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==Overview of Anti-Ischemic Therapy in UA / NSTEMI==
==ACC / AHA Guidelines for Initial Therapy (DO NOT EDIT) <ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, ''et al'' |title=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=JACC |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi:10.1016/j.jacc.2007.02.013 |url=}}</ref> <ref name="pmid21444888">{{cite journal |author=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 |title=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 |journal=[[Circulation]] |volume= |issue= |pages= |year=2011 |month=March |pmid=21444888 |doi=10.1161/CIR.0b013e318212bb8b |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=21444888 |accessdate=2011-04-08}}</ref>==
Goals of treatment in [[ACS]] are to relieve the ischemia, limit the amount of myocardial damage and to prevent adverse outcomes, namely death and myocardial [re]infarction. As mentioned under initial therapy, unless contraindicated, [[Aspirin]], a beta blocker, an anticoagulant, a glycoprotein IIb/IIA inhibitor and a thienopyridine should be included in the treatment.
{{cquote| 
Risk stratification early in the course of admission is important sot hat patients who are intermediate to high risk, including those with ongoing ischemia and evidence of hemodynamic instability should eb admitted to a cricital care unit, whenever possible.


==ACC / AHA Guidelines (DO NOT EDIT) <ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, ''et al'' |title=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=JACC |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi:10.1016/j.jacc.2007.02.013 |url=}}</ref>==
{{cquote| 
===Class I===
===Class I===


1. Bed/chair rest with continuous ECG monitoring is recommended for all [[UA]] / [[NSTEMI]] patients during the early hospital phase. (Level of Evidence: C) [1] [2]
1. The history, [[physical examination]], [[12 lead ECG]], and initial [[cardiac biomarker tests]] should be integrated to assign patients with [[chest pain]] into 1 of 4 categories: '''a non cardiac diagnosis''', [[chronic stable angina]], '''possible ACS''', and '''definite ACS'''. ''(Level of Evidence: C)''


2. Supplemental [[oxygen]] should be administered to patients with [[UA]] / [[NSTEMI]] with an arterial saturation <90%, respiratory distress, or other high risk features for [[hypoxemia]]. ([[Pulse oximetry]] is useful for continuous measurement of SaO²) (Level of Evidence: B)
2. Patients with probable or possible [[ACS]] but whose initial [[12 lead ECG]] and [[cardiac biomarker]] levels are normal should be observed in a facility with cardiac monitoring (e.g., chest pain unit or hospital telemetry ward), and repeat ECG (or continuous 12-lead ECG monitoring) and repeat cardiac biomarker measurement(s) should be obtained at predetermined, specified time intervals. ''(Level of Evidence: B)''


3. Patients with [[UA]] / [[NSTEMI]] with ongoing ischemic discomfort should receive sublingual [[NTG]] (0.4 mg) every 5 min for a total of 3 doses, after which assessment should be made about the need for intravenous NTG, if not contraindicated. (Level of Evidence: C)
3. In patients with suspected [[ACS]] in whom [[ischemic heart disease]] is present or suspected, if the follow-up [[12 lead ECG]] and [[cardiac biomarker]]s measurements are normal, a stress test (exercise or pharmacological) to provoke ischemia should be performed in the ED, in a chest pain unit, or on an outpatient basis in a timely fashion (within 72 h) as an alternative to inpatient admission. Low-risk patients with a negative diagnostic test can be managed as outpatients. ''(Level of Evidence: C)''


4. Intravenous [[NTG]] is indicated in the first 48 h after [[UA]] / [[NSTEMI]] for treatment of persistent [[ischemia]], [[heart failure]], or [[hypertension]]. The decision to administer intravenous [[NTG]] and the dose used should not preclude therapy with other proven mortality reducing interventions such as [[beta blockers]] or [[ACE inhibitors]]. (Level of Evidence: B)
4. In low-risk patients who are referred for outpatient stress testing, precautionary appropriate pharmacotherapy (e.g., [[ASA]], sublingual [[NTG]], and/or [[beta blocker]]s) should be given while awaiting results of the stress test. ''(Level of Evidence: C)''


5. Oral [[beta blocker]] therapy should be initiated within the first 24 h for patients who do not have 1 or more of the following: a- Signs of Heart Failure, b- Evidence of a low-output state, c- Increased risk for cardiogenic shock, or d- Other relative contraindications to beta blockade (PR interval >0.24 sec, second or third degree [[heart block]], active [[asthma]], or reactive airway disease). (Level of Evidence: B)
5. Patients with definite [[ACS]] and ongoing ischemic symptoms, positive [[cardiac biomarker]]s, new [[ST-segment deviation]]s, new deep [[T-wave]] inversions, hemodynamic abnormalities, or a positive stress test should be admitted to the hospital for further management. Admission to the critical care unit is recommended for those with active, ongoing ischemia/injury or hemodynamic or electrical instability. Otherwise, a telemetry step-down unit is reasonable. ''(Level of Evidence: C)''


