Unstable angina non ST elevation myocardial infarction recommendations for PCI: Difference between revisions

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| [[File:Siren.gif|30px|link=Unstable angina/ NSTEMI resident survival guide]]|| <br> || <br>
| [[Unstable angina/ NSTEMI resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
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{{Unstable angina / NSTEMI}}
{{Unstable angina / NSTEMI}}
{{CMG}}; '''Associate Editors-In-Chief:''' Smita Kohli, M.D.; [[Varun Kumar]], M.B.B.S.; [[Lakshmi Gopalakrishnan]], M.B.B.S.
{{CMG}}; '''Associate Editors-In-Chief:''' Smita Kohli, M.D.; [[Varun Kumar]], M.B.B.S.; [[Lakshmi Gopalakrishnan]], M.B.B.S. Jair Basantes de la Calle, M.D.


==Overview of Recommendations for Percutaneous coronary intervention (PCI) in Unstable angina/NSTEMI==
==Overview==
*[[Coronary angiography]] is useful for defining the coronary artery anatomy in patients with [[UA]]/[[NSTEMI]] and for identifying subsets of high-risk patients who can benefit from early [[revascularization]]. The benefits of early invasive strategy have been discussed in previous section (see [[Unstable angina / non ST elevation myocardial infarction initial conservative versus initial invasive strategies | Initial Conservative Versus Initial Invasive Strategies]]) .  
[[Coronary angiography]] is useful for defining the coronary artery anatomy in patients with [[UA]]/[[NSTEMI]] and for identifying subsets of high-risk patients who can benefit from early [[revascularization]]. The benefits of early invasive strategy have been discussed in the previous section (see [[Unstable angina / non ST elevation myocardial infarction initial conservative versus initial invasive strategies]]). Coronary [[revascularization]] with either [[PCI]] or [[CABG]] helps improve prognosis, relieve symptoms, prevent [[ischemic]] complications, and improve functional capacity. In recent years, increased utilization of [[PCI]] has been noticed mainly secondary to technical advancements which have led to less complications associated with the procedure.  
*Coronary [[revascularization]] with either [[PCI]] or [[CABG]] helps improve prognosis, relieve symptoms, prevent [[ischemic]] complications, and improve functional capacity. In recent years, increased utilization of [[PCI]] has been noticed mainly secondary to technical advancements and as a result of this, less complications associated with the procedure.  
 
*[[PCI]] term refers to the whole group of percutaneous techniques, including standard [[balloon angioplasty]] ([[PTCA]]), [[intracoronary stenting]], and atheroablative technologies(like [[atherectomy]], [[thrombectomy]], or laser [[angioplasty]]). Today, majority of PCIs involve [[balloon dilation]] and [[coronary stenting]].  
The term [[PCI]] refers to the whole group of percutaneous techniques, including standard [[balloon angioplasty]] ([[PTCA]]), [[intracoronary stenting]], and atheroablative technologies (such as [[atherectomy]], [[thrombectomy]], or laser [[angioplasty]]). Today, the majority of PCIs involve balloon dilation and coronary stenting. The two main classes of [[stents]] available currently include [[bare metal stent]]s and [[drug eluting stents]]. Drug eluting stents have been demonstrated to markedly reduce the risk of [[restenosis]] compared with bare-metal stents. With the increasing use of [[GP IIb/IIIa inhibitors]], [[clopidogrel]], and/or other [[antithrombotic]] drugs in [[UA]]/[[NSTEMI]] patients, complications related to [[PCI]] have decreased dramatically, and both acute and long-term outcomes following PCI have improved with success rates as high as 95%.
*Two main classes of [[stents]] available currently include [[bare metal stent]] and [[drug eluting stents]]. Drug eluting stents have been demonstrated to markedly reduce the risk of [[restenosis]] compared with bare-metal stents.  
*With the increasing use of [[GP IIb/IIIa inhibitors]], [[clopidogrel]], and/or other [[antithrombotic]] drugs in [[UA]]/[[NSTEMI]] patients, complications related to [[PCI]] have decreased dramatically and both acute and long-term outcomes following PCI have improved with success rates as high as 95%.


==Platelet Inhibitors and PCI==
==Platelet Inhibitors and PCI==
*[[Aspirin]] is one of the oldest [[platelet inhibitors]] and has been repeatedly shown to improve outcomes in [[CAD]] patients.
*[[Aspirin]] is one of the oldest platelet inhibitors and has been shown to repeatedly improve outcomes in [[CAD]] patients.
*Thienopyridines (like [[clopidogrel]], [[prasugrel]], [[ticagrelor]]) are becoming increasingly important in [[PCI]] patients due to their benefit in reducing [[stent thrombosis]].  
*Thienopyridines (such as [[clopidogrel]], [[prasugrel]], [[ticagrelor]]) are becoming increasingly important in [[PCI]] patients due to their role in reducing [[stent thrombosis]].  
*Along with [[aspirin]], [[thienopyridines]] (i.e. either [[prasugrel]] or [[clopidogrel]]) form the '''dual antiplatelet therapy''' that are now routinely recommended before or at the time of [[PCI]].  
*Along with [[aspirin]], [[thienopyridines]] (i.e. either [[prasugrel]] or [[clopidogrel]]) form the dual antiplatelet therapy that is now routinely recommended before or at the time of [[PCI]].  
*An important advance in the treatment of patients with [[UA]]/[[NSTEMI]] who are undergoing [[PCI]] was the introduction of platelet GP IIb/IIIa receptor inhibitors(like [[abciximab]], [[tirofiban]], [[eptifibatide]]) in the 1990s. All three [[GP IIb/IIIa inhibitors]] have been shown to reduce the incidence of [[ischemic]] complications in patients with [[UA]]/[[NSTEMI]].  
*An important advancement in the treatment of patients with [[UA]]/[[NSTEMI]] undergoing [[PCI]] was the introduction of platelet GP IIb/IIIa receptor inhibitors (like [[abciximab]], [[tirofiban]], [[eptifibatide]]) in the 1990s. All three [[GP IIb/IIIa inhibitors]] have been shown to reduce the incidence of [[ischemic]] complications in patients with [[UA]]/[[NSTEMI]].  
*[[Abciximab]] is not recommended if [[PCI]] is not planned.
*[[Abciximab]] is not recommended if [[PCI]] is not planned.


