Unstable angina non ST elevation myocardial infarction long-term medical therapy and secondary prevention: Difference between revisions
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{{WikiDoc Cardiology Network Infobox}} | |||
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'''Associate Editor-in-Chief:''' [[Varun Kumar]], M.B.B.S.; [[Lakshmi Gopalakrishnan]], M.B.B.S. | |||
{{Editor Join}} | {{Editor Join}} | ||
==Overview of Long-Term Medical Therapy and Secondary Prevention for Unstable angina / NSTEMI== | |||
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. | |||
Below are the ACC/AHA guidelines and recommendations for long term medical therapy after [[UA]]/[[NSTEMI]] as well as for risk factor modification: | |||
==ACC / AHA Guidelines - Antiplatelet Therapy (DO NOT EDIT)<ref name="pmid21444888">{{cite journal |author=Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS |title=2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines |journal=[[Circulation]] |volume= |issue= |pages= |year=2011 |month=March |pmid=21444888 |doi=10.1161/CIR.0b013e318212bb8b |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=21444888 |accessdate=2011-04-12}}</ref>== | |||
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===Class I=== | ===Class I=== | ||
1. For [[UA]]/[[NSTEMI]] patients treated medically without [[stent]]ing, [[aspirin]]'''Φ''' (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 and ideally for up to 1 year. ''(Level of Evidence: B)'' | '''1.''' For [[UA]]/[[NSTEMI]] patients treated medically without [[stent]]ing, [[aspirin]]'''Φ''' (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 and ideally for up to 1 year. ''(Level of Evidence: B)'' | ||
2. 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 GI intolerance (despite use of gastroprotective agents such as [[PPI]]s). (Level of Evidence: A) | '''2.''' [[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 GI intolerance (despite use of gastroprotective agents such as [[PPI]]s). (Level of Evidence: A) | ||
===Class IIa=== | ===Class IIa=== | ||
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)'' | '''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)'' | ||
===Class IIb=== | ===Class IIb=== | ||
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)'' | '''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)'' | ||
2. Continuation of [[clopidogrel]] or [[prasugrel]] beyond 15 months may be considered in patients following [[DES]] placement. (Level of Evidence: C) | '''2.''' Continuation of [[clopidogrel]] or [[prasugrel]] beyond 15 months may be considered in patients following [[DES]] placement. (Level of Evidence: C) | ||
===Class III=== | ===Class III=== | ||
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: B)'' | '''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: B)'' | ||
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patients who have mechanical heart valves, the INR should be at least 2.5 (based on type of prosthesis).}} | patients who have mechanical heart valves, the INR should be at least 2.5 (based on type of prosthesis).}} | ||
==ACC / AHA Guidelines- Beta Blockers (DO NOT EDIT) <ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, | |||
==ACC / AHA Guidelines - Beta Blockers (DO NOT EDIT)<ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B |title=ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine |journal=[[Journal of the American College of Cardiology]] |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi=10.1016/j.jacc.2007.02.013 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(07)00511-6 |accessdate=2011-04-12}}</ref>== | |||
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===Class I=== | ===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)'' | '''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)'' | '''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=== | ===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)''}} | '''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, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B |title=ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine |journal=[[Journal of the American College of Cardiology]] |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi=10.1016/j.jacc.2007.02.013 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(07)00511-6 |accessdate=2011-04-12}}</ref>== | |||
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===Class I=== | ===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)'' | '''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)'' | '''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 | '''3.''' Long term [[Aldosterone antagonist]] 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=== | ===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)'' | '''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)'' | '''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)'' | '''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=== | ===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)''}} | '''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)''}} | ||
==ACC / AHA Guidelines - Nitroglycerin (DO NOT EDIT)<ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B |title=ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine |journal=[[Journal of the American College of Cardiology]] |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi=10.1016/j.jacc.2007.02.013 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(07)00511-6 |accessdate=2011-04-12}}</ref>== | |||
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===Class I=== | ===Class I=== | ||
1. [[Nitroglycerin]] to treat ischemic symptoms is recommended. ''(Level of Evidence: C)''}} | '''1.''' [[Nitroglycerin]] to treat [[ischemic]] symptoms is recommended. ''(Level of Evidence: C)''}} | ||
==ACC / AHA Guidelines - Calcium Channel Blockers (DO NOT EDIT)<ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B |title=ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine |journal=[[Journal of the American College of Cardiology]] |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi=10.1016/j.jacc.2007.02.013 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(07)00511-6 |accessdate=2011-04-12}}</ref>== | |||
