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| {{SI}} | | __NOTOC__ |
| {{WikiDoc Cardiology Network Infobox}} | | {| class="infobox" style="float:right;" |
| {{CMG}} | | |- |
| | | [[File:Siren.gif|30px|link=Unstable angina/ NSTEMI resident survival guide]]|| <br> || <br> |
| | | [[Unstable angina/ NSTEMI resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']] |
| | |} |
| | {{Unstable angina / NSTEMI}} |
| | {{CMG}}; '''Associate Editors-in-Chief:''' [[Varun Kumar]], M.B.B.S.; [[Lakshmi Gopalakrishnan]], M.B.B.S. |
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| {{Editor Join}}
| | ==Overview== |
| | Similar to patients with [[STEMI]], patients with [[UA]]/[[NSTEMI]] also require secondary prevention at the time of discharge. Patients and their families should be educated regarding the specific targets for [[LDL]] cholesterol and [[HDL]] cholesterol, [[blood pressure]], [[body mass index]] ([[BMI]]), physical activity, and other appropriate lifestyle modifications. |
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| ==Overview of Long-Term Medical Therapy and Secondary Prevention for UA / NSTEMI== | | ==You can read in greater detail about each of the ACC/AHA guidelines for long term medical therapy and risk factor modification after UA/NSTEMI by clicking on the links below:<ref name="pmid22800849">{{cite journal| author=2012 Writing Committee Members. Jneid H, Anderson JL, Wright RS, Adams CD, Bridges CR et al.| title=2012 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction (Updating the 2007 Guideline and Replacing the 2011 Focused Update): A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2012 | volume= 126 | issue= 7 | pages= 875-910 | pmid=22800849 | doi=10.1161/CIR.0b013e318256f1e0 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22800849 }} </ref>== |
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| ==ACC / AHA Guidelines- Antiplatelet Therapy (DO NOT EDIT) <ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, ''et al'' |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=JACC |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi:10.1016/j.jacc.2007.02.013 |url=}}</ref>==
| | *[[UA/NSTEMI long-term medical therapy and secondary prevention ACC/AHA guidelines for antiplatelet therapy|Antiplatelet therapy]] |
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| | *[[UA/NSTEMI long-term medical therapy and secondary prevention ACC/AHA guidelines for beta blockers|Beta-blockers]] |
| ===Class I===
| | *[[UA/NSTEMI long-term medical therapy and secondary prevention ACC/AHA guidelines for inhibitors of the RAS|Renin-angiotensin-aldosterone inhibitors]] |
| | * [[UA/NSTEMI long-term medical therapy and secondary prevention ACC/AHA guidelines for nitroglycerin|Nitroglycerin therapy]] |
| | * [[UA/NSTEMI long-term medical therapy and secondary prevention ACC/AHA guidelines for CCB|Calcium channel blockers]] |
| | * [[UA/NSTEMI long-term medical therapy and secondary prevention ACC/AHA guidelines for warfarin therapy|Warfarin therapy]] |
| | * [[UA/NSTEMI long-term medical therapy and secondary prevention ACC/AHA guidelines for lipid management|Lipid management]] |
| | *[[Unstable angina / non ST elevation myocardial infarction long-term medical therapy and secondary prevention ACC/AHA guidelines for blood pressure control|Blood pressure control]] |
| | *[[Unstable angina / non ST elevation myocardial infarction long-term medical therapy and secondary prevention ACC/AHA guidelines for diabetes mellitus|Diabetes mellitus]] |
| | *[[Unstable angina / non ST elevation myocardial infarction long-term medical therapy and secondary prevention ACC/AHA guidelines for smoking cessation|Smoking cessation]] |
| | * [[Unstable angina / non ST elevation myocardial infarction long-term medical therapy and secondary prevention ACC/AHA guidelines for weight management|Weight management]] |
| | *[[UA/NSTEMI long-term medical therapy and secondary prevention ACC/AHA guidelines for Physical Activity|Physical activity]] |
| | * [[Unstable angina / non ST elevation myocardial infarction long-term medical therapy and secondary prevention ACC/AHA guidelines for patient education|Patient education]] |
| | * [[Unstable angina / non ST elevation myocardial infarction long-term medical therapy and secondary prevention ACC/AHA guidelines for influenza|Influenza]] |