===Clinical trial data:===
====Clinical Trial Data====
Multiple randomized trials have previously shown good outcomes with the use of [[GP IIb/IIIa inhibitors]] in [[UA]]/[[NSTEMI]] patients but some recent trials ave also shown that these results may be confined to high risk groups and those with [[troponin]] elevations.  
Multiple randomized trials have previously shown good outcomes with the use of [[GP IIb/IIIa inhibitors]] in [[UA]]/[[NSTEMI]] patients but some recent trials ave also shown that these results may be confined to high risk groups and those with [[troponin]] elevations.  
*'''EARLY ACS trial'''<ref name="pmid19332455">{{cite journal |author=Giugliano RP, White JA, Bode C, Armstrong PW, Montalescot G, Lewis BS, van 't Hof A, Berdan LG, Lee KL, Strony JT, Hildemann S, Veltri E, Van de Werf F, Braunwald E, Harrington RA, Califf RM, Newby LK |title=Early versus delayed, provisional eptifibatide in acute coronary syndromes |journal=[[The New England Journal of Medicine]] |volume=360 |issue=21 |pages=2176–90 |year=2009 |month=May |pmid=19332455 |doi=10.1056/NEJMoa0901316 |url=http://dx.doi.org/10.1056/NEJMoa0901316 |accessdate=2011-04-13}}</ref> revealed that in patients who had [[acute coronary syndromes]] without ST-segment elevation, the use of [[eptifibatide]] 12 hours or more before [[angiography]] was not superior to the provisional use of eptifibatide after angiography. The early use of eptifibatide was associated with an increased risk of non-life-threatening bleeding and need for transfusion.  
*''EARLY ACS trial''<ref name="pmid19332455">{{cite journal |author=Giugliano RP, White JA, Bode C, Armstrong PW, Montalescot G, Lewis BS, van 't Hof A, Berdan LG, Lee KL, Strony JT, Hildemann S, Veltri E, Van de Werf F, Braunwald E, Harrington RA, Califf RM, Newby LK |title=Early versus delayed, provisional eptifibatide in acute coronary syndromes |journal=[[The New England Journal of Medicine]] |volume=360 |issue=21 |pages=2176–90 |year=2009 |month=May |pmid=19332455 |doi=10.1056/NEJMoa0901316 |url=http://dx.doi.org/10.1056/NEJMoa0901316 |accessdate=2011-04-13}}</ref> revealed that in patients who had [[acute coronary syndromes]] without ST-segment elevation, the use of [[eptifibatide]] 12 hours or more before [[angiography]] was not superior to the provisional use of eptifibatide after angiography. The early use of eptifibatide was associated with an increased risk of non-life threatening bleeding and need for transfusion.  
*'''ISAR-REACT 2 trial'''<ref name="pmid16533938">{{cite journal |author=Kastrati A, Mehilli J, Neumann FJ, Dotzer F, ten Berg J, Bollwein H, Graf I, Ibrahim M, Pache J, Seyfarth M, Schühlen H, Dirschinger J, Berger PB, Schömig A |title=Abciximab in patients with acute coronary syndromes undergoing percutaneous coronary intervention after clopidogrel pretreatment: the ISAR-REACT 2 randomized trial |journal=[[JAMA : the Journal of the American Medical Association]] |volume=295 |issue=13 |pages=1531–8 |year=2006 |month=April |pmid=16533938 |doi=10.1001/jama.295.13.joc60034 |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=16533938 |accessdate=2011-04-13}}</ref> studied [[abciximab]] in [[NSTEMI]] patients. This was a multicenter, randomized, double-blind, placebo-controlled study enrolling 2022 patients with [[NSTEMI]] undergoing [[PCI]]. Results showed that [[abciximab]] reduces the risk of adverse events in patients with [[NSTEMI]] undergoing PCI after pretreatment with 600 mg of [[clopidogrel]]. The benefits provided by abciximab appear to be confined to patients presenting with an elevated [[troponin]] level. The benefit of [[GP IIb/IIIa inhibition]] appears greater when used in high-risk patients and in those with [[ST segment]] changes. The benefit was also seen in high risk patients with or without [[revascularization]].  
*''ISAR-REACT 2 trial''<ref name="pmid16533938">{{cite journal |author=Kastrati A, Mehilli J, Neumann FJ, Dotzer F, ten Berg J, Bollwein H, Graf I, Ibrahim M, Pache J, Seyfarth M, Schühlen H, Dirschinger J, Berger PB, Schömig A |title=Abciximab in patients with acute coronary syndromes undergoing percutaneous coronary intervention after clopidogrel pretreatment: the ISAR-REACT 2 randomized trial |journal=[[JAMA : the Journal of the American Medical Association]] |volume=295 |issue=13 |pages=1531–8 |year=2006 |month=April |pmid=16533938 |doi=10.1001/jama.295.13.joc60034 |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=16533938 |accessdate=2011-04-13}}</ref> studied [[abciximab]] in [[NSTEMI]] patients. This was a multicenter, randomized, double-blind, placebo-controlled study enrolling 2022 patients with [[NSTEMI]] undergoing [[PCI]]. Results showed that [[abciximab]] reduces the risk of adverse events in patients with [[NSTEMI]] undergoing PCI after pretreatment with 600 mg of [[clopidogrel]]. The benefits provided by abciximab appear to be confined to patients presenting with an elevated [[troponin]] level. The benefit of [[GP IIb/IIIa inhibition]] appears greater when used in high-risk patients and in those with [[ST segment]] changes. The benefit was also seen in high risk patients with or without [[revascularization]].  
*In the '''ACUITY trial'''<ref name="pmid17299194">{{cite journal |author=Stone GW, Bertrand ME, Moses JW, Ohman EM, Lincoff AM, Ware JH, Pocock SJ, McLaurin BT, Cox DA, Jafar MZ, Chandna H, Hartmann F, Leisch F, Strasser RH, Desaga M, Stuckey TD, Zelman RB, Lieber IH, Cohen DJ, Mehran R, White HD |title=Routine upstream initiation vs deferred selective use of glycoprotein IIb/IIIa inhibitors in acute coronary syndromes: the ACUITY Timing trial |journal=[[JAMA : the Journal of the American Medical Association]] |volume=297 |issue=6 |pages=591–602 |year=2007 |month=February |pmid=17299194 |doi=10.1001/jama.297.6.591 |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=17299194 |accessdate=2011-04-13}}</ref> superiority of early [[GP IIb/IIIa inhibitor]] therapy also was not found, but investigators could not exclude as much as a 29% benefit with GP IIb/IIIa therapy nor show non inferiority of delayed administration. In addition, drug exposure before [[angiography]] was much shorter (4 hours), which might substantially diminish the opportunity for differential efficacy. Despite a lack of clarity from the overall and subgroup results, an argument can be made against the routine upstream use of GP IIb/IIIa therapy in all [[NSTEMI]] patients intended for an invasive strategy. In particular, those with a normal baseline [[troponin]] level and those over the age of 75 years, in whom there was no evidence for benefit but who showed an increased risk of bleeding, might be excluded. On the other hand, high risk patients, [[diabetic]] patients and those with [[troponin]] elevation have been shown to have positive trends which go along with the results of previous trials. Although, this puts forward a debate to the routine early use of [[GP IIb/IIIa inhibitors]] in [[UA]]/[[NSTEMI]] patients, the current guidelines favor the use of [[GP IIb/IIIa inhibitors]] in patients undergoing [[PCI]].
*In the ''ACUITY trial''<ref name="pmid17299194">{{cite journal |author=Stone GW, Bertrand ME, Moses JW, Ohman EM, Lincoff AM, Ware JH, Pocock SJ, McLaurin BT, Cox DA, Jafar MZ, Chandna H, Hartmann F, Leisch F, Strasser RH, Desaga M, Stuckey TD, Zelman RB, Lieber IH, Cohen DJ, Mehran R, White HD |title=Routine upstream initiation vs deferred selective use of glycoprotein IIb/IIIa inhibitors in acute coronary syndromes: the ACUITY Timing trial |journal=[[JAMA : the Journal of the American Medical Association]] |volume=297 |issue=6 |pages=591–602 |year=2007 |month=February |pmid=17299194 |doi=10.1001/jama.297.6.591 |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=17299194 |accessdate=2011-04-13}}</ref> superiority of early [[GP IIb/IIIa inhibitor]] therapy also was not found, but investigators could not exclude as much as a 29% benefit with GP IIb/IIIa therapy nor show non inferiority of delayed administration. In addition, drug exposure before [[angiography]] was much shorter (4 hours), which might substantially diminish the opportunity for differential efficacy. Despite a lack of clarity from the overall and subgroup results, an argument can be made against the routine upstream use of GP IIb/IIIa therapy in all [[NSTEMI]] patients intended for an invasive strategy. In particular, those with a normal baseline [[troponin]] level and those over the age of 75 years, in whom there was no evidence for benefit but who showed an increased risk of bleeding, might be excluded. On the other hand, high risk patients, [[diabetic]] patients and those with [[troponin]] elevation have been shown to have positive trends which go along with the results of previous trials. Although, this puts forward a debate to the routine early use of [[GP IIb/IIIa inhibitors]] in [[UA]]/[[NSTEMI]] patients, the current guidelines favor the use of [[GP IIb/IIIa inhibitors]] in patients undergoing [[PCI]].
 
