lakshmi Gopalakrishnan]], M.B.B.S.
| | ==2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes (DO NOT EDIT) <ref name=Guidelines> 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) </ref>== |
| | | ===Recommendations for Anemia, Bleeding, and Transfusion=== |
| {{Editor Join}}
| | {|class="wikitable" style="width:80%" |
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| ==Overview of Bleeding complications and Blood transfusion associated with Unstable angina/NSTEMI==
| | | colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] |
| *Advancements in the efficacy and increased utilization of synergistic [[anti-platelet]] agents, [[anticoagulant]] therapies, and invasive risk stratification in high-risk patients with [[unstable angina]] and non-ST-segment elevation myocardial infarction ([[NSTEMI]]) has led to a 40% decrease in mortality from [[coronary artery disease]] (CAD) over the preceding 20 years. <ref name="Anderson"> Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey WE II, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS. 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).'' Circulation 2007 116: e148 – e304. PMID 17679616</ref> <ref name="Anderson2"> Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey WE II, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS. Correction of 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).'' J Am Coll Cardiol. 2008 Mar 4; 51(9): 974. PMID 17692738 </ref>
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| | | | bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.'''All patients with NSTE-ACS should be evaluated for the risk of bleeding. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> |
| *The advanced management of [[NSTEMI]] minimizes [[ischemic]] events; however the paradigm is that it also increases the risk of bleeding and necessitation for blood transfusion.<ref>Boersma E, Harrington RA, Moliterno DJ, White H, Théroux P, Van de Werf F, de Torbal A, Armstrong PW, Wallentin LC, Wilcox RG, Simes J, Califf RM, Topol EJ, Simoons ML. Platelet glycoproteinIIb/IIIa inhibitors in acute coronary syndromes: a meta-analysis of all major randomised clinical trials. Lancet. 2002;359:189-98</ref><ref>James S, Armstrong P, Califf R, Husted S, Kontny F, Niemminen M, Pfisterer M, Simoons ML, Wallentin L. Safety and efficacy of abciximab combined with dalteparin in treatment of acute coronary syndromes. Eur Heart J. 2002;23:1538–45.</ref> <ref name="Anderson"> Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey WE II, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS. 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).'' Circulation 2007 116: e148 – e304. PMID 17679616</ref> <ref name="Anderson2"> Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey WE II, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS. Correction of 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).'' J Am Coll Cardiol. 2008 Mar 4; 51(9): 974. PMID 17692738 </ref>
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| | | | bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.'''Anticoagulant and antiplatelet therapy should be weight-based where appropriate and should be adjusted when necessary for CKD to decrease the risk of bleeding in patients with NSTE-ACS ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> |
| *Recent analyses and randomized controlled trials demonstrate an independent association between bleeding complications, blood transfusions, and poor outcomes among [[NSTEMI]] patients.<ref>Rao SV, O'Grady K, Pieper KS, Granger CB, Newby LK, Mahaffey KW, Moliterno DJ, Lincoff AM, Armstrong PW, Van de Werf F, Califf RM, Harrington RA. A comparison of the clinical impact of bleeding measured by two different classifications among patients with acute coronary syndromes. J Am Coll Cardiol. 2006;47:809–16.</ref><ref>Eikelboom JW, Mehta SR, Anand SS, Xie C, Fox KAA, Yusuf S. Adverse impact of bleeding on prognosis in patients with acute coronary syndromes. Circulation. 2006;114:774–82.</ref> <ref name="Anderson"> Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey WE II, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS. 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).'' Circulation 2007 116: e148 – e304. PMID 17679616</ref> <ref name="Anderson2"> Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey WE II, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS. Correction of 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).'' J Am Coll Cardiol. 2008 Mar 4; 51(9): 974. PMID 17692738 </ref>
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| *Clinical trials of [[antithrombotic]] therapies associated with decreased bleeding complications have demonstrated improvements in short-term and long-term survival.
