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STEMI Guidelines

STEMI Guidelines

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Sections

  • 1. Introduction
  • 2. Initial Evaluation and Management
  • A. Clinical Assessment
  • B. Early Risk Stratification
  • C. Immediate Management
  • 3. Early Hospital Care
  • A. Anti-Ischemic Therapy
  • B. Initial Conservative Versus Initial Invasive Strategies
  • C. Antiplatelet and Anticoagulation Therapy (UPDATED)
  • D. Risk Stratification
  • A. Medical Regimen
  • the medical regimen
  • Secondary Prevention (UPDATED)

ACCF/AHA Pocket Guideline

Management
of Patients With
Unstable Angina/
Non–ST-Elevation
Myocardial
Infarction
(Adapted from the 2007
ACCF/AHA Guideline and the
2011 ACCF/AHA Focused Update)
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© 2011 American College of Cardiology Foundation and the
American Heart Association, Inc.
The following material was adapted from the 2011 ACCF/
AHA Focused Update Incorporated Into the ACC/AHA 2007
Guidelines for the Management of Patients With Unstable
Angina/Non–ST-Elevation Myocardial Infarction. (J Am Coll
Cardiol 2011;57:e215–367). This pocket guideline is
available on the Web sites of the American College of
Cardiology (www.cardiosource.org) and the American Heart
Association (my.americanheart.org).
For a copy of the full report or published executive summary, visit
ACC/AHA 2007 Guidelines for the Management of Patients With
Unstable Angina/Non–ST-Elevation Myocardial Infarction (J Am
Coll Cardiol 2007;50:e1-e157) and the 2011 ACCF/AHA Focused
Update (J Am Coll Cardiol 2011;57:1920-1959).
For copies of this document, please contact Elsevier Inc. Reprint
Department, email: reprints@elsevier.com; phone 212-633-3813;
fax 212-633-3820.
Permissions: Multiple copies, modifications, alterations,
enhancement and/or distribution of this document are not
permitted without the express permission of the American College
of Cardiology Foundation. Please contact Elsevier’s permission
department at healthpermissions@elsevier.com.
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Contents
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
2. Initial Evaluation and Management . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
A. Clinical Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
B. Early Risk Stratification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
C. Immediate Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
3. Early Hospital Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
A. Anti-Ischemic Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
B. Initial Conservative Versus Initial Invasive Strategies (UPDATED) . . . . . . . 15
C. Antiplatelet and Anticoagulant Therapy (UPDATED) . . . . . . . . . . . . . . . . . . 20
D. Risk Stratification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
4. Hospital Discharge and Post-Hospital Discharge Care . . . . . . . . . 30
A. Medical Regimen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
B. Convalescent and Long-Term Medical Therapy and
Secondary Prevention (UPDATED) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
5. Coronary Revascularization
(see 2011 PCI and CABG Guidelines) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
2
3
1. Introduction
Coronary artery disease is the leading cause of death
in the United States. Unstable angina (UA) and the closely
related condition non–ST-segment elevation myocardial
infarction (MI) (NSTEMI) are very common manifestations of
this disease and are responsible for approximately 1.5 million
hospitalizations in the United States each year. UA and NSTEMI
are examples of acute coronary syndrome (ACS), which is
characterized by an imbalance between myocardial oxygen
supply and demand. The most common cause is the reduced
myocardial perfusion that results from coronary artery
narrowing caused by a nonocclusive thrombus that has
developed on a disrupted atherosclerotic plaque. UA and
NSTEMI are considered to be closely related conditions whose
pathogenesis and clinical presentations are similar but of
differing severity; they differ primarily in whether the ischemia
is severe enough to cause sufficient myocardial damage to
release detectable quantities of a marker of myocardial injury.
The customary American College of Cardiology Foundation/
American Heart Association (ACCF/AHA) classification of
recommendations and levels of evidence is used and displayed
in Table 1.
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Table 1. Applying Classification of
Recommendations and Level of Evidence


LEVEL A
Multiple populations
evaluated*
Data derived from
multiple randomized
clinical trials or meta-
analyses
LEVEL B
Limited populations
evaluated*
Data derived from a
single randomized
trial or nonrandomized
studies
LEVEL C
Very limited populations
evaluated*
Only consensus opinion
of experts, case studies,
or standard of care
CLASS I
Benefit >>> Risk
Procedure/Treatment
SHOULD be performed/
administered
■ Recommendation that
procedure or treatment
is useful/effective
■ Sufficient evidence from
multiple randomized trials
or meta-analyses
■ Recommendation that
procedure or treatment
is useful/effective
■ Evidence from single
randomized trial or
nonrandomized studies
■ Recommendation that
procedure or treatment is
useful/effective
■ Only expert opinion, case
studies, or standard of care
CLASS IIa
Benefit >> Risk
Additional studies with
focused objectives needed
IT IS REASONABLE to per-
form procedure/administer
treatment
■ Recommendation in favor
of treatment or procedure
being useful/effective
■ Some conflicting evidence
from multiple randomized
trials or meta-analyses
■ Recommendation in favor
of treatment or procedure
being useful/effective
■ Some conflicting evidence
from single randomized trial
or nonrandomized studies
■ Recommendation in favor
of treatment or procedure
being useful/effective
■ Only diverging expert
opinion, case studies,
or standard-of-care
should
is recommended
is indicated
is useful/effective/beneficial
Suggested phrases for
writing recommendations
is reasonable
can be useful/effective/beneficial
is probably recommended or indicated
S I Z E O F T R E A T M E N T E F F E C T
E
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(
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)

O
F

T
R
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A
T
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N
T