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===Class I=== | ===Class I=== | ||
1. [[Calcium channel blocker]]s are recommended for ischemic symptoms when [[beta blocker]]s are not successful. ''(Level of Evidence: B)'' | '''1.''' [[Calcium channel blocker]]s are recommended for ischemic symptoms when [[beta blocker]]s are not successful. ''(Level of Evidence: B)'' | ||
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)''}} | '''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)''}} | ||
==ACC / AHA Guidelines - Warfarin Therapy (DO NOT EDIT)<ref name="pmid21444888">{{cite journal |author=Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS |title=2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines |journal=[[Circulation]] |volume= |issue= |pages= |year=2011 |month=March |pmid=21444888 |doi=10.1161/CIR.0b013e318212bb8b |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=21444888 |accessdate=2011-04-12}}</ref>== | |||
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===Class I=== | ===Class I=== | ||
1. Use of [[warfarin]] in conjunction with [[ASA]] and/or a [[thienopyridine]] agent is associated with an increased risk of bleeding, and patients and clinicians should watch for bleeding, especially gastrointestinal, and seek medical evaluation for evidence of bleeding ''(Level of Evidence: A)'' | '''1.''' Use of [[warfarin]] in conjunction with [[ASA]] and/or a [[thienopyridine]] agent is associated with an increased risk of bleeding, and patients and clinicians should watch for bleeding, especially gastrointestinal, and seek medical evaluation for evidence of bleeding ''(Level of Evidence: A)'' | ||
===Class IIb=== | ===Class IIb=== | ||
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)''}} | '''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)''}} | ||
==ACC / AHA Guidelines - Lipid Management (DO NOT EDIT)<ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B |title=ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine |journal=[[Journal of the American College of Cardiology]] |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi=10.1016/j.jacc.2007.02.013 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(07)00511-6 |accessdate=2011-04-12}}</ref>== | |||
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===Class I=== | ===Class I=== | ||
1. The following lipid recommendations are beneficial: | '''1.''' The following lipid recommendations are beneficial: | ||
::a. Lipid management should include assessment of a fasting lipid profile for all patients, within 24 h of hospitalization. ''(Level of Evidence: C)'' | ::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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::g. Promoting daily physical activity and weight management are recommended. ''(Level of Evidence: B)'' | ::g. Promoting daily physical activity and weight management are recommended. ''(Level of Evidence: B)'' | ||
2. Treatment of [[triglyceride]]s and [[non-HDL-C]] is useful, including the following: | '''2.''' Treatment of [[triglyceride]]s and [[non-HDL-C]] is useful, including the following: | ||
::a. If [[triglyceride]]s are 200-499 mg/dL, [[non HDL-C]] should be <130 mg/dL. ''(Level of Evidence: B)'' | ::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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===Class IIa=== | ===Class IIa=== | ||
1. The following lipid management strategies can be beneficial: | '''1.''' The following lipid management strategies can be beneficial: | ||
::a. Further reduction of [[LDL-C]] to <70 mg/dL is reasonable. ''(Level of Evidence: A)'' | ::a. Further reduction of [[LDL-C]] to <70 mg/dL is reasonable. ''(Level of Evidence: A)'' | ||
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===Class IIb=== | ===Class IIb=== | ||
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)''}} | '''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)''}} | ||
==ACC / AHA Guidelines - Blood Pressure Control (DO NOT EDIT)<ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B |title=ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine |journal=[[Journal of the American College of Cardiology]] |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi=10.1016/j.jacc.2007.02.013 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(07)00511-6 |accessdate=2011-04-12}}</ref>== | |||
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===Class I=== | ===Class I=== | ||
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: | '''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: | ||
::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)'' | ::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)'' | ||
::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)''}} | ::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)''}} | ||
==ACC / AHA Guidelines- Diabetes Mellitus (DO NOT EDIT) <ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, | |||
==ACC / AHA Guidelines - Diabetes Mellitus (DO NOT EDIT)<ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B |title=ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine |journal=[[Journal of the American College of Cardiology]] |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi=10.1016/j.jacc.2007.02.013 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(07)00511-6 |accessdate=2011-04-12}}</ref>== | |||
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===Class I=== | ===Class I=== | ||
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: | '''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: | ||
: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)'' | :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)'' | ||
:b. It is useful to coordinate the patient’s diabetic care with the patient’s [[primary care physician]] or [[endocrinologist]]. ''(Level of Evidence: C)''}} | :b. It is useful to coordinate the patient’s diabetic care with the patient’s [[primary care physician]] or [[endocrinologist]]. ''(Level of Evidence: C)''}} | ||
==ACC / AHA Guidelines- Smoking Cessation (DO NOT EDIT) <ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, | |||