| | *[[UA/NSTEMI long-term medical therapy and secondary prevention ACC/AHA guidelines depression|Depression]] |
| | *[[UA/NSTEMI long-term medical therapy and secondary prevention ACC/AHA guidelines Nonsteroidal Anti-Inflammatory Drugs|Nonsteroidal anti-inflammatory drugs]] |
| | *[[UA/NSTEMI long-term medical therapy and secondary prevention ACC/AHA guidelines hormone therapy|Hormone therapy]] |
| | * [[UA/NSTEMI long-term medical therapy and secondary prevention ACC/AHA guidelines antioxidant vitamins and folic acid|Antioxidant vitamins and folic Acid]] |
| | *[[Unstable angina / non ST elevation myocardial infarction long-term medical therapy and secondary prevention ACC/AHA guidelines quality care and outcomes|Quality care and outcomes]] |
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| 1. For [[UA]]/[[NSTEMI]] patients treated medically without [[stent]]ing, [[aspirin]] (75 to 162 mg per day) should be prescribed indefinitely ''(Level of Evidence: A)'' [[clopidogrel]] (75 mg per day) should be prescribed for at least 1 month ''(Level of Evidence: A)'' and ideally for up to 1 year. ''(Level of Evidence: B)''
| | Identifying and, when present, treating [[Coronary heart disease risk factors|Category I]] risk factors can be an optimal secondary prevention strategy in patients with UA/NSTEMI. You can read more about general coronary heart disease secondary prevention [[Coronary heart disease secondary prevention|HERE]] |
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| 2. For [[UA]]/[[NSTEMI]] patients treated with [[bare-metal stent]]s, [[aspirin]] 162 to 325 mg per day should be prescribed for at least 1 month ''(Level of Evidence: B)'', then continued indefinitely at a dose of 75 to 162 mg per day ''(Level of Evidence: A)''; [[clopidogrel]] should be prescribed at a dose of 75 mg per day for a minimum of 1 month and ideally for up to 1 year (unless the patient is at increased risk of bleeding, then it should be given for a minimum of 2 weeks). ''(Level of Evidence: B)''
| | ==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>== |
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| 3. For [[UA]]/[[NSTEMI]] patients treated with [[DES]], [[aspirin]] 162 to 325 mg per day should be prescribed for at least 3 months after [[sirolimus-eluting stent]] implantation and 6 months after [[paclitaxel-eluting stent]] implantation then continued indefinitely at a dose of 75 to 162 mg per day. ''(Level of Evidence: B)'' [[Clopidogrel]] 75 mg daily should be given for at least 12 months to all post-[[PCI]] patients receiving [[DES]]. ''(Level of Evidence: B)''
| | ===Hormone Therapy=== |
| | {|class="wikitable" |
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| | |colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (No Benefit) |
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| | |bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' Hormone therapy with [[estrogen]] plus [[progestin]], or [[estrogen]] alone, should not be given as new drugs for secondary prevention of coronary events to postmenopausal women after NSTE-ACS and should not be continued in previous users unless the benefits outweigh the estimated risks. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki> |
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| 4. [[Clopidogrel]] 75 mg daily (preferred) or [[ticlopidine]] (in the absence of contraindications) should be given to patients recovering from [[UA]]/[[NSTEMI]] when [[ASA]] is contraindicated or not tolerated because of hypersensitivity or gastrointestinal intolerance (but with gastroprotective agents such as [[proton-pump inhibitor]]s). ''(Level of Evidence: A)''
| | ===Antioxidant Vitamins and Folic Acid=== |
| | {|class="wikitable" |
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| | |colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (No Benefit) |
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| | |bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' Antioxidant vitamin supplements (e.g., vitamins E, C, or beta carotene) should not be used for secondary prevention in patients with NSTE-ACS. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki> |
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| | |bgcolor="LightCoral"|<nowiki>"</nowiki>'''2.''' [[Folic acid]], with or without vitamins B6 and B12, should not be used for secondary prevention in patients with NSTE-ACS. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki> |
