Loading in 2 Seconds...
Loading in 2 Seconds...
Support for implementing NICE guidance: Unstable angina and NSTEMI Unstable angina and NSTEMI, CG94, 2010. 3 rd Edition March 2014 . Updated guidance.
Unstable angina and NSTEMI, CG94, 2010
3rd Edition March 2014
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Recommendation 1.3.6 has been replaced by recommendation 1.3.18 in MI – secondary prevention: Secondary prevention in primary and secondary care for patients following a myocardial infarction.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.
Key priorities for implementation
Costs and savings
Hyperglycaemia in ACS
Find out more
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
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
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
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 categories derived from Myocardial Ischaemia National Audit Project (MINAP) database
Consider intravenous eptifibatide or tirofibanas part of the early management for patients who:
Carefully consider choice and dose of antithrombin for patients with high bleeding risk associated with:
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:
Offer coronary angiography (with PCI if indicated) within 96 hours of first admission to patients with:
Perform angiography as soon as possible for patients who are:
When the role of revascularisation or the strategy is unclear, discuss with:
Discuss choice of strategy with the patient
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
Before discharge offer patients advice and information about:
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:
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 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).
Visit www.nice.org.uk/guidance/CG94 for:
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 email@example.com
To open the links in this slide set right click over the link and choose ‘Open Hyperlink’