| | |} |
| | | {|class="wikitable" |
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| ==Incidence==
| | |colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm) |
| *The reported incidence of major bleeding events in the [[ACS]] period varies significantly across clinical trials with best estimates between <1 and 14%.<ref>Popma JJ, Satler LF, Pichard AD, Kent K, Campbell A, Clark C, Merritt A, Leon MB. Vascular complications after balloon and new device angioplasty. Circulation. 1993;88:1569–1578.</ref> <ref>Stone GW, Grines CL, Cox DA, Garcia E, Tcheng J, Griffin J, Stuckey T, Turco M, Carroll M, Lansky A. Comparison of angioplasty with stenting, with or without abciximab, in acute myocardial infarction. N Engl J Med. 2002;346:957–966.</ref> <ref name="Anderson"> Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey WE II, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS. 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).'' Circulation 2007 116: e148 – e304. PMID 17679616</ref> <ref name="Anderson2"> Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey WE II, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS. Correction of 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).'' J Am Coll Cardiol. 2008 Mar 4; 51(9): 974. PMID 17692738 </ref>
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| *Differences in individual patient’s propensity to experience a bleeding event may contribute to the observed variance in bleeding incidence for [[NSTEMI]] patients. <ref name="Anderson"> Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey WE II, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS. 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).'' Circulation 2007 116: e148 – e304. PMID 17679616</ref> <ref name="Anderson2"> Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey WE II, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS. Correction of 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).'' J Am Coll Cardiol. 2008 Mar 4; 51(9): 974. PMID 17692738 </ref>
| | |bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' A strategy of routine blood transfusion in hemodynamically stable patients with NSTE-ACS and hemoglobin levels greater than 8 g/dL is not recommended ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> |
| *The existence of multiple bleeding definitions accounts in part for the disparity of the reported incidence of bleeding complications among [[NSTEMI]] patients. <ref name="Anderson"> Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey WE II, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS. 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).'' Circulation 2007 116: e148 – e304. PMID 17679616</ref> <ref name="Anderson2"> Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey WE II, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS. Correction of 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).'' J Am Coll Cardiol. 2008 Mar 4; 51(9): 974. PMID 17692738 </ref>
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| ==Definitions for bleeding complications==
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| *The two most commonly employed bleeding severity classification schemes are the Thrombolysis In Myocardial Infarction (TIMI) and the Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO) scales.<ref>Chesebro JH, Knatterud G, Roberts R, Borer J, Cohen LS, Dalen J, Dodge HT, Francis CK, Hillis D, Ludbrook P. Thrombolysis In Myocardial Infarction (TIMI) trial, phase I: a comparison between intravenous tissue plasminogen activator and intravenous streptokinase. Clinical findings through hospital discharge. Circulation. 1987; 76:142–154. </ref> <ref name="Anderson"> Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey WE II, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS. 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).'' Circulation 2007 116: e148 – e304. PMID 17679616</ref> <ref name="Anderson2"> Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey WE II, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS. Correction of 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).'' J Am Coll Cardiol. 2008 Mar 4; 51(9): 974. PMID 17692738 </ref>
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| # The GUSTO scale categorizes bleeding as severe or life-threatening, moderate, mild, or none and defines bleeding based on clinical outcomes such as hemodynamic compromise or [[intracranial hemorrhage]].
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| # The TIMI definition categorizes bleeding as major, minor, minimal, or none and is dependent on changes in laboratory parameters (hemoglobin or hematocrit) and not necessarily on clinically defined events (although intracranial hemorrhage is considered a TIMI major bleed).
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| *Additional definitions of bleeding events adopt variations of the GUSTO and TIMI classification schemes such as those developed in the SYNERGY,<ref>Ferguson JJ, Califf RM, Antman EM, Cohen M, Grines CL, Goodman S, Kereiakes DJ, Langer A, Mahaffey KW, Nessel CC, Armstrong PW, Avezum A, Aylward P, Becker RC, Biasucci L, Borzak S, Col J, Frey MJ, Fry E, Gulba DC, Guneri S, Gurfinkel E, Harrington R, Hochman JS, Kleiman NS, Leon MB, Lopez-Sendon JL, Pepine CJ, Ruzyllo W, Steinhubl SR, Teirstein PS, Toro-Figueroa L, White H; SYNERGY Trial Investigators. Enoxaparin vs unfractionated heparin in high-risk patients with non-ST-segment elevation acute coronary syndromes managed with an intended early invasive strategy: primary results of the SYNERGY randomized trial. JAMA. 2004;292:45-54.</ref> PURSUIT<ref>The PURSUIT Trial Investigators. Inhibition of platelet glycoprotein IIb/IIIa with eptifibatide in patients with acute coronary syndromes. The PURSUIT Trial Investigators. Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy. N Engl J Med. 1998;339:436–43.</ref> and OASIS-5<ref>Fifth Organization to Assess Strategies in Acute Ischemic Syndromes Investigators, Yusuf S, Mehta SR, Chrolavicius S, Afzal R, Pogue J, Granger CB, Budaj A, Peters RJ, Bassand JP, Wallentin L, Joyner C, Fox KA. Comparison of fondaparinux and enoxaparin in acute coronary syndromes. N Engl J Med. 2006;354:1464-76.</ref> trials or have adopted trial specific definitions for bleeding complications such as those in FRISC<ref>Fragmin and Fast Revascularization during Instability in Coronary artery disease Investigators, Long-term low-molecular-mass heparin in unstable coronary artery disease: FRISC II prospective randomized multicentre study. Lancet 1999;354:701–707.</ref>, ESSENCE<ref>Cohen M, Demers C, Gurfinkel EP, Turpie AG, Fromell GJ, Goodman S, Langer A, Califf RM, Fox KA, Premmereur J, Bigonzi F. A comparison of low-molecular-weight heparin with unfractionated heparin for unstable coronary artery disease. Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q-Wave Coronary Events Study Group.
