Unstable angina non ST elevation myocardial infarction additional management considerations for antiplatelet and anticoagulant therapy: Difference between revisions
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'''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]])'' | '''b)''' Discontinue [[clopidogrel]] 5 to 7 d before elective [[CABG]].<ref name="pmid11726894">{{cite journal| author=Bizzarri F, Scolletta S, Tucci E, Lucidi M, Davoli G, Toscano T et al.| title=Perioperative use of tirofiban hydrochloride (Aggrastat) does not increase surgical bleeding after emergency or urgent coronary artery bypass grafting. | journal=J Thorac Cardiovasc Surg | year= 2001 | volume= 122 | issue= 6 | pages= 1181-5 | pmid=11726894 | doi=10.1067/mtc.2001.117838 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11726894 }} </ref><ref name="pmid10969673">{{cite journal| author=Lincoff AM, LeNarz LA, Despotis GJ, Smith PK, Booth JE, Raymond RE et al.| title=Abciximab and bleeding during coronary surgery: results from the EPILOG and EPISTENT trials. Improve Long-term Outcome with abciximab GP IIb/IIIa blockade. Evaluation of Platelet IIb/IIIa Inhibition in STENTing. | journal=Ann Thorac Surg | year= 2000 | volume= 70 | issue= 2 | pages= 516-26 | pmid=10969673 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10969673 }} </ref><ref name="pmid11016325">{{cite journal| author=Dyke CM, Bhatia D, Lorenz TJ, Marso SP, Tardiff BE, Hogeboom C et al.| title=Immediate coronary artery bypass surgery after platelet inhibition with eptifibatide: results from PURSUIT. Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrelin Therapy. | journal=Ann Thorac Surg | year= 2000 | volume= 70 | issue= 3 | pages= 866-71; discussion 871-2 | pmid=11016325 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11016325 }} </ref> ''([[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]])'' | ||
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Revision as of 21:22, 5 November 2012
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Unstable angina / NSTEMI Microchapters |
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Differentiating Unstable Angina/Non-ST Elevation Myocardial Infarction from other Disorders |
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Special Groups |
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Diagnosis |
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Laboratory Findings |
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Treatment |
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Antitplatelet Therapy |
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Additional Management Considerations for Antiplatelet and Anticoagulant Therapy |
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Risk Stratification Before Discharge for Patients With an Ischemia-Guided Strategy of NSTE-ACS |
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Mechanical Reperfusion |
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Discharge Care |
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Case Studies |
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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]
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) (DO NOT EDIT)[1]
Additional Management of Antiplatelets and Anticoagulants (DO NOT EDIT)[1]
| 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.[2] (Level of Evidence: B) |
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a) If, after stress testing, the patient is classified as not at low risk, diagnostic angiography should be performed.[3][2] (Level of Evidence: A) |
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b) If, after stress testing, the patient is classified as being at low risk, the instructions noted below should be followed in preparation for discharge[3][2]:
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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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a) Continue ASA.[18][19][20][21][22][23][24] (Level of Evidence: A) |
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b) Discontinue clopidogrel 5 to 7 d before elective CABG.[18][22][25] (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) |
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c) Discontinue intravenous GP IIb/IIIa inhibitor (eptifibatide or tirofiban) 4 h before CABG. (Level of Evidence: B) |
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d) Anticoagulant therapy should be managed as follows:
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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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a) Continue aspirin. (Level of Evidence: A) |
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b) Administer a loading dose of a P2Y12 receptor inhibitor if not started before diagnostic angiography. (Level of Evidence: A) |
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c) 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) " |
| "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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a) Continue aspirin. (Level of Evidence: A) |
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b) Administer a loading dose of clopidogrel or ticagrelor* if not given before diagnostic angiography. (Level of Evidence: B) |
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c) Discontinue IV GP IIb/IIIa inhibitor if started previously. (Level of Evidence: B) |
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d) Anticoagulant therapy should be managed as follows:
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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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a) Continue aspirin indefinitely. (Level of Evidence: A) |
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b) Continue clopidogrel or ticagrelor* for up to 12 months. (Level of Evidence: B) |
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c) Discontinue IV GP IIb/IIIa inhibitor if started previously. (Level of Evidence: A) |
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d) 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. " |
| "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) " |
* The recommended maintenance dose of aspirin to be used with ticagrelor is 81 mg daily. The benefits of ticagrelor were observed irrespective of prior therapy with clopidogrel. When possible, discontinue ticagrelor at least 5 d before any surgery. Issues of patient compliance may be especially important. Consideration should be given to the potential and as yet undetermined risk of intracranial hemorrhage in patients with prior stroke or TIA.