== 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Revascularization in NSTEMI ==
 
=== Coronary Angiography and Revascularization in Patients With NSTE-ACS ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''1.''' In patients with NSTE-ACS who are at elevated risk of recurrent ischemic events and are appropriate candidates for revascularization, an invasive strategy with the intent to proceed with revascularization is indicated to reduce cardiovascular events ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''2.''' In patients with NSTE-ACS and cardiogenic shock who are appropriate candidates for revascularization, emergency revascularization is recommended to reduce risk of death''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen" |<nowiki>"</nowiki>'''3.''' In appropriate patients with NSTE-ACS who have refractory angina or hemody-namic or electrical instability, an immediate invasive strategy with intent to perform revascularization is indicated to improve outcomes ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])'' <nowiki>"</nowiki>
|}
 
=== <ref name="pmid35286170">{{cite journal| author=| title=Correction to: 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. | journal=Circulation | year= 2022 | volume= 145 | issue= 11 | pages= e771 | pmid=35286170 | doi=10.1161/CIR.0000000000001061 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=35286170  }}</ref> ===
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |" 4'''.'''In patients with NSTE-ACS who are initially stabilized and are at high risk of clinical events, it is reasonable to choose an early invasive strategy (within 24 hours) over a delayed invasive strategy to improve out-comes (Level of Evidence B-R)".
|-
| bgcolor="LemonChiffon" |<nowiki>''</nowiki> 5. In patients with NSTE-ACS who are initially stabilized and are at intermediate or low risk of clinical events, an invasive strategy with intent to perform revascularization is reasonable before hospital discharge to improve outcomes (Level of Evidence B-R)<nowiki>''</nowiki>
|-
| bgcolor="LemonChiffon" | <nowiki>''</nowiki>6. In patients with NSTE-ACS who have failed PCI and have ongoing ischemia, hemodynamic compromise, or threatened occlusion of an artery with substantial myocardium at risk, who are appropriate candidates for CABG, emergency CABG is reasonable  (Level of Evidence B- NR)<nowiki>''</nowiki>
|}
<ref name="pmid35286170" />
{| class="wikitable" style="width:80%"
|-
| colspan="1" style="text-align:center; background:LightCoral" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm)
|-
| bgcolor="LightCoral" |"7'''.''' In patients with NSTE-ACS who present in cardiogenic shock, routine multivessel PCI of non-culprit lesions in the same setting should not be performe. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence:B-R]])'' <nowiki>"</nowiki>
|}
<ref name="pmid35286170" />


Also refer to the section on [[PCI]].


==2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non -ST-Elevation Myocardial Infarction (DO NOT EDIT)<ref name="pmid21444888">{{cite journal| author=Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE et al.| title=2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2011 | volume= 123 | issue= 18 | pages= e426-579 | pmid=21444888 | doi=10.1161/CIR.0b013e318212bb8b | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21444888  }} </ref>==
 
 
 
==2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes (DO NOT EDIT) <ref name=Guidelines> Ezra A. Amsterdam, MD, FACC; Nanette K. Wenger, MD et al.2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes.  A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. JACC. September 2014 (ahead of print) </ref>==
 
===Early Invasive and Ischemia-Guided Strategies===
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
 
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' An urgent/immediate invasive strategy (diagnostic angiography with intent to perform revascularization if appropriate based on [[coronary anatomy]]) is indicated in patients (men and women) with NSTE-ACS who have refractory [[angina]] or hemodynamic or electrical instability (without serious comorbidities or contraindications to such procedures). ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
 
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' An early invasive strategy (diagnostic [[angiography]] with intent to perform revascularization if appropriate based on coronary anatomy) is indicated in initially stabilized patients with NSTEACS (without serious comorbidities or contraindications to such procedures) who have an elevated risk for clinical events. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
 
{|class="wikitable"
|-
|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (No Benefit)
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' An early invasive strategy (i.e., diagnostic [[angiography]] with intent to perform revascularization) is not recommended in patients with:<br>
a. Extensive comorbidities (e.g., hepatic, renal, pulmonary failure, cancer), in whom the risks of revascularization and comorbid conditions are likely to outweigh the benefits of revascularization. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <br>
b. Acute [[chest pain]] and a low likelihood of [[ACS]] ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' who are [[troponin]] negative, especially women. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
<nowiki>"</nowiki>
|}
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' It is reasonable to choose an early invasive strategy (within 24 hours of admission) over a delayed invasive strategy (within 25 to 72 hours) for initially stabilized high-risk patients with NSTE-ACS. For those not at high/intermediate risk, a delayed invasive approach is reasonable. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' In initially stabilized patients, an ischemia-guided strategy may be considered for patients with NSTE-ACS (without serious comorbidities or contraindications to this approach) who have an elevated risk for clinical events. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' The decision to implement an [[ischemia]]-guided strategy in initially stabilized patients (without serious comorbidities or contraindications to this approach) may be reasonable after considering clinician and patient preference. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
 
===PCI—General Considerations===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' A strategy of multivessel PCI, in contrast to culprit lesion-only PCI, may be reasonable in patients undergoing coronary revascularization as part of treatment for NSTE-ACS. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
 
===PCI—Antiplatelet and Anticoagulant Therapy===
 
====Oral and Intravenous Antiplatelet Agents====
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Patients already taking daily [[aspirin]] before [[PCI]] should take 81 mg to 325 mg non–enteric-coated aspirin before [[PCI]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Patients not on aspirin therapy should be given non–enteric-coated [[aspirin]] 325 mg as soon as possible before [[PCI]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' After PCI, [[aspirin]] should be continued indefinitely at a dose of 81 mg to 325 mg daily. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''4.''' A loading dose of a P2Y12 receptor inhibitor should be given before the procedure in patients undergoing PCI with stenting. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]]) Options include: <br>
a. [[Clopidogrel]]: 600 mg ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]]) or <br>
b. [[Prasugrel]]: 60 mg ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]]) or <br>
c. [[Ticagrelor]]: 180 mg ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''5.''' In patients with NSTE-ACS and high-risk features (e.g., elevated [[troponin]]) not adequately pretreated with [[clopidogrel]] or [[ticagrelor]], it is useful to administer a GP IIb/IIIa inhibitor ([[abciximab]], double-bolus [[eptifibatide]], or high-dose bolus [[tirofiban]]) at the time of [[PCI]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''6.''' In patients receiving a stent ([[bare-metal stent]] or [[drug-eluting stent]] [DES]) during [[PCI]] for NSTEACS,
P2Y12 inhibitor therapy should be given for at least 12 months. Options include: <br>
a. [[Clopidogrel]]: 75 mg daily ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' or <br>
b. [[Prasugrel]]: 10 mg daily ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' or <br>
c. [[Ticagrelor]]: 90 mg twice daily ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
 
