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==Overview of Additional Management Considerations for Antiplatelet and Anticoagulant Therapy in UA / NSTEMI==
==Overview==


==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 for Additional Management Considerations for Antiplatelets and Anticoagulants==<ref name="pmid22800849">{{cite journal| author=2012 Writing Committee Members. Jneid H, Anderson JL, Wright RS, Adams CD, Bridges CR et al.| title=2012 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction (Updating the 2007 Guideline and Replacing the 2011 Focused Update): A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2012 | volume= 126 | issue= 7 | pages= 875-910 | pmid=22800849 | doi=10.1161/CIR.0b013e318256f1e0 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22800849  }} </ref> (DO NOT EDIT)==
{{cquote| 
===[[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 arrhythmias), a stress test should be performed. (Level of Evidence: B)
{|class="wikitable"
* If, after stress testing, the patient is classified as not at low risk, diagnostic angiography should be performed. (Level of Evidence: A)
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
 
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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 arrhythmias), a stress test should be performed. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])
* If, after stress testing, the patient is classified as not at low risk, diagnostic angiography should be performed. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])
* If, after stress testing, the patient is classified as being at low risk, the instructions noted below should be followed in preparation for discharge:
* If, after stress testing, the patient is classified as being at low risk, the instructions noted below should be followed in preparation for discharge:
** Continue aspirin indefinitely. (Level of Evidence: A)
** Continue aspirin indefinitely. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])
** Continue clopidogrel or ticagrelor for up to 12 months. (Level of Evidence: B)
** Continue clopidogrel or ticagrelor for up to 12 months. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])
** Discontinue IV GP IIb/IIIa inhibitor if started previously. (Level of Evidence: A)
** Discontinue IV GP IIb/IIIa inhibitor if started previously. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])
** Continue UFH for 48 hours (Level of Evidence: A) or administer enoxaparin (Level of Evidence: A) or fondaparinux (Level of Evidence: B) for the duration of hospitalization, up to 8 days, and then discontinue anticoagulant therapy.
** Continue UFH for 48 hours ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]]) or administer enoxaparin ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]]) or fondaparinux ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]]) for the duration of hospitalization, up to 8 days, and then discontinue anticoagulant therapy.'' <nowiki>"</nowiki>
 
'''2.''' For [[UA]] / [[NSTEMI]] patients in whom [[CABG]] is selected as a postangiography management strategy, the instructions noted below should be followed.


::'''a.''' Continue [[ASA]]. ''(Level of Evidence: A)''
|-
::'''b.''' Discontinue [[clopidogrel]] 5 to 7 d before elective [[CABG]]. ''(Level of Evidence: B)'' More urgent surgery, if necessary, may be performed by experienced surgeons if the incremental bleeding risk is considered acceptable. ''(Level of Evidence: C)''
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' For [[UA]] / [[NSTEMI]] patients in whom [[CABG]] is selected as a postangiography management strategy, the instructions noted below should be followed.
::'''c.''' Discontinue intravenous [[GP IIb/IIIa inhibitor]] ([[eptifibatide]] or [[tirofiban]]) 4 h before [[CABG]]. ''(Level of Evidence: B)''
::'''a.''' Continue [[ASA]]. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])
::'''b.''' Discontinue [[clopidogrel]] 5 to 7 d before elective [[CABG]]. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]]) More urgent surgery, if necessary, may be performed by experienced surgeons if the incremental bleeding risk is considered acceptable. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])
::'''c.''' Discontinue intravenous [[GP IIb/IIIa inhibitor]] ([[eptifibatide]] or [[tirofiban]]) 4 h before [[CABG]]. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])
::'''d.''' Anticoagulant therapy should be managed as follows:
::'''d.''' Anticoagulant therapy should be managed as follows:


:::* Continue [[UFH]]. ''(Class I Level of Evidence: B)''
:::* Continue [[UFH]]. ''(Class I [[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
:::* Discontinue [[enoxaparin]] 12 to 24 h before [[CABG]] and dose with [[UFH]] per institutional practice. ''(Level of Evidence: B)''
:::* Discontinue [[enoxaparin]] 12 to 24 h before [[CABG]] and dose with [[UFH]] per institutional practice. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])
:::* Discontinue [[fondaparinux]] 24 h before [[CABG]] and dose with [[UFH]] per institutional practice. ''(Level of Evidence: B)''
:::* Discontinue [[fondaparinux]] 24 h before [[CABG]] and dose with [[UFH]] per institutional practice. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])
:::* Discontinue [[bivalirudin]] 3 h before [[CABG]] and dose with [[UFH]] per institutional practice. ''(Level of Evidence: B)''
:::* Discontinue [[bivalirudin]] 3 h before [[CABG]] and dose with [[UFH]] per institutional practice. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
 
 
'''3.''' In patients taking a P2Y12 receptor inhibitor in whom CABG is planned and can be delayed, it is recommended that the drug be discontinued to allow for dissipation of the antiplatelet effect (Level of Evidence: B). The period of withdrawal should be at least 5 days in patients receiving clopidogrel (Level of Evidence: B) or ticagrelor (Level of Evidence: C) and at least 7 days in patients receiving prasugrel (Level of Evidence: C) unless the need for revascularization and/or the net benefit of the P2Y12 receptor inhibitor therapy outweighs the potential risks of excess bleeding. (Level of Evidence: C)


'''4.''' For UA/NSTEMI patients in whom PCI has been selected as a postangiography management strategy, the instructions noted below should be followed:
|-
* Continue aspirin. (Level of Evidence: A)
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' In patients taking a P2Y12 receptor inhibitor in whom CABG is planned and can be delayed, it is recommended that the drug be discontinued to allow for dissipation of the antiplatelet effect ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]]). The period of withdrawal should be at least 5 days in patients receiving clopidogrel ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]]) or ticagrelor ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]]) and at least 7 days in patients receiving prasugrel ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]]) unless the need for revascularization and/or the net benefit of the P2Y12 receptor inhibitor therapy outweighs the potential risks of excess bleeding. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
* Administer a loading dose of a P2Y12 receptor inhibitor if not started before diagnostic angiography. (Level of Evidence: A)
* Discontinue anticoagulant therapy after PCI for uncomplicated cases. (Level of Evidence: B)


'''5.''' For [[UA]] / [[NSTEMI]] patients in whom medical therapy is selected as a management strategy and in whom no significant obstructive [[CAD]] on angiography was found, [[antiplatelet]] and [[anticoagulant therapy]] should be administered at the discretion of the clinician ''(Level of Evidence: C)''. For patients in whom evidence of [[coronary atherosclerosis]] is present (e.g., luminal irregularities or intravascular ultrasound demonstrated lesions), albeit without flow-limiting stenoses, long-term treatment with [[ASA]] and other secondary prevention measures should be prescribed. ''(Level of Evidence: C)''
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''4.''' For UA/NSTEMI patients in whom PCI has been selected as a postangiography management strategy, the instructions noted below should be followed:
* Continue aspirin. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])
* Administer a loading dose of a P2Y12 receptor inhibitor if not started before diagnostic angiography. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])
* Discontinue anticoagulant therapy after PCI for uncomplicated cases. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>


|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''5.''' For [[UA]] / [[NSTEMI]] patients in whom medical therapy is selected as a management strategy and in whom no significant obstructive [[CAD]] on angiography was found, [[antiplatelet]] and [[anticoagulant therapy]] should be administered at the discretion of the clinician ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]]). For patients in whom evidence of [[coronary atherosclerosis]] is present (e.g., luminal irregularities or intravascular ultrasound demonstrated lesions), albeit without flow-limiting stenoses, long-term treatment with [[ASA]] and other secondary prevention measures should be prescribed. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>


