Unstable Angina / Non ST Elevation Myocardial Infarction: Treatment
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Any recommendations found on these pages are for education use only. wiki doc is not a substitute for a licensed healthcare provider. Please see the disclaimers page for important information regarding limitations of the information found here. In recommending therapies, wiki doc suggests that the following classification scheme be used. This is the classification scheme used by the ACC / AHA Guidelines Committee. Use the Class designation to indicate whether the therapy is recommended or not and the certainty surrounding that recommendation. Use the Level of Evidence designation to indicate the strength of the data associated with that recommendation.
Classification of Recommendations
- Class I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is beneficial, useful, and effective.
- Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment.
- Class IIa: Weight of evidence/opinion is in favor of usefulness/efficacy.
- Class IIb: Usefulness/efficacy is less well established by evidence/opinion.
- Class III: Conditions for which there is evidence and/or general agreement that a procedure/treatment is not useful/effective and in some cases may be harmful.
Level of Evidence
- Level of Evidence A: Data derived from multiple randomized clinical trials or meta-analyses.
- Level of Evidence B: Data derived from a single randomized trial, or nonrandomized studies.
- Level of Evidence C: Only consensus opinion of experts,case studies, or standard-of-care.
wiki doc cites here the ACC / AHA Guidelines Based Therapy for ST Elevation MI. DO NOT EDIT THESE GUIDELINES. You can make comments regarding the guidelines in the discussion section.
Pharmacotherapy
Acute Pharmacotherapies
Recommendations for Antiplatelet Therapy Guidelines: Do not edit
- CLASS I
1. Aspirin should be administered to UA/NSTEMI patients as soon as possible after hospital presentation and continued indefinitely in patients not known to be intolerant of that medication. (Level of Evidence: A)
2. Clopidogrel (loading dose followed by daily maintenance dose)* should be administered to UA/NSTEMI patients who are unable to take ASA because of hypersensitivity or major gastrointestinal intolerance. (Level of Evidence: A)
3. In UA/NSTEMI patients with a history of gastrointestinal bleeding, when ASA and clopidogrel are administered alone or in combination, drugs to minimize the risk of recurrent gastrointestinal bleeding (e.g., proton-pump inhibitors) should be prescribed concomitantly. (Level of Evidence: B)
4. For UA/NSTEMI patients in whom an initial invasive strategy is selected, antiplatelet therapy in addition to aspirin should be initiated before diagnostic angiography (upstream) with either clopidogrel (loading dose followed by daily maintenance dose)* or an intravenous GP IIb/IIIa inhibitor. (Level of Evidence: A) Abciximab as the choice for upstream GP IIb/IIIa therapy is indicated only if there is no appreciable delay to angiography and PCI is likely to be performed; otherwise, IV eptifibatide or tirofiban is the preferred choice of GP IIb/IIIa inhibitor. (Level of Evidence: B)
5. For UA/NSTEMI patients in whom an initial conservative (i.e., noninvasive) strategy is selected (see Section 3.3), clopidogrel (loading dose followed by daily maintenance dose)* should be added to ASA and anticoagulant therapy as soon as possible after admission and administered for at least 1 month (Level of Evidence: A) and ideally up to 1 year. (Level of Evidence: B)
6. For UA/NSTEMI patients in whom an initial conservative strategy is selected, if recurrent symptoms/ischemia, HF, or serious arrhythmias subsequently appear, then diagnostic angiography should be performed. (Level of Evidence: A) Either an intravenous GP IIb/IIIa inhibitor (eptifibatide or tirofiban; Level of Evidence: A) or clopidogrel (loading dose followed by daily maintenance dose; Level of Evidence: A) should be added to ASA and anticoagulant therapy before diagnostic angiography (upstream).(Level of Evidence: C)
- CLASS IIa
1. For UA/NSTEMI patients in whom an initial conservative strategy is selected and who have recurrent ischemic discomfort with clopidogrel, ASA, and anticoagulant therapy, it is reasonable to add a GP IIb/IIIa antagonist before diagnostic angiography. (Level of Evidence: C)
2. For UA/NSTEMI patients in whom an initial invasive strategy is selected, it is reasonable to initiate antiplatelet therapy with both clopidogrel (loading dose followed by daily maintenance dose)* and an intravenous GP IIb/IIIa inhibitor. (Level of Evidence: B) Abciximabas the choice for upstream GP IIb/IIIa therapy is indicated only if there is no appreciable delay to angiography and PCI is likely to be performed; otherwise, IV eptifibatide or tirofiban is the preferred choice of GP IIb/IIIa inhibitor. (Level of Evidence: B)
3. For UA/NSTEMI patients in whom an initial invasive strategy is selected, it is reasonable to omit upstream administration of an intravenous GP IIb/IIIa antagonist before diagnostic angiography if bivalirudin is selected as the anticoagulant and at least 300 mg of clopidogrel was administered at least 6 h earlier than planned catheterization or PCI. (Level of Evidence: B)
- CLASS IIb
For UA/NSTEMI patients in whom an initial conservative (i.e., noninvasive) strategy is selected, it may be reasonable to add eptifibatide or tirofiban to anticoagulant and oral antiplatelet therapy. (Level of Evidence: B)
- CLASS III
Abciximab should not be administered to patients in whom PCI is not planned. (Level of Evidence: A)
Recommendations for Anticoagulant Therapy
Guidelines: Do not edit
- CLASS I
Anticoagulant therapy should be added to antiplatelet therapy in UA/NSTEMI patients as soon as possible after presentation. a. For patients in whom an invasive strategy is selected, regimens with established efficacy at a Level of Evidence: A include enoxaparin and UFH, and those with established efficacy at a Level of Evidence: B include bivalirudin and fondaparinux.