{|class="wikitable"
|-
|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (No Benefit)
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' [[Prasugrel]] should not be administered to patients with a prior history of [[stroke]] or [[transient ischemic attack]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' It is reasonable to choose [[ticagrelor]] over [[clopidogrel]] for P2Y12 inhibition treatment in patients with NSTE-ACS treated with an early invasive strategy and/or coronary stenting. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' It is reasonable to choose [[prasugrel]] over [[clopidogrel]] for P2Y12 treatment in patients with NSTEACS who undergo [[PCI]] who are not at high risk of [[bleeding]] complications. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' In patients with NSTE-ACS and high-risk features (e.g., elevated [[troponin]]) treated with [[UFH]] and adequately pretreated with [[clopidogrel]], it is reasonable to administer a GP IIb/IIIa inhibitor ([[abciximab]], double-bolus [[eptifibatide]], or high-bolus dose [[tirofiban]]) at the time of [[PCI]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''4.''' After [[PCI]], it is reasonable to use 81 mg per day of aspirin in preference to higher maintenance doses. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''5.''' If the risk of morbidity from bleeding outweighs the anticipated benefit of a recommended duration of P2Y12 inhibitor therapy after stent implantation, earlier discontinuation (e.g., <12 months) of P2Y12 inhibitor therapy is reasonable. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Continuation of DAPT beyond 12 months may be considered in patients undergoing stent implantation. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
 
====Anticoagulant Therapy in Patients Undergoing PCI====
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' An anticoagulant should be administered to patients with NSTE-ACS undergoing [[PCI]] to reduce the risk of intracoronary and catheter [[thrombus]] formation. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Intravenous [[UFH]] is useful in patients with NSTE-ACS undergoing [[PCI]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' [[Bivalirudin]] is useful as an anticoagulant with or without prior treatment with [[UFH]] in patients with NSTE-ACS undergoing [[PCI]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''4.''' An additional dose of 0.3 mg/kg IV enoxaparin should be administered at the time of [[PCI]] to patients with NSTE-ACS who have received fewer than 2 therapeutic subcutaneous doses (e.g., 1 mg/kg SC) or received the last subcutaneous [[enoxaparin]] dose 8 to 12 hours before [[PCI]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''5.''' If [[PCI]] is performed while the patient is on [[fondaparinux]], an additional 85 IU/kg of [[UFH]] should be given intravenously immediately before [[PCI]] because of the risk of catheter [[thrombosis]] (60 IU/kg IV if a GP IIb/IIIa inhibitor used with [[UFH]] dosing based on the target-activated clotting time). ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''6.''' In patients with NSTE-ACS, anticoagulant therapy should be discontinued after [[PCI]] unless there is a compelling reason to continue such therapy. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
 
{|class="wikitable"
|-
|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (No Benefit)
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' [[Fondaparinux]] should not be used as the sole anticoagulant to support [[PCI]] in patients with NSTEACS due to an increased risk of catheter [[thrombosis]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' In patients with NSTE-ACS undergoing [[PCI]] who are at high risk of bleeding, it is reasonable to use [[bivalirudin]] monotherapy in preference to the combination of UFH and a GP IIb/IIIa receptor antagonist. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
 
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Performance of [[PCI]] with [[enoxaparin]] may be reasonable in patients treated with upstream subcutaneous [[enoxaparin]] for NSTE-ACS. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
 
==2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non -ST-Elevation Myocardial Infarction and 2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (DO NOT EDIT)<ref name="pmid19942100">{{cite journal |author=Kushner FG, Hand M, Smith SC, King SB, Anderson JL, Antman EM, Bailey SR, Bates ER, Blankenship JC, Casey DE, Green LA, Hochman JS, Jacobs AK, Krumholz HM, Morrison DA, Ornato JP, Pearle DL, Peterson ED, Sloan MA, Whitlow PL, Williams DO |title=2009 focused updates: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction (updating the 2004 guideline and 2007 focused update) and ACC/AHA/SCAI guidelines on percutaneous coronary intervention (updating the 2005 guideline and 2007 focused update) a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines |journal=[[Journal of the American College of Cardiology]] |volume=54|issue=23|pages=2205–41 |year=2009 |month=December |pmid=19942100|doi=10.1016/j.jacc.2009.10.015|url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(09)03518-9|accessdate=2011-12-06}}</ref><ref name="pmid21444888">{{cite journal| author=Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE et al.| title=2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2011 | volume= 123 | issue= 18 | pages= e426-579 | pmid=21444888 | doi=10.1161/CIR.0b013e318212bb8b | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21444888  }} </ref><ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B |title=ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine |journal=[[Journal of the American College of Cardiology]] |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi=10.1016/j.jacc.2007.02.013 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(07)00511-6 |accessdate=2011-04-13}}</ref>==
===PCI (DO NOT EDIT)<ref name="pmid21444888">{{cite journal| author=Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE et al.| title=2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2011 | volume= 123 | issue= 18 | pages= e426-579 | pmid=21444888 | doi=10.1161/CIR.0b013e318212bb8b | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21444888  }} </ref>===
===PCI (DO NOT EDIT)<ref name="pmid21444888">{{cite journal| author=Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE et al.| title=2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2011 | volume= 123 | issue= 18 | pages= e426-579 | pmid=21444888 | doi=10.1161/CIR.0b013e318212bb8b | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21444888  }} </ref>===


Line 32: Line 217:
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
|-
| bgcolor="LightGreen"|
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' An early invasive [[PCI]] strategy is indicated for patients with [[UA]] / [[NSTEMI]] who have no serious comorbidity and who have coronary lesions amenable to [[PCI]] and any of the high risk features.<nowiki>"</nowiki>
<nowiki>"</nowiki>'''1.''' An early invasive [[PCI]] strategy is indicated for patients with [[UA]] / [[NSTEMI]] who have no serious comorbidity and who have coronary lesions amenable to [[PCI]] and any of the high risk features. <nowiki>"</nowiki>
|-
|-
| bgcolor="LightGreen"|
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' [[Percutaneous coronary intervention]] (or [[CABG]]) is recommended for [[UA]] / [[NSTEMI]] patients with 1 or 2 vessel [[CAD]] with or without significant proximal [[left anterior descending CAD]] but with a large area of viable [[myocardium]] and high risk criteria on non invasive testing. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
<nowiki>"</nowiki>'''2.''' [[Percutaneous coronary intervention]] (or [[CABG]]) is recommended for [[UA]] / [[NSTEMI]] patients with 1 or 2 vessel [[CAD]] with or without significant proximal [[left anterior descending CAD]] but with a large area of viable [[myocardium]] and high risk criteria on non invasive testing. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|-
|-
| bgcolor="LightGreen"|
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' [[Percutaneous coronary intervention]] (or [[CABG]]) is recommended for [[UA]]/[[NSTEMI]] patients with multi vessel coronary disease with suitable coronary anatomy, with normal [[LV function]], and without [[diabetes mellitus]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
<nowiki>"</nowiki>'''3.''' [[Percutaneous coronary intervention]] (or [[CABG]]) is recommended for [[UA]]/[[NSTEMI]] patients with multi vessel coronary disease with suitable coronary anatomy, with normal [[LV function]], and without [[diabetes mellitus]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' <nowiki>"</nowiki>
|-
|-
| bgcolor="LightGreen"|
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''4.''' An intravenous platelet [[GP IIb/IIIa inhibitor]] is generally recommended in [[UA]]/[[NSTEMI]] patients undergoing [[PCI]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
<nowiki>"</nowiki>'''4.''' An intravenous platelet [[GP IIb/IIIa inhibitor]] is generally recommended in [[UA]]/[[NSTEMI]] patients undergoing [[PCI]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|}
|}


