UA/NSTEMI Guidelines

2007

Based on the ACC/AHA Guidelines for the
Management of Patients With Unstable Angina/Non-
ST-Elevation Myocardial Infarction: A Report of the
ACC/AHA 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.

1990 1992 1994 1996 1998 2000 2002
1990
ACC/AHA
AMI
R. Gunnar
1994
AHCPR/NHLBI
UA
E. Braunwald
1996 1999
Rev Upd
ACC/AHA AMI
T. Ryan
2004
2007
Rev Upd
ACC/AHA STEMI
E. Antman
2000 2002 2007
Rev Upd Rev
ACC/AHA UA/NSTEMI
E. Braunwald J. Anderson
2004 2007
Figure 1. Evolution of Guidelines for Management of Patients
with AMI
The first guideline published by the ACC/AHA described the
management of patients with acute myocardial infarction (AMI). The
subsequent three documents were the Agency for Healthcare and
Quality/National Heart, Lung and Blood Institute sponsored guideline
on management of unstable angina (UA), the revised/updated
ACC/AHA guideline on AMI, and the revised/updated ACC/AHA
guideline on unstable angina/non-ST segment myocardial infarction
(UA/NSTEMI). The present guideline is a revision and deals strictly
with the management of patients presenting with ST segment
elevation myocardial infarction (STEMI). The names of the chairs of
the writing committees for each of the guidelines are shown at the
bottom of each box. Rev, Revised; Upd,
Update
Evolution of Guidelines for ACS
Copyright 2007 American College of Cardiology Foundation. Restrictions may apply.
Anderson, J. L. et al. J Am Coll Cardiol 2007;50:e1-e157
Acute Coronary Syndromes
Hospitalizations in the U.S. Due to
Acute Coronary Syndromes (ACS)
Acute Coronary
Syndromes*
1.57 Million Hospital Admissions - ACS
UA/NSTEMI

STEMI

1.24 million
Admissions per year
.33 million
Admissions per year
Heart Disease and Stroke Statistics 2007 Update. Circulation 2007; 115:69-171.
*Primary and secondary diagnoses. About 0.57 million NSTEMI and 0.67 million
UA.
Risk Stratification
Risk Stratification
1. Integral prerequisite to decision making
a) Intensive initial assessment
b) Continuous clinical assessment
c) Targeted ECG and marker data

2. Risk based on contingent probabilities
a) Probability of obstructive CAD causing ischemia
b) Risk given presence of obstructive CAD

3. Risk scores should be a routine part of
assessment throughout the hospital course and
periodically after discharge
Risk Assessment Dependent on
Contingent Probabilities
Likelihood of
obstructive CAD as
cause of symptoms
Dominated by acute
findings
Exam
Symptoms
Markers
Traditional risk factors
are of limited utility
Does this patient have
symptoms due to acute
ischemia from
obstructive CAD?
Risk of bad
outcome
Dominated by
acute findings
Older age very
important
Hemodynamic
abnormalities
critical
ECG, markers
What is the likelihood
of death, MI, heart
failure?
24h 3-4 days 6 months
R
i
s
k

Physiological monitoring
Periodic physical exams
Cardiac markers
ECG
Time
Risk Scores
TIMI GRACE Future
H
i
s
t
o
r
y

Age
Hypertension
Diabetes
Smoking
cholesterol
Family history
History of CAD
Age Continuous
assessment

P
r
e
s
e
n
t
a
t
i
o
n

Severe angina
Aspirin within 7 days
Elevated markers
ST segment
deviation
Heart rate
Systolic BP
Elevated markers
Heart failure
Cardiac arrest
Elevated markers
ST segment
deviation
New markers