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| N Engl J Med. 1997;337:447-52.
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| </ref>, CURE<ref>Yusuf S, Zhao F, Mehta SR, Chrolavicius S, Tognoni G, Fox KK; Clopidogrel in Unstable Angina to Prevent Recurrent Events Trial Investigators. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med. 2001;345:494 –502.</ref> and ACUITY<ref>Stone GW, McLaurin BT, Cox DA, Bertrand ME, Lincoff AM, Moses JW, White HD, Pocock SJ, Ware JH, Feit F, Colombo A, Aylward PE, Cequier AR, Darius H, Desmet W, Ebrahimi R, Hamon M, Rasmussen LH, Rupprecht HJ, Hoekstra J, Mehran R, Ohman EM; ACUITY Investigators. Bivalirudin for patients with acute coronary syndromes. N Engl J Med. 2006;355:2203-16.</ref> trials.
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| '''GUSTO scale:'''
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| *Severe or life-threatening: Either [[intracranial hemorrhage]] or bleeding that causes hemodynamic compromise and requires intervention
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| *Moderate: Bleeding that requires blood transfusion but does not result in hemodynamic compromise
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| *Mild: Bleeding that does not meet criteria for either severe or moderate bleeding
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| '''TIMI scale:'''
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| *Major: [[Intracranial hemorrhage]] or a 5 g/dl decrease in the hemoglobin concentration or a 15% absolute decrease in the hematocrit.
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| *Minor:
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| **Observed blood loss: 3 g/dl decrease in the hemoglobin concentration or 10% decrease in the [[hematocrit]]
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| **No observed blood loss: 4 g/dl decrease in the hemoglobin concentration or 12% decrease in the hematocrit
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| *Minimal: Any clinically overt sign of hemorrhage (including imaging) that is associated with a <3 g/dl decrease in the hemoglobin concentration or <9% decrease in the hematocrit
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| '''OASIS-2 trial:'''
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| *Major bleeding:
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| #Life-threatening (fatal, intracranial, requiring surgical intervention or 4 units of blood or [[plasma expanders]])
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| #Other major bleeding episodes (any event requiring transfusion of 2 or 3 units or judged to be disabling).
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| *Minor Bleeding: All other bleeding events.
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| '''OASIS-5 trial:'''
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| *Major Bleeding:
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| #Fatal, intracranial, retroperitoneal, intraocular leading to vision loss.
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| #Decrease in Hgb 3 g/dL adjusted for transfusion.
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| #Transfusion of 2 units.
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| *Minor Bleeding: Any other clinically significant bleeding not meeting Major criteria leading to study drug interruption, surgery, or transfusion of 1 unit of blood.
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| '''CURE trial:'''
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| *Major bleeding:
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| #Life-threatening (fatal, intracranial, requiring surgical intervention, results in hypotension, decrease in Hgb 5 g/dL, or required 4 units of blood).
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| #Other major bleeding episodes (requiring transfusion of 2 or 3 units, intraocular).
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| *Minor bleeding: Led to discontinuation of study drug
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| '''ACUITY trial:
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| *Major Bleeding:
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| #Intracranial or intraocular bleeding.
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| #Hemorrhage at the access site requiring intervention or hematoma with a diameter of at least 5 cm.
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| #Hemoglobin decrease of at least 4 g per deciliter without an overt bleeding source or at least 3 g per deciliter with such a source.
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| #Reoperation for bleeding.
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| #Transfusion of a blood product.
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| *Minor Bleeding: not defined
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| '''The existence of multiple trial-specific definitions of bleeding events, in addition to TIMI and GUSTO precludes the ability to compare bleeding complication rates across NSTEMI.'''
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| '''The variability of pharmacological therapies employed in NSTEMI trials further confounds the ability to clearly define and to determine a single estimate of the incidence of bleeding complications among NTEMI patients.'''
