Unstable angina non ST elevation myocardial infarction additional management considerations for antiplatelet and anticoagulant therapy: Difference between revisions
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==Overview== | ==Overview== | ||
==ACC / AHA Guidelines for Additional Management Considerations for Antiplatelets and Anticoagulants | ==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)== | ||
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===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] | {|class="wikitable" | ||
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|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (No Benefit) | |||
'''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]]). | |- | ||
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''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]]).([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' <nowiki>"</nowiki> | |||
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===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]] | {|class="wikitable" | ||
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| colspan="1" style="text-align:center; background:LemonChiffon"|[[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. | |- | ||
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' <nowiki>"</nowiki> | |||
'''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. | |- | ||
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki> | |||
'''3.''' If [[Left Ventricular Ejection Fraction]] is ≤40%, it is reasonable to perform [[diagnostic angiography]]. | |- | ||
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' If [[Left Ventricular Ejection Fraction]] is ≤40%, it is reasonable to perform [[diagnostic angiography]]. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki> | |||
'''4.''' If [[Left Ventricular Ejection Fraction]] is >40%, it is reasonable to perform a [[stress test]]. | |- | ||
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''4.''' If [[Left Ventricular Ejection Fraction]] is >40%, it is reasonable to perform a [[stress test]]. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki> | |||
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===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]] | {|class="wikitable" | ||
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| colspan="1" style="text-align:center; background:LemonChiffon"|[[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 P2Y12 receptor inhibitor therapy may be considered if results of testing may alter management. (Level of Evidence: B) | |- | ||
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki> | |||
'''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) | |- | ||
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki> | |||
|} | |||
==See Also== | ==See Also== | ||
* [[The Living Guidelines: UA/NSTEMI | The UA / NSTEMI Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines]] | * [[The Living Guidelines: UA/NSTEMI | The UA / NSTEMI Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines]] | ||
==References== | ==References== |
Revision as of 14:24, 5 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
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)
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"2. For UA / NSTEMI patients in whom CABG is selected as a postangiography management strategy, the instructions noted below should be followed.
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"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:
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"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:
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"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:
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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 arrhythmias), Left Ventricular Ejection Fraction should be measured. (Level of Evidence: B) " |
Class III (No Benefit) |
"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
References
- ↑ 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.