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| ===Class IIa=== | | ===Plan of Care for Patients With NSTE-ACS=== |
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| 1. For [[UA]]/[[NSTEMI]] patients in whom the [[physician]] is concerned about the risk of bleeding, a lower initial [[aspirin]] dose after [[PCI]] of 75 to 162 mg per day is reasonable. ''(Level of Evidence: C)''
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| | | | colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] |
| ===Class IIb===
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| | | | bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Posthospital systems of care designed to prevent hospital readmissions should be used to facilitate the transition to effective, coordinated outpatient care for all patients with NSTE-ACS. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> |
| 1. For [[UA]]/[[NSTEMI]] patients who have an indication for [[anticoagulation]], add [[warfarin]] to maintain an international normalization ratio of 2.0 to 3.0. ''(Level of Evidence: B)''
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| | | | bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' An evidence-based plan of care (e.g., GDMT) that promotes medication adherence, timely follow up with the healthcare team, appropriate dietary and physical activities, and compliance with interventions for secondary prevention should be provided to patients with NSTE-ACS. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> |
| ===Class III===
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| | | | bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' On activities (e.g., lifting, climbing stairs, yard work, and household activities) that are permissible and those to avoid. Specific mention should be made of resumption of driving, return to work, and sexual activity. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> |
| 1. [[Dipyridamole]] is not recommended as an [[antiplatelet]] agent in post-[[UA]]/[[NSTEMI]] patients because it has not been shown to be effective. ''(Level of Evidence: A)''}}
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| | | | bgcolor="LightGreen"|<nowiki>"</nowiki>'''4.''' An annual [[influenza]] [[vaccination]] is recommended for patients with cardiovascular disease. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> |
| ==ACC / AHA Guidelines- Beta Blockers (DO NOT EDIT) <ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, ''et al'' |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=JACC |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi:10.1016/j.jacc.2007.02.013 |url=}}</ref>==
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| ===Class I===
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| 1. [[Beta blocker]]s are indicated for all patients recovering from [[UA]] / [[NSTEMI]] unless contraindicated. Treatment should begin within a few days of the event, if not initiated acutely, and should be continued indefinitely. ''(Level of Evidence: B)''
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| 2. Patients recovering from [[UA]] / [[NSTEMI]] with moderate or severe [[LV failure]] should receive [[beta blocker]] therapy with a gradual titration scheme. ''(Level of Evidence: B)''
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| ===Class IIa===
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| 1. It is reasonable to prescribe [[beta blocker]]s to low-risk patients (i.e., normal LV function, revascularized, no high risk features) recovering from [[UA]] / [[NSTEMI]] in the absence of absolute contraindications. ''(Level of Evidence: B)''}}
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| ==ACC / AHA Guidelines- Inhibition Of The Renin-Angiotensin-Aldosterone System (DO NOT EDIT) <ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, ''et al'' |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=JACC |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi:10.1016/j.jacc.2007.02.013 |url=}}</ref>==
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| ===Class I=== | |
