ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction—Executive Summary

ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction—Executive Summary: A Report of the American College of Cardiology/American Heart Association 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): Developed in Collaboration With the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons.

Anderson JL, Adams CD, Antman EM, et al.

J Am Coll Cardiol. 2007;50:652-726.

http://www.cardiosource.com/guidelinefocus/gfc_acs.asp

Twenty points to remember about these guidelines are:

Initial Evaluation:

1. Patients with chest discomfort whose symptoms are not improved 5 minutes after taking nitroglycerin (NTG) are advised to call emergency medical service (EMS) before taking more NTG. Patients with chronic stable angina may take up to a maximum of three doses, 5 minutes apart, if symptoms are significantly improved by the first dose of NTG. They should still call EMS if symptoms are not resolved completely.

2. An electrocardiogram (ECG) should be performed on the patient with chest pain within 10 minutes of arrival to the emergency department (ED). Patients with chest pain should be rapidly stratified into one of four categories: noncardiac diagnosis, definite acute coronary syndrome (ACS), possible ACS, and chronic stable angina.

3. A cardiac-specific troponin is the preferred biomarker in patients presenting with symptoms consistent with ACS.

4. Patients with possible ACS, but with normal ECG and biomarkers over 12 to 16 hours should generally have a stress test performed prior to ED discharge or within 72 hours of discharge. These patients should be treated with appropriate pharmacotherapy while awaiting the stress test.

5. Patients with low probability of coronary artery disease (CAD) and possible ACS can also be evaluated by computed tomography angiography in lieu of a stress test.

Early Management:

6. Patients with hemodynamic instability or those with ongoing symptoms should be admitted to a coronary care unit, whereas others should be admitted to a step-down unit.

7. Oral beta-blockers should be instituted within the first 24 hours in absence of contraindications. Intravenous beta-blockers should only be used for specific indications and not as a routine therapy.

8. Nonsteroidal anti-inflammatory drugs (COX-1 or COX-2 inhibitors) other than aspirin (ASA) should be discontinued on admission to the hospital in a patient with ACS.

9. Use of morphine as an analgesic has been associated with a worse outcome in observational studies. The guidelines have downgraded it from a Class I to a Class IIa recommendation.

10. Antiplatelet therapy:

a. ASA should be administered to patients with ACS as soon as possible (unless contraindicated) and continued lifelong. Patients with ASA allergy or intolerance should be treated with clopidogrel.

b. Clopidogrel, in addition to ASA, should be initiated in patients in whom either a conservative or an early invasive therapy is considered, but the likelihood of surgical disease requiring early coronary artery bypass grafting (CABG) is low.

c. Upstream use of eptifibatide or tirofiban should be considered in high-risk patients and those with troponin elevation, especially if an invasive therapy is contemplated. Abciximab should not be used unless there is no appreciable delay to percutaneous coronary intervention (PCI). Abciximab can be used safely for PCI in patients who have not received upstream glycoprotein (GP) IIb/IIIa inhibitors and may be better than tirofiban in this population. GP IIb/IIIa inhibitors provide incremental benefit in patients with elevated troponin undergoing PCI even among those pretreated with clopidogrel.

11. Anticoagulant therapy:

a. In patients treated with conservative therapy, the preferred anticoagulant may be fondaparinux, enoxaparin (for 8 days or duration of hospitalization), or unfractionated heparin (UFH) (for 48 hours) (in that order).

b. In patients treated with invasive therapy, enoxaparin or UFH-based regimens have the most supporting evidence.

c. For patients undergoing CABG, ASA should be continued while clopidogrel should be stopped 5-7 days before, and low-molecule GP IIb/IIIa inhibitors stopped 4 hours before the surgery. Enoxaparin should be stopped 12-24 hours prior and fondaparinux stopped 24 hours prior to CABG, and UFH started.

d. All patients receiving intravenous GP IIb/IIIa inhibitors must also receive concomitant UFH or another antithrombotic agent.

12. Early invasive therapy is preferable in the high-risk patients with ongoing symptoms or hemodynamic instability, whereas either early invasive or conservative therapy can be used in other patients based on physician and patient preference. In patients who are stable for 12-24 hours on conservative therapy, noninvasive stress testing should be performed prior to discharge.

13. Choice of surgical versus percutaneous revascularization (similar to that in a patient with stable disease) should be determined by a patient’s anatomy, left ventricular function, and presence or absence of diabetes and other comorbidities.

14. Patients with non–ST-elevation myocardial infarction (NSTEMI) who had totally occluded vessels on angiography did not benefit from PCI in the OAT trial (similar to those with STEMI) and should not be intervened upon.