E
F
F
E
C
T
treatment/strategy A is recom-
mended/indicated in preference
to treatment B
treatment A should be chosen
over treatment B
Comparative
effectiveness phrases

treatment/strategy A is probably
recommended/indicated in preference
to treatment B
it is reasonable to choose treatment A
over treatment B
5
* Data available from clinical trials or
registries about the usefulness/
efficacy in different subpopulations,
such as sex, age, history of diabetes,
history of prior myocardial infarction,
history of heart failure, and prior
aspirin use. A recommendation with
Level of Evidence B or C does not
imply that the recommendation is
weak. Many important clinical
questions addressed in the
guidelines do not lend themselves to
clinical trials. Although randomized
trials are unavailable, there may be a
very clear clinical consensus that a
particular test or therapy is useful or
effective.
† For comparative effectiveness
recommendations (Class I and IIa;
Level of Evidence A and B only),
studies that support the use of
comparator verbs should involve
direct comparisons of the treatments
or strategies being evaluated.
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Class IIb
Benefit r Risk
Additional studies with broad
objectives needed; additional
registry data would be helpful
Procedure/Treatment
MAY BE CONSIDERED
■ Recommendation’s
usefulness/efficacy less
well established
■ Greater conflicting
evidence from multiple
randomized trials or
meta-analyses
■ Recommendation’s
usefulness/efficacy less
well established
■ Greater conflicting
evidence from single
randomized trial or
nonrandomized studies
■ Recommendation’s
usefulness/efficacy less
well established
■ Only diverging expert
opinion, case studies, or
standard-of-care
Class III No Benefit
or Class III Harm
Procedure/
Test Treatment
COR III: Not No Proven
No Benefit Helpful Benefit
COR III: Excess Cost Harmful
Harm w/o Benefit to Patients
or Harmful
■ Recommendation that
procedure or treatment is
not useful/effective and
may be harmful
■ Sufficient evidence from
multiple randomized trials
or meta-analyses
■ Recommendation that
procedure or treatment is
not useful/effective and
may be harmful
■ Evidence from single
randomized trial or
nonrandomized studies
■ Recommendation that
procedure or treatment is
not useful/effective and
may be harmful
■ Only expert opinion, case
studies, or standard-of-care
may/might be considered
may/might be reasonable
usefulness/effectiveness is
unknown /unclear/uncertain or
not well established
COR III: COR III:
No Benefit Harm
is not potentially
recommended harmful
is not indicated causes harm
should not associated with
be done excess morbid-
is not useful/ ity/mortality
beneficial/ should not
effective be done
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6
2. Initial Evaluation and Management
A. Clinical Assessment
Recommendations for Initial Triage
Class I 1. Patients with symptoms of ACS (chest discomfort
with or without radiation to the arm[s], back, neck,
jaw or epigastrium; shortness of breath; weakness;
diaphoresis; nausea; lightheadedness) should be
instructed to call 9-1-1 and should be transported to
the hospital by ambulance rather than by friends or
relatives. (Level of Evidence: B)
2. Prehospital emergency medical services (EMS)
providers should administer 162 to 325 mg of aspirin
(ASA; chewed) to chest pain patients suspected of
having ACS unless contraindicated or already taken
by the patient. (Level of Evidence: C)
3. Health care providers should instruct patients
with suspected ACS for whom nitroglycerin (NTG)
has been prescribed previously to take not more
than 1 dose of NTG sublingually in response to chest
discomfort/pain. If chest discomfort/pain is
unimproved or is worsening 5 minutes after 1 NTG
dose has been taken, it is recommended that the
patient or family member/friend/caregiver call 9-1-1
immediately to access EMS before taking additional
NTG. In patients with chronic stable angina, if
symptoms are significantly improved by 1 NTG, it is
appropriate to instruct the patient or family
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member/friend/caregiver to repeat NTG every 5
minutes for a maximum of 3 doses and call 9-1-1 if
symptoms have not resolved completely. (Level of
Evidence: C)
4. Patients with a suspected ACS with chest
discomfort or other ischemic symptoms at rest for
greater than 20 minutes, hemodynamic instability, or
recent syncope or presyncope should be referred
immediately to an emergency department (ED). (Level
of Evidence: C)
B. Early Risk Stratification
Recommendations
Class I 1. Patients who present with chest discomfort or
other ischemic symptoms should undergo early risk
stratification for the risk of cardiovascular events
(e.g., death or re-MI) that focuses on history,
including anginal symptoms, physical findings,
electrocardiogram (ECG) findings, and biomarkers of
cardiac injury (Table 2). (Level of Evidence: C)
2. A 12-lead ECG should be performed and shown
to an experienced emergency physician as soon as
possible after ED arrival, with a goal of within 10
minutes for all patients with symptoms suggestive of
ACS. (Level of Evidence: B)
3. If the initial ECG is not diagnostic but the patient
remains symptomatic and there is high clinical
suspicion for ACS, serial ECGs, initially at 15- to
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30-minute intervals, should be performed to detect
the potential for development of ST-segment
elevation or depression. (Level of Evidence: B)
4. Cardiac biomarkers should be measured in all
patients who present with chest discomfort
consistent with ACS. A cardiac-specific troponin is
the preferred biomarker. Patients with negative
cardiac biomarkers within 6 hours of the onset of
symptoms consistent with ACS should have
biomarkers remeasured in the time frame of 8 to 12
hours after symptom onset. (Level of Evidence: B)
5. The initial evaluation of the patient with sus-
pected ACS should include the consideration of
noncoronary causes for the development of
unexplained symptoms. (Level of Evidence: C)
Class IIa 1. Use of risk stratification models, such as the TIMI
or GRACE risk score or PURSUIT risk model, can be
useful to assist in decision making regarding
treatment options in patients with suspected ACS
(Table 2 and Figure 1). (Level of Evidence: B)
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Table 2. TIMI Risk Score for
Unstable Angina/Non–ST Elevation MI
All-Cause Mortality, New or Recurrent MI,
or Severe Recurrent Ischemia Requiring
Urgent Revascularization Through 14 d
TIMI Risk Score After Randomization, %
0–1 4.7
2 8.3
3 13.2
4 19.9
5 26.2
6–7 40.9
The TIMI risk score is determined by the sum of the presence of 7 variables at admission;
1 point is given for each of the following variables:

age 65 y or older;

at least 3 risk factors for CAD;

prior coronary stenosis of 50% or more;