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| 1. [[Angiotensin-converting enzyme inhibitor]]s should be given and continued indefinitely for patients recovering from [[UA]] / [[NSTEMI]] with [[HF]], LV dysfunction ([[LVEF]] <40%), [[hypertension]], or [[diabetes mellitus]], unless contraindicated. ''(Level of Evidence: A)'' | |
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| 2. An [[angiotensin receptor blocker]] should be prescribed at discharge to those [[UA]] / [[NSTEMI]] patients who are intolerant of an [[ACE inhibitor]] and who have either clinical or radiological signs of [[HF]] and [[LVEF]] <40%. ''(Level of Evidence: A)''
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| 3. Long term Aldosterone Receptor Blockade should be prescribed for [[UA]] / [[NSTEMI]] patients without significant renal dysfunction (estimated [[creatinine clearance]] should be >30 mL/min) or [[hyperkalemia]] ([[potassium]] should be ≤5 mEq/liter) who are already receiving therapeutic doses of an [[ACE inhibitor]], have an [[LVEF]] ≤40%, and have either symptomatic [[heart failure]] or [[diabetes mellitus]]. ''(Level of Evidence: A)''
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| ===Class IIa=== | |
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| 1. [[Angiotensin-converting enzyme inhibitor]]s are reasonable for patients recovering from [[UA]] / [[NSTEMI]] in the absence of LV dysfunction, [[hypertension]], or [[diabetes mellitus]] unless contraindicated. ''(Level of Evidence: A)''
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| 2. [[Angiotensin-converting enzyme inhibitor]]s are reasonable for patients with [[HF]] and [[LVEF]] >40%. ''(Level of Evidence: A)''
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| 3. In [[UA]] / [[NSTEMI]] patients who do not tolerate [[ACE inhibitor]]s, an [[angiotensin receptor blocker]] can be useful as an alternative to [[ACE inhibitor]]s in long term management provided there are either clinical or radiological signs of [[HF]] and [[LVEF]] <40%. ''(Level of Evidence: B)''
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| ===Class IIb===
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| 1. The combination of an [[ACE inhibitor]] and an [[angiotensin receptor blocker]] may be considered in the long-term management of patients recovering from [[UA]] / [[NSTEMI]] with persistent symptomatic [[HF]] and [[LVEF]] <40% despite conventional therapy including an [[ACE inhibitor]] or an [[angiotensin receptor blocker]] alone. ''(Level of Evidence: B)''}}
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| ==ACC / AHA Guidelines- Nitroglycerin (DO NOT EDIT) <ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, ''et al'' |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=JACC |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi:10.1016/j.jacc.2007.02.013 |url=}}</ref>==
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| ===Class I===
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| 1. [[Nitroglycerin]] to treat ischemic symptoms is recommended. ''(Level of Evidence: C)''}}
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| ==ACC / AHA Guidelines- Calcium Channel Blockers (DO NOT EDIT) <ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, ''et al'' |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=JACC |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi:10.1016/j.jacc.2007.02.013 |url=}}</ref>==
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| ===Class I===
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| 1. [[Calcium channel blocker]]s are recommended for ischemic symptoms when [[beta blocker]]s are not successful. ''(Level of Evidence: B)''
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| 2. [[Calcium channel blocker]]s are recommended for ischemic symptoms when [[beta blocker]]s are contraindicated or cause unacceptable side effects. ''(Level of Evidence: C)''}}
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| ==ACC / AHA Guidelines- Warfarin Therapy (DO NOT EDIT) <ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, ''et al'' |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=JACC |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi:10.1016/j.jacc.2007.02.013 |url=}}</ref>==
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| ===Class I===
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| 1. Use of [[warfarin]] in conjunction with [[ASA]] and/or [[clopidogrel]] is associated with an increased risk of bleeding and should be monitored closely. ''(Level of Evidence: A)''