6. In [[UA]] / [[NSTEMI]] patients with continuing or frequently recurring [[ischemia]] and in whom [[beta blockers]] are contraindicated, a non dihydropyridine [[calcium channel blocker]] (e.g., [[verapamil]] or [[diltiazem]]) should be given as initial therapy in the absence of clinically significant Left Ventricular dysfunction or other contraindications. (Level of Evidence: B)
6. Patients with possible [[ACS]] and negative [[cardiac biomarker]]s who are unable to exercise or who have an abnormal resting ECG should undergo a [[pharmacological stress test]]. ''(Level of Evidence: B)''


7. An [[Angiotensin Converting Enzyme inhibitor]] ([[ACE]]) should be administered orally within the first 24 h to [[UA]] / [[NSTEMI]] patients with [[pulmonary congestion]] or [[LV ejection fraction]] ([[LVEF]]) ≤40%, in the absence of [[hypotension]] (systolic blood pressure <100 mmHg or <30 mmHg below baseline) or known contraindications to that class of medications. (Level of Evidence: A)
7. Patients with definite [[ACS]] and [[ST-segment elevation]] in leads V7 to V9 due to [[left circumflex artery]] occlusion should be evaluated for immediate [[reperfusion therapy]]. ''(Level of Evidence: A)''


8. An [[angiotensin receptor blocker]] should be administered to [[UA]] / [[NSTEMI]] patients who are intolerant of [[ACE inhibitors]] and have either clinical or radiological signs of [[HF]] or [[LVEF]] ≤40%. (Level of Evidence: A)
8. Patients discharged from the ED or chest pain unit should be given specific instructions for activity, medications, additional testing, and follow-up with a personal physician. ''(Level of Evidence: C)''
 
9. Because of the increased risks of mortality, reinfarction, [[hypertension]], [[HF]], and [[myocardial rupture]] associated with their use, [[non steroidal anti-inflammatory drugs]] ([[NSAIDs]]), except for [[ASA]], whether non selective or cyclo oxygenase (COX)-2–selective agents, should be discontinued at the time a patient presents with [[UA]] / [[NSTEMI]]. (Level of Evidence: C)  


===Class IIa===
===Class IIa===


1. It is reasonable to administer supplemental [[oxygen]] to all patients with [[UA]] / [[NSTEMI]] during the first 6 h after presentation. (Level of Evidence: C)
1. In patients with suspected [[ACS]] with a low or intermediate probability of [[CAD]], in whom the follow up [[12 lead ECG]] and [[cardiac biomarkers]] measurements are normal, performance of a non invasive coronary imaging test (i.e., Cardiac / Coronary [[CT Angiography]]) is reasonable as an alternative to stress testing. ''(Level of Evidence: B)''}}
 
2. In the absence of contradictions to its use, it is reasonable to administer [[morphine sulfate]] intravenously to [[UA]] / [[NSTEMI]] patients if there is uncontrolled ischemic chest discomfort despite [[NTG]], provided that additional therapy is used to manage the underlying [[ischemia]]. (Level of Evidence: B)
 
3. It is reasonable to administer intravenous (IV) [[beta blockers]] at the time of presentation for [[hypertension]] to [[UA]] / [[NSTEMI]] patients who do not have 1 or more of the following: a- Signs of [[HF]], b- Evidence of a low-output state, c- Increased risk for [[cardiogenic shock]], d- Other relative contraindications to beta blockade (PR interval >0.24 s, second or third degree [[heart block]], active [[asthma]], or reactive airway disease). (Level of Evidence: B)
 
4. Oral long acting non dihydropyridine calcium antagonists are reasonable for use in [[UA]] / [[NSTEMI]] patients for recurrent [[ischemia]] in the absence of contraindications after [[beta blockers]] and [[nitrates]] have been fully used. (Level of Evidence: C)
 
5. An [[ACE inhibitor]] administered orally within the first 24 h of [[UA]] / [[NSTEMI]] can be useful in patients without [[pulmonary congestion]] or [[LVEF]] ≤40% in the absence of [[hypotension]] (systolic blood pressure <100 mm Hg or less than 30 mm Hg below baseline) or known contraindications to that class of medications. (Level of Evidence: B)
 
6. [[Intra aortic balloon pump]] ([[IABP]]) counter pulsation is reasonable in [[UA]] / [[NSTEMI]] patients for severe [[ischemia]] that is continuing or recurs frequently despite intensive medical therapy, for hemodynamic instability in patients before or after [[coronary angiography]], and for mechanical complications of [[myocardial infarction]] ([[MI]]). (Level of Evidence: C)
 
===Class IIb===
 
1. The use of extended-release forms of non dihydropyridine [[calcium antagonists]] instead of a [[beta blocker]] may be considered in patients with [[UA]] / [[NSTEMI]]. (Level of Evidence: B)
 
2. Immediate-release dihydropyridine [[calcium antagonists]] in the presence of adequate beta blockade may be considered in patients with [[UA]] / [[NSTEMI]] with ongoing ischemic symptoms or [[hypertension]]. (Level of Evidence: B)
 