'''6.''' For UA/NSTEMI patients in whom medical therapy is selected as a management strategy and in whom coronary artery disease was found on angiography, the following approach is recommended:
|-
* Continue aspirin. (Level of Evidence: A)
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''6.''' For UA/NSTEMI patients in whom medical therapy is selected as a management strategy and in whom coronary artery disease was found on angiography, the following approach is recommended:
* Administer a loading dose of clopidogrel or ticagrelor if not given before diagnostic angiography. (Level of Evidence: B)
* Continue aspirin. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])
* Discontinue IV GP IIb/IIIa inhibitor if started previously. (Level of Evidence: B)
* Administer a loading dose of clopidogrel or ticagrelor if not given before diagnostic angiography. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])
* Discontinue IV GP IIb/IIIa inhibitor if started previously. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])
* Anticoagulant therapy should be managed as follows:
* Anticoagulant therapy should be managed as follows:
**1. Continue IV UFH for at least 48 hours or until discharge if given before diagnostic angiography (Level of Evidence: A)
**1. Continue IV UFH for at least 48 hours or until discharge if given before diagnostic angiography ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])
**2. Continue enoxaparin for duration of hospitalization, up to 8 days, if given before diagnostic angiography. (Level of Evidence: A)
**2. Continue enoxaparin for duration of hospitalization, up to 8 days, if given before diagnostic angiography. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])
**3. Continue fondaparinux for duration of hospitalization, up to 8 days, if given before diagnostic angiography. (Level of Evidence: B)
**3. Continue fondaparinux for duration of hospitalization, up to 8 days, if given before diagnostic angiography. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])
**4. Either discontinue bivalirudin or continue at a dose of 0.25 mg/kg per hour for up to 72 hours at the physician’s discretion if given before diagnostic angiography. (Level of Evidence: B)
**4. Either discontinue bivalirudin or continue at a dose of 0.25 mg/kg per hour for up to 72 hours at the physician’s discretion if given before diagnostic angiography. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>


'''7.''' For UA/NSTEMI patients in whom a conservative strategy is selected and who do not undergo angiography or stress testing, the instructions noted below should be followed:
|-
* Continue aspirin indefinitely. (Level of Evidence: A)
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''7.''' For UA/NSTEMI patients in whom a conservative strategy is selected and who do not undergo angiography or stress testing, the instructions noted below should be followed:
* Continue clopidogrel or ticagrelor for up to 12 months. (Level of Evidence: B)
* Continue aspirin indefinitely. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])
* Discontinue IV GP IIb/IIIa inhibitor if started previously. (Level of Evidence: A)
* Continue clopidogrel or ticagrelor for up to 12 months. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])
* Continue UFH for 48 hours (Level of Evidence: A) or administer enoxaparin (Level of Evidence: A) or fondaparinux (Level of Evidence: B) for the duration of hospitalization, up to 8 days, and then discontinue anticoagulant therapy.
* Discontinue IV GP IIb/IIIa inhibitor if started previously. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])
* Continue UFH for 48 hours ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]]) or administer enoxaparin ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]]) or fondaparinux ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]]) for the duration of hospitalization, up to 8 days, and then discontinue anticoagulant therapy.'' <nowiki>"</nowiki>


'''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)''
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|}


===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]===
===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]===
Line 74: Line 82:
===[[ACC AHA guidelines classification scheme#Classification of Recommendations|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 P2Y12 receptor inhibitor 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 P2Y12 receptor inhibitor therapy might be considered if results of testing may alter management. (Level of Evidence: C)


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

Revision as of 14:15, 5 October 2012

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

Overview

ACC / AHA Guidelines for Additional Management Considerations for Antiplatelets and Anticoagulants==[1] (DO NOT EDIT)