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| ===Class IIb===
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| 1. [[Warfarin]] either without ([[INR]] 2.5 to 3.5) or with low-dose [[ASA]] (75 to 81 mg per d; [[INR]] 2.0 to 2.5) may be reasonable for patients at high [[CAD]] risk and low bleeding risk who do not require or are intolerant of [[clopidogrel]]. ''(Level of Evidence: B)''}}
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| ==ACC / AHA Guidelines- Lipid Management (DO NOT EDIT) <ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, ''et al'' |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=JACC |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi:10.1016/j.jacc.2007.02.013 |url=}}</ref>==
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| ===Class I===
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| 1. The following lipid recommendations are beneficial: | |
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| ::a. Lipid management should include assessment of a fasting lipid profile for all patients, within 24 h of hospitalization. ''(Level of Evidence: C)''
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| ::b. [[Hydroxymethyl glutaryl-coenzyme A reductase inhibitors]] ([[statins]]), in the absence of contraindications, regardless of baseline [[LDL-C]] and diet modification, should be given to post-[[UA]] / [[NSTEMI]] patients, including post revascularization patients. ''(Level of Evidence: A)''
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| ::c. For hospitalized patients, lipid-lowering medications should be initiated before discharge. ''(Level of Evidence: A)''
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| ::d. For [[UA]] / [[NSTEMI]] patients with elevated [[LDL-C]] (≥100 mg/dL), [[cholesterol]] lowering therapy should be initiated or intensified to achieve an [[LDL-C]] of <100 mg/dL. ''(Level of Evidence: A)'' Further titration to <70 mg/dL is reasonable ''(Level of Evidence: A)''
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| ::e. Therapeutic options to reduce non [[HDL-C]] are recommended, including more intense [[LDL-C]] lowering therapy. ''(Level of Evidence: B)''
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| ::f. Dietary therapy for all patients should include reduced intake of [[saturated fat]]s (to <7% of total calories), [[cholesterol]] (to <200 mg/d), and trans fat (to <1% of energy). ''(Level of Evidence: B)''
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| ::g. Promoting daily physical activity and weight management are recommended. ''(Level of Evidence: B)''
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| 2. Treatment of [[triglyceride]]s and [[non-HDL-C]] is useful, including the following:
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| ::a. If [[triglyceride]]s are 200-499 mg/dL, [[non HDL-C]] should be <130 mg/dL. ''(Level of Evidence: B)''
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| ::b. If [[triglyceride]]s are ≥500 mg/dL, therapeutic options to prevent [[pancreatitis]] are [[fibrate]] or [[niacin]] before [[LDL]]-lowering therapy is recommended. It is also recommended that [[LDL-C]] be treated to goal after [[triglyceride]] lowering therapy. Achievement of a [[non HDL-C]] <130 mg/dL (i.e., 30 mg/dL greater than [[LDL-C]] target) if possible is recommended. ''(Level of Evidence: C)''
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| ===Class IIa===
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| 1. The following lipid management strategies can be beneficial:
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| ::a. Further reduction of [[LDL-C]] to <70 mg/dL is reasonable. ''(Level of Evidence: A)''
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| ::b. If baseline [[LDL cholesterol]] is 70-100 mg/dL, it is reasonable to treat [[LDL-C]] to less than 70 mg/dL. ''(Level of Evidence: B)''
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| ::c. Further reduction of [[non HDL-C]] to <100 mg/dL is reasonable; if [[triglyceride]]s are 200 to 499 mg/dL, [[non HDL-C]] target is <130 mg/dL. ''(Level of Evidence: B)''
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| ::d. Therapeutic options to reduce [[non-HDL-C]] (after [[LDL-C]] lowering) include [[niacin]] or [[fibrate]] therapy.