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| ==Predictors and Causes of Bleeding <small><ref name="Anderson"> Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey WE II, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS. 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).'' Circulation 2007 116: e148 – e304. PMID 17679616</ref> <ref name="Anderson2"> Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey WE II, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS. Correction of 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).'' J Am Coll Cardiol. 2008 Mar 4; 51(9): 974. PMID 17692738 </ref></small>==
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| *[[Elderly|Age >75]]
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| *[[Female|Female gender]]
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| *[[Diabetes]]
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| *[[Hypertension]]
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| *[[Anemia]]
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| *[[smoking|History of smoking]]
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| *[[peripheral arterial disease|History of peripheral arterial disease]]
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| *[[ST segment deviation|Baseline ST segment deviation > 1mm]]
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| *[[cardiac biomarker|Baseline cardiac biomarker elevation]]
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| *[[Vasopressor|Treatment with IV vasopressors in first 24 h]]
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| *[[Pulmonary artery|Pulmonary artery catheter]]
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| *[[Percutaneous coronary intervention]]
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| *[[Intra-aortic balloon pump]]
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| *[[Cardiac catheterization]]
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| *[[Bleeding|History of prior bleeding]]
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| *[[Fibrinolytic therapy]]
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| *[[unfractionated heparin|Treated with unfractionated heparin in first 24 h]]
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| *[[LMWH|Treated with LMWH in first 24 h]]
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| *[[GP IIb/IIIa inhibitor|Treatment with GP IIb/IIIa inhibitors in first 24h]]
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| *[[Glomerular filtration rate|Glomerular filtration rate <30 mL/min]]
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| ==Blood Transfusions==
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| *'''Inicidence:''' 5-10% of [[NSTEMI]] patients receive blood transfusions.<ref>Sunil V. Rao, Karen Chiswell, Jie-Lena Sun, Christopher B. Granger, L. Kristin Newby, Frans Van de Werf, Harvey D. White, Paul W. Armstong, Robert M. Califf and Robert A. Harrington. International Variation in the Use of Blood Transfusion in Patients With Non–ST-Segment Elevation Acute Coronary Syndromes. Am J Cardiol. 2008;101:25-29.</ref>
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| *'''Indication:'''
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| **The ''appropriate use'' of blood transfusion administration is highly subjective due to lack of definitive data on transfusion triggers in patients with [[CAD]]. However, there is an association between transfusion and short-term mortality among [[NSTEMI]] patients.
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| *'''Clinical trial data:'''
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| **Yang and colleagues analyzed data from 74,271 [[NSTEMI]]/[[unstable angina]] patients and found a significant association between blood transfusion and in-hospital mortality.<ref>Yang X, Alexander KP, Chen AY, Roe MT, Brindis RG, Rao SV, Gibler WB,Ohman EM, Peterson ED; CRUSADE Investigators. The implications of blood transfusions for patients with non-ST-segment elevation acute coronary syndromes: results from the CRUSADE National Quality Improvement Initiative. J Am Coll Cardiol. 2005;46:1490–1495.</ref>
| |
| **Wu and colleagues analyzed 78,974 elderly patients with acute [[MI]] and associated the reception of blood transfusion with a significant increased risk of 30-day death when baseline [[HCT]] was > 33%.<ref>Wu W-C, Rathore SS, Wang Y, Radford MJ, Krumholz HM. Blood transfusion in elderly patients with acute myocardial infarction. N Engl J Med. 2001;345:1230-1236.</ref>
| |
| **Rao and colleagues examined 24,111 [[NSTEMI]] patients and found that blood transfusion was associated with a significantly higher risk of 30-day mortality if the nadir [[HCT]] was > 24%.<ref>Rao SV, Jollis JG, Harrington RA, Granger CB, Newby LK, Armstrong PW, Moliterno DJ, Lindblad L, Pieper K, Topol EJ, Stamler JS, Califf RM. Relationship of blood transfusion and clinical outcomes in patients with acute coronary syndromes. JAMA. 2004;292:1555– 62</ref>
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|
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| '''Given this equipoise, it seems reasonable to conclude that routine use of transfusion to maintain arbitrary hemoglobin levels in asymptomatic patients should be avoided.'''
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| | |
| | |
| ==Prognosis==
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| *Regardless of which bleeding definition is utilized, multiple studies have demonstrated a clear association between bleeding in the [[NSTEMI]] population and adverse outcomes including death, [[stroke]], [[MI]] and unplanned [[revascularization]].
