Unstable angina / non ST elevation myocardial infarction initial therapy

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ACC / AHA Guidelines (DO NOT EDIT)

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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] 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) 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) 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) 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) 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) 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) 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) 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 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) 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)

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See Also

• The UA / NSTEMI Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines

Sources

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