Electronic health
records

Copyright 2007 American College of Cardiology Foundation. Restrictions may apply.
Anderson, J. L. et al. J Am Coll Cardiol 2007;50:e1-e157
Kaplan-Meier Estimates of Probability of Death Based on Admission Electrocardiogram
Copyright 2007 American College of Cardiology Foundation. Restrictions may apply.
Anderson, J. L. et al. J Am Coll Cardiol 2007;50:e1-e157
Timing of Release of Various Biomarkers After Acute Myocardial Infarction
Copyright 2007 American College of Cardiology Foundation. Restrictions may apply.
Anderson, J. L. et al. J Am Coll Cardiol 2007;50:e1-e157
Troponin I Levels to Predict the Risk of Mortality in Acute Coronary Syndromes
Early Hospital Care
2007 ACC/AHA UA/NSTEMI Guideline Revision
Selection of Strategy: Invasive
vs. Conservative Strategy (1)
An early invasive strategy (i.e., diagnostic
angiography with intent to perform
revascularization) is indicated with
refractory angina or hemodynamic or
electrical instability (I, B).
2007 ACC/AHA UA/NSTEMI Guideline Revision
Selection of Strategy: Invasive
vs. Conservative Strategy (2)
An early invasive strategy is indicated in initially stabilized patients
(without serious comorbidities or contraindications to such
procedures) who have an elevated risk for clinical events (I, A). Scores
indicating elevated risk include combinations of the following:
Recurrent angina/ischemia at rest or low-level activities
Elevated cardiac biomarkers
New/presumably new ST-segment depression
Signs or symptoms of HF or new/worsening mitral regurgitation
High-risk findings from noninvasive testing
Hemodynamic instability
Sustained ventricular tachycardia
PCI within 6 months
Prior CABG
High risk score
LVEF < 0.40
2007 ACC/AHA UA/NSTEMI Guideline Revision
Selection of Strategy: Invasive
vs. Conservative Strategy (3)
In initially stabilized patients, an initially
conservative (i.e., a selectively invasive) strategy may
be considered in patients (without serious
comorbidities or contraindications to such
procedures) who have an elevated risk for clinical
events, including those who are troponin-positive
(IIb, B). The decision to implement an initial
conservative strategy may consider physician and
patient preferences (IIb, C).
A conservative strategy is recommended in women
with low-risk features (I, B).
2007 ACC/AHA UA/NSTEMI Guideline Revision
Initial Invasive Strategy:
Antiplatelet, Anticoagulant Therapy
Initiate anticoagulant therapy as soon as possible after
presentation (I, A)
Enoxaparin or UFH (I, A)
Bivalirudin or fondaparinux (I, B)
Prior to angiography, initiate one (I, A) or both (IIa, B)
Clopidogrel
IV GP IIb/IIIa inhibitor
Use both if:
Delay to angiography
High risk features
Early recurrent ischemic symptoms
Algorithm for
Patients with
UA/NSTEMI
Managed by an
Initial Invasive
Strategy
Proceed to Diagnostic Angiography
ASA (Class I, LOE: A)
Clopidogrel if ASA intolerant (Class I,
LOE: A)
Diagnosis of UA/NSTEMI is Likely or
Definite
Invasive Strategy
Initiate A/C Rx (Class I, LOE: A)
Acceptable options: enoxaparin or UFH (Class I, LOE: A)
bivalirudin or fondaparinux (Class I, LOE: B)
Select Management Strategy
Proceed with an
Initial
Conservative
Strategy
Anderson JL. J Am Coll Cardiol 2007;50:e1-157. Figure 7
A
B
B1
B2
Prior to Angiography
Initiate at least one (Class I, LOE: A) or
both (Class IIa, LOE: B) of the following:

Clopidogrel
IV GP IIb/IIIa inhibitor
Factors favoring admin of both clopidogrel
and GP IIb/IIIa inhibitor include:
Delay to Angiography
High Risk Features
Early recurrent ischemic discomfort
2007 ACC/AHA UA/NSTEMI Guideline Revision
Initial Conservative Strategy:
Early Hospital Care (1)
ASA; clopidogrel if intolerant (I, A)
Anticoagulant therapy should be added to
antiplatelet therapy as soon as possible after
presentation (I, A)
Enoxaparin or UFH (I, A)
Fondaparinux (I, B)
Enoxaparin or fondaparinux preferable (IIa, B)
Initiate clopidogrel, loading dose + maintenance
dose (I, A)
Consider IV eptifibatide or tirofiban (IIb, B)
2007 ACC/AHA UA/NSTEMI Guideline Revision
Initial Conservative Strategy:
Early Hospital Care (2)
If LVEF is < 0.40, it is reasonable to perform diagnostic
angiography (IIa, B)
A stress test should be performed for assessment of
ischemia (I, B)
If the patient is classified as not as low risk, diagnostic
angiography should be performed (I, A)
Measurement of BNP or NT-pro-BNP may be considered
to supplement assessment of global risk in patients with
suspected ACS (IIb, B)
2007 ACC/AHA UA/NSTEMI Guideline Revision
Initial Conservative Strategy:
Early Hospital Care (3)
Beta blocker therapy
Initiate oral therapy within first 24 hr unless HF,
low-output state, increased risk for cardiogenic
shock, or relative contraindications (I, B)
IV therapy for high blood pressure without
contraindications (IIa, B)
IV therapy may be harmful with contraindications
to beta blockade, signs of HF or low-output state,
or other risk factors for cardiogenic shock (III, A)
2007 ACC/AHA UA/NSTEMI Guideline Revision


Initial Conservative Strategy:
Early Hospital Care (4)
Lipid management
Fasting lipid profile within 24 hr (I, C)
Statin (in absence of contraindications) should be given
regardless of baseline LDL-C pre-discharge (I, A)

ACE inhibitor (oral)
Within 24 hr with pulmonary congestion or LVEF 40, in
absence of hypotension (systolic blood pressure <100
mmHg or <30 mmHg below baseline) or known
contraindications (I, A)
ARB if ACE intolerant (I, A)
Can be useful without pulmonary congestion or LVEF
< 0.40 (IIa, B)
No IV ACE-I in first 24 hr because of increased risk of
hypotension (III, B)
Initiate clopidogrel (Class I, LOE: A)
Consider adding IV eptifibatide or tirofiban (Class
IIb, LOE: B)
Conservative Strategy
Initiate A/C Rx (Class I, LOE: A):
Acceptable options: enoxaparin or UFH (Class I,
LOE: A) or fondaparinux (Class I, LOE: B), but
enoxaparin or fondaparinux are preferable (Class IIA,
LOE: B)
Select Management Strategy
ASA (Class I, LOE: A)
Clopidogrel if ASA intolerant (Class I, LOE: A)
Diagnosis of UA/NSTEMI is Likely
or Definite
Algorithm for Patients with UA/NSTEMI
Managed by an Initial Conservative Strategy
Proceed with
Invasive
Strategy
(Continued)
Anderson JL. J Am Coll Cardiol 2007;50:e1-157. Figure 8
C2
C1
A
Any subsequent events necessitating
angiography?
EF greater
than 0.40
Evaluate LVEF
Low Risk
Cont ASA indefinitely (Class I, LOE A)
Cont clopidogrel for at least one month (Class I, LOE A) and ideally up to
1 yr (Class I, LOE B)
DC IV GP IIb/IIIa if started previously (Class I, LOE A)
DC A/C Rx (Class I, LOE A)
(Class I, LOE: B)
Proceed to Dx
Angiography
Yes
EF 0.40 or
less Stress Test
(Class I, LOE: A)
No
Not Low Risk
(Class IIa,
LOE: B)
Algorithm for Patients with UA/NSTEMI
Managed by an Initial Conservative Strategy
(Continued)
Anderson JL. J Am Coll Cardiol 2007;50:e1-157. Figure 8
(Class I, LOE: A)
(Class IIa, LOE: B)
O
L
M
N
K
E-1 E-2
D
Revascularization and
Late Hospital Care
Cont ASA (Class I, LOE: A)
DC clopidogrel 5 to 7 d prior to
elective CABG (Class I, LOE: B)
DC IV GP IIb/IIIa 4 h prior to
CABG (Class I, LOE: B)
Cont UFH (Class I, LOE: B); DC
enoxaparin 12 to 24 h prior to
CABG; DC fondaparinux 24 h
prior to CABG; DC bivalirudin 3 h
prior to CABG. Dose with UFH
per institutional practice (Class I,
LOE: B)
Cont ASA (Class I, LOE A)
LD of clopidogrel if not given
pre angio (Class I, LOE: A)
&
IV GP IIb/IIIa if not started
pre angio (Class I, LOE: A)