Line 49: Line 230:
|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]
|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]
|-
|-
|bgcolor="LightCoral"|
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' [[Percutaneous coronary intervention]] (or [[CABG]]) is not recommended for patients with 1 or 2 vessel [[CAD]] without significant proximal [[left anterior descending CAD]] with no current symptoms or symptoms that are unlikely to be due to [[myocardial ischemia]] and who have no [[ischemia]] on noninvasive testing. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
<nowiki>"</nowiki>'''1.''' [[Percutaneous coronary intervention]] (or [[CABG]]) is not recommended for patients with 1 or 2 vessel [[CAD]] without significant proximal [[left anterior descending CAD]] with no current symptoms or symptoms that are unlikely to be due to [[myocardial ischemia]] and who have no [[ischemia]] on noninvasive testing. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''2.''' In the absence of high risk features associated with [[UA]] / [[NSTEMI]], [[PCI]] is not recommended for patients with [[UA]] / [[NSTEMI]] who have single vessel or multi vessel [[CAD]] and no trial of medical therapy, or who have one or more of the following:
|-
| bgcolor="LightCoral"|'''a)''' Only a small area of [[myocardium]] at risk. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
|-
| bgcolor="LightCoral"|'''b)''' All lesions or the culprit lesion to be dilated with morphology that conveys a low likelihood of success. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
|-
| bgcolor="LightCoral"|'''c)''' A high risk of procedure related [[morbidity]] or [[mortality]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
|-
| bgcolor="LightCoral"|'''d)''' Insignificant disease (<50% coronary [[stenosis]]). ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
|-
|-
|bgcolor="LightCoral"|
| bgcolor="LightCoral"|'''e)''' Significant [[left main CAD]] and candidacy for [[CABG]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
<nowiki>"</nowiki>'''2.''' In the absence of high risk features associated with [[UA]] / [[NSTEMI]], [[PCI]] is not recommended for patients with [[UA]] / [[NSTEMI]] who have single vessel or multi vessel [[CAD]] and no trial of medical therapy, or who have one or more of the following:
 
:a) Only a small area of [[myocardium]] at risk. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
:b) All lesions or the culprit lesion to be dilated with morphology that conveys a low likelihood of success. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
:c) A high risk of procedure related [[morbidity]] or [[mortality]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
:d) Insignificant disease (<50% coronary [[stenosis]]). ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''
:e) Significant [[left main CAD]] and candidacy for [[CABG]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
|-
|bgcolor="LightCoral"|
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''3.''' A [[PCI]] strategy in stable patients with persistently occluded [[infarct related coronary arteries]] after [[NSTEMI]] is not indicated. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
<nowiki>"</nowiki>'''3.''' A [[PCI]] strategy in stable patients with persistently occluded [[infarct related coronary arteries]] after [[NSTEMI]] is not indicated. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
|}


Line 69: Line 251:
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|-
|bgcolor="LemonChiffon"|
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' [[Percutaneous coronary intervention]] is reasonable for focal saphenous vein graft ([[SVG]]) lesions or multiple stenosis in [[UA]] / [[NSTEMI]] patients who are undergoing medical therapy and who are poor candidates for reoperative surgery. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
<nowiki>"</nowiki>'''1.''' [[Percutaneous coronary intervention]] is reasonable for focal saphenous vein graft ([[SVG]]) lesions or multiple stenosis in [[UA]] / [[NSTEMI]] patients who are undergoing medical therapy and who are poor candidates for reoperative surgery. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|-
|-
|bgcolor="LemonChiffon"|
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' [[Percutaneous coronary intervention]] (or [[CABG]]) is reasonable for [[UA]] / [[NSTEMI]] patients with 1 or 2 vessel [[CAD]] with or without significant proximal [[left anterior descending CAD]] but with a moderate area of viable [[myocardium]] and [[ischemia]] on noninvasive testing. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
<nowiki>"</nowiki>'''2.''' [[Percutaneous coronary intervention]] (or [[CABG]]) is reasonable for [[UA]] / [[NSTEMI]] patients with 1 or 2 vessel [[CAD]] with or without significant proximal [[left anterior descending CAD]] but with a moderate area of viable [[myocardium]] and [[ischemia]] on noninvasive testing. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|-
|-
|bgcolor="LemonChiffon"|
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' [[Percutaneous coronary intervention]] (or [[CABG]]) can be beneficial compared with medical therapy for [[UA]] / [[NSTEMI]] patients with 1 vessel disease with significant proximal [[left anterior descending CAD]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
<nowiki>"</nowiki>'''3.''' [[Percutaneous coronary intervention]] (or [[CABG]]) can be beneficial compared with medical therapy for [[UA]] / [[NSTEMI]] patients with 1 vessel disease with significant proximal [[left anterior descending CAD]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|-
|-
|bgcolor="LemonChiffon"|
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''4.''' Use of [[PCI]] is reasonable in patients with [[UA]] / [[NSTEMI]] with significant [[left main CAD]] (>50% diameter [[stenosis]]) who are candidates for [[revascularization]] but are not eligible for [[CABG]] or who require emergent intervention at [[angiography]] for hemodynamic instability. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
<nowiki>"</nowiki>'''4.''' Use of [[PCI]] is reasonable in patients with [[UA]] / [[NSTEMI]] with significant [[left main CAD]] (>50% diameter [[stenosis]]) who are candidates for [[revascularization]] but are not eligible for [[CABG]] or who require emergent intervention at [[angiography]] for hemodynamic instability. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
|}


Line 86: Line 264:
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|-
|bgcolor="LemonChiffon"|
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' In the absence of high-risk features associated with [[UA]] / [[NSTEMI]], [[PCI]] may be considered in patients with [[CAD|single-vessel]] or [[CAD|multi vessel CAD]] who are undergoing medical therapy and who have 1 or more lesions to be dilated with a reduced likelihood of success. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
<nowiki>"</nowiki>'''1.''' In the absence of high-risk features associated with [[UA]] / [[NSTEMI]], [[PCI]] may be considered in patients with [[CAD|single-vessel]] or [[CAD|multi vessel CAD]] who are undergoing medical therapy and who have 1 or more lesions to be dilated with a reduced likelihood of success. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
|-
|bgcolor="LemonChiffon"|
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' [[Percutaneous coronary intervention]] may be considered for [[UA]] / [[NSTEMI]] patients who are undergoing medical therapy who have 2 or 3 vessel disease, significant proximal [[left anterior descending CAD]], and treated [[diabetes]] or abnormal [[LV function]], with anatomy suitable for catheter based therapy. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
<nowiki>"</nowiki>'''2.''' [[Percutaneous coronary intervention]] may be considered for [[UA]] / [[NSTEMI]] patients who are undergoing medical therapy who have 2 or 3 vessel disease, significant proximal [[left anterior descending CAD]], and treated [[diabetes]] or abnormal [[LV function]], with anatomy suitable for catheter based therapy. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
|}


==2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (Updating the 2004 Guideline and 2007 Focused Update) - Timing of Angiography and Antiplatelet Therapy in UA/NSTEMI<ref name="pmid19942100">{{cite journal |author=Kushner FG, Hand M, Smith SC, King SB, Anderson JL, Antman EM, Bailey SR, Bates ER, Blankenship JC, Casey DE, Green LA, Hochman JS, Jacobs AK, Krumholz HM, Morrison DA, Ornato JP, Pearle DL, Peterson ED, Sloan MA, Whitlow PL, Williams DO |title=2009 focused updates: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction (updating the 2004 guideline and 2007 focused update) and ACC/AHA/SCAI guidelines on percutaneous coronary intervention (updating the 2005 guideline and 2007 focused update) a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines |journal=[[Journal of the American College of Cardiology]] |volume=54|issue=23|pages=2205–41 |year=2009 |month=December |pmid=19942100|doi=10.1016/j.jacc.2009.10.015|url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(09)03518-9|accessdate=2011-12-06}}</ref> (DO NOT EDIT)==
===Timing of Angiography and Antiplatelet Therapy in UA/NSTEMI (DO NOT EDIT)<ref name="pmid19942100">{{cite journal |author=Kushner FG, Hand M, Smith SC, King SB, Anderson JL, Antman EM, Bailey SR, Bates ER, Blankenship JC, Casey DE, Green LA, Hochman JS, Jacobs AK, Krumholz HM, Morrison DA, Ornato JP, Pearle DL, Peterson ED, Sloan MA, Whitlow PL, Williams DO |title=2009 focused updates: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction (updating the 2004 guideline and 2007 focused update) and ACC/AHA/SCAI guidelines on percutaneous coronary intervention (updating the 2005 guideline and 2007 focused update) a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines |journal=[[Journal of the American College of Cardiology]]|volume=54|issue=23|pages=2205–41 |year=2009 |month=December|pmid=19942100|doi=10.1016/j.jacc.2009.10.015|url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(09)03518-9|accessdate=2011-12-06}}</ref>===