** Patients weighing <60 kg have an increased exposure to the active metabolite of prasugrel and an increased risk of bleeding on a 10-mg once-daily maintenance dose. Consideration should be given to lowering the maintenance dose to 5 mg in patients who weigh <60 kg, although the effectiveness and safety of the 5-mg dose have not been studied prospectively. For post-PCI patients, a daily maintenance dose should be given for at least 12 mo for patients receiving DES and up to 12 months for patients receiving BMS unless the risk of bleeding outweighs the anticipated net benefit afforded by a P2Y12 receptor inhibitor. Do not use prasugrel in patients with active pathological bleeding or a history of TIA or stroke. In patients age ≥75 y, prasugrel is generally not recommended because of the increased risk of fatal and intracranial bleeding and uncertain benefit except in high-risk situations (patients with diabetes or a history of prior MI), in which its effect appears to be greater and its use may be considered. Do not start prasugrel in patients likely to undergo urgent CABG. When possible, discontinue prasugrel at least 7 d before any surgery. Additional risk factors for bleeding include body weight <60 kg, propensity to bleed, and concomitant use of medications that increase the risk of bleeding (eg, warfarin, heparin, fibrinolytic therapy, or chronic use of nonsteroidal anti-inflammatory drugs).
Related Chapters
References
- ↑ 1.0 1.1 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.
- ↑ 2.0 2.1 2.2 "Invasive compared with non-invasive treatment in unstable coronary-artery disease: FRISC II prospective randomised multicentre study. FRagmin and Fast Revascularisation during InStability in Coronary artery disease Investigators". Lancet. 354 (9180): 708–15. 1999. PMID 10475181.
- ↑ 3.0 3.1 Cannon CP, Weintraub WS, Demopoulos LA, Vicari R, Frey MJ, Lakkis N; et al. (2001). "Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban". N Engl J Med. 344 (25): 1879–87. doi:10.1056/NEJM200106213442501. PMID 11419424. Review in: ACP J Club. 2002 Jan-Feb;136(1):4
- ↑ Cairns JA, Gent M, Singer J, Finnie KJ, Froggatt GM, Holder DA; et al. (1985). "Aspirin, sulfinpyrazone, or both in unstable angina. Results of a Canadian multicenter trial". N Engl J Med. 313 (22): 1369–75. doi:10.1056/NEJM198511283132201. PMID 3903504.
- ↑ Lewis HD, Davis JW, Archibald DG, Steinke WE, Smitherman TC, Doherty JE; et al. (1983). "Protective effects of aspirin against acute myocardial infarction and death in men with unstable angina. Results of a Veterans Administration Cooperative Study". N Engl J Med. 309 (7): 396–403. doi:10.1056/NEJM198308183090703. PMID 6135989.
- ↑ Ridker PM, Cushman M, Stampfer MJ, Tracy RP, Hennekens CH (1997). "Inflammation, aspirin, and the risk of cardiovascular disease in apparently healthy men". N Engl J Med. 336 (14): 973–9. doi:10.1056/NEJM199704033361401. PMID 9077376.
- ↑ Wallentin L, Becker RC, Budaj A, Cannon CP, Emanuelsson H, Held C; et al. (2009). "Ticagrelor versus clopidogrel in patients with acute coronary syndromes". N Engl J Med. 361 (11): 1045–57. doi:10.1056/NEJMoa0904327. PMID 19717846. Review in: Ann Intern Med. 2009 Dec 15;151(12):JC6-4
- ↑ James SK, Roe MT, Cannon CP, Cornel JH, Horrow J, Husted S; et al. (2011). "Ticagrelor versus clopidogrel in patients with acute coronary syndromes intended for non-invasive management: substudy from prospective randomised PLATelet inhibition and patient Outcomes (PLATO) trial". BMJ. 342: d3527. doi:10.1136/bmj.d3527. PMC 3117310. PMID 21685437.
- ↑ Yusuf S, Zhao F, Mehta SR, Chrolavicius S, Tognoni G, Fox KK; et al. (2001). "Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation". N Engl J Med. 345 (7): 494–502. doi:10.1056/NEJMoa010746. PMID 11519503. Review in: ACP J Club. 2002 Mar-Apr;136(2):45
- ↑ "Inhibition of the platelet glycoprotein IIb/IIIa receptor with tirofiban in unstable angina and non-Q-wave myocardial infarction. Platelet Receptor Inhibition in Ischemic Syndrome Management in Patients Limited by Unstable Signs and Symptoms (PRISM-PLUS) Study Investigators". N Engl J Med. 338 (21): 1488–97. 1998. doi:10.1056/NEJM199805213382102. PMID 9599103.
- ↑ "Inhibition of platelet glycoprotein IIb/IIIa with eptifibatide in patients with acute coronary syndromes. The PURSUIT Trial Investigators. Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy". N Engl J Med. 339 (7): 436–43. 1998. doi:10.1056/NEJM199808133390704. PMID 9705684.