| |
| | |
| ===Clinical trial data:===
| |
| *Moscucci and colleagues examined the [[GRACE]] registry of 24,045 patients with [[ACS]] (including [[unstable angina]], [[NSTEMI]], and [[STEMI]]) and found an association between GRACE major bleeding and increased in-hospital mortality.<ref>Moscucci M, Fox KA, Cannon CP, Klein W, López-Sendón J, Montalescot G, White K, Goldberg RJ. Predictors of major bleeding in acute coronary syndromes: the Global Registry of Acute Coronary Events (GRACE). Eur Heart J. 2003;24:1815–23.</ref>
| |
| *An analysis by Rao et al.,<ref>Rao SV, O'Grady K, Pieper KS, Granger CB, Newby LK, Mahaffey KW, Moliterno DJ, Lincoff AM, Armstrong PW, Van de Werf F, Califf RM, Harrington RA. A comparison of the clinical impact of bleeding measured by two different classifications among patients with acute coronary syndromes. J Am Coll Cardiol. 2006;47:809–16.</ref> examined 26,452 [[ACS]]-patients enrolled in the PURSUIT, PARAGON B, and GUSTO IIb trials and demonstrated an increased in risk between bleeding severity and 30-day and 6-month death.
| |
| *Eikelboom et al.,<ref>Eikelboom JW, Mehta SR, Anand SS, Xie C, Fox KAA, Yusuf S. Adverse impact of bleeding on prognosis in patients with acute coronary syndromes. Circulation. 2006;114:774–82.</ref> and Manoukian et. al., <ref>Manoukian SV, Feit F, Mehran R, Voeltz MD, Ebrahimi R, Hamon M, Dangas GD, Lincoff AM, White HD, Moses JW, King SB 3rd, Ohman EM, Stone GW.
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| Impact of major bleeding on 30-day mortality and clinical outcomes in patients with acute coronary syndromes: an analysis from the ACUITY Trial. J Am Coll Cardiol. 2007;49:1362-8.
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| </ref> have described a similar, significant association between major bleeding in [[NSTEMI]] and [[unstable angina]] patients and adverse outcomes.
| |
| | |
| '''Prognosis between TIMI and GRACE scales:'''
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| *The prognostic significance of different bleeding definitions (GUSTO vs TIMI) was assessed by Rao and colleagues.
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| *Both GUSTO and TIMI bleeding were associated with an increased risk for 30-day death or [[MI]] when examined separately. When both definitions were included in the same model, increasing GUSTO bleeding severity was associated with a stepwise increase in the adjusted hazard of death or MI, whereas TIMI bleeding did not correlate with prognosis.
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| Therefore, bleeding defined by clinical events is likely more important in terms of prognosis rather than bleeding defined solely on the basis of reductions in hemoglobin concentration.
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| | |
| ===Mechanisms of Bleeding and Increased Mortality:===
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| *Despite the strong association between bleeding and adverse [[ischemic]] events, the direct causality of bleeding complications and adverse ischemic events remains uncertain.
| |
| | |
| '''1. Anemia and Anemia induced Hemodynamic Compromise:'''
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| *During [[NSTEMI]]/[[unstable angina]], oxygen delivery to the [[hypoxic]] [[myocardium]] is normally augmented by a compensatory coronary vasodilatory response.
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| *Stenotic coronary vessels are devoid of the vasodilatory response and therefore compensatory increases in [[heart rate]] and myocardial [[contractility]] are employed to maintain systemic oxygen demands.
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| *The pathophysiology underlying poor outcomes in [[anemic]]-[[NSTEMI]] patients may be explained by the combination of reduced oxygen delivery to the already [[hypoxic myocardium]] and the high myocardial oxygen demand secondary to the compensatory increases in [[heart rate]] and [[stroke volume]].
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| | |
| '''Bleeding therefore, may worsen [[myocardial ischemia]] in the [[NSTEMI]] patient by inducing a mild [[anemia]] and state of tissue [[hypoperfusion]]. The subsequent, compensatory tachycardiac and upregulated myocardial contractility state result in a deleterious, myocardial oxygen supply and demand disparity.'''<ref>Sabatine MS, Morrow DA, Giugliano RP, Burton PB, Murphy SA, McCabe CH, Gibson CM, Braunwald E. Association of hemoglobin levels with clinical outcomes in acute coronary syndromes. Circulation. 2005;111:2042–2049.</ref>
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| | |
| | |
| '''2. Potentiation of the inflammatory response:'''
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| *Bleeding events precipitate recurrent [[ischemic]] events by potentiating the inflammatory response through activation of the platelet and coagulation cascades.
| |
| | |
| | |
| '''3. Reception of packed red blood cells:'''
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| *Mechanistic studies have shown that transfusion of red cells paradoxically does not improve oxygen delivery.<ref>Stamler JS, Jia L, Eu JP, McMahon TJ, Demchenko IT, Bonaventura J,
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| Gernert K, Piantadosi CA. Blood flow regulation by S-nitrosohemoglobin
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| in the physiological oxygen gradient. Science. 1997;276:2034–2037.
| |
| </ref>
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| *Stored blood is characterized by an increased affinity for oxygen because of decreased 2,3 DPG levels.
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| *Stored RBCs have alterations in their morphology and adhesion properties which many speculate increases the risk of vessel occlusion.