{|class="wikitable"
{|class="wikitable"
Line 108: Line 284:
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' It is reasonable for initially stabilized high-risk patients with [[UA]]/[[NSTEMI]] ([[GRACE risk score]] greater than 140) to undergo an early invasive strategy within 12 to 24 hours of admission. For patients not at high risk, an early invasive approach is also reasonable. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' It is reasonable for initially stabilized high-risk patients with [[UA]]/[[NSTEMI]] ([[GRACE risk score]] greater than 140) to undergo an early invasive strategy within 12 to 24 hours of admission. For patients not at high risk, an early invasive approach is also reasonable. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
|}
==See Also==
* [[The Living Guidelines: UA/NSTEMI | 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 <ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B |title=ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine |journal=[[Journal of the American College of Cardiology]] |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi=10.1016/j.jacc.2007.02.013 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(07)00511-6 |accessdate=2011-04-13}}</ref>
*The ACC/AHA 2009 Guidelines for STEMI and PCI: Focused updates<ref>[http://content.onlinejacc.org/cgi/content/full/j.jacc.2009.10.015]</ref>


==References==
==References==
{{reflist|2}}
{{Reflist|2}}
{{WH}}
{{WS}}


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Latest revision as of 18:49, 5 December 2022
Resident
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Unstable angina non ST elevation myocardial infarction recommendations for PCI On the Web

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Risk calculators and risk factors for Unstable angina non ST elevation myocardial infarction recommendations for PCI

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-In-Chief: Smita Kohli, M.D.; Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S. Jair Basantes de la Calle, M.D.

Overview

Coronary angiography is useful for defining the coronary artery anatomy in patients with UA/NSTEMI and for identifying subsets of high-risk patients who can benefit from early revascularization. The benefits of early invasive strategy have been discussed in the previous section (see Unstable angina / non ST elevation myocardial infarction initial conservative versus initial invasive strategies). Coronary revascularization with either PCI or CABG helps improve prognosis, relieve symptoms, prevent ischemic complications, and improve functional capacity. In recent years, increased utilization of PCI has been noticed mainly secondary to technical advancements which have led to less complications associated with the procedure.

The term PCI refers to the whole group of percutaneous techniques, including standard balloon angioplasty (PTCA), intracoronary stenting, and atheroablative technologies (such as atherectomy, thrombectomy, or laser angioplasty). Today, the majority of PCIs involve balloon dilation and coronary stenting. The two main classes of stents available currently include bare metal stents and drug eluting stents. Drug eluting stents have been demonstrated to markedly reduce the risk of restenosis compared with bare-metal stents. With the increasing use of GP IIb/IIIa inhibitors, clopidogrel, and/or other antithrombotic drugs in UA/NSTEMI patients, complications related to PCI have decreased dramatically, and both acute and long-term outcomes following PCI have improved with success rates as high as 95%.

Platelet Inhibitors and PCI

Clinical Trial Data

Multiple randomized trials have previously shown good outcomes with the use of GP IIb/IIIa inhibitors in UA/NSTEMI patients but some recent trials ave also shown that these results may be confined to high risk groups and those with troponin elevations.

  • EARLY ACS trial[1] revealed that in patients who had acute coronary syndromes without ST-segment elevation, the use of eptifibatide 12 hours or more before angiography was not superior to the provisional use of eptifibatide after angiography. The early use of eptifibatide was associated with an increased risk of non-life threatening bleeding and need for transfusion.
  • ISAR-REACT 2 trial[2] studied abciximab in NSTEMI patients. This was a multicenter, randomized, double-blind, placebo-controlled study enrolling 2022 patients with NSTEMI undergoing PCI. Results showed that abciximab reduces the risk of adverse events in patients with NSTEMI undergoing PCI after pretreatment with 600 mg of clopidogrel. The benefits provided by abciximab appear to be confined to patients presenting with an elevated troponin level. The benefit of GP IIb/IIIa inhibition appears greater when used in high-risk patients and in those with ST segment changes. The benefit was also seen in high risk patients with or without revascularization.
  • In the ACUITY trial[3] superiority of early GP IIb/IIIa inhibitor therapy also was not found, but investigators could not exclude as much as a 29% benefit with GP IIb/IIIa therapy nor show non inferiority of delayed administration. In addition, drug exposure before angiography was much shorter (4 hours), which might substantially diminish the opportunity for differential efficacy. Despite a lack of clarity from the overall and subgroup results, an argument can be made against the routine upstream use of GP IIb/IIIa therapy in all NSTEMI patients intended for an invasive strategy. In particular, those with a normal baseline troponin level and those over the age of 75 years, in whom there was no evidence for benefit but who showed an increased risk of bleeding, might be excluded. On the other hand, high risk patients, diabetic patients and those with troponin elevation have been shown to have positive trends which go along with the results of previous trials. Although, this puts forward a debate to the routine early use of GP IIb/IIIa inhibitors in UA/NSTEMI patients, the current guidelines favor the use of GP IIb/IIIa inhibitors in patients undergoing PCI.

2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Revascularization in NSTEMI

Coronary Angiography and Revascularization in Patients With NSTE-ACS

Class I
"1. In patients with NSTE-ACS who are at elevated risk of recurrent ischemic events and are appropriate candidates for revascularization, an invasive strategy with the intent to proceed with revascularization is indicated to reduce cardiovascular events (Level of Evidence: A) "
"2. In patients with NSTE-ACS and cardiogenic shock who are appropriate candidates for revascularization, emergency revascularization is recommended to reduce risk of death(Level of Evidence: B-R) "
"3. In appropriate patients with NSTE-ACS who have refractory angina or hemody-namic or electrical instability, an immediate invasive strategy with intent to perform revascularization is indicated to improve outcomes (Level of Evidence: C-LD) "

[4]

Class IIa
" 4.In patients with NSTE-ACS who are initially stabilized and are at high risk of clinical events, it is reasonable to choose an early invasive strategy (within 24 hours) over a delayed invasive strategy to improve out-comes (Level of Evidence B-R)".
'' 5. In patients with NSTE-ACS who are initially stabilized and are at intermediate or low risk of clinical events, an invasive strategy with intent to perform revascularization is reasonable before hospital discharge to improve outcomes (Level of Evidence B-R)''
''6. In patients with NSTE-ACS who have failed PCI and have ongoing ischemia, hemodynamic compromise, or threatened occlusion of an artery with substantial myocardium at risk, who are appropriate candidates for CABG, emergency CABG is reasonable (Level of Evidence B- NR)''

[4]

Class III (Harm)
"7. In patients with NSTE-ACS who present in cardiogenic shock, routine multivessel PCI of non-culprit lesions in the same setting should not be performe. (Level of Evidence:B-R) "

[4]