==ACC / AHA Guidelines - Smoking Cessation (DO NOT EDIT)<ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B |title=ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine |journal=[[Journal of the American College of Cardiology]] |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi=10.1016/j.jacc.2007.02.013 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(07)00511-6 |accessdate=2011-04-12}}</ref>== | |||
{{cquote| | {{cquote| | ||
===Class I=== | ===Class I=== | ||
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)''}} | '''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)''}} | ||
==ACC / AHA Guidelines - Weight Management (DO NOT EDIT)<ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B |title=ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine |journal=[[Journal of the American College of Cardiology]] |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi=10.1016/j.jacc.2007.02.013 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(07)00511-6 |accessdate=2011-04-12}}</ref>== | |||
{{cquote| | {{cquote| | ||
===Class I=== | ===Class I=== | ||
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: | '''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: | ||
: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)'' | :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)'' | ||
: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)'' | :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)'' | ||
: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)''}} | :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)''}} | ||
==ACC / AHA Guidelines- Physical Activity (DO NOT EDIT) <ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, | |||
==ACC / AHA Guidelines - Physical Activity (DO NOT EDIT)<ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B |title=ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine |journal=[[Journal of the American College of Cardiology]] |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi=10.1016/j.jacc.2007.02.013 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(07)00511-6 |accessdate=2011-04-12}}</ref>== | |||
{{cquote| | {{cquote| | ||
===Class I=== | ===Class I=== | ||
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)'' | '''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)'' | ||
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)'' | '''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)'' | ||
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)'' | '''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)'' | ||
===Class IIb=== | ===Class IIb=== | ||
1. The expansion of physical activity to include resistance training on 2 day per week may be reasonable. ''(Level of Evidence: C)''}} | '''1.''' The expansion of physical activity to include resistance training on 2 day per week may be reasonable. ''(Level of Evidence: C)''}} | ||
==ACC / AHA Guidelines - Patient Education (DO NOT EDIT)<ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B |title=ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine |journal=[[Journal of the American College of Cardiology]] |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi=10.1016/j.jacc.2007.02.013 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(07)00511-6 |accessdate=2011-04-12}}</ref>== | |||
{{cquote| | {{cquote| | ||
===Class I=== | ===Class I=== | ||
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)''}} | '''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)''}} | ||
==ACC / AHA Guidelines - Influenza Vaccination (DO NOT EDIT)<ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B |title=ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine |journal=[[Journal of the American College of Cardiology]] |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi=10.1016/j.jacc.2007.02.013 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(07)00511-6 |accessdate=2011-04-12}}</ref>== | |||
{{cquote| | {{cquote| | ||
===Class I=== | ===Class I=== | ||
1. An annual [[influenza]] vaccination is recommended for patients with [[cardiovascular disease]]. ''(Level of Evidence: B)''}} | '''1.''' An annual [[influenza]] vaccination is recommended for patients with [[cardiovascular disease]]. ''(Level of Evidence: B)''}} | ||
==ACC / AHA Guidelines - Depression (DO NOT EDIT)<ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B |title=ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine |journal=[[Journal of the American College of Cardiology]] |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi=10.1016/j.jacc.2007.02.013 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(07)00511-6 |accessdate=2011-04-12}}</ref>== | |||
{{cquote| | {{cquote| | ||
===Class IIa=== | ===Class IIa=== | ||
1. It is reasonable to consider screening [[UA]] / [[NSTEMI]] patients for [[depression]] and refer/treat when indicated. ''(Level of Evidence: B)''}} | '''1.''' It is reasonable to consider screening [[UA]] / [[NSTEMI]] patients for [[depression]] and refer/treat when indicated. ''(Level of Evidence: B)''}} | ||
==ACC / AHA Guidelines - Nonsteroidal Anti-Inflammatory Drugs (DO NOT EDIT)<ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B |title=ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine |journal=[[Journal of the American College of Cardiology]] |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi=10.1016/j.jacc.2007.02.013 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(07)00511-6 |accessdate=2011-04-12}}</ref>== | |||
{{cquote| | {{cquote| | ||
===Class I=== | ===Class I=== | ||
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)'' | '''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)'' | ||
===Class IIa=== | ===Class IIa=== | ||
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)'' | '''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)'' | ||
===Class IIb=== | ===Class IIb=== | ||
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)'' | '''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)'' | ||
===Class III=== | ===Class III=== | ||
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)''}} | '''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)''}} | ||
