slide1 n.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Support for implementing NICE guidance: Unstable angina and NSTEMI Unstable angina and NSTEMI, CG94, 2010 PowerPoint Presentation
Download Presentation
Support for implementing NICE guidance: Unstable angina and NSTEMI Unstable angina and NSTEMI, CG94, 2010

Loading in 2 Seconds...

play fullscreen
1 / 23

Support for implementing NICE guidance: Unstable angina and NSTEMI Unstable angina and NSTEMI, CG94, 2010 - PowerPoint PPT Presentation


  • 166 Views
  • Uploaded on

Support for implementing NICE guidance: Unstable angina and NSTEMI Unstable angina and NSTEMI, CG94, 2010. 3 rd Edition March 2014 . Updated guidance.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Support for implementing NICE guidance: Unstable angina and NSTEMI Unstable angina and NSTEMI, CG94, 2010' - sandra_john


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
slide1

Support for implementing NICE guidance: Unstable angina and NSTEMI

Unstable angina and NSTEMI, CG94, 2010

3rd Edition March 2014

updated guidance
Updated guidance

This guideline updates and replaces recommendations for the early management of unstable angina and NSTEMI from NICE technology appraisal guidance 47 and 80.

Recommendation 1.3.6 has been replaced by recommendation 1.3.18 in MI – secondary prevention: Secondary prevention in primary and secondary care for patients following a myocardial infarction.

Recommendation 1.5.11 has been updated to take into account people with a learning disability.

what this presentation covers
What this presentation covers

Background

Scope

Key priorities for implementation

Costs and savings

Discussion

NHS Evidence

Hyperglycaemia in ACS

Find out more

background 1
Background:1

Cholesterol-rich plaques form on coronary artery walls narrowing the lumen. Blood supply to myocarduim is compromised causing pain on exertion

An unstable plaque may tear and expose underlying athermoma. This stimulates clot (thrombus) formation

The thrombus partly blocks the artery, interrupting blood supply to heart muscle (myocardial ischaemia)

Unstable angina – myocardial ischaemia with no evidence of heart muscle death (myocardial necrosis)

NSTEMI – myocardial ischaemia with evidence of myocardial necrosis

background 2
Background:2

Outcomes vary widely among patients with NSTEMI and unstable angina

Scoring systems attempt to stratify risk of future adverse cardiovascular events

Guideline defines patients likely to benefit from interventions

scope
Scope

This guideline covers:

Adults with a diagnosis of unstable angina or NSTEMI

This guideline does not cover:

ST-segment-elevation myocardial infarction (STEMI)

Specific complications of unstable angina and NSTEMI such as cardiac arrest or acute heart failure

Management after discharge from hospital

key priorities for implementation
Key priorities for implementation
  • Assess risk of adverse cardiovascular events
  • Consider glycoprotein inhibitors for patients atintermediate or higher risk
  • Offer angiography within 96 hours to patients at intermediate or higher risk
  • Discuss revascularisation with other healthcare professionals and choice of strategy with patient
  • Consider ischaemia testing before discharge
  • Rehabilitation and discharge planning
risk assessment 1
Risk assessment: 1

As soon as the diagnosis of unstable angina or NSTEMI is made, and aspirin and antithrombin therapy have been offered, formally assess individual risk of future adverse cardiovascular events using an established risk scoring system that predicts 6-month mortality (for example, Global Registry of Acute Cardiac Events [GRACE]).

risk assessment 2
Risk assessment: 2

Risk categories derived from Myocardial Ischaemia National Audit Project (MINAP) database

antiplatelet therapy 1
Antiplatelet therapy: 1
  • Aspirin – offer a 300 mg loading dose as soon as possible unless there is clear evidence that a patient is allergic to it
  • Clopidogrel – offer as a treatment option for up to 12 months to people who have had an NSTEMI, regardless of treatment.
antiplatelet therapy 2
Antiplatelet therapy: 2

Consider intravenous eptifibatide or tirofibanas part of the early management for patients who:

  • have intermediate or higher risk ( 3.0%)

and

  • are scheduled to undergo angiographywithin 96 hours of admission
antithrombin therapy
Antithrombin therapy
  • Fondaparinux – for patients without high bleeding risk who are not undergoing coronary angiography within 24 hours of admission
  • Unfractionated heparin – for patients likely to undergo coronary angiography within 24 hours of admission
  • Offer systemic unfractionated heparin in the cardiac catheter laboratory to patients receiving fondaparinux who are undergoing PCI
antithrombin considerations
Antithrombin considerations

Carefully consider choice and dose of antithrombin for patients with high bleeding risk associated with:

  • advancing age
  • known bleeding complications
  • renal impairment
  • low body weight

As an alternative to the combination of a heparin plus a GPI, consider bivalirudin for patients at intermediate or higher risk of adverse cardiovascular events (predicted 6-month mortality above 3%), who:

  • have angiography scheduled within 24 hours

and

  • are not on fondaparinux or a GPI
management strategies 1
Management strategies: 1

Offer coronary angiography (with PCI if indicated) within 96 hours of first admission to patients with:

  • intermediate or higher risk ( 3.0%) and
  • no contraindications (such as comorbidity or active bleeding)

Perform angiography as soon as possible for patients who are:

  • clinically unstable or
  • at high ischaemic risk
management strategies 2
Management strategies: 2

When the role of revascularisation or the strategy is unclear, discuss with:

  • interventional cardiologist
  • cardiac surgeon
  • other healthcare professionals relevant to the needs of the patient

Discuss choice of strategy with the patient

testing for ischaemia
Testing for ischaemia

To detect and quantify inducible ischaemia, consider ischaemia testing before discharge for patients whose condition has been managed conservatively and who have not had coronary angiography

rehabilitation and discharge planning
Rehabilitation and discharge planning

Before discharge offer patients advice and information about:

  • diagnosis
  • arrangements for follow-up
  • cardiac rehabilitation
  • management of cardiovascular risk factors
  • drugs for secondary prevention
  • lifestyle changes
costs and savings
Costs and savings

The guideline on unstable angina and NSTEMI is unlikely to result in a significant change in resource use in the NHS.

However, recommendations in the following areas may result in additional costs/savings depending on local circumstances:

  • Considering intravenous eptifibatide or tirofiban as part of the early management for patients
  • Offering fondaparinux to patients who do not have a high bleeding risk
  • Offering ischaemia testing before discharge
discussion
Discussion

Which risk-scoring system should we be using to formally assess risk of future adverse cardiovascular events after diagnosis?

Do we have a robust mechanism for the timely and appropriate identification and risk assessment of patients?

How do we use eptifibatide and tirofiban and will this need to change?

Do we need to think about wider discussion across the team when considering revascularisation?

How do we need to update our dischargeinformation for patients?

hyperglycaemia in acs
Hyperglycaemia in ACS

Hyperglycaemia in ACS is a powerful predictor of poorer survival and increased risk of complications while in hospital.

In October 2011 NICE published clinical guideline 130 and a NICE pathway on Hyperglycaemia in ACS.

The guideline and pathway cover the management of hyperglycaemia within the first 48 hours in all patients admitted to hospital for acute coronary syndromes (ACS).

find out more
Find out more

Visit www.nice.org.uk/guidance/CG94 for:

  • the guideline
  • the quick reference guide
  • ‘Understanding NICE guidance’
  • costing statement
  • audit support, including patient questionnaire
  • chest pain algorithm, including clinical case scenarios
  • online educational tool
what do you think
What do you think?

Did the implementation tool you accessed today meet your requirements, and will it help you to put the NICE guidance into practice?

We value your opinion and are looking for ways to improve our tools. Please complete this short evaluation form.

If you are experiencing problems accessing or using this tool, please email implementation@nice.org.uk

To open the links in this slide set right click over the link and choose ‘Open Hyperlink’