b. For patients in whom a conservative strategy is selected, regimens using either enoxaparin‡ or UFH (Level of Evidence: A) or fondaparinux (Level of Evidence: B) have established efficacy. ‡See also Class IIa recommendation below.
c. In patients in whom a conservative strategy is selected and who have an increased risk of bleeding, fondaparinux is preferable. (Level of Evidence: B)
- CLASS IIa
For UA/NSTEMI patients in whom an initial conservative strategy is selected, enoxaparin‡ or fondaparinux is preferable to UFH as anticoagulant therapy, unless CABG is planned within 24 h. (Level of Evidence: B)
Recomendations for Additional Management Considerations for Antiplatelet and Anticoagulant Therapy
Guidelines: do not edit
- CLASS I
1. For UA/NSTEMI patients in whom an initial conservative strategy is selected and no subsequent features appear that would necessitate diagnostic angiography (recurrent symptoms/ischemia, HF, or serious arrhythmias), a stress test should be performed. (Level of Evidence: B).
a. If, after stress testing, the patient is classified as not at low risk, diagnostic angiography should be performed. (Level of Evidence: A)
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 (Level of Evidence: A):
-Continue ASA indefinitely. (Level of Evidence: A)
-Continue clopidogrel for at least 1 month (Level of Evidence: A) and ideally up to 1 year. (Level of Evidence: B)
-Discontinue intravenous GP IIb/IIIa inhibitor if started previously. (Level of Evidence: A)
-Continue UFH for 48 h or administer enoxaparin or fondaparinux for the duration of hospitalization, up to 8 d, and then discontinue anticoagulant therapy. (Level of Evidence: A)
2. For UA/NSTEMI patients in whom CABG is selected as a postangiography management strategy, the instructions noted below should be followed.
a. Continue ASA. (Level of Evidence: A)
b. Discontinue clopidogrel 5 to 7 d before elective CABG. (Level of Evidence: B) More urgent surgery, if necessary, may be performed by experienced surgeons if the incremental bleeding risk is considered acceptable. (Level of Evidence: C)
c. Discontinue intravenous GP IIb/IIIa inhibitor (eptifibatide or tirofiban) 4 h before CABG. (Level of Evidence: B)
d. Anticoagulant therapy should be managed as follows:
-Continue UFH. (Level of Evidence: B)
-Discontinue enoxaparin* 12 to 24 h before CABG and dose with UFH per institutional practice. (Level of Evidence: B)
-Discontinue fondaparinux 24 h before CABG and dose with UFH per institutional practice. (Level of Evidence: B)
-Discontinue bivalirudin 3 h before CABG and dose with UFH per institutional practice. (Level of Evidence: B)
3. For UA/NSTEMI patients in whom PCI has been selected as a postangiography management strategy, the instructions noted below should be followed:
a. Continue ASA. (Level of Evidence: A)
b. Administer a loading dose of clopidogrel† if not started before diagnostic angiography. (Level of Evidence: A)
c. Administer an intravenous GP IIb/IIIa inhibitor (abciximab, eptifibatide, or tirofiban) if not started before diagnostic angiography for troponin-positive and other high-risk patients (Level of Evidence: A). See Class IIa recommendation below if bivalirudin was selected as the anticoagulant.
d. Discontinue anticoagulant therapy after PCI for uncomplicated cases. (Level of Evidence: B)
4. For UA/NSTEMI patients in whom medical therapy is selected as a postangiography 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)
5. For UA/NSTEMI patients in whom medical therapy is selected as a postangiography management strategy and in whom CAD was found on angiography, the following approach is recommended:
a. Continue ASA. (Level of Evidence: A)
b. Administer a loading dose of clopidogrel† if not given before diagnostic angiography. (Level of Evidence: A)
c. Discontinue intravenous GP IIb/IIIa inhibitor if started previously. (Level of Evidence: B)
d. Anticoagulant therapy should be managed as follows:
-Continue intravenous UFH for at least 48 h or until discharge if given before diagnostic angiography. (Level of Evidence: A)
-Continue enoxaparin for duration of hospitalization, up to 8 d, if given before diagnostic angiography. (Level of Evidence: A)
-Continue fondaparinux for duration of hospitalization, up to 8 d, if given before diagnostic angiography. (Level of Evidence: B)
-Either discontinue bivalirudin or continue at a dose of 0.25 mg per kg per h for up to 72 h at the physician’s discretion, if given before diagnostic angiography. (Level of Evidence: B)
6. 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:
a. Continue ASA indefinitely. (Level of Evidence: A)
b. Continue clopidogrel for at least 1 month (Level of Evidence: A) and ideally up to 1 year. (Level of Evidence: B)
c. Discontinue IV GP IIb/IIIa inhibitor if started previously. (Level of Evidence: A)
d. Continue UFH for 48 h or administer enoxaparin or fondaparinux for the duration of hospitalization, up to 8 d, and then discontinue anticoagulant therapy. (Level of Evidence: A)
7. 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), LVEF should be measured. (Level of Evidence: B)
- CLASS IIa
1. For UA/NSTEMI patients in whom PCI is selected as a postangiography 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)
2. If LVEF is less than or equal to 0.40, it is reasonable to perform diagnostic angiography. (Level of Evidence: B)
3. If LVEF is greater than 0.40, it is reasonable to perform a stress test. (Level of Evidence: B)
- CLASS IIb
For UA/NSTEMI patients in whom PCI is selected as a postangiography management strategy, it may be reasonable to omit an intravenous GP IIb/IIIa inhibitor if not started before diagnostic angiography for troponin-negative patients without other clinical or angiographic highrisk features. (Level of Evidence: C)
- CLASS III
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. (Level of Evidence: A)
Chronic Pharmacotherapies
References
Surgery and Device Based Therapy
Recommendations for PCI Guidelines: Do not edit
- 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 listed in Section 3.3. (See Section 3.3 for specific recommendations and their Level of Evidence.)
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 noninvasive testing. (Level of Evidence: B)
3. Percutaneous coronary intervention (or CABG) is recommended for UA/NSTEMI patients with multivessel 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) See Section 3.2.3 and Figures 7, 8, and 9 for details on timing and dosing recommendations (see Table 13).
- Class IIa
1. Percutaneous coronary intervention is reasonable for focal saphenous vein graft (SVG) lesions or multiple stenoses 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 (greater than 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 multivessel 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)
- 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 singlevessel or multivessel CAD and no trial of medical therapy, or who have 1 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 (less than 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 infarctrelated coronary arteries after NSTEMI is not indicated. (Level of Evidence: B)
Recommendations for CABG Guidelines: Do not edit
- Class I
1. Coronary artery bypass graft surgery is recommended for UA/NSTEMI patients with significant left main CAD (greater than 50% stenosis). (Level of Evidence: A)
2. Coronary artery bypass graft surgery is recommended for UA/ NSTEMI patients with 3-vessel disease; the survival benefit is greater in patients with abnormal LV function (LVEF less than 0.50). (Level of Evidence: A)
3. Coronary artery bypass graft surgery is recommended for UA/ NSTEMI patients with 2-vessel disease with significant proximal left anterior descending CAD and either abnormal LV function (LVEF less than 0.50) or ischemia on noninvasive testing. (Level of Evidence: A)
4. Coronary artery bypass graft surgery is recommended for UA/ NSTEMI patients in whom percutaneous revascularization is not optimal or possible and who have ongoing ischemia not responsive to maximal nonsurgical therapy. (Level of Evidence: B)
5. Coronary artery bypass graft surgery (or PCI) 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 noninvasive testing. (Level of Evidence: B)
6. Coronary artery bypass graft surgery (or PCI) is recommended for UA/NSTEMI patients with multivessel coronary disease with suitable coronary anatomy, with normal LV function, and without diabetes mellitus. (Level of Evidence: A)
- Class IIa
1. For patients with UA/NSTEMI and multivessel disease, CABG with use of the internal mammary arteries can be beneficial over PCI in patients being treated for diabetes. (Level of Evidence: B)
2. It is reasonable to perform CABG with the internal mammary artery for UA/NSTEMI patients with multivessel disease and treated diabetes mellitus. (Level of Evidence: B)
3. Repeat CABG is reasonable for UA/NSTEMI patients with multiple SVG stenoses, especially when there is significant stenosis of a graft that supplies the LAD. (Level of Evidence: C)
4. Coronary artery bypass graft surgery (or PCI) 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)
5. Coronary artery bypass graft surgery (or PCI) 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)
6. Coronary artery bypass surgery (or PCI with stenting) is reasonable for patients with multivessel disease and symptomatic myocardial ischemia. (Level of Evidence: B)
- Class IIb
Coronary artery bypass graft surgery may be considered in patients with UA/NSTEMI who have 1- or 2-vessel disease not involving the proximal LAD with a modest area of ischemic myocardium when percutaneous revascularization is not optimal or possible. (If there is a large area of viable myocardium and high-risk criteria on noninvasive testing, this recommendation becomes a Class I recommendation.) (Level of Evidence: B)
- Class III
Coronary artery bypass graft surgery (or PCI) 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)