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| ::e. [[Nicotinic acid]] ([[niacin]]) and fibric acid derivatives ([[fenofibrate]], [[gemfibrozil]]) can be useful as therapeutic options (after [[LDL-C]]– lowering therapy) for [[HDL-C]] <40 mg/dL. ''(Level of Evidence: B)''
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| ::f. [[Nicotinic acid]] ([[niacin]]) and fibric acid derivatives ([[fenofibrate]], [[gemfibrozil]]) can be useful as therapeutic options (after [[LDL-C]] lowering therapy) for [[triglyceride]]s >200 mg/dL. ''(Level of Evidence: B)''
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| ::g. The addition of plant stanol/sterols (2 g/day) and/or viscous fiber (>10 g/day) is reasonable to further lower [[LDL-C]]. ''(Level of Evidence: A)''
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| ===Class IIb===
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| 1. Encouraging consumption of [[omega-3 fatty acids]] in the form of fish or in capsule form (1 g per d) for risk reduction may be reasonable. For treatment of elevated [[triglyceride]]s, higher doses (2 to 4 g per d) may be used for risk reduction. ''(Level of Evidence: B)''}}
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| ==ACC / AHA Guidelines- Blood Pressure Control (DO NOT EDIT) <ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, ''et al'' |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=JACC |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi:10.1016/j.jacc.2007.02.013 |url=}}</ref>==
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| ===Class I===
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| 1. [[Blood pressure]] control according to JNC 7 guidelines is recommended (i.e., [[blood pressure]] <140/90 mmHg or <130/80 mmHg if the patient has [[diabetes mellitus]] or [[chronic kidney disease]]). ''(Level of Evidence: A)'' Additional measures recommended to treat and control blood pressure include the following:
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| ::a. Patients should initiate and/or maintain lifestyle modifications, including weight control, increased physical activity, alcohol moderation, sodium reduction, and emphasis on increased consumption of fresh fruits, vegetables, and low-fat dairy products. ''(Level of Evidence: B)''
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| ::b. For patients with [[blood pressure]] ≥140/90 mmHg (or ≥130/80 mmHg for individuals with [[chronic kidney disease]] or [[diabetes mellitus]]), it is useful to add [[blood pressure]] medication as tolerated, treating initially with [[beta blocker]]s and/or [[ACE inhibitor]]s, with addition of other drugs such as [[thiazide]]s as needed to achieve target blood pressure. ''(Level of Evidence: A)''}}
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| ==ACC / AHA Guidelines- Diabetes Mellitus (DO NOT EDIT) <ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, ''et al'' |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=JACC |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi:10.1016/j.jacc.2007.02.013 |url=}}</ref>==
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| {{cquote|
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| ===Class I===
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| 1. [[Diabetes]] management should include lifestyle and pharmacotherapy measures to achieve a near-normal [[HbA1c]] level of <7%. ''(Level of Evidence: B)'' [[Diabetes]] management should also include the following:
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| :a. Vigorous modification of other risk factors (e.g., physical activity, weight management, [[blood pressure]] control, and [[cholesterol]] management) as recommended should be initiated and maintained. ''(Level of Evidence: B)''
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| :b. It is useful to coordinate the patient’s diabetic care with the patient’s [[primary care physician]] or [[endocrinologist]]. ''(Level of Evidence: C)''}}
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| ==ACC / AHA Guidelines- Smoking Cessation (DO NOT EDIT) <ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, ''et al'' |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=JACC |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi:10.1016/j.jacc.2007.02.013 |url=}}</ref>==
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| {{cquote|
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| ===Class I===
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| 1. [[Smoking cessation]] and avoidance of exposure to environmental [[tobacco]] smoke at work and home are recommended. Follow-up, referral to special programs, or [[pharmacotherapy]] (including [[nicotine replacement]]) is useful, as is adopting a stepwise strategy aimed at [[smoking cessation]] (the 5 A’s are: '''A'''sk, '''A'''dvise, '''A'''ssess, '''A'''ssist, and '''A'''rrange). ''(Level of Evidence: B)''}}
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| ==ACC / AHA Guidelines- Weight Management (DO NOT EDIT) <ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, ''et al'' |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=JACC |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi:10.1016/j.jacc.2007.02.013 |url=}}</ref>==
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| {{cquote|
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| ===Class I===