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| *Stored RBCs, devoid of NO produces vasoconstriction, platelet aggregation, and ineffective oxygen delivery.
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| *[[Nitric oxide]] is essential for oxygen uptake into tissues and is the most potent vasodilator.
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| | |
| '''The synergistic effects of high oxygen affinity and ineffective oxygen delivery of RBC transfusion may account, in part, for poor outcomes among transfused [[NSTEMI]] patients.'''
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| | |
| '''4. Cessation of antiplatelet and/or antithrombin therapies:'''
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| *Analyzing the GRACE database of [[NSTEMI]] patients who suffered major bleeding (n=506) within 2 days of admission, Spencer and colleagues discovered that NSTEMI patients with a bleeding event were less likely to have received [[ASA]], [[thienopyridines]], [[unfractionated heparin]] or [[low-molecular-weight heparin]] during their hospitalization.
| |
| *Mortality rates among [[ACS]] patients who experienced a major bleeding event were higher if [[aspirin]] (OR, 7.55 (95% CI, 4.43 to 12.88)); [[thienopyridines]], (OR, 8.91 (95% CI, 4.39 to 18.12)); and [[unfractionated heparin]], (OR, 1.91 (95% CI, 1.09 to 3.36)) were discontinued, compared to [[NSTEMI]] patients who experienced a major bleeding event but continued therapy with these agents.<ref>Spencer FA, Moscucci M, Granger CB, Gore JM, Goldberg RJ, Steg PG, Goodman SG, Budaj A, Fitzgerald G, Fox KA; for the GRACE Investigators. Does Comorbidity Account for the Excess Mortality in Patients With Major Bleeding in Acute Myocardial Infarction? Circulation. 2007;116:2793-801.</ref>
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| ==Prevention==
| |
| *An optimal [[NSTEMI]]/[[unstable angina]] management algorithm maximizes the [[anticoagulant]] benefit of pharmacological agents, employs coronary intervention when indicated, while simultaneously minimizing bleeding risks.
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| *Recent trials (OASIS, ACUTIY etc) have correlated reductions in bleeding events with improvements in outcomes of death, [[MI]] and [[stroke]].
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| *Reduction of bleeding complications has therefore become a priority in [[NSTEMI]]/[[unstable angina]] management.
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| | |
| '''Alternative means of vascular access for coronary intervention:'''
| |
| | |
| Since the introduction of [[GP IIb/IIIa inhibitors]] into practice the risk of transfemoral access site bleeding complications has increased by 10%.
| |
| *Femoral [[arteriotomy]] with femoral head [[fluoroscopy]] reduces access site complications.
| |
| *Radial artery approach for PCI, is associated with a substantial reduction in bleeding and vascular complications.<ref>Agostoni P, Biondi-Zoccai GG, de Benedictis ML, Rigattieri S, Turri M, Anselmi M, Vassanelli C, Zardini P, Louvard Y, Hamon M. Radial versus femoral approach for percutaneous coronary diagnostic and interventional procedures; Systematic overview and meta-analysis of randomized trials. J Am Coll Cardiol. 2004;44:349-56.</ref>
| |
| *No benefit has been associated with femoral vascular closure devices.
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| | |
| '''Judicious dosing of [[antithrombotic]] and [[antiplatelet]] therapies:'''
| |
| *15% of major bleeding events in [[NSTEMI]]/[[unstable angina]] patients are preventable with proper bleeding risk assessment and proper administration of [[anticoagulative]] agents.
| |
| *Data from the CRUSADE registry, reported that 42% of 140,000 [[NSTEMI]] patients received at least one excess dose of [[antithrombotic]] agent during their hospitalization.<ref>Alexander KP, Chen AY, Roe MT, Newby LK, Gibson CM, Allen-LaPointe NM, Pollack C, Gibler WB, Ohman EM, Peterson ED; CRUSADE Investigators. Excess dosing of antiplatelet and antithrombin agents in the treatment of non-ST-segment elevation acute coronary syndromes. JAMA. 2005;294:3108-16.</ref>. The excess dosing of antithrombotic agents were directly associated with increase rate of bleeding and a prolonged length of hospital stay.
| |
| *Risk factors for receiving excessive doses of [[unfractionated heparin]], [[low-molecular-weight heparin]] or [[GP IIb/IIIA inhibitors]] included:
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| **Elderly
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| **Female
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| **Low body weight
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| **[[Diabetes]]
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| **[[Heart failure]]
| |
| | |
| '''Synergy of [[ASA]] and [[Plavix]]:'''
| |
| *The administration of [[aspirin]] and [[clopidogrel]] to [[NSTEMI]]/[[unstable angina]] patients is efficacious and supported by published guidelines.
