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{{Unstable angina / NSTEMI}}
{{CMG}}; '''Associate Editors-in-Chief:''' [[Varun Kumar]], M.B.B.S.; [[Lakshmi Gopalakrishnan]], M.B.B.S.


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==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.


==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>==


==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]]
{{cquote|
*[[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]]


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]]


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>==


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"
|-
|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.''' 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>
|}


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"
|-
|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.''' 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>
|-
|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>
|}


===Class IIa===
===Plan of Care for Patients With NSTE-ACS===
 
{|class="wikitable"
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)''
|-
 
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
===Class IIb===
|-
 
| 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)''
|-
 
| 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===
|-
 
| 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)''}}
|-
 
| 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>==
|-
{{cquote| 
|}
===Class I===
 
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)''
 
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)''
 
===Class IIa===
 
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)''}}
 
==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>==
{{cquote| 
===Class I===
 
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)''
 
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)''
 
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)''
 
===Class IIa===
 
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)''
 
2. [[Angiotensin-converting enzyme inhibitor]]s are reasonable for patients with [[HF]] and [[LVEF]] >40%. ''(Level of Evidence: A)''
 
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)''
 
===Class IIb===
 
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)''}}
 
==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, ''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>


==References==
==References==
{{reflist|2}}
{{Reflist|2}}
 
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Latest revision as of 21:19, 5 December 2022
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-in-Chief: Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.

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.

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:[1]

Identifying and, when present, treating 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 HERE

2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes (DO NOT EDIT) [2]

Hormone Therapy

Class III (No Benefit)
"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. (Level of Evidence: A)"

Antioxidant Vitamins and Folic Acid

Class III (No Benefit)
"1. Antioxidant vitamin supplements (e.g., vitamins E, C, or beta carotene) should not be used for secondary prevention in patients with NSTE-ACS. (Level of Evidence: A)"
"2. Folic acid, with or without vitamins B6 and B12, should not be used for secondary prevention in patients with NSTE-ACS. (Level of Evidence: A)"

Plan of Care for Patients With NSTE-ACS

Class I
"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. (Level of Evidence: B)"
"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. (Level of Evidence: C)"
"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. (Level of Evidence: B)"
"4. An annual influenza vaccination is recommended for patients with cardiovascular disease. (Level of Evidence: C)"

References

  1. ↑ 2012 Writing Committee Members. Jneid H, Anderson JL, Wright RS, Adams CD, Bridges CR; et al. (2012). "2012 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction (Updating the 2007 Guideline and Replacing the 2011 Focused Update): A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". Circulation. 126 (7): 875–910. doi:10.1161/CIR.0b013e318256f1e0. PMID 22800849.
  2. ↑ 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)

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