- ↑ Théroux P, Ouimet H, McCans J, Latour JG, Joly P, Lévy G; et al. (1988). "Aspirin, heparin, or both to treat acute unstable angina". N Engl J Med. 319 (17): 1105–11. doi:10.1056/NEJM198810273191701. PMID 3050522.
- ↑ Yusuf S, Wittes J, Friedman L (1988). "Overview of results of randomized clinical trials in heart disease. I. Treatments following myocardial infarction". JAMA. 260 (14): 2088–93. PMID 2901501.
- ↑ Cohen M, Demers C, Gurfinkel EP, Turpie AG, Fromell GJ, Goodman S; et al. (1997). "A comparison of low-molecular-weight heparin with unfractionated heparin for unstable coronary artery disease. Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q-Wave Coronary Events Study Group". N Engl J Med. 337 (7): 447–52. doi:10.1056/NEJM199708143370702. PMID 9250846.
- ↑ Antman EM, Cohen M, Radley D, McCabe C, Rush J, Premmereur J; et al. (1999). "Assessment of the treatment effect of enoxaparin for unstable angina/non-Q-wave myocardial infarction. TIMI 11B-ESSENCE meta-analysis". Circulation. 100 (15): 1602–8. PMID 10517730.
- ↑ Antman EM, McCabe CH, Gurfinkel EP, Turpie AG, Bernink PJ, Salein D; et al. (1999). "Enoxaparin prevents death and cardiac ischemic events in unstable angina/non-Q-wave myocardial infarction. Results of the thrombolysis in myocardial infarction (TIMI) 11B trial". Circulation. 100 (15): 1593–601. PMID 10517729.
- ↑ Mehta SR, Granger CB, Eikelboom JW, Bassand JP, Wallentin L, Faxon DP; et al. (2007). "Efficacy and safety of fondaparinux versus enoxaparin in patients with acute coronary syndromes undergoing percutaneous coronary intervention: results from the OASIS-5 trial". J Am Coll Cardiol. 50 (18): 1742–51. doi:10.1016/j.jacc.2007.07.042. PMID 17964037.
- ↑ 18.0 18.1 Bizzarri F, Scolletta S, Tucci E, Lucidi M, Davoli G, Toscano T; et al. (2001). "Perioperative use of tirofiban hydrochloride (Aggrastat) does not increase surgical bleeding after emergency or urgent coronary artery bypass grafting". J Thorac Cardiovasc Surg. 122 (6): 1181–5. doi:10.1067/mtc.2001.117838. PMID 11726894.
- ↑ Bybee KA, Powell BD, Valeti U, Rosales AG, Kopecky SL, Mullany C; et al. (2005). "Preoperative aspirin therapy is associated with improved postoperative outcomes in patients undergoing coronary artery bypass grafting". Circulation. 112 (9 Suppl): I286–92. doi:10.1161/CIRCULATIONAHA.104.522805. PMID 16159833.
- ↑ Dacey LJ, Munoz JJ, Johnson ER, Leavitt BJ, Maloney CT, Morton JR; et al. (2000). "Effect of preoperative aspirin use on mortality in coronary artery bypass grafting patients". Ann Thorac Surg. 70 (6): 1986–90. PMID 11156107.
- ↑ Goldman S, Copeland J, Moritz T, Henderson W, Zadina K, Ovitt T; et al. (1988). "Improvement in early saphenous vein graft patency after coronary artery bypass surgery with antiplatelet therapy: results of a Veterans Administration Cooperative Study". Circulation. 77 (6): 1324–32. PMID 3286040.
- ↑ 22.0 22.1 Lincoff AM, LeNarz LA, Despotis GJ, Smith PK, Booth JE, Raymond RE; et al. (2000). "Abciximab and bleeding during coronary surgery: results from the EPILOG and EPISTENT trials. Improve Long-term Outcome with abciximab GP IIb/IIIa blockade. Evaluation of Platelet IIb/IIIa Inhibition in STENTing". Ann Thorac Surg. 70 (2): 516–26. PMID 10969673.
- ↑ Mangano DT, Multicenter Study of Perioperative Ischemia Research Group (2002). "Aspirin and mortality from coronary bypass surgery". N Engl J Med. 347 (17): 1309–17. doi:10.1056/NEJMoa020798. PMID 12397188.
- ↑ Antithrombotic Trialists' Collaboration (2002). "Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients". BMJ. 324 (7329): 71–86. PMC 64503. PMID 11786451. Review in: ACP J Club. 2002 Jul-Aug;137(1):5
- ↑ Dyke CM, Bhatia D, Lorenz TJ, Marso SP, Tardiff BE, Hogeboom C; et al. (2000). "Immediate coronary artery bypass surgery after platelet inhibition with eptifibatide: results from PURSUIT. Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrelin Therapy". Ann Thorac Surg. 70 (3): 866–71, discussion 871-2. PMID 11016325.