2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes (DO NOT EDIT) [5]

Early Invasive and Ischemia-Guided Strategies

Class I
"1. An urgent/immediate invasive strategy (diagnostic angiography with intent to perform revascularization if appropriate based on coronary anatomy) is indicated in patients (men and women) with NSTE-ACS who have refractory angina or hemodynamic or electrical instability (without serious comorbidities or contraindications to such procedures). (Level of Evidence: A)"
"2. An early invasive strategy (diagnostic angiography with intent to perform revascularization if appropriate based on coronary anatomy) is indicated in initially stabilized patients with NSTEACS (without serious comorbidities or contraindications to such procedures) who have an elevated risk for clinical events. (Level of Evidence: B)"
Class III (No Benefit)
"1. An early invasive strategy (i.e., diagnostic angiography with intent to perform revascularization) is not recommended in patients with:

a. Extensive comorbidities (e.g., hepatic, renal, pulmonary failure, cancer), in whom the risks of revascularization and comorbid conditions are likely to outweigh the benefits of revascularization. (Level of Evidence: C)
b. Acute chest pain and a low likelihood of ACS (Level of Evidence: C) who are troponin negative, especially women. (Level of Evidence: B) "

Class IIa
"1. It is reasonable to choose an early invasive strategy (within 24 hours of admission) over a delayed invasive strategy (within 25 to 72 hours) for initially stabilized high-risk patients with NSTE-ACS. For those not at high/intermediate risk, a delayed invasive approach is reasonable. (Level of Evidence: B)"
Class IIb
"1. In initially stabilized patients, an ischemia-guided strategy may be considered for patients with NSTE-ACS (without serious comorbidities or contraindications to this approach) who have an elevated risk for clinical events. (Level of Evidence: B)"
"2. The decision to implement an ischemia-guided strategy in initially stabilized patients (without serious comorbidities or contraindications to this approach) may be reasonable after considering clinician and patient preference. (Level of Evidence: C)"

PCI—General Considerations

Class IIb
"1. A strategy of multivessel PCI, in contrast to culprit lesion-only PCI, may be reasonable in patients undergoing coronary revascularization as part of treatment for NSTE-ACS. (Level of Evidence: B)"

PCI—Antiplatelet and Anticoagulant Therapy

Oral and Intravenous Antiplatelet Agents

Class I
"1. Patients already taking daily aspirin before PCI should take 81 mg to 325 mg non–enteric-coated aspirin before PCI. (Level of Evidence: B)"
"2. Patients not on aspirin therapy should be given non–enteric-coated aspirin 325 mg as soon as possible before PCI. (Level of Evidence: B)"
"3. After PCI, aspirin should be continued indefinitely at a dose of 81 mg to 325 mg daily. (Level of Evidence: B)"
"4. A loading dose of a P2Y12 receptor inhibitor should be given before the procedure in patients undergoing PCI with stenting. (Level of Evidence: A) Options include:

a. Clopidogrel: 600 mg (Level of Evidence: B) or
b. Prasugrel: 60 mg (Level of Evidence: B) or
c. Ticagrelor: 180 mg (Level of Evidence: B)"

"5. In patients with NSTE-ACS and high-risk features (e.g., elevated troponin) not adequately pretreated with clopidogrel or ticagrelor, it is useful to administer a GP IIb/IIIa inhibitor (abciximab, double-bolus eptifibatide, or high-dose bolus tirofiban) at the time of PCI. (Level of Evidence: A)"
"6. In patients receiving a stent (bare-metal stent or drug-eluting stent [DES]) during PCI for NSTEACS,

P2Y12 inhibitor therapy should be given for at least 12 months. Options include:
a. Clopidogrel: 75 mg daily (Level of Evidence: B) or
b. Prasugrel: 10 mg daily (Level of Evidence: B) or
c. Ticagrelor: 90 mg twice daily (Level of Evidence: B)"

Class III (No Benefit)
"1. Prasugrel should not be administered to patients with a prior history of stroke or transient ischemic attack. (Level of Evidence: B)"
Class IIa
"1. It is reasonable to choose ticagrelor over clopidogrel for P2Y12 inhibition treatment in patients with NSTE-ACS treated with an early invasive strategy and/or coronary stenting. (Level of Evidence: B)"
"2. It is reasonable to choose prasugrel over clopidogrel for P2Y12 treatment in patients with NSTEACS who undergo PCI who are not at high risk of bleeding complications. (Level of Evidence: B)"
"3. In patients with NSTE-ACS and high-risk features (e.g., elevated troponin) treated with UFH and adequately pretreated with clopidogrel, it is reasonable to administer a GP IIb/IIIa inhibitor (abciximab, double-bolus eptifibatide, or high-bolus dose tirofiban) at the time of PCI. (Level of Evidence: B)"
"4. After PCI, it is reasonable to use 81 mg per day of aspirin in preference to higher maintenance doses. (Level of Evidence: B)"
"5. If the risk of morbidity from bleeding outweighs the anticipated benefit of a recommended duration of P2Y12 inhibitor therapy after stent implantation, earlier discontinuation (e.g., <12 months) of P2Y12 inhibitor therapy is reasonable. (Level of Evidence: C)"
Class IIb
"1. Continuation of DAPT beyond 12 months may be considered in patients undergoing stent implantation. (Level of Evidence: C)"

Anticoagulant Therapy in Patients Undergoing PCI

Class I
"1. An anticoagulant should be administered to patients with NSTE-ACS undergoing PCI to reduce the risk of intracoronary and catheter thrombus formation. (Level of Evidence: C)"
"2. Intravenous UFH is useful in patients with NSTE-ACS undergoing PCI. (Level of Evidence: C)"
"3. Bivalirudin is useful as an anticoagulant with or without prior treatment with UFH in patients with NSTE-ACS undergoing PCI. (Level of Evidence: B)"
"4. An additional dose of 0.3 mg/kg IV enoxaparin should be administered at the time of PCI to patients with NSTE-ACS who have received fewer than 2 therapeutic subcutaneous doses (e.g., 1 mg/kg SC) or received the last subcutaneous enoxaparin dose 8 to 12 hours before PCI. (Level of Evidence: B)"
"5. If PCI is performed while the patient is on fondaparinux, an additional 85 IU/kg of UFH should be given intravenously immediately before PCI because of the risk of catheter thrombosis (60 IU/kg IV if a GP IIb/IIIa inhibitor used with UFH dosing based on the target-activated clotting time). (Level of Evidence: B)"
"6. In patients with NSTE-ACS, anticoagulant therapy should be discontinued after PCI unless there is a compelling reason to continue such therapy. (Level of Evidence: C)"
Class III (No Benefit)
"1. Fondaparinux should not be used as the sole anticoagulant to support PCI in patients with NSTEACS due to an increased risk of catheter thrombosis. (Level of Evidence: B)"
Class IIa
"1. In patients with NSTE-ACS undergoing PCI who are at high risk of bleeding, it is reasonable to use bivalirudin monotherapy in preference to the combination of UFH and a GP IIb/IIIa receptor antagonist. (Level of Evidence: B)"
Class IIb
"1. Performance of PCI with enoxaparin may be reasonable in patients treated with upstream subcutaneous enoxaparin for NSTE-ACS. (Level of Evidence: B)"

2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non -ST-Elevation Myocardial Infarction and 2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (DO NOT EDIT)[6][7][8]

PCI (DO NOT EDIT)[7]