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| 1. Weight management, as measured by [[body mass index]] and/or waist circumference, should be assessed on each visit. A [[body mass index]] of 18.5 to 24.9 kg/m² and a waist circumference (measured horizontally at the [[iliac crest]]) of <40 inches for men and <35 inches for women is recommended. ''(Level of Evidence: B)'' Additional weight management practices recommended include the following:
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| :a. On each patient visit, it is useful to consistently encourage weight maintenance / reduction through an appropriate balance of physical activity, caloric intake, and formal behavioral programs when indicated to maintain/achieve a [[body mass index]] between 18.5 and 24.9 kg/m². ''(Level of Evidence: B)''
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| :b. If waist circumference is ≥35 inches in women or ≥40 inches in men, it is beneficial to initiate lifestyle changes and consider treatment strategies for [[metabolic syndrome]] as indicated. ''(Level of Evidence: B)''
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| :c. The initial goal of weight loss therapy should be to reduce body weight by approximately 10% from baseline. With success, further weight loss can be attempted if indicated through further assessment. ''(Level of Evidence: B)''}}
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| ==ACC / AHA Guidelines- Physical Activity (DO NOT EDIT) <ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, ''et al'' |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=JACC |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi:10.1016/j.jacc.2007.02.013 |url=}}</ref>==
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| {{cquote|
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| ===Class I===
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| 1. The patient’s risk after [[UA]] / [[NSTEMI]] should be assessed on the basis of an in-hospital determination of risk. A physical activity history or an [[exercise test]] to guide initial prescription is beneficial. ''(Level of Evidence: B)''
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| 2. Guided/modified by an individualized exercise prescription, patients recovering from [[UA]] / [[NSTEMI]] generally should be encouraged to achieve physical activity duration of 30 to 60 min/day, preferably 7 (but at least 5) day/week of moderate aerobic activity, such as brisk walking, supplemented by an increase in daily lifestyle activities (e.g., walking breaks at work, gardening, and household work). ''(Level of Evidence: B)''
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| 3. [[Cardiac rehabilitation]] / secondary prevention programs are recommended for patients with [[UA]] / [[NSTEMI]], particularly those with multiple modifiable risk factors and/or those moderate- to high-risk patients in whom supervised exercise training is particularly warranted. ''(Level of Evidence: B)'' | |
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| ===Class IIb===
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| 1. The expansion of physical activity to include resistance training on 2 day per week may be reasonable. ''(Level of Evidence: C)''}}
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| ==ACC / AHA Guidelines- Patient Education (DO NOT EDIT) <ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, ''et al'' |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=JACC |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi:10.1016/j.jacc.2007.02.013 |url=}}</ref>==
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| {{cquote|
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| ===Class I===
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| 1. Beyond the detailed instructions for daily exercise, patients should be given specific instruction on activities (e.g., heavy lifting, climbing stairs, yard work, and household activities) that are permissible and those that should be avoided. Specific mention should be made regarding resumption of driving, return to work, and sexual activity. ''(Level of Evidence: C)''}}
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| ==ACC / AHA Guidelines- Influenza Vaccination (DO NOT EDIT) <ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, ''et al'' |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=JACC |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi:10.1016/j.jacc.2007.02.013 |url=}}</ref>==
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| {{cquote|
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| ===Class I===
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| 1. An annual [[influenza]] vaccination is recommended for patients with [[cardiovascular disease]]. ''(Level of Evidence: B)''}}
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| ==ACC / AHA Guidelines- Depression (DO NOT EDIT) <ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, ''et al'' |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=JACC |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi:10.1016/j.jacc.2007.02.013 |url=}}</ref>==
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| {{cquote|
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| ===Class IIa===
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| 1. It is reasonable to consider screening [[UA]] / [[NSTEMI]] patients for [[depression]] and refer/treat when indicated. ''(Level of Evidence: B)''}}
