ACS.ppt

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.

19901990 19921992 19941994 19961996 19981998 20002000 2002200219901990

ACC/AHAACC/AHAAMI AMI

R. GunnarR. Gunnar

19941994AHCPR/AHCPR/NHLBINHLBI

UA UA E. BraunwaldE. Braunwald

19961996 19991999 RevRev UpdUpd ACC/AHA AMI ACC/AHA AMI T. Ryan T. Ryan

2004 2004 20072007 Rev Rev Upd Upd ACC/AHA STEMI ACC/AHA STEMI

E. AntmanE. Antman

2000 2002 2000 2002 2007 2007 Rev UpdRev Upd RevRev

ACC/AHA UA/NSTEMI ACC/AHA UA/NSTEMI E. Braunwald J. AndersonE. Braunwald J. Anderson

20042004 20072007

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 makinga) Intensive initial assessmentb) Continuous clinical assessmentc) Targeted ECG and marker data

2. Risk based on contingent probabilitiesa) Probability of obstructive CAD causing ischemiab) 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

Ris

k

Physiological monitoringPeriodic physical examsCardiac markersECG

Time

Risk ScoresTIMI GRACE Future

History

AgeHypertensionDiabetesSmoking↑cholesterolFamily historyHistory of CAD

Age Continuous assessment

Presentation

Severe anginaAspirin within 7 daysElevated markersST segment deviation

Heart rateSystolic BPElevated markersHeart failureCardiac arrestElevated markersST segment deviation

New markers

Electronic health records



Kaplan-Meier Estimates of Probability of Death Based on Admission Electrocardiogram



Timing of Release of Various Biomarkers After Acute Myocardial Infarction



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).



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



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).


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 inhibitorUse 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 StrategyInitiate 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 StrategyProceed with an

Initial Conservative

Strategy

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

A

B

B1

B2

Prior to AngiographyInitiate at least one (Class I, LOE: A) or both (Class IIa, LOE: B) of the following:

ClopidogrelIV GP IIb/IIIa inhibitor

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

Delay to AngiographyHigh Risk Features

Early recurrent ischemic discomfort


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)



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)



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)



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 StrategyInitiate 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

MN

K

E-1 E-2

D

(Class I,

LOE: B)

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

Antiplatelet and A/C Rx

at physician’s discretion (Class I, LOE: C)

No significant obstructive

CAD on angiography

CAD on angiography

Medical therapyPCICABG

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

Yes

No


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)


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).



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)



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)



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)



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

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