| |
| *The absolute increase in major bleeding is 1% higher with dual [[antiplatelet]] therapy compared with [[aspirin]] alone.
| |
| *In a post hoc analysis of the CURE trial, Peters et al.,<ref>Peters RJ, Mehta SR, Fox KA, Zhao F, Lewis BS, Kopecky SL, Diaz R, Commerford PJ, Valentin V, Yusuf S; Clopidogrel in Unstable angina to prevent Recurrent Events (CURE) Trial Investigators. Effects of aspirin dose when used alone or in combination with clopidogrel in patients with acute coronary syndromes: observations from the Clopidogrel in Unstable angina to prevent Recurrent Events (CURE) study. Circulation. 2003;108:1682-7.</ref> described an increased incidence in major bleeding directly associated with [[aspirin]] (ASA) dose. (ASA alone: dose 100 mg; 1.9%, 101–199 mg; 2.8%, 200 mg; 3.7%, P=0.0001 ASA+clopidogrel: dose 100 mg; 3.0%, 101–199 mg; 3.4%, 200 mg; 4.9%, P=0.0009).
| |
| *Although the ideal dose of [[aspirin]] is unknown, these data do suggest that lower doses of aspirin are safer when combined with [[thienopyridines]].
| |
| | |
| '''Newer pharmacological strategies to reduce bleeding:'''
| |
| *'''[[Bivalirudin]]:'''
| |
| **REPLACE-2 trial assigned 6,010 patients undergoing urgent or elective [[PCI]] to receive [[unfractionated heaparin]] with planned [[GP IIb/IIIa inhibitor]] or [[bivalirudin]] with provisional use of a GP IIb/IIIa inhibitor.<ref>Lincoff AM, Bittl JA, Harrington RA, Feit F, Kleiman NS, Jackman JD,
| |
| Sarembock IJ, Cohen DJ, Spriggs D, Ebrahimi R, Keren G, Carr J,
| |
| Cohen EA, Betriu A, Desmet W, Kereiakes DJ, Rutsch W, Wilcox RG, de
| |
| Feyter PJ, Vahanian A, Topol EJ, REPLACE-2 Investigators. Bivalirudin
| |
| and provisional glycoprotein IIb/IIIa blockade compared with heparin
| |
| and planned glycoprotein IIb/IIIa blockade during percutaneous coronary
| |
| intervention: REPLACE-2 randomized trial. JAMA 2003;289:853–863.
| |
| </ref>
| |
| **Composite, 30-day endpoint demonstrated no statistically significant difference in the primary quadruple endpoint of death, [[MI]], target vessel [[revascularization]], or major bleeding between study groups. This was driven by a statistically significant 40% relative risk reduction in major bleeding in patients assigned to [[bivalirudin]].
| |
| **ACUITY trial assigned 13,819 moderate-to-high-risk [[NSTEMI]] patients to one of three treatment arms: heparin ([[unfractionated heparin]] or [[enoxaparin]]) with [[GP IIb/IIIa inhibitor]], [[bivalirudin]] with [[GP IIb/IIIa inhibitor]], or bivalirudin alone (with provisional use of a GP IIb/IIIa inhibitor).
| |
| ***Primary endpoint was net clinical benefit at 30-days that consisted of death, [[MI]], ischemia-driven [[revascularization]], or non-[[CABG]] major bleeding.
| |
| ***The bivalirudin-alone strategy was superior to the other two arms (heparin/enoxaparin + GP IIb/IIIa: 11.7%, bivalirudin + GP IIb/IIIa: 11.8%, bivalirudin alone: 10.1%, P < 0.001).
| |
| ***There were no significant differences in the rates of death, MI, or revascularization between the three arms, but there was a substantial reduction in ACUITY major bleeding among patients assigned to the bivalirudin alone strategy.
| |
|
| |
| *'''[[Fondaparinux]]:'''
| |
| **OASIS-5 trial randomized 20,078 [[NSTEMI]] patients to receive [[fondaparinux]] or [[enoxaparin]] for 6 days.
| |
| ***Primary outcome of [[MI]], [[refractory ischemia]], or death at 9 days was not statistically different between study arms (5.8 vs. 5.7%, HR 1.01: 95% CI: 0.90–1.13).
| |
| ***There was however, a significant lower rate of major bleeding at 9 days in patients treated with fondaparinux compared with enoxaparin (2.2 vs. 4.1%, HR 0.52: 95% CI: 0.44–0.61).
| |
| ***At 30-day follow-up, there was a statistically significant 17% reduction in 30-day mortality among patients treated with fondaparinux versus enoxaparin (2.9 vs. 3.5%, HR 0.83: 95% CI: 0.71–0.97).
