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ua nstemi guidelines audio webcast a presentation discussion of treatment essentials
UA/NSTEMI Guidelines Audio-Webcast: A Presentation & Discussion of Treatment Essentials

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.

Presented by:

Jeffrey L. Anderson, MD, FACC, Moderator

Elliott M. Antman, MD, FACC

Robert M. Califf, MD, MACCA. Michael Lincoff, MD, FACC

slide2

Disclosures

Jeffrey L. Anderson, MD, FACC

slide3

Disclosures

Elliott M. Antman, MD, FACC

slide4

Disclosures

Robert M. Califf, MD, MACC

slide5

Disclosures

Robert M. Califf, MD, MACC

slide6

Disclosures

Robert M. Califf, MD, MACC

slide7

Disclosures

A. Michael Lincoff, MD, FACC

slide8

Evolution of Guidelines for ACS

2004

2007

1990

1992

1994

1996

1998

2000

2002

1990ACC/AHAAMI R. Gunnar

1994AHCPR/NHLBIUA E. Braunwald

1996 1999Rev Upd ACC/AHA AMI T. Ryan

2000 2002 2007

Rev UpdRev

ACC/AHA UA/NSTEMI

E. Braunwald J. Anderson

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

2004 2007

Rev Upd

ACC/AHA STEMI

E. Antman

slide9

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 millionAdmissions per year

.33 millionAdmissions 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 stratification1
Risk Stratification
  • Integral prerequisite to decision making
    • Intensive initial assessment
    • Continuous clinical assessment
    • Targeted ECG and marker data
  • Risk based on contingent probabilities
    • Probability of obstructive CAD causing ischemia
    • Risk given presence of obstructive CAD
  • 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?

Risk Assessment Dependent on Contingent Probabilities
slide13

Physiological monitoring

Periodic physical exams

Cardiac markers

ECG

Risk

24h

3-4 days

6 months

Time

algorithm for patients with ua nstemi managed by an initial invasive strategy
Algorithm for Patients with UA/NSTEMI Managed by an Initial Invasive Strategy

Diagnosis of UA/NSTEMI is Likely or Definite

ASA (Class I, LOE: A)

Clopidogrel if ASA intolerant (Class I, LOE: A)

A

Proceed with an Initial Conservative Strategy

Select Management Strategy

B

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)

B1

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

B2

Factors favoring admin of both clopidogrel and GP IIb/IIIa inhibitor include:

Delay to Angiography

High Risk Features

Early recurrent ischemic discomfort

Proceed to Diagnostic Angiography

Anderson JL. J Am Coll Cardiol 2007;50:e1-157. Figure 7

slide17

Algorithm for Patients with UA/NSTEMI Managed by an Initial Conservative Strategy

Diagnosis of UA/NSTEMI is Likely or Definite

ASA (Class I, LOE: A)

Clopidogrel if ASA intolerant (Class I, LOE: A)

A

Proceed with Invasive Strategy

Select Management Strategy

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)

C1

Initiate clopidogrel (Class I, LOE: A)

Consider adding IV eptifibatide or tirofiban (Class IIb, LOE: B)

C2

(Continued)

Anderson JL. J Am Coll Cardiol 2007;50:e1-157.Figure 8

slide18

Algorithm for Patients with UA/NSTEMI Managed by an Initial Conservative Strategy

(Continued)

Any subsequent events necessitating angiography?

D

Yes

No

(Class I,

LOE: B)

L

Evaluate LVEF

M

(Class I, LOE: B)

(Class IIa, LOE: B)

N

EF 0.40 or less

O

EF greater

than 0.40

Stress Test

(Class IIa, LOE: B)

E-1

E-2

Proceed to Dx Angiography

Not Low Risk

Low Risk

(Class I, LOE: A)

(Class I, LOE: A)

K

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)

Anderson JL. J Am Coll Cardiol 2007;50:e1-157.Figure 8

slide20

Management after Diagnostic Angiography in Patients with UA/NSTEMI

Dx Angiography

F

Select Post Angiography Management Strategy

CABG

PCI

Medical therapy

G

CAD on angiography

H

No significant obstructive CAD on angiography

  • 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)

J

  • 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 physician‘s discretion (Class I, LOE: B)

I

Antiplatelet and A/C Rx at physician’s discretion (Class I, LOE: C)

Anderson JL. J Am Coll Cardiol 2007;50:e1-157.In press. Figure 9

slide21

Long-Term Antithrombotic Therapy at Hospital Discharge after UA/NSTEMI

UA/NSTEMI Patient Groups at Discharge

Medical Tx w/o Stent

Bare Metal Stent

Drug Eluting Stent

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)

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

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)

Indication for Anticoagulation?

Yes

No

Continue with dual antiplatelet tx as above.

Add: Warfarin (INR 2.0 to 2.5) (Class IIb LOE: B)

Anderson JL. J Am Coll Cardiol 2007;50:e1-157.Figure 11.

preparation for discharge after ua nstemi
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
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