Class I
"1. An early invasive PCI strategy is indicated for patients with UA / NSTEMI who have no serious comorbidity and who have coronary lesions amenable to PCI and any of the high risk features."
"2. Percutaneous coronary intervention (or CABG) is recommended for UA / NSTEMI patients with 1 or 2 vessel CAD with or without significant proximal left anterior descending CAD but with a large area of viable myocardium and high risk criteria on non invasive testing. (Level of Evidence: B)"
"3. Percutaneous coronary intervention (or CABG) is recommended for UA/NSTEMI patients with multi vessel coronary disease with suitable coronary anatomy, with normal LV function, and without diabetes mellitus. (Level of Evidence: A)"
"4. An intravenous platelet GP IIb/IIIa inhibitor is generally recommended in UA/NSTEMI patients undergoing PCI. (Level of Evidence: A)"
Class III
"1. Percutaneous coronary intervention (or CABG) is not recommended for patients with 1 or 2 vessel CAD without significant proximal left anterior descending CAD with no current symptoms or symptoms that are unlikely to be due to myocardial ischemia and who have no ischemia on noninvasive testing. (Level of Evidence: C)"
"2. In the absence of high risk features associated with UA / NSTEMI, PCI is not recommended for patients with UA / NSTEMI who have single vessel or multi vessel CAD and no trial of medical therapy, or who have one or more of the following:
a) Only a small area of myocardium at risk. (Level of Evidence: C)
b) All lesions or the culprit lesion to be dilated with morphology that conveys a low likelihood of success. (Level of Evidence: C)
c) A high risk of procedure related morbidity or mortality. (Level of Evidence: C)
d) Insignificant disease (<50% coronary stenosis). (Level of Evidence: C)
e) Significant left main CAD and candidacy for CABG. (Level of Evidence: B)"
"3. A PCI strategy in stable patients with persistently occluded infarct related coronary arteries after NSTEMI is not indicated. (Level of Evidence: B)"
Class IIa
"1. Percutaneous coronary intervention is reasonable for focal saphenous vein graft (SVG) lesions or multiple stenosis in UA / NSTEMI patients who are undergoing medical therapy and who are poor candidates for reoperative surgery. (Level of Evidence: C)"
"2. Percutaneous coronary intervention (or CABG) is reasonable for UA / NSTEMI patients with 1 or 2 vessel CAD with or without significant proximal left anterior descending CAD but with a moderate area of viable myocardium and ischemia on noninvasive testing. (Level of Evidence: B)"
"3. Percutaneous coronary intervention (or CABG) can be beneficial compared with medical therapy for UA / NSTEMI patients with 1 vessel disease with significant proximal left anterior descending CAD. (Level of Evidence: B)"
"4. Use of PCI is reasonable in patients with UA / NSTEMI with significant left main CAD (>50% diameter stenosis) who are candidates for revascularization but are not eligible for CABG or who require emergent intervention at angiography for hemodynamic instability. (Level of Evidence: B)"
Class IIb
"1. In the absence of high-risk features associated with UA / NSTEMI, PCI may be considered in patients with single-vessel or multi vessel CAD who are undergoing medical therapy and who have 1 or more lesions to be dilated with a reduced likelihood of success. (Level of Evidence: B)"
"2. Percutaneous coronary intervention may be considered for UA / NSTEMI patients who are undergoing medical therapy who have 2 or 3 vessel disease, significant proximal left anterior descending CAD, and treated diabetes or abnormal LV function, with anatomy suitable for catheter based therapy. (Level of Evidence: B)"

Timing of Angiography and Antiplatelet Therapy in UA/NSTEMI (DO NOT EDIT)[6]

Class I
"1. Patients with definite or likely UA/NSTEMI selected for an invasive approach should receive dual antiplatelet therapy (Level of Evidence: A). Aspirin should be initiated on presentation (Level of Evidence: A), clopidogrel (before or at the time of PCI) (Level of Evidence: A) or prasugrel (at the time of PCI) (Level of Evidence: B) is recommended as a second antiplatelet agent."
Class IIa
"1. It is reasonable for initially stabilized high-risk patients with UA/NSTEMI (GRACE risk score greater than 140) to undergo an early invasive strategy within 12 to 24 hours of admission. For patients not at high risk, an early invasive approach is also reasonable. (Level of Evidence: B)"

References

  1. ↑ Giugliano RP, White JA, Bode C, Armstrong PW, Montalescot G, Lewis BS, van 't Hof A, Berdan LG, Lee KL, Strony JT, Hildemann S, Veltri E, Van de Werf F, Braunwald E, Harrington RA, Califf RM, Newby LK (2009). "Early versus delayed, provisional eptifibatide in acute coronary syndromes". The New England Journal of Medicine. 360 (21): 2176–90. doi:10.1056/NEJMoa0901316. PMID 19332455. Retrieved 2011-04-13. Unknown parameter |month= ignored (help)
  2. ↑ Kastrati A, Mehilli J, Neumann FJ, Dotzer F, ten Berg J, Bollwein H, Graf I, Ibrahim M, Pache J, Seyfarth M, Schühlen H, Dirschinger J, Berger PB, Schömig A (2006). "Abciximab in patients with acute coronary syndromes undergoing percutaneous coronary intervention after clopidogrel pretreatment: the ISAR-REACT 2 randomized trial". JAMA : the Journal of the American Medical Association. 295 (13): 1531–8. doi:10.1001/jama.295.13.joc60034. PMID 16533938. Retrieved 2011-04-13. Unknown parameter |month= ignored (help)
  3. ↑ Stone GW, Bertrand ME, Moses JW, Ohman EM, Lincoff AM, Ware JH, Pocock SJ, McLaurin BT, Cox DA, Jafar MZ, Chandna H, Hartmann F, Leisch F, Strasser RH, Desaga M, Stuckey TD, Zelman RB, Lieber IH, Cohen DJ, Mehran R, White HD (2007). "Routine upstream initiation vs deferred selective use of glycoprotein IIb/IIIa inhibitors in acute coronary syndromes: the ACUITY Timing trial". JAMA : the Journal of the American Medical Association. 297 (6): 591–602. doi:10.1001/jama.297.6.591. PMID 17299194. Retrieved 2011-04-13. Unknown parameter |month= ignored (help)
  4. ↑ 4.0 4.1 4.2 "Correction to: 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 145 (11): e771. 2022. doi:10.1161/CIR.0000000000001061. PMID 35286170 Check |pmid= value (help).
  5. ↑ Ezra A. Amsterdam, MD, FACC; Nanette K. Wenger, MD et al.2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. JACC. September 2014 (ahead of print)
  6. ↑ 6.0 6.1 Kushner FG, Hand M, Smith SC, King SB, Anderson JL, Antman EM, Bailey SR, Bates ER, Blankenship JC, Casey DE, Green LA, Hochman JS, Jacobs AK, Krumholz HM, Morrison DA, Ornato JP, Pearle DL, Peterson ED, Sloan MA, Whitlow PL, Williams DO (2009). "2009 focused updates: ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction (updating the 2004 guideline and 2007 focused update) and ACC/AHA/SCAI guidelines on percutaneous coronary intervention (updating the 2005 guideline and 2007 focused update) a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". Journal of the American College of Cardiology. 54 (23): 2205–41. doi:10.1016/j.jacc.2009.10.015. PMID 19942100. Retrieved 2011-12-06. Unknown parameter |month= ignored (help)
  7. ↑ 7.0 7.1 Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE; et al. (2011). "2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". Circulation. 123 (18): e426–579. doi:10.1161/CIR.0b013e318212bb8b. PMID 21444888.
  8. ↑ Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B (2007). "ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine". Journal of the American College of Cardiology. 50 (7): e1–e157. doi:10.1016/j.jacc.2007.02.013. PMID 17692738. Retrieved 2011-04-13. Unknown parameter |month= ignored (help)

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