ST-segment deviation on ECG presentation;

at least 2 anginal events in prior 24 h;

use of aspirin in prior 7 d;

elevated serum cardiac biomarkers.
Prior coronary stenosis of 50% or more remained relatively insensitive to missing information
and remained a significant predictor of events.
Reprinted with permission from Antman EM, Cohen M, Bernink PJ, et al. The TIMI risk score for unstable angina/
non-ST elevation MI: A method for prognostication and therapeutic decision making. JAMA 2000; 284:835-42.
Copyright © 2000 American Medical Association.
CAD indicates coronary artery disease; ECG, electrocardiogram; MI, myocardial infarction.
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Figure 1. GRACE Prediction Score Card and Nomogram
for All-Cause Mortality From Discharge to 6 Months
Findings
During Hospitalization
Initial Serum Points
Creatinine, mg/dL
0-0.39 .............................. 1
0.4-0.79 ........................... 3
0.8-1.19 ........................... 5
1.2-1.59 ........................... 7
1.6-1.99 ........................... 9
2-3.99 ............................ 15

4 ................................. 20
Elevated Cardiac
Enzymes ........................ 15
No In-Hospital
Percutaneous
Coronary Intervention ..... 14
7
8
9

Medical History
Age in Years Points

29 .................................... 0
30-39 .................................. 0
40-49 ................................ 18
50-59 ................................ 36
60-69 ................................ 55
70-79 ................................ 73
80-89 ................................ 91

90 ................................ 100
History of Congestive
Heart Failure ...................... 24
History of
Myocardial Infarction ......... 12
2
1
3
Findings at Initial
Hospital Presentation
Resting Heart Points
Rate, beats/min

49.9 ............................... 0
50-69.9 .............................3
70-89.9 .............................9
90-109.9 ......................... 14
110-149.9 .......................23
150-199.9 ....................... 35

200 ..............................43
Systolic Blood Pressure,
mm HG

79.9 ............................. 24
80-99.9 ........................... 22
100-119.9 .......................18
120-139.9 ....................... 14
140-159.9 .......................10
160-199.9 .........................4

200 ................................0
ST-Segment Depression .. 11
4
5
6
1
2
3
4
Points
5
6
7
8
9
Total Risk Score
Mortality Risk
(Sum of Points)
(From Plot)
Predicted All-Cause Mortality From Hospital Discharge to 6 Months
0.50
0.45
0.40
0.35
0.30
0.25
0.20
0.15
0.10
0.05
0
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Total Risk Score
70 90 110 130 150 170 190 210
Eagle KA, Lim MJ, Dabbous OH, et al. A validated prediction model for all forms of acute coronary syndrome: estimating
the risk of 6-month post-discharge death in an international registry. JAMA 2004; 291:2727-33. ©Copyright 2004 American
Medical Association.
Risk Calculator for 6-Month Post-Discharge Mortality After Hospitalization for Acute Coronary Syndrome
Record the points for each variable at the bottom left and sum the points to calculate the total risk score.
Find the total score on the x-axis of the nomogram plot. The corresponding probability on the y-axis is the
estimated probability of all-cause mortality from hospital discharge to 6 months.
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C. Immediate Management
Recommendations
Class I 1. The history, physical examination, 12-lead ECG,
and initial cardiac biomarker tests should be
integrated to assign patients with chest pain to 1 of
4 categories: a noncardiac diagnosis, chronic stable
angina, possible ACS, and definite ACS. (Level of
Evidence: C)
2. Patients with probable or possible ACS but whose
initial 12-lead ECG and cardiac biomarker levels are
normal should be observed in a facility with cardiac
monitoring and repeat ECG (or continuous 12-lead
ECG monitoring) and repeat cardiac biomarker
measurement(s) should be obtained at
predetermined, specified time intervals. (Level of
Evidence: B)
3. In patients with suspected ACS in whom ischemic
heart disease is present or suspected, if the follow-
up 12-lead ECG and biomarker measurements are
normal, a stress test (exercise or pharmacological)
to provoke ischemia should be performed in the ED,
in a chest pain unit, or on an outpatient basis in a
timely fashion (within 72 h) as an alternative to
inpatient admission. Low-risk patients with a
negative stress diagnostic test can be managed as
outpatients. (Level of Evidence: C)
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4. In low-risk patients who are referred for
outpatient stress testing (see above), precautionary
pharmacotherapy (e.g., ASA, sublingual NTG, and/
or beta blockers) should be considered while
awaiting results of the stress test. (Level of Evidence: C)
5. Patients with definite ACS and ongoing ischemic
symptoms, positive cardiac biomarkers, new ST-
segment deviations, new deep T-wave inversions,
hemodynamic abnormalities, or a positive stress test
should be admitted to the hospital for further
management. Admission to the critical care unit is
recommended for those with active, ongoing
ischemia/injury and hemodynamic or electrical
instability. Otherwise, a telemetry step-down unit is
reasonable. (Level of Evidence: C)
5. Patients with possible ACS and negative cardiac
biomarkers who are unable to exercise or who have
an abnormal resting ECG should undergo a
pharmacological stress test. (Level of Evidence: B)
6. Patients discharged from the ED or chest pain unit
should be given specific instructions for activity,
medications, additional testing, and follow-up with a
personal physician. (Level of Evidence: C)
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3. Early Hospital Care
A. Anti-Ischemic Therapy
Recommendations
Class I 1. Bed/chair rest with continuous ECG monitoring
is recommended for all UA/NSTEMI patients during
the early hospital phase. (Level of Evidence: C)
2. Supplemental oxygen should be administered
to UA/NSTEMI patients with an arterial saturation
less than 90%, respiratory distress, or other high-risk
features for hypoxemia. (Level of Evidence: B)
3. Patients with UA/NSTEMI with ongoing ischemic
discomfort should receive sublingual NTG (0.4 mg)
every 5 minutes for a total of 3 doses, after which
assessment should be made about the need for
intravenous NTG, if not contraindicated. (Level of
Evidence: C)
4. Intravenous NTG is indicated in the first 48 hours
in patients with UA/NSTEMI for treatment of
persistent ischemia, heart failure, or hypertension.
The decision to administer intravenous NTG and the
dose used should not preclude therapy with other
proven mortality-reducing interventions such as
beta blockers or angiotensin-converting enzyme
(ACE) inhibitors. (Level of Evidence: B)
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5. Oral beta-blocker therapy within 24 hours
should be administered to patients without a
contraindication (Level of Evidence: B)
6. In UA/NSTEMI patients with continuing or
frequently recurring ischemia and in whom beta
blockers are contraindicated, a nondihydropyridine
calcium channel blocker antagonist (e.g., verapamil
or diltiazem) should be given as initial therapy in
the absence of clinically significant left ventricular
(LV) dysfunction or other contraindications. (Level of
Evidence: B)
7. An ACE inhibitor should be administered orally within
the first 24 hours to patients with pulmonary
congestion or left ventricular ejection fraction (LVEF)
less than or equal to 0.40 in the absence of hypotension
(systolic blood pressure <100 mm Hg or <30 mm Hg
below baseline) or known contraindications. An
angiotensin receptor blocker may be used for ACE
intolerant patients. (Level of Evidence: A)
15
B. Initial Conservative Versus Initial Invasive Strategies
(UPDATED)
Recommendations
Class I 1. An early invasive strategy (i.e., diagnostic
angiography with intent to perform
revascularization) is indicated in UA/NSTEMI
patients who have refractory angina or
hemodynamic or electrical instability (without
serious comorbidities or contraindications to such
procedures). (Level of Evidence: B)
2. An early invasive strategy (i.e., diagnostic
angiography with intent to perform
revascularization) is indicated in initially stabilized
UA/NSTEMI patients (without serious comorbidities
or contraindications to such procedures) who have
an elevated risk for clinical events (Table 3). (Level of
Evidence: A)
3. In women with low-risk features, a conservative
strategy is recommended. (Level of Evidence: B)
Class IIa 1. It is reasonable to choose an early invasive
strategy (within 12 to 24 h of admission) over a
delayed invasive strategy for initially stabilized high-
risk patients with UA/NSTEMI. For patients not at
high risk, a delayed invasive approach is also
reasonable. (Level of Evidence: B)
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Class IIb 1. In initially stabilized patients, an initially
conservative (i.e., a selectively invasive) strategy
may be considered as a treatment strategy for UA/
NSTEMI patients (without serious comorbidity or
contraindications) who have an elevated risk of
clinical events (Table 4) including those who are
troponin positive. (Level of Evidence B) The decision to
implement an initial conservative strategy in these
patients may be made considering physician and
patient preference. (Level of Evidence: C)
17
Table 3. Selection of Initial Treatment Strategy:
Invasive Versus Conservative Strategy (Updated)
Strategy Status Patient Characteristics
Invasive Generally preferred Recurrent angina or ischemia at rest or with low-
level activities despite intensive medical therapy
Elevated cardiac biomarkers (TnT or TnI)
New or presumably new ST-segment depression
Signs or symptoms of HF or new or worsening
mitral regurgitation
High-risk findings from noninvasive testing
Hemodynamic instability
Sustained ventricular tachycardia
PCI within 6 mo
Prior CABG
High-risk score (e.g., TIMI, GRACE)
Mild to moderate renal dysfunction
Diabetes mellitus
Reduced left ventricular function (LVEF <40%)