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 arrhythmias), a stress test should be performed. (Level of Evidence: B)
  • If, after stress testing, the patient is classified as not at low risk, diagnostic angiography should be performed. (Level of Evidence: A)
  • If, after stress testing, the patient is classified as being at low risk, the instructions noted below should be followed in preparation for discharge:
"2. For UA / NSTEMI patients in whom CABG is selected as a postangiography management strategy, the instructions noted below should be followed.
a. Continue ASA. (Level of Evidence: A)
b. Discontinue clopidogrel 5 to 7 d before elective CABG. (Level of Evidence: B) More urgent surgery, if necessary, may be performed by experienced surgeons if the incremental bleeding risk is considered acceptable. (Level of Evidence: C)
c. Discontinue intravenous GP IIb/IIIa inhibitor (eptifibatide or tirofiban) 4 h before CABG. (Level of Evidence: B)
d. Anticoagulant therapy should be managed as follows:
"3. In patients taking a P2Y12 receptor inhibitor in whom CABG is planned and can be delayed, it is recommended that the drug be discontinued to allow for dissipation of the antiplatelet effect (Level of Evidence: B). The period of withdrawal should be at least 5 days in patients receiving clopidogrel (Level of Evidence: B) or ticagrelor (Level of Evidence: C) and at least 7 days in patients receiving prasugrel (Level of Evidence: C) unless the need for revascularization and/or the net benefit of the P2Y12 receptor inhibitor therapy outweighs the potential risks of excess bleeding. (Level of Evidence: C) "
"4. For UA/NSTEMI patients in whom PCI has been selected as a postangiography management strategy, the instructions noted below should be followed:
"5. For UA / NSTEMI patients in whom medical therapy is selected as a management strategy and in whom no significant obstructive CAD on angiography was found, antiplatelet and anticoagulant therapy should be administered at the discretion of the clinician (Level of Evidence: C). For patients in whom evidence of coronary atherosclerosis is present (e.g., luminal irregularities or intravascular ultrasound demonstrated lesions), albeit without flow-limiting stenoses, long-term treatment with ASA and other secondary prevention measures should be prescribed. (Level of Evidence: C) "
"6. For UA/NSTEMI patients in whom medical therapy is selected as a management strategy and in whom coronary artery disease was found on angiography, the following approach is recommended:
  • Continue aspirin. (Level of Evidence: A)
  • Administer a loading dose of clopidogrel or ticagrelor if not given before diagnostic angiography. (Level of Evidence: B)
  • Discontinue IV GP IIb/IIIa inhibitor if started previously. (Level of Evidence: B)
  • Anticoagulant therapy should be managed as follows:
    • 1. Continue IV UFH for at least 48 hours or until discharge if given before diagnostic angiography (Level of Evidence: A)
    • 2. Continue enoxaparin for duration of hospitalization, up to 8 days, if given before diagnostic angiography. (Level of Evidence: A)
    • 3. Continue fondaparinux for duration of hospitalization, up to 8 days, if given before diagnostic angiography. (Level of Evidence: B)
    • 4. Either discontinue bivalirudin or continue at a dose of 0.25 mg/kg per hour for up to 72 hours at the physician’s discretion if given before diagnostic angiography. (Level of Evidence: B) "
"7. For UA/NSTEMI patients in whom a conservative strategy is selected and who do not undergo angiography or stress testing, the instructions noted below should be followed:
"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 arrhythmias), Left Ventricular Ejection Fraction should be measured. (Level of Evidence: B) "

Class III

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)

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)

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 IIb

1. Platelet function testing to determine platelet inhibitory response in patients with UA/NSTEMI (or, after ACS and PCI) on P2Y12 receptor inhibitor 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 P2Y12 receptor inhibitor 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 [2]

References

  1. ↑ 2012 Writing Committee Members. Jneid H, Anderson JL, Wright RS, Adams CD, Bridges CR; et al. (2012). "2012 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction (Updating the 2007 Guideline and Replacing the 2011 Focused Update): A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". Circulation. 126 (7): 875–910. doi:10.1161/CIR.0b013e318256f1e0. PMID 22800849.
  2. ↑ 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 |month= ignored (help)

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