==ACC / AHA Guidelines - Hormone Therapy (DO NOT EDIT)<ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B |title=ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine |journal=[[Journal of the American College of Cardiology]] |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi=10.1016/j.jacc.2007.02.013 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(07)00511-6 |accessdate=2011-04-12}}</ref>== | |||
{{cquote| | {{cquote| | ||
===Class III=== | ===Class III=== | ||
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) '' | '''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) '' | ||
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)''}} | '''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)''}} | ||
==ACC / AHA Guidelines - Antioxidant Vitamins and Folic Acid (DO NOT EDIT)<ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B |title=ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine |journal=[[Journal of the American College of Cardiology]] |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi=10.1016/j.jacc.2007.02.013 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(07)00511-6 |accessdate=2011-04-12}}</ref>== | |||
{{cquote| | {{cquote| | ||
===Class III=== | ===Class III=== | ||
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)'' | '''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)'' | ||
'''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)''}} | |||
==See Also== | ==See Also== | ||
Line 238: | Line 278: | ||
==Sources== | ==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, | *The ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction <ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B |title=ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine |journal=[[Journal of the American College of Cardiology]] |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi=10.1016/j.jacc.2007.02.013 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(07)00511-6 |accessdate=2011-04-12}}</ref> | ||
*2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients With [[Unstable Angina]] / [[Non–ST-Elevation Myocardial Infarction]] <ref name="pmid21444889">{{cite journal |author=Wright RS, Anderson JL, Adams CD, Bridges CR, Casey DE, Ettinger SM, Fesmire FM, Ganiats TG, Jneid H, Lincoff AM, Peterson ED, Philippides GJ, Theroux P, Wenger NK, Zidar JP |title=2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction (Updating the 2007 Guideline): A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines |journal=[[Circulation]] |volume= |issue= |pages= |year=2011 |month=March |pmid=21444889 |doi=10.1161/CIR.0b013e31820f2f3e |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=21444889 |accessdate=2011-03-31}}</ref> | *2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients With [[Unstable Angina]] / [[Non–ST-Elevation Myocardial Infarction]] <ref name="pmid21444889">{{cite journal |author=Wright RS, Anderson JL, Adams CD, Bridges CR, Casey DE, Ettinger SM, Fesmire FM, Ganiats TG, Jneid H, Lincoff AM, Peterson ED, Philippides GJ, Theroux P, Wenger NK, Zidar JP |title=2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction (Updating the 2007 Guideline): A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines |journal=[[Circulation]] |volume= |issue= |pages= |year=2011 |month=March |pmid=21444889 |doi=10.1161/CIR.0b013e31820f2f3e |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=21444889 |accessdate=2011-03-31}}</ref> | ||
==References== | ==References== | ||
{{reflist | {{reflist}} | ||
{{WH}} | {{WH}} | ||
{{WS}} | {{WS}} |
Revision as of 17:52, 12 April 2011
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Overview of Long-Term Medical Therapy and Secondary Prevention for Unstable angina / NSTEMI
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. Below are the ACC/AHA guidelines and recommendations for long term medical therapy after UA/NSTEMI as well as for risk factor modification:
ACC / AHA Guidelines - Antiplatelet Therapy (DO NOT EDIT)[1]
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Class I1. For UA/NSTEMI patients treated medically without stenting, aspirinΦ (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 and ideally for up to 1 year. (Level of Evidence: B) 2. 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 GI intolerance (despite use of gastroprotective agents such as PPIs). (Level of Evidence: A) Class IIa1. 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) Class IIb1. 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) 2. Continuation of clopidogrel or prasugrel beyond 15 months may be considered in patients following DES placement. (Level of Evidence: C) Class III1. 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: B)
Φ In patients allergic to ASA, clopidogrel alone can be used or ASA desensitization can be tried. † For patients allergic to clopidogrel, ticlopidine 250mg orally twice daily is recommended. ‡ Continue ASA indefinitely and warfarin longer term as indicated for specific conditions such as atrial fibrillation; LV thrombus; or cerebral, venous, or pulmonary emboli. § An INR of 2.0 to 2.5 is preferable while given with ASA and clopidogrel, especially in older patients and those with other risk factors for bleeding. For UA/NSTEMI patients who have mechanical heart valves, the INR should be at least 2.5 (based on type of prosthesis). |
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ACC / AHA Guidelines - Beta Blockers (DO NOT EDIT)[2]
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Class I1. Beta blockers 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 IIa1. It is reasonable to prescribe beta blockers 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)[2]
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Class I1. Angiotensin-converting enzyme inhibitors 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 antagonist 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 IIa1. Angiotensin-converting enzyme inhibitors 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 inhibitors are reasonable for patients with HF and LVEF >40%. (Level of Evidence: A) 3. In UA / NSTEMI patients who do not tolerate ACE inhibitors, an angiotensin receptor blocker can be useful as an alternative to ACE inhibitors in long term management provided there are either clinical or radiological signs of HF and LVEF <40%. (Level of Evidence: B) Class IIb1. 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)[2]
