ACC/AHA 2007 guidelines for the management of patients with unstable angina/non ST-Elevation myocardial infarction

ACC/AHA 2007 guidelines for the management of patients with unstable angina/non ST-Elevation myocardial infarction

1st August 2007
American Association of Cardiovascular and Pulmonary Rehabilitation
Society for Academic Emergency Medicine
Summary, Abstract,

Source: National Guidelines Clearinghouse

GUIDELINE OBJECTIVE(S)
  • To address the diagnosis and management of patients with unstable angina (UA) and the closely related condition of non-ST-elevation myocardial infarction (NSTEMI)
  • To assist both cardiovascular specialists and nonspecialists in the proper evaluation and management of patients with an acute onset of symptoms suggestive of these conditions
  • To provide recommendations and supporting evidence for the continued management of patients with these conditions in both inpatient and outpatient settings
TARGET POPULATION

Adult patients with unstable angina and non-ST-segment elevation myocardial infarction (UA/NSTEMI)

Special populations considered include women, patients with diabetes mellitus, post-coronary artery bypass (CABG) patients, older adults, patients with chronic kidney disease, cocaine and methamphetamine users, patients with variant (Prinzmetal's) angina, patients with Cardiovascular ""Syndrome X"" and patients with Takotsubo Cardiomyopathy.

Excluded from these guidelines are:

  • Patients diagnosed as having ST-elevation myocardial infarction (STEMI). These patients should be managed as indicated according to the American College of Cardiology/American Heart Association (ACC/AHA) Guidelines for Management of Patients with Acute Myocardial Infarction. (Patients with acute myocardial infarction and with definite ischemic electrocardiogram changes who are not suitable for acute reperfusion should be diagnosed and managed as patients with unstable angina.)
  • Patients who experience periprocedural myocardial damage that is reflected in release of the MB isoenzyme of creatine kinase (CK-MB) or troponin
INTERVENTIONS AND PRACTICES CONSIDERED

Initial Evaluation and Management

  • Clinical assessment, including 12-lead electrocardiogram, biomarker determination, physical examination, and stress test
  • Instructions to call 9-1-1 if signs of acute coronary syndrome
  • Pre-hospital aspirin (ASA) and nitroglycerin (NTG) as appropriate
  • Risk stratification

    • Early Hospital Care

  • Anti-ischemic and analgesic therapy, including NTG, beta blockers, angiotensin-converting enzyme (ACE) inhibitors, calcium channel blockers, angiotensin receptor blocker (ARB), morphine sulfate, long-acting nondihydro0pyridine calcium antagonists, supplemental oxygen
  • Anti-platelet and anticoagulant therapy, including ASA, clopidogrel, glycoprotein (GP) IIb/IIIa inhibitors, enoxaparin, unfractionated heparin (UFH)
  • Consideration of conservative versus invasive initial strategies
  • Risk stratification at discharge

    • Revascularization

  • Percutaneous coronary intervention (PCI)
  • Coronary artery bypass graft (CABG) surgery

    • Post-Discharge Care

    1. Continuation of medications to control ischemia
    2. Long-term medical therapy, including anti-platelet therapy, beta blockers, inhibitors of the rennin-angiotensins-aldosterone system (ACE inhibitors, ARBs), NTG, calcium channel blockers, warfarin
    3. Secondary prevention, including lipid management, blood pressure control, treatment of diabetes mellitus, smoking cessation, weight management, physical activity, patient education, influenza immunization, depression screening, and pain relief
    4. Post-discharge follow-up and cardiac rehabilitation
    5. Consideration of special groups
    MAJOR OUTCOMES CONSIDERED
    • Sensitivity, specificity, and accuracy of diagnostic tests
    • Risk of death or nonfatal myocardial infarction
    • Morbidity and mortality associated with unstable angina and non-ST-segment elevation myocardial infarction
    • Quality of life