===Class III===
 
1. [[Nitrates]] should not be administered to [[UA]] / [[NSTEMI]] patients with systolic blood pressure <90mmHg or ≥30 mmHg below baseline, severe [[bradycardia]] (<50 bpm), [[tachycardia]] (>100 bpm) in the absence of symptomatic [[heart failure]], or [[right ventricular infarction]]. (Level of Evidence: C)
 
2. [[Nitroglycerin]] or other [[nitrates]] should not be administered to patients with [[UA]] / [[NSTEMI]] who had received a phosphodiesterase inhibitor for erectile dysfunction within 24 h of [[sildenafil]] or 48 h of [[tadalafil]] use. The suitable time for the administration of [[nitrates]] after [[vardenafil]] has not been determined. (Level of Evidence: C)
 
3. Immediate-release dihydropyridine [[calcium antagonists]] should not be administered to patients with [[UA]] / [[NSTEMI]] in the absence of a [[beta blocker]]. (Level of Evidence: A)
 
4. An intravenous [[ACE inhibitor]] should not be given to patients within the first 24 h of [[UA]] / [[NSTEMI]] because of the increased risk of [[hypotension]]. (A possible exception may be patients with refractory [[hypertension]].) (Level of Evidence: B)


5. It may be harmful to administer intravenous [[beta blockers]] to [[UA]] / [[NSTEMI]] patients who have contraindications to beta blockade, signs of [[HF]] or low-output state, or other risk factors for [[cardiogenic shock]]. (Level of Evidence: A)


6. [[Non steroidal anti-inflammatory drugs]] (except for [[ASA]]), whether non selective or COX-2–selective agents, should not be administered during hospitalization for [[UA]] / [[NSTEMI]] because of the increased risks of mortality, reinfarction, [[hypertension]], [[heart failure]], and [[myocardial rupture]] associated with their use. (Level of Evidence: C)}}


==See Also==
==See Also==

Revision as of 20:08, 8 April 2011

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ACC / AHA Guidelines for Initial Therapy (DO NOT EDIT) [1] [2]

“

Class I

1. The history, physical examination, 12 lead ECG, and initial cardiac biomarker tests should be integrated to assign patients with chest pain into 1 of 4 categories: a non cardiac diagnosis, chronic stable angina, possible ACS, and definite ACS. (Level of Evidence: C)

2. Patients with probable or possible ACS but whose initial 12 lead ECG and cardiac biomarker levels are normal should be observed in a facility with cardiac monitoring (e.g., chest pain unit or hospital telemetry ward), and repeat ECG (or continuous 12-lead ECG monitoring) and repeat cardiac biomarker measurement(s) should be obtained at predetermined, specified time intervals. (Level of Evidence: B)

3. In patients with suspected ACS in whom ischemic heart disease is present or suspected, if the follow-up 12 lead ECG and cardiac biomarkers measurements are normal, a stress test (exercise or pharmacological) to provoke ischemia should be performed in the ED, in a chest pain unit, or on an outpatient basis in a timely fashion (within 72 h) as an alternative to inpatient admission. Low-risk patients with a negative diagnostic test can be managed as outpatients. (Level of Evidence: C)

4. In low-risk patients who are referred for outpatient stress testing, precautionary appropriate pharmacotherapy (e.g., ASA, sublingual NTG, and/or beta blockers) should be given while awaiting results of the stress test. (Level of Evidence: C)

5. Patients with definite ACS and ongoing ischemic symptoms, positive cardiac biomarkers, new ST-segment deviations, new deep T-wave inversions, hemodynamic abnormalities, or a positive stress test should be admitted to the hospital for further management. Admission to the critical care unit is recommended for those with active, ongoing ischemia/injury or hemodynamic or electrical instability. Otherwise, a telemetry step-down unit is reasonable. (Level of Evidence: C)

6. Patients with possible ACS and negative cardiac biomarkers who are unable to exercise or who have an abnormal resting ECG should undergo a pharmacological stress test. (Level of Evidence: B)

7. Patients with definite ACS and ST-segment elevation in leads V7 to V9 due to left circumflex artery occlusion should be evaluated for immediate reperfusion therapy. (Level of Evidence: A)

8. Patients discharged from the ED or chest pain unit should be given specific instructions for activity, medications, additional testing, and follow-up with a personal physician. (Level of Evidence: C)

Class IIa

1. In patients with suspected ACS with a low or intermediate probability of CAD, in whom the follow up 12 lead ECG and cardiac biomarkers measurements are normal, performance of a non invasive coronary imaging test (i.e., Cardiac / Coronary CT Angiography) is reasonable as an alternative to stress testing. (Level of Evidence: B)

”


See Also

Sources

  • The ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction [1]

References

  1. ↑ 1.0 1.1 Anderson JL, Adams CD, Antman EM; et al. (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". JACC. 50 (7): e1–e157. PMID 17692738. Text "doi:10.1016/j.jacc.2007.02.013 " ignored (help); Unknown parameter |month= ignored (help)
  2. ↑ 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 (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. doi:10.1161/CIR.0b013e318212bb8b. PMID 21444888. Retrieved 2011-04-08. Unknown parameter |month= ignored (help)

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