15. The risk of death or recurrent MI in patients with NSTEMI ACS is highest in the first 2 months and returns to a baseline risk of those with stable CAD by 3 months. Low-risk patients (and fully revascularized patients) should be followed up at 2-6 weeks, whereas high-risk patients should be re-evaluated within 2 weeks.

16. All patients with ACS should receive ASA, statins, beta-blockers, and clopidogrel (for at least 1 year). Angiotensin-converting enzyme inhibitors (or angiotensin-receptor blockers) should be initiated in patients with abnormal left ventricular ejection fraction, hypertension, diabetes, or heart failure. These medications are best initiated in the hospital since the likelihood that they will be continued long-term is highest. The blood pressure goal should be less than 140/90 mm Hg for all patients and less than 130/80 mm Hg for patients with diabetes mellitus or chronic kidney disease.

17. Hormone replacement therapy (HRT) should not be started in patients with ACS. Patients on HRT at the time of ACS should be advised to discontinue it.

18. Patients with diabetes should be treated with aggressive glucose control while hospitalized. Other diagnostic and therapeutic interventions should be in a manner similar to those of nondiabetics.

19. Special attention to drug dosing and altered pharmacodynamics is warranted while treating the elderly and patients with renal impairment.

20. Return to activity should be guided by an exercise tolerance test. Exercise training can begin within 1-2 weeks after coronary revascularization. Patients should be encouraged to walk (or engage in other physical activity) for 30-60 minutes daily. Patients with uncomplicated NSTEMI ACS can return to driving within 1 week of discharge unless prohibited by State law. Patients with complicated MI should delay driving for 2-3 weeks. Hitinder S. Gurm, M.B.B.S., F.A.C.C.

Diabetes and Mortality Following Acute Coronary Syndromes

Diabetes and Mortality Following Acute Coronary Syndromes

JAMA. 2007;298:765-775.

Sean M. Donahoe, MD; Garrick C. Stewart, MD; Carolyn H. McCabe, BS; Satishkumar Mohanavelu, MS; Sabina A. Murphy, MPH; Christopher P. Cannon, MD; Elliott M. Antman, MD

Context The worldwide epidemic of diabetes mellitus is increasing the burden of cardiovascular disease, the leading cause of death among persons with diabetes. The independent effect of diabetes on mortality following acute coronary syndromes (ACS) is uncertain.

Objective To evaluate the influence of diabetes on mortality following ACS using a large database spanning the full spectrum of ACS.

Design, Setting, and Patients A subgroup analysis of patients with diabetes enrolled in randomized clinical trials that evaluated ACS therapies. Patients with ACS in 11 independent Thrombolysis in Myocardial Infarction (TIMI) Study Group clinical trials from 1997 to 2006 were pooled, including 62 036 patients (46 577 with ST-segment elevation myocardial infarction [STEMI] and 15 459 with unstable angina/non-STEMI [UA/NSTEMI]), of whom 10 613 (17.1%) had diabetes. A multivariable model was constructed to adjust for baseline characteristics, aspects of ACS presentation, and treatments for the ACS event.
Main Outcome Measures Mortality at 30 days and 1 year following ACS among patients with diabetes vs patients without diabetes.

Results Mortality at 30 days was significantly higher among patients with diabetes than without diabetes presenting with UA/NSTEMI (2.1% vs 1.1%, P < .001) and STEMI (8.5% vs 5.4%, P < .001). After adjusting for baseline characteristics and features and management of the ACS event, diabetes was independently associated with higher 30-day mortality after UA/NSTEMI (odds ratio [OR], 1.78; 95% confidence interval [CI], 1.24-2.56) or STEMI (OR, 1.40; 95% CI, 1.24-1.57). Diabetes at presentation with ACS was associated with significantly higher mortality 1 year after UA/NSTEMI (hazard ratio [HR], 1.65; 95% CI, 1.30-2.10) or STEMI (HR, 1.22; 95% CI, 1.08-1.38). By 1 year following ACS, patients with diabetes presenting with UA/NSTEMI had a risk of death that approached patients without diabetes presenting with STEMI (7.2% vs 8.1%). Conclusion Despite modern therapies for ACS, diabetes confers a significant adverse prognosis, which highlights the importance of aggressive strategies to manage this high-risk population with unstable ischemic heart disease.

ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction

Aug 6, 2007

ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction

LINK: http://www.cardiosource.com/guidelines/UA-NSTEMI.FullText.pdf


Aug 6, 2007

Highlights From the 2007 UA/NSTEMI Revision:

Text and summary table from Dr. Nanette Wenger, MD, MACP, FACC, FAHA

LINK: http://www.cardiosource.com/images/acs_gfc_chart.pdf

ICTUS Trial

Three year follow-up from the ICTUS trial: Early intervention or selective-based treatment for coronary heart disease?

Christopher CannonTIMI Study Group, Boston, MA, USA19 June 2007

Globally, coronary artery disease (CAD) is the leading cause of mortality, with non-ST-segment elevation myocardial infarction (NSTEMI) and unstable angina (UA) being the most common manifestations of this condition.

There has been much debate over the past decade regarding the optimal management of patients with CAD.

Should we provide routine early invasive strategies, or do we need to adopt a more “conservative” approach based on selective intervention focused towards high-risk patients?

Cardiac catheterization and revascularization: The two main approaches
There are two general approaches to the use of cardiac catheterization and revascularization in UA/NSTEMI.

The “early invasive” strategy involves routine early cardiac catheterization and revascularization with percutaneous coronary intervention (PCI), or bypass surgery depending on the coronary anatomy.

The “conservative” strategy involves providing initial medical management, with catheterization and revascularization only for recurrent ischemia either at rest or on a non-invasive stress test.

The ACC/AHA guidelines were updated in 2002, and were based on the results of the FRagmin and Fast Revascularization during InStability in coronary artery disease (FRISC II) and Treat Angina with aggrastat and determine Cost of Therapy with Invasive or Conservative Strategy - Thrombolysis In Myocardial Infarction 18 (TACTICS-TIMI 18) trials, both of which compared early invasive strategies with the conservative approach.

The results of these trials suggested that patients who received early invasive therapy benefited more than those who underwent conservative treatment.

However, to date, 10 randomized trials have studied the relative merits of an invasive versus a conservative strategy. These include the FRISC-II, RITA-3, and TACTICS. These trials yielded varying results.

Of note, the other recent long-term follow-up data available from the RITA-3 trial demonstrated a benefit of a significantly lower cardiovascular mortality rate in the early invasive arm which was observed over five years. [1] A meta-analysis of the contemporary trial has confirmed an overall significant reduction in death, MI or rehospitalization during follow-up was observed. [2]

The most recent trial, Invasive Treatment Versus Conservative Treatment in Unstable Coronary Syndromes (ICTUS), examined an invasive versus conservative approach in 1200 patients. All patients received aspirin, enoxaparin, abciximab for PCI and intensive statin therapy. At one, year there was no significant difference in the rate of the primary endpoint, death, MI, or rehospitalization for angina. [3]

During the index hospitalization, there was a higher rate of MI in the invasive arm, although this trial used a definition of MI that included any elevation of any biomarker following PCI, and thus had a much higher peri-procedural MI rate compared with prior trials.

Throughout the three year follow-up period, the higher overall rate of MI (again using their definition of MI) persisted, with rates of 18 versus 12 (p=0). No difference in mortality was seen. [4]

How do we incorporate this new information? Based on multiple randomized trials, an early invasive strategy remains the recommended approach to higher risk patients with UA/NSTEMI who have either ST-segment changes, positive troponin, or other other high-risk indicators, such as recurrent ischemia, evidence of congestive heart failure. [5]

References

de Winter RJ, Windhausen F, Cornel JH, et al. Early invasive versus selectively invasive management for acute coronary syndromes. N Engl J Med 2005; 353:1095-104.

Bavry AA, Kumbhani DJ, Rassi AN, Bhatt DL, Askari AT. Benefit of early invasive therapy in acute coronary syndromes: a meta-analysis of contemporary randomized clinical trials. J Am Coll Cardiol 2006; 48:1319-25.

Hirsch A, Windhausen F, Tijssen JG, Verheugt FW, Cornel JH, de Winter RJ. Long-term outcome after an early invasive versus selective invasive treatment strategy in patients with non-ST-elevation acute coronary syndrome and elevated cardiac troponin T (the ICTUS trial): a follow-up study. Lancet 2007; 369:827-35.

Fox KAA, Poole-Wilson P, Clayton TC, et al. 5-year outcome of an interventional strategy in non-ST-elevation acute coronary syndrome: the British Heart Foundation RITA 3 randomised trial. Lancet 2005; 366:914-920.

Braunwald E, Antman EM, Beasley JW, et al. ACC/AHA guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction-2002: Summary Article: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina). Circulation 2002; 106:1893-900.