DC A/C Rx after PCI for
uncomplicated cases
(Class I, LOE: B)
Cont ASA (Class I, LOE: A)
LD of clopidogrel if not
given pre angio (Class I, LOE A)*
DC IV GP IIb/IIIa after
at least 12 h if started pre angio
(Class I, LOE: B)
Cont IV UFH for at least 48 h (Class
I, LOE: A) or enoxaparin or
fondaparinux for dur of hosp (LOE: A);
either DC bivalirudin or cont at a dose
of 0.25 mg/kg/hr for up to 72 h at
physicians discretion (Class I, LOE:
B)
Antiplatelet
and A/C Rx
at
physicians
discretion
(Class I,
LOE: C)
No
significant
obstructive
CAD on
angiography
CAD on angiography
Medical therapy PCI CABG
Select Post Angiography Management Strategy
Dx Angiography
Management after Diagnostic Angiography in
Patients with UA/NSTEMI
Anderson JL. J Am Coll Cardiol 2007;50:e1-157. In press. Figure 9
G
H
I
J
F
Long-Term Antithrombotic Therapy at Hospital
Discharge after UA/NSTEMI
Medical Tx w/o
Stent
Bare Metal
Stent
Drug Eluting
Stent
ASA 162 to 325 mg/d for at least
1 mo, then 75 to 162 mg/d
indefinitely (Class I LOE: A)
&
Clopidogrel 75 mg/d for at least
1 mo and up to 1 yr (Class I LOE:B)
Add: Warfarin (INR 2.0 to
2.5) (Class IIb LOE: B)
Continue with dual
antiplatelet tx as above.
Indication for
Anticoagulation?
ASA 75 to 162 mg/d
indefinitely (Class I LOE: A)
&
Clopidogrel 75 mg/d at least
1 mo (Class I LOE: A) and up
to 1 yr (Class I LOE: B)
ASA 162 to 325 mg/d for at
least 3 to 6 months, then 75
to 162 mg/d indefinitely
(Class I LOE: A)
&
Clopidogrel 75 mg/d for at
least 1 yr (Class I LOE: B)
Anderson JL. J Am Coll Cardiol 2007;50:e1-157. Figure 11.
UA/NSTEMI
Patient Groups
at Discharge
Ye
s
No
2007 ACC/AHA UA/NSTEMI Guideline Revision
More Aggressive Long-Term
Antiplatelet Therapy
Medical therapy without stenting
ASA 75-162 mg/d indefinitely (I, A)
+
clopidogrel 75 mg/d, at least 1 mo (I, A), ideally up to 1 yr (I, B)

Bare metal stent
ASA 162-325 mg/d at least 1 mo, 75-162 mg/d indefinitely (I, A)
+
clopidogrel 75 mg/d, at least 1 mo (I, A), ideally up to 1 yr (I, B)