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Class I1. Nitroglycerin to treat ischemic symptoms is recommended. (Level of Evidence: C) |
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ACC / AHA Guidelines - Calcium Channel Blockers (DO NOT EDIT)[2]
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Class I1. Calcium channel blockers are recommended for ischemic symptoms when beta blockers are not successful. (Level of Evidence: B) 2. Calcium channel blockers are recommended for ischemic symptoms when beta blockers are contraindicated or cause unacceptable side effects. (Level of Evidence: C) |
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ACC / AHA Guidelines - Warfarin Therapy (DO NOT EDIT)[1]
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Class I1. Use of warfarin in conjunction with ASA and/or a thienopyridine agent is associated with an increased risk of bleeding, and patients and clinicians should watch for bleeding, especially gastrointestinal, and seek medical evaluation for evidence of bleeding (Level of Evidence: A) Class IIb1. 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)[2]
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Class I1. The following lipid recommendations are beneficial:
2. Treatment of triglycerides and non-HDL-C is useful, including the following:
Class IIa1. The following lipid management strategies can be beneficial:
Class IIb1. 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 triglycerides, 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)[2]
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Class I1. 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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ACC / AHA Guidelines - Diabetes Mellitus (DO NOT EDIT)[2]
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Class I1. 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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ACC / AHA Guidelines - Smoking Cessation (DO NOT EDIT)[2]
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Class I1. 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: Ask, Advise, Assess, Assist, and Arrange). (Level of Evidence: B) |
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ACC / AHA Guidelines - Weight Management (DO NOT EDIT)[2]
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Class I1.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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ACC / AHA Guidelines - Physical Activity (DO NOT EDIT)[2]
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Class I1. 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) 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) 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) Class IIb1. 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)[2]
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Class I1. 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)[2]
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Class I1. 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)[2]
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Class IIa1. 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)[2]
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Class I1. 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 salicylates. (Level of Evidence: C) Class IIa1. It is reasonable to use nonselective NSAIDs, such as naproxen, if initial therapy with acetaminophen, small doses of narcotics, or non acetylated salicylates is insufficient. (Level of Evidence: C) Class IIb1. Non steroidal anti inflammatory drugs 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 salicylates, or non selective NSAIDs. In all cases, the lowest effective doses should be used for the shortest possible time. (Level of Evidence: C) Class III1. Non steroidal anti inflammatory drugs 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 salicylates, or non selective NSAIDs provides acceptable levels of pain relief. (Level of Evidence: C) |
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ACC / AHA Guidelines - Hormone Therapy (DO NOT EDIT)[2]
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Class III1. 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) 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)[2]
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Class III1. 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) 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
Sources
- The ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction [2]
- 2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients With Unstable Angina / Non–ST-Elevation Myocardial Infarction [3]
References
- ↑ 1.0 1.1 Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS (2011). "2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". Circulation. doi:10.1161/CIR.0b013e318212bb8b. PMID 21444888. Retrieved 2011-04-12. Unknown parameter
|month=
ignored (help) - ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 2.15 2.16 Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B (2007). "ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine". Journal of the American College of Cardiology. 50 (7): e1–e157. doi:10.1016/j.jacc.2007.02.013. PMID 17692738. Retrieved 2011-04-12. Unknown parameter
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ignored (help) - ↑ Wright RS, Anderson JL, Adams CD, Bridges CR, Casey DE, Ettinger SM, Fesmire FM, Ganiats TG, Jneid H, Lincoff AM, Peterson ED, Philippides GJ, Theroux P, Wenger NK, Zidar JP (2011). "2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction (Updating the 2007 Guideline): A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". Circulation. doi:10.1161/CIR.0b013e31820f2f3e. PMID 21444889. Retrieved 2011-03-31. Unknown parameter
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ignored (help)