Unstable angina non ST elevation myocardial infarction additional management considerations for antiplatelet and anticoagulant therapy: Difference between revisions
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==ACC / AHA Guidelines (DO NOT EDIT) <ref name="pmid21444889">{{cite journal |author=Wright RS, Anderson JL, Adams CD, Bridges CR, Casey DE, Ettinger SM, Fesmire FM, Ganiats TG, Jneid H, Lincoff AM, Peterson ED, Philippides GJ, Theroux P, Wenger NK, Zidar JP |title=2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction (Updating the 2007 Guideline): 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=21444889 |doi=10.1161/CIR.0b013e31820f2f3e |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=21444889 |accessdate=2011-03-31}}</ref>== | ==ACC / AHA Guidelines (DO NOT EDIT) <ref name="pmid21444889">{{cite journal |author=Wright RS, Anderson JL, Adams CD, Bridges CR, Casey DE, Ettinger SM, Fesmire FM, Ganiats TG, Jneid H, Lincoff AM, Peterson ED, Philippides GJ, Theroux P, Wenger NK, Zidar JP |title=2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction (Updating the 2007 Guideline): 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=21444889 |doi=10.1161/CIR.0b013e31820f2f3e |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=21444889 |accessdate=2011-03-31}}</ref>== | ||
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===Class I=== | ===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]=== | ||
'''1.''' For [[UA]] / [[NSTEMI]] patients in whom an initial conservative strategy is selected and no subsequent features appear that would necessitate [[diagnostic angiography]] (recurrent symptoms / [[ischemia]], [[heart failure]] or serious [[arrhythmia]]s), a [[stress test]] should be performed. ''(Level of Evidence: B)''. | '''1.''' For [[UA]] / [[NSTEMI]] patients in whom an initial conservative strategy is selected and no subsequent features appear that would necessitate [[diagnostic angiography]] (recurrent symptoms / [[ischemia]], [[heart failure]] or serious [[arrhythmia]]s), a [[stress test]] should be performed. ''(Level of Evidence: B)''. | ||
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'''8.''' For [[UA]] / [[NSTEMI]] patients in whom an initial conservative strategy is selected and in whom no subsequent features appear that would necessitate [[diagnostic angiography]] (recurrent symptoms / [[ischemia]], [[HF]], or serious [[arrhythmia]]s), [[Left Ventricular Ejection Fraction]] should be measured. ''(Level of Evidence: B)'' | '''8.''' For [[UA]] / [[NSTEMI]] patients in whom an initial conservative strategy is selected and in whom no subsequent features appear that would necessitate [[diagnostic angiography]] (recurrent symptoms / [[ischemia]], [[HF]], or serious [[arrhythmia]]s), [[Left Ventricular Ejection Fraction]] should be measured. ''(Level of Evidence: B)'' | ||
===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]=== | |||
===Class IIa=== | '''1.''' Intravenous [[fibrinolytic therapy]] is not indicated in patients without acute [[ST segment elevation]], a [[true posterior MI]], or a presumed new [[left bundle branch block]] ([[LBBB]]). ''(Level of Evidence: A)'' | ||
===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]=== | |||
'''1.''' For [[UA]] / [[NSTEMI]] patients in whom PCI has been selected as a postangiography management strategy, it is reasonable to administer an IV [[GP IIb/IIIa inhibitor]] ([[abciximab]], [[eptifibatide]], or [[tirofiban]]) if not started before diagnostic angiography, particularly for troponin-positive and/or other high-risk patients. ''(Level of Evidence: A)'' | '''1.''' For [[UA]] / [[NSTEMI]] patients in whom PCI has been selected as a postangiography management strategy, it is reasonable to administer an IV [[GP IIb/IIIa inhibitor]] ([[abciximab]], [[eptifibatide]], or [[tirofiban]]) if not started before diagnostic angiography, particularly for troponin-positive and/or other high-risk patients. ''(Level of Evidence: A)'' | ||
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===Class IIb=== | ===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]=== | ||