Drug-eluting stent
ASA 162-325 mg/d at least 3 (sirolimus)-6 (paclitaxel) mo, 75-162
mg/d indefinitely (I, A)
+
clopidogrel 75 mg/d at least 1 yr (I, B)
2007 ACC/AHA UA/NSTEMI Guideline Revision
Discharge Planning:
Secondary Prevention (1)
Clopidogrel, initial conservative strategy
Continue at least 1 mo (I, A)
Continue ideally up to 1 yr (I, A)
ACE inhibitor
Continue indefinitely with HF, LV dysfunction with LVEF < 0.40,
hypertension or diabetes (I, A)
Reasonable in absence of LV dysfunction, hypertension or diabetes
(IIa, A)
Reasonable with HF and LVEF >0.40 (IIa, A)
Consider ACE/ARB combination with persistent HF and LVEF
<0.40 despite conventional therapy including ACE or ARB (IIb, B)
Angiotensin Receptor Blocker (ARB) should be administered at
discharge (I, A) and long-term (IIa, B) with ACE inhibitor
intolerance and signs of HF with LVEF < 0.40 (I, A).
2007 ACC/AHA UA/NSTEMI Guideline Revision
Discharge Planning:
Secondary Prevention (2)
Aldosterone receptor blockade should be prescribed long
term if without significant renal dysfunction or
hyperkalemia, already on ACE inhibitor, with LVEF
< 0.40, and either symptomatic HF or diabetes (I, A).
Lipid management
Statin regardless of baseline LDL-C (I, A) initiated prior to
discharge (I, A)
Goal LDL-C <100 mg/dl (I, A), with <70 mg/dl reasonable (IIa, A)
Treatment of triglycerides and non-HDL-C useful
If TG 200-499 mg/dl, non-HDL-C should be <130 mg/dl (I, B)
TG 500 mg/dl, fibrate or niacin before LDL-C lowering to prevent
pancreatitis (I, C)
2007 ACC/AHA UA/NSTEMI Guideline Revision
Discharge Planning:
Secondary Prevention (3)
Blood Pressure Control
<140/90 mmHg (I, A)
<130/80 mmHg with diabetes mellitus or
chronic kidney disease (I, A)
Smoking cessation and avoidance of
exposure to environmental tobacco is
recommended (I, B)
Education, referral to programs and
pharmacotherapy is useful (I, B)
2007 ACC/AHA UA/NSTEMI Guideline Revision
Discharge Planning:
Secondary Prevention (4)
NSAIDS
Discontinue at UA/NSTEMI presentation (I, C)
No NSAID, nonselective or COX-2 selective (except ASA),
during hospitalization for patients re high risk of mortality,
reinfarction, BP, HF, or myocardial rupture (II, C)
At discharge, chronic musculoskeletal pain relief with
acetaminophen, small dose narcotics, non-acetylated
salicylates (I, A)
Nonselective NSAID (e.g., naproxen) reasonable if above
insufficient (IIa, C)
For intolerable discomfort, increasing COX-2 selectivity,
lowest dose for shortest time (IIb, C)
2007 ACC/AHA UA/NSTEMI Guideline Revision
Discharge Planning:
Secondary Prevention (5)
Discharge education/referral
Medications, diet, exercise, smoking cessation, cardiac
rehabilitation (I, C)
Return appointment
2-6 wk low risk medically-treated or revascularized
patients (I, C)
Within 14 days for higher-risk patients (I, C)
Menopausal hormone therapy (estrogen plus progestin
or estrogen alone) should not be given de novo for
secondary prevention of coronary events (III, A)
Antioxidant vitamin supplements (C, E, or beta carotene)
and folic acid (with or without B6 and B12) should not be
used for secondary prevention (III, A)
Preparation for Discharge After UA/NSTEMI
Antiplatelet Rx
ASA 75 - 162 mg/day
Clopidogrel 75 mg/day
Beta Blocker
ACEI / ARB
Especially if DM, HF, EF <40%, HTN
Statin
LDL <100 mg/dL (ideally <70 mg/dL)
Secondary Prevention Measures
Smoking Cessation
BP <140/90 mm HG or <130/80 mm HG for DM or chronic kidney
disease
HbA1C <7%
BMI 18.5-24.9
Physical Exercise 30-60 min at least 5 days/wk