Conservative Generally preferred Low risk score (e.g., TIMI, GRACE)
Patient or physician preference in the absence of
high-risk features
CABG indicates coronary artery bypass graft surgery; GRACE, Global Registry of Acute Coronary Events; HF,
heart failure; LVEF, left ventricular ejection fraction; PCI, percutaneous coronary intervention; TIMI, Thrombolysis in
Myocardial Infarction; TnI, troponin I; and TnT, troponin T.
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Table 4. Short-Term Risk of Death or
Nonfatal MI in Patients With UA/NSTEMI*
High Risk Intermediate Risk Low Risk
At least 1 of the following features No high-risk feature, but must have No high- or intermediate-risk feature
Feature must be present: 1 of the following: but may have any of the following features:
History Accelerating tempo of ischemic symptoms Prior MI, peripheral or cerebrovascular
in preceding 48 h disease, or CABG; prior aspirin use
Character of pain Prolonged ongoing (>20 min) rest pain Prolonged (>20 min) rest angina, Increased angina frequency,
now resolved, with moderate or high severity, or duration
likelihood of CAD Angina provoked at a lower
Rest angina (>20 min) or threshold
relieved with rest or sublingual NTG New onset angina with onset
Nocturnal angina 2 wk to 2 mo prior
New-onset or progressive CCS class III or to presentation
IV angina in the past 2 wk without pro-
longed (>20 min) rest pain but
with intermediate or high likelihood of CAD
Clinical findings Pulmonary edema, most likely due to ischemia Age >70 years
New or worsening MR murmur
S
3
or new/worsening rales
Hypotension, bradycardia, tachycardia
Age >75 y
ECG Angina at rest with transient ST-segment T-wave changes Normal or unchanged ECG
changes >0.5 mm Pathological Q waves or resting
Bundle-branch block, new or presumed new ST-depression <1 mm in multiple
Sustained ventricular tachycardia lead groups (anterior, inferior, lateral)
Cardiac markers Elevated cardiac TnT, TnI, or CK-MB Slightly elevated cardiac TnT, TnI, or Normal
(e.g., TnT or TnI >0.1 ng per mL) CK-MB (e.g., TnT >0.01
but <0.1 ng per mL)
*Estimation of the short-term risks of death and nonfatal cardiac ischemic events in UA (or NSTEMI) is a com-
plex multivariable problem that cannot be fully specified in a table such as this; therefore, this table is meant to
offer general guidance and illustration rather than rigid algorithms.
Adapted from AHCPR Clinical Practice Guidelines No. 10, Unstable Angina: Diagnosis and Management, May 1994.
19
Table 4. Short-Term Risk of Death or
Nonfatal MI in Patients With UA/NSTEMI*
High Risk Intermediate Risk Low Risk
At least 1 of the following features No high-risk feature, but must have No high- or intermediate-risk feature
Feature must be present: 1 of the following: but may have any of the following features:
History Accelerating tempo of ischemic symptoms Prior MI, peripheral or cerebrovascular
in preceding 48 h disease, or CABG; prior aspirin use
Character of pain Prolonged ongoing (>20 min) rest pain Prolonged (>20 min) rest angina, Increased angina frequency,
now resolved, with moderate or high severity, or duration
likelihood of CAD Angina provoked at a lower
Rest angina (>20 min) or threshold
relieved with rest or sublingual NTG New onset angina with onset
Nocturnal angina 2 wk to 2 mo prior
New-onset or progressive CCS class III or to presentation
IV angina in the past 2 wk without pro-
longed (>20 min) rest pain but
with intermediate or high likelihood of CAD
Clinical findings Pulmonary edema, most likely due to ischemia Age >70 years
New or worsening MR murmur
S
3
or new/worsening rales
Hypotension, bradycardia, tachycardia
Age >75 y
ECG Angina at rest with transient ST-segment T-wave changes Normal or unchanged ECG
changes >0.5 mm Pathological Q waves or resting
Bundle-branch block, new or presumed new ST-depression <1 mm in multiple
Sustained ventricular tachycardia lead groups (anterior, inferior, lateral)
Cardiac markers Elevated cardiac TnT, TnI, or CK-MB Slightly elevated cardiac TnT, TnI, or Normal
(e.g., TnT or TnI >0.1 ng per mL) CK-MB (e.g., TnT >0.01
but <0.1 ng per mL)
CABG indicates coronary artery bypass graft surgery; CAD, coronary artery disease; CCS, Canadian
Cardiovascular Society; CK-MB, creatine kinase, MB fraction; ECG, electrocardiogram; MI, myocardial
infarction; MR, mitral regurgitation; NTG, nitroglycerin; TnI, troponin I; TnT, troponin T; UA/NSTEMI, unstable
angina/non–ST-elevation myocardial infarction.
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C. Antiplatelet and Anticoagulation Therapy (UPDATED)
A growing number of antiplatelet and antithrombotic agents are
now available for use in ACS. The decision of which agents to
use, when to administer them and at what doses is complex.
See Figures 2, 3, 4, and 5; and Table 5 for guidance.
Figure 2. Flowchart for Class I and Class IIa Recommendations