'''1.''' Platelet function testing to determine platelet inhibitory response in patients with [[UA]] / [[NSTEMI]] (or, after [[ACS]] and [[PCI]]) on [[thienopyridine]] therapy may be considered if results of testing may alter management. ''(Level of Evidence: B)'' | '''1.''' Platelet function testing to determine platelet inhibitory response in patients with [[UA]] / [[NSTEMI]] (or, after [[ACS]] and [[PCI]]) on [[thienopyridine]] therapy may be considered if results of testing may alter management. ''(Level of Evidence: B)'' | ||
'''2.''' Genotyping for a CYP2C19 loss of function variant in patients with [[UA]] / [[NSTEMI]] (or, after [[ACS]] and with [[PCI]]) on [[clopidogrel]] therapy might be considered if results of testing may alter management. ''(Level of Evidence: C | '''2.''' Genotyping for a CYP2C19 loss of function variant in patients with [[UA]] / [[NSTEMI]] (or, after [[ACS]] and with [[PCI]]) on [[clopidogrel]] therapy might be considered if results of testing may alter management. ''(Level of Evidence: C)''}} | ||
==See Also== | ==See Also== |
Revision as of 18:10, 1 October 2012
Unstable angina / NSTEMI Microchapters |
Differentiating Unstable Angina/Non-ST Elevation Myocardial Infarction from other Disorders |
Special Groups |
Diagnosis |
Laboratory Findings |
Treatment |
Antitplatelet Therapy |
Additional Management Considerations for Antiplatelet and Anticoagulant Therapy |
Risk Stratification Before Discharge for Patients With an Ischemia-Guided Strategy of NSTE-ACS |
Mechanical Reperfusion |
Discharge Care |
Case Studies |
Unstable angina non ST elevation myocardial infarction additional management considerations for antiplatelet and anticoagulant therapy On the Web |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview of Additional Management Considerations for Antiplatelet and Anticoagulant Therapy in UA / NSTEMI
ACC / AHA Guidelines (DO NOT EDIT) [1]
“ |
Class I1. For UA / NSTEMI patients in whom an initial conservative strategy is selected and no subsequent features appear that would necessitate diagnostic angiography (recurrent symptoms / ischemia, heart failure or serious arrhythmias), a stress test should be performed. (Level of Evidence: B).
Class III1. Intravenous fibrinolytic therapy is not indicated in patients without acute ST segment elevation, a true posterior MI, or a presumed new left bundle branch block (LBBB). (Level of Evidence: A) Class IIa1. For UA / NSTEMI patients in whom PCI has been selected as a postangiography management strategy, it is reasonable to administer an IV GP IIb/IIIa inhibitor (abciximab, eptifibatide, or tirofiban) if not started before diagnostic angiography, particularly for troponin-positive and/or other high-risk patients. (Level of Evidence: A) 2. For UA / NSTEMI patients in whom PCI is selected as a post angiography management strategy, it is reasonable to omit administration of an intravenous GP IIb/IIIa antagonist if bivalirudin was selected as the anticoagulant and at least 300 mg of clopidogrel was administered at least 6 h earlier. (Level of Evidence: B) 3. If Left Ventricular Ejection Fraction is ≤40%, it is reasonable to perform diagnostic angiography. (Level of Evidence: B) 4. If Left Ventricular Ejection Fraction is >40%, it is reasonable to perform a stress test. (Level of Evidence: B)
Class IIb1. Platelet function testing to determine platelet inhibitory response in patients with UA / NSTEMI (or, after ACS and PCI) on thienopyridine therapy may be considered if results of testing may alter management. (Level of Evidence: B) 2. Genotyping for a CYP2C19 loss of function variant in patients with UA / NSTEMI (or, after ACS and with PCI) on clopidogrel therapy might be considered if results of testing may alter management. (Level of Evidence: C) |
” |
See Also
Sources
- 2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction [1]
References
- ↑ 1.0 1.1 Wright RS, Anderson JL, Adams CD, Bridges CR, Casey DE, Ettinger SM, Fesmire FM, Ganiats TG, Jneid H, Lincoff AM, Peterson ED, Philippides GJ, Theroux P, Wenger NK, Zidar JP (2011). "2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction (Updating the 2007 Guideline): A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". Circulation. doi:10.1161/CIR.0b013e31820f2f3e. PMID 21444889. Retrieved 2011-03-31. Unknown parameter
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