| |
| ***The incidence of catheter-related thrombus was higher among patients assigned to fondaparinux compared with those assigned to enoxparin (1.3% vs. 0.2%), necessitating a protocol amendment that mandated the addition of unfractionated heparin during PCI in patients treated with fondaparinux undergoing coronary intervention.
| |
| | |
| [[Fondaparinux]] should not be the sole [[anticoagulant]] used in patients with [[ACS]] undergoing [[PCI]].
| |
| | |
| | |
| ==Recommendations==
| |
| *Variability in bleeding definitions across clinical trials makes it difficult to compare the risks of different therapies; however, it is evident that there is an association between [[bleeding]] and [[blood transfusion]] and an increased risk of adverse events including death, [[MI]], and [[stroke]]<ref name="Anderson"> Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey WE II, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS. 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).'' Circulation 2007 116: e148 – e304. PMID 17679616</ref> <ref name="Anderson2"> Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey WE II, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS. Correction of 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).'' J Am Coll Cardiol. 2008 Mar 4; 51(9): 974. PMID 17692738 </ref>.
| |
| *Patients at high risk for [[bleeding|bleeding complications]], such as the elderly, females, and those with [[renal dysfunction]] should be identified as requiring strategies to minimize bleeding risk<ref name="Anderson"> Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey WE II, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS. 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).'' Circulation 2007 116: e148 – e304. PMID 17679616</ref> <ref name="Anderson2"> Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey WE II, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS. Correction of 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).'' J Am Coll Cardiol. 2008 Mar 4; 51(9): 974. PMID 17692738 </ref>.
| |
| *When an invasive strategy is employed, consideration should be given to the use of the [[radial artery]] approach<ref name="Anderson"> Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey WE II, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS. 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).'' Circulation 2007 116: e148 – e304. PMID 17679616</ref> <ref name="Anderson2"> Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey WE II, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS. Correction of 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).'' J Am Coll Cardiol. 2008 Mar 4; 51(9): 974. PMID 17692738 </ref>.
| |
| *Prudent dosing of [[thrombolytic therapy|antithrombotic therapy]] and [[antiplatelet therapy|antiplatelet therapies]] is essential<ref name="Anderson"> Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey WE II, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS. 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).'' Circulation 2007 116: e148 – e304. PMID 17679616</ref> <ref name="Anderson2"> Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey WE II, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS. Correction of 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).'' J Am Coll Cardiol. 2008 Mar 4; 51(9): 974. PMID 17692738 </ref>.
| |
| *Consideration of agents such as [[bivalirudin]] and [[fondaparinux]], which have been shown to reduce [[ischemic]] complications while simultaneously reducing bleeding risk for a [[NSTEMI]]/[[unstable angina]] management scheme seems reasonable<ref name="Anderson"> Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey WE II, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS. 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).'' Circulation 2007 116: e148 – e304. PMID 17679616</ref> <ref name="Anderson2"> Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey WE II, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS. Correction of 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).'' J Am Coll Cardiol. 2008 Mar 4; 51(9): 974. PMID 17692738 </ref>.
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|
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|
| | ==Complications of Bleeding and Blood Transfusion Associated with UA/NSTEMI== |
| | You can read in greater detail about each of the topic by clicking below on the link for that topic: |
| | *[[Unstable angina and complications of bleeding and transfusion incidence |Incidence]] |
| | *[[Unstable angina and complications of bleeding and transfusion - definitions for bleeding complications |Definitions]] |
| | *[[Unstable angina and complications of bleeding and transfusion - predictors and causes of bleeding |Predictors and causes of bleeding]] |
| | *[[Unstable angina and complications of bleeding and transfusion - blood transfusions |Blood transfusions]] |
| | *[[Unstable angina and complications of bleeding and transfusion prognosis |Prognosis]] |
| | *[[Unstable angina and complications of bleeding and transfusion prevention |Prevention]] |
| | *[[Unstable angina and complications of bleeding and transfusion recommendations |Recommendations]]''' |
|
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|
| ==References== | | ==References== |
| {{Reflist|2}} | | {{Reflist|2}} |
| | {{WH}} |
| | {{WS}} |
|
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| ==See Also==
| | [[Category:Ischemic heart diseases]] |
| * [[The Living Guidelines: UA/NSTEMI]]
| | [[Category:Intensive care medicine]] |
| * [[Chronic stable angina]]
| | [[Category:Disease]] |
| * [[Non ST Elevation Myocardial Infarction]]
| |
| * [[ST Elevation Myocardial Infarction]]
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| {{Circulatory system pathology}}
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| [[Category:Cardiology]] | | [[Category:Cardiology]] |
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