for Initial Management of UA/NSTEMI (Initial Conservative
Strategy) (Updated)
Diagnosis of UA/NSTEMI is Likely or Definite
ASA (Class I, LOE: A)
Clopidogrel if ASA intolerant (Class I, LOE: B)
Select Management Strategy
Initial Conservative Strategy or Unknown
Initiate anticoagulant therapy (Class I, LOE: A)
Acceptable options include
º Euo/apa||u o| ulh (C|ass l, L0E. A)
º loudapa||uu/ (C|ass l, L0E. B)*
º Euo/apa||u o| loudapa||uu/ p|ele||ed ove| ulh
(Class IIa, LOE: B)
Initiate clopidogrel (Class I, LOE: B)
For Invasive Strategy
see Figure 3.
*If fondaparinux is
used with an invasive
strategy (Class I,
LOE: B), it must be
coadministered with
another anticoagulant
with Factor IIa activity,
for example, UFH.
ASA indicates aspirin; CABG, coronary artery bypass graft; D/C, discontinue; GP, glycoprotein; IV,
intravenous; LOE, level of evidence; PCI, percutaneous coronary intervention; STEMI, ST-elevation
myocardial infarction; UA/NSTEMI, unstable angina/non-ST-elevation myocardial infarction; and UFH,
unfractionated heparin.
21
Figure 3. Flowchart for Class I and Class IIa
Recommendations for Initial Management of UA/NSTEMI
(Invasive Strategy) (Updated)
*If fondaparinux is used
with an invasive strategy
(Class I, LOE: B), it must be
coadministered with another
anticoagulant with Factor IIa
activity, for example, UFH.
†Timing of invasive strategy
generally is assumed to be
4 to 48 hours. If immediate
angiography is selected, see
STEMI guidelines.
‡Precatheterization triple-
antiplatelet therapy (ASA,
clopidogrel, glycoprotein
inhibitors) is a Class IIb,
LOE: B recommendation for
selected high-risk patients.
Diagnosis of UA/NSTEMI is Likely or Definite
ASA (Class I, LOE: A)
Clopidogrel if ASA intolerant (Class I, LOE: B)
Select Management Strategy
Initiate anticoagulant therapy (Class I, LOE: A)*
Acceptable options include
º Euo/apa||u o| ulh (C|ass l, L0E. A)
º B|va|||ud|u (C|ass l, L0E. B)
Precatheterization: Add second antiplatelet agent (Class I, LOE: A)‡
º C|op|dog|e| (C|ass l, L0E. B) o|
º ßP llb/llla |uH|b|lo| (C|ass l, L0E. A)
º (lV epl|l|bal|de o| l||ol|bau p|ele||ed)
Next step per triage decision at angiography
PCI:
Class I:
º C|op|dog|e| (|l uol beguu p|e-
catheterization) (LOE: A) or
º P|asug|e| (L0E. B) or
º Se|ecl|ve|y, a ßP llb/llla
inhibitor (if not begun
precatheterization) (LOE: A)
CABG:
Maintenance ASA
(Class I, LOE: A)
Medical
Therapy: D/C
GP IIb/IIIa
inhibitors if
begun and give
clopidogrel per
conservative
strategy
For Initial
Conservative Strategy
see Figure 2.
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ASA indicates aspirin; CABG, coronary artery bypass graft; D/C, discontinue; GP, glycoprotein; IV, intravenous; LOE,
level of evidence; PCI, percutaneous coronary intervention; STEMI, ST-elevation myocardial infarction; UA/NSTEMI,
unstable angina/non-ST-elevation myocardial infarction; and UFH, unfractionated heparin.
Invasive Strategy†
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Figure 4. Management After Diagnostic Angiography
in Patients With UA/NSTEMI (Updated)
J
Diagnostic Angiography
* See Dosing Table 5.
† Evidence exists that GP IIb/IIIa inhibitors may not be necessary if the patient
received a preloading dose of at least 300 mg of clopidogrel at least 6 h earlier (Class I, LOE: B for clopidogrel
administration) and bivalidrudin is selected as anticoagulant (Class IIa, LOE: B).
‡ Additional bolus of UFH is recommended if fondaparinux is selected as anticoagulant (see Dosing Table 5).
§ For patients in whom the clinician believes coronary atherosclerosis is present, albeit without any significant,
flow-limiting stenosis, long-term treatment with antiplatelet agents and other secondary prevention measures
should be considered.
ASA indicates aspirin; CABG, coronary artery bypass graft; CAD, coronary artery disease; GP, glycoprotein;
IV, intravenous; LD, loading dose; PCI, percutaneous coronary intervention; pre angio, before angiography;
UA/NSTEMI, unstable angina/non–ST-elevation myocardial infarction; UFH, unfractionated heparin.
Select Post-Angiography Management Strategy
CABG PCI Medical therapy
Continue ASA*
(Class I, LOE: A)
Discontinue clopidogrel at
least 5 d (Class I, LOE: B)
and prasugrel at least 7 d
(Class I, LOE: C) prior to
elective CABG
Discontinue IV GP IIb/IIIa
4 h prior to CABG
(Class I, LOE: B)
Continue UFH (Class I,
LOE:B); discontinue enox-
aparin 12 to 24 h prior to
CABG; discontinue fonda-
parinux 24 h prior to CABG;
Discontinue bivalirudin 3 h
prior to CABG. Dose with
UFH per institutional
practice (Class I, LOE: B)
Continue ASA*
(Class I, LOE: A)
LD of a
thienopyridine if
not given pre angio
(Class I, LOE: B)
*
and it is reasonable
to give IV GP IIb/
IIa if not started pre
angio (Class IIa,
LOE: A)
*†
Discontinue anti-
coagulant after PCI
for uncomplicated
cases
(Class I, LOE: B)

Continue ASA
*

(Class I, LOE: A)
LD of clopidogrel if not
given pre angio
(Class I, LOE: B)
*
Discontinue IV GP IIb/IIIa
after at least 12 h if started
pre angio (Class I, LOE: B)
Continue IV UFH for at
least 48 h (Class I, LOE: A)
or enoxaparin or
fondaparinux for duration
of hospitalization (Class I,
LOE: A); either discontinue
bivalirudin or continue at a
dose of 0.25 mg/kg/hr for
up to 72 h at physician’s
discretion (Class I, LOE: B)
No
significant
obstructive
CAD on
angiography
CAD on angiography
Antiplatelet and
anticoagulant
therapy at
physician’s
discretion
§

(Class I, LOE: C)
23
Figure 5. Long-Term Antithrombotic Therapy
at Hospital Discharge After UA/NSTEMI (Updated)

UA/NSTEMI Patient
Groups at Discharge
* For ASA allergic patients, use clopidogrel alone (indefinitely), or try ASA desensitization.
† For clopidogrel allergic patients, use ticlopidine, 250 mg by mouth twice daily, or prasugrel.
‡ Continue ASA indefinitely and warfarin longer term as indicated for specific conditions such as atrial fibrillation;
LV thrombus, cerebral, venous or pulmonary emboli.
§
When risk of bleeding is a concern, a lower initial ASA (75 to 162 mg/d) after PCI is reasonable
(Class IIa, LOE: C)
ASA indicates aspirin; INR, international normalized ratio; LOE, Level of Evidence; LV, left ventricular;
UA/NSTEMI, unstable angina/non–ST-elevation myocardial infarction.
Medical Therapy
Without Stent
Bare-Metal Stent
Group
Drug-Eluting Stent
Group
ASA
*
75 to 162 mg/d
indefinitely (Class I, LOE: A)
&
Clopidogrel

75 mg/d for
at least 1 mo and ideally
up to 1 y
(Class I, LOE: B)
ASA
*
162 to 325 mg/d
§
for
at least 3 to 6 mo, then 75
to 162 mg/d indefinitely
(Class I, LOE: A)
&
Clopidogrel

75 mg/d or
prasugrel 10 mg/d for at
least 1 y (Class I, LOE: B)
Indication for Anticoagulation?
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 or
prasugrel 10 mg/d for at least
1 y (Class I, LOE: B)
Add: Warfarin
‡§
(Class IIb, LOE: B) to
maintain INR of 2–3
Continue with dual antiplatelet
therapy as above
Yes No
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During PCI Comments
Patient Received Initial Patient Did Not Receive Initial
Drug* Medical Treatment Medical Treatment ➤ All Patients to Receive ASA (162–325 mg)
(With a Thienopyridine) (With a Thienopyridine)
Glycoprotein IIb/IIIa Receptor Antagonists
Abciximab Of uncertain benefit LD of 0.25 mg/kg IV bolus
MD of 0.125 mcg/kg per min (maximum 10 mcg/
min) (Class I, LOE: A)
➤ Continue for up to 12 h at the discretion of the physician.
Eptifibatide Of uncertain benefit LD of 180 mcg/kg IV bolus followed 10 min later by
second IV bolus of 180 mcg/kg
MD of 2.0 mcg/kg per min, started after first bolus;
reduce infusion by 50% in patients with estimated
creatinine clearance <50 mL/min (Class I, LOE: A)
➤ A LD of eptifibatide is FDA approved when the medication is initiated in UA/NSTEMI patients who
are started on medical therapy and when there is an appreciable delay in angiography/PCI: LD of
180 mcg/kg IV bolus followed by MD of 2.0 mcg/kg per min started after bolus reduce infusion
by 50% in patients with estimated creatinine clearance <50 mL/min (Class I, LOE: B)
➤ Infusion should be continued for 12 to 18 h at the discretion of the physician.
Tirofiban Of uncertain benefit LD of 25 mcg/kg IV bolus
MD of IV infusion of 0.15 mcg/kg per min; reduce
rate of infusion by 50% in patients with estimated
creatinine clearance <30 mL/min (Class I, LOE: B)
➤ Increased dosing over previous recommendation.
➤ Continue for up to 18 h at the discretion of the physician.
➤ A lower-dose regimen for tirofiban is FDA approved and has been shown to be effective when
used to treat UA/NSTEMI patients who are started on medical therapy and when there is a sub-
stantial delay to angiography/PCI (e.g., 48 h):
LD of 50 mcg/mL administered at an initial rate of 0.4 mcg/kg per min for 30 min
MD of a continuous infusion of 0.1 mcg/kg per min. Continue the infusion through angiography
and for 12 to 24 h after angioplasty or atherectomy.
Thienopyridines
Clopidogrel† If 600 mg given orally,
then no additional
treatment
A second LD of 300 mg
may be given orally to
supplement a prior LD of
300 mg (Class I, LOE: C)
LD of 300-600 mg orally (Class I, LOE: A)
MD of 75 mg orally per d (Class I, LOE: A)
An MD of 150 mg orally per d for initial 6 d may be
considered (Class IIb, LOE: B)
➤ Optimum LD requires clinical consideration.
➤ Dose for patients >75 y of age has not been established.
➤ There is a recommended duration of therapy for all post-PCI patients receiving a BMS or DES.
➤ Caution should be exercised for use with a PPI.
➤ Period of withdrawal before surgery should be at least 5 d.
(For full explanations, see footnote.)
Prasugrel

No data are available to
guide decision making
LD of 60 mg orally
MD of 10 mg orally per d (Class I, LOE: B)
➤ There are no data for treatment with prasugrel before PCI.
➤ MD of 5 mg orally per d in special circumstances.
➤ Special dosing for patients <60 kg or >75 y of age.
➤ There is a recommended duration of therapy for all post-PCI patients receiving a BMS or DES.
➤ Contraindicated for use in patients with prior history of TIA or stroke.
(For full explanations, see footnote.)
Table 5. Dosing Table for Selected Antiplatelet
and Anticoagulant Therapies (Updated)
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During PCI Comments
Patient Received Initial Patient Did Not Receive Initial
Drug* Medical Treatment Medical Treatment ➤ All Patients to Receive ASA (162–325 mg)
(With a Thienopyridine) (With a Thienopyridine)
Glycoprotein IIb/IIIa Receptor Antagonists
Abciximab Of uncertain benefit LD of 0.25 mg/kg IV bolus
MD of 0.125 mcg/kg per min (maximum 10 mcg/
min) (Class I, LOE: A)
➤ Continue for up to 12 h at the discretion of the physician.
Eptifibatide Of uncertain benefit LD of 180 mcg/kg IV bolus followed 10 min later by
second IV bolus of 180 mcg/kg
MD of 2.0 mcg/kg per min, started after first bolus;
reduce infusion by 50% in patients with estimated
creatinine clearance <50 mL/min (Class I, LOE: A)
➤ A LD of eptifibatide is FDA approved when the medication is initiated in UA/NSTEMI patients who
are started on medical therapy and when there is an appreciable delay in angiography/PCI: LD of
180 mcg/kg IV bolus followed by MD of 2.0 mcg/kg per min started after bolus reduce infusion
by 50% in patients with estimated creatinine clearance <50 mL/min (Class I, LOE: B)
➤ Infusion should be continued for 12 to 18 h at the discretion of the physician.
Tirofiban Of uncertain benefit LD of 25 mcg/kg IV bolus
MD of IV infusion of 0.15 mcg/kg per min; reduce
rate of infusion by 50% in patients with estimated
creatinine clearance <30 mL/min (Class I, LOE: B)
➤ Increased dosing over previous recommendation.
➤ Continue for up to 18 h at the discretion of the physician.
➤ A lower-dose regimen for tirofiban is FDA approved and has been shown to be effective when
used to treat UA/NSTEMI patients who are started on medical therapy and when there is a sub-
stantial delay to angiography/PCI (e.g., 48 h):
LD of 50 mcg/mL administered at an initial rate of 0.4 mcg/kg per min for 30 min
MD of a continuous infusion of 0.1 mcg/kg per min. Continue the infusion through angiography
and for 12 to 24 h after angioplasty or atherectomy.
Thienopyridines
Clopidogrel† If 600 mg given orally,
then no additional
treatment
A second LD of 300 mg
may be given orally to
supplement a prior LD of
300 mg (Class I, LOE: C)
LD of 300-600 mg orally (Class I, LOE: A)
MD of 75 mg orally per d (Class I, LOE: A)
An MD of 150 mg orally per d for initial 6 d may be
considered (Class IIb, LOE: B)
➤ Optimum LD requires clinical consideration.
➤ Dose for patients >75 y of age has not been established.
➤ There is a recommended duration of therapy for all post-PCI patients receiving a BMS or DES.
➤ Caution should be exercised for use with a PPI.
➤ Period of withdrawal before surgery should be at least 5 d.
(For full explanations, see footnote.)
Prasugrel

No data are available to
guide decision making
LD of 60 mg orally
MD of 10 mg orally per d (Class I, LOE: B)
➤ There are no data for treatment with prasugrel before PCI.
➤ MD of 5 mg orally per d in special circumstances.
➤ Special dosing for patients <60 kg or >75 y of age.
➤ There is a recommended duration of therapy for all post-PCI patients receiving a BMS or DES.
➤ Contraindicated for use in patients with prior history of TIA or stroke.
(For full explanations, see footnote.)
Table 5. Dosing Table for Selected Antiplatelet
and Anticoagulant Therapies (Updated)
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* This list is in alphabetical order and is not meant to indicate a particular therapy preference. This drug table does not
make recommendations for combinations of listed drugs. It is only meant to indicate an approved or recommended
dosage if a drug is chosen for a given situation.

For post-PCI patients receiving a DES or BMS, a daily MD should be given for at least 12 mo unless the risk of bleeding
outweighs the anticipated net benefit afforded by a thienopyridine. The necessity for giving an LD of clopidogrel before
PCI is driven by the pharmacokinetics of clopidogrel, for which a period of several hours is required to achieve desired
levels of platelet inhibition. Patients who have a reduced-function CYP2C19 allele have significantly lower levels of the
active metabolite of clopidogrel, diminished platelet inhibition, and a higher rate of MACE, including stent thrombosis. In
NSTEMI patients taking clopidogrel for whom CABG is planned and can be delayed, it is reasonable to discontinue the
clopidogrel to allow for dissipation of the antiplatelet effect unless the urgency for revascularization and/or the net benefit
of clopidogrel outweigh the potential risks of excess bleeding. The period of withdrawal should be at least 5 d in patients
receiving clopidogrel.
During PCI Comments
Patient Received Initial Patient Did Not Receive Initial
Drug* Medical Treatment Medical Treatment ➤ All Patients to Receive ASA (162–325 mg)
(With a Thienopyridine) (With a Thienopyridine)
Parenteral Anticoagulants
Bivalirudin For patients who have
received UFH, wait 30
min, then give 0.75
mg/kg bolus, then 1.75
mg/kg per h infusion
(Class I, LOE: B)
0.75 mg/kg bolus, 1.75 mg/kg per h infusion ➤ Bivalirudin may be used to support PCI and UA/NSTEMI with or without previously administered
UFH with the addition of 600 mg of clopidogrel.
➤ In UA/NSTEMI patients undergoing PCI who are at high risk of bleeding, bivalirudin anticoagula-
tion is reasonable.
UFH IV GP IIb/IIIa planned:
target ACT 200–250 s
No IV GP IIb/IIIa
planned: target
ACT 250–300 s for
HemoTec, 300–350 s
for Hemochron
(Class I, LOE: B)
IV GP IIb/IIIa planned: 50–70 U/kg bolus to achieve
an ACT of 200–250 s
No IV GP IIb/IIIa planned: 70–100 U/kg bolus to
achieve target ACT of 250–300 s for HemoTec,
300–350 s for Hemochron (Class I, LOE:B)
Table 5. Dosing Table for Selected Antiplatelet
and Anticoagulant Therapies continued from previous page
27

Patients weighing <60 kg have an increased exposure to the active metabolite of prasugrel and an increased risk of
bleeding on a 10-mg once-daily MD. Consider lowering the MD to 5 mg in patients who weigh <60 kg. The effectiveness
and safety of the 5-mg dose have not been studied prospectively. For post-PCI patients receiving a DES or BMS, a daily
MD should be given for at least 12 and up to 15 mo unless the risk of bleeding outweighs the anticipated net benefit
afforded by a thienopyridine. Do not use prasugrel in patients with active pathological bleeding or a history of TIA or
stroke. In patients ≥75 years of age, prasugrel is generally not recommended because of the increased risk of fatal and
intracranial bleeding and uncertain benefit, except in high-risk situations (patients with diabetes or a history of prior MI),
for which its effect appears to be greater and its use may be considered. Do not start prasugrel in patients likely to under-
go urgent CABG. When possible, discontinue prasugrel at least 7 d before any surgery. Additional risk factors for bleeding
include body weight <60 kg, propensity to bleed, concomitant use of medications that increase the risk of bleeding (e.g.,
warfarin, heparin, fibrinolytic therapy, or long-term use of nonsteroidal anti-inflammatory drugs).
ACT indicates activated clotting time; BMS, bare-metal stent; GP, glycoprotein; IU, international unit; IV, intravenous;
LD, loading dose; MD, maintenance dose; PCI, percutaneous coronary intervention; PES, paclitaxel-eluting stent; SC,
subcutaneous; SES, sirolimus-eluting stent; U, units; UA/NSTEMI, unstable angina/non–ST-elevation myocardial infarction;
UFH, unfractionated heparin.
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During PCI Comments
Patient Received Initial Patient Did Not Receive Initial
Drug* Medical Treatment Medical Treatment ➤ All Patients to Receive ASA (162–325 mg)
(With a Thienopyridine) (With a Thienopyridine)
Parenteral Anticoagulants
Bivalirudin For patients who have
received UFH, wait 30
min, then give 0.75
mg/kg bolus, then 1.75
mg/kg per h infusion
(Class I, LOE: B)
0.75 mg/kg bolus, 1.75 mg/kg per h infusion ➤ Bivalirudin may be used to support PCI and UA/NSTEMI with or without previously administered
UFH with the addition of 600 mg of clopidogrel.
➤ In UA/NSTEMI patients undergoing PCI who are at high risk of bleeding, bivalirudin anticoagula-
tion is reasonable.
UFH IV GP IIb/IIIa planned:
target ACT 200–250 s
No IV GP IIb/IIIa
planned: target
ACT 250–300 s for
HemoTec, 300–350 s
for Hemochron
(Class I, LOE: B)
IV GP IIb/IIIa planned: 50–70 U/kg bolus to achieve
an ACT of 200–250 s
No IV GP IIb/IIIa planned: 70–100 U/kg bolus to
achieve target ACT of 250–300 s for HemoTec,
300–350 s for Hemochron (Class I, LOE:B)
Table 5. Dosing Table for Selected Antiplatelet
and Anticoagulant Therapies continued from previous page
28
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D. Risk Stratification
Recommendations
Class I 1. Noninvasive stress testing is recommended in
low- and intermediate-risk patients who have been
free of ischemia at rest or with low-level activity and
of heart failure for a minimum of 12 to 24 hours
(Level of Evidence: C)
2. Choice of stress test is based on the resting ECG,
ability to perform exercise, local expertise, and
technologies available. Treadmill exercise is useful
in patients able to exercise in whom the ECG is free
of baseline ST-segment abnormalities, bundle-
branch block, LV hypertrophy, intraventricular
conduction defect, paced rhythm, preexcitation, and
digoxin effect. (Level of Evidence: C)
3. An imaging modality should be added in patients
with resting ST-segment depression (≥0.10 mV), LV
hypertrophy, bundle-branch block, intraventricular
conduction defect, preexcitation, or digoxin who are
able to exercise. In patients undergoing a low-level
exercise test, an imaging modality can add
sensitivity. (Level of Evidence: B)
4. Pharmacological stress testing with imaging
is recommended when physical limitations (e.g.,
arthritis, amputation, severe peripheral vascular
disease, severe chronic obstructive pulmonary
disease, general debility) preclude adequate exercise
stress. (Level of Evidence: B)
29
5. Prompt angiography without noninvasive risk
stratification should be performed for failure of
stabilization with intensive medical treatment. (Level
of Evidence: B)
6. A noninvasive test (echocardiogram or
radionuclide angiogram) is recommended