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| ==ACC / AHA Guidelines- Nonsteroidal Anti-Inflammatory Drugs (DO NOT EDIT) <ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, ''et al'' |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=JACC |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi:10.1016/j.jacc.2007.02.013 |url=}}</ref>==
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| {{cquote|
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| ===Class I===
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| 1. At the time of preparation for hospital discharge, the patient’s need for treatment of chronic musculoskeletal discomfort should be assessed, and a stepped-care approach to treatment should be used for selection of treatments. Pain relief should begin with [[acetaminophen]], small doses of [[narcotics]], or [[non acetylated salicylate]]s. ''(Level of Evidence: C)''
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| ===Class IIa===
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| 1. It is reasonable to use nonselective [[NSAID]]s, such as [[naproxen]], if initial therapy with [[acetaminophen]], small doses of [[narcotics]], or [[non acetylated salicylate]]s is insufficient. ''(Level of Evidence: C)''
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| ===Class IIb===
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| 1. [[Non steroidal anti inflammatory drug]]s with increasing degrees of relative [[COX-2]] selectivity may be considered for pain relief only for situations in which intolerable discomfort persists despite attempts at stepped-care therapy with [[acetaminophen]], small doses of [[narcotics]], [[non acetylated salicylate]]s, or non selective [[NSAID]]s. In all cases, the lowest effective doses should be used for the shortest possible time. ''(Level of Evidence: C)''
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| ===Class III===
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| 1. [[Non steroidal anti inflammatory drug]]s with increasing degrees of relative [[COX-2]] selectivity should not be administered to [[UA]] / [[NSTEMI]] patients with chronic musculoskeletal discomfort when therapy with [[acetaminophen]], small doses of [[narcotics]], [[non acetylated salicylate]]s, or non selective [[NSAID]]s provides acceptable levels of pain relief. ''(Level of Evidence: C)''}}
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| ==ACC / AHA Guidelines- Hormone Therapy (DO NOT EDIT) <ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, ''et al'' |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=JACC |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi:10.1016/j.jacc.2007.02.013 |url=}}</ref>==
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| {{cquote|
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| ===Class III===
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| 1. [[Hormone therapy]] with [[estrogen]] plus [[progestin]], or [[estrogen]] alone, should not be given de novo to postmenopausal women after [[UA]] / [[NSTEMI]] for secondary prevention of coronary events. ''(Level of Evidence: A) ''
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| 2. Postmenopausal women who are already taking [[estrogen]] plus [[progestin]], or [[estrogen]] alone, at the time of [[UA]] / [[NSTEMI]] in general should not continue [[hormone therapy]]. However, women who are more than 1 to 2 years past the initiation of [[hormone therapy]] who wish to continue such therapy for another compelling indication should weigh the risks and benefits, recognizing the greater risk of cardiovascular events and [[breast cancer]] (combination therapy) or [[stroke]] ([[estrogen]]). [[Hormone therapy]] should not be continued while patients are on bed rest in the hospital. ''(Level of Evidence: B)''}}
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| ==ACC / AHA Guidelines- Antioxidant Vitamins and Folic Acid (DO NOT EDIT) <ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, ''et al'' |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=JACC |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi:10.1016/j.jacc.2007.02.013 |url=}}</ref>==
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| {{cquote|
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| ===Class III===
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| 1. Antioxidant vitamin supplements (e.g., [[vitamin E]], [[vitamin C]], or [[beta carotene]]) should not be used for secondary prevention in [[UA]] / [[NSTEMI]] patients. (Level of Evidence: A)
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| 2. [[Folic acid]], with or without [[vitamin B6]] and [[vitamin B12]], should not be used for secondary prevention in [[UA]] / [[NSTEMI]] patients. (Level of Evidence: A)}}
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| ==See Also==
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| * [[The Living Guidelines: UA/NSTEMI | The UA / NSTEMI Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines]]
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| ==Sources==
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| *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, ''et al'' |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=JACC |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi:10.1016/j.jacc.2007.02.013 |url=}}</ref>
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| ==References== | | ==References== |
| {{reflist|2}} | | {{Reflist|2}} |
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| | [[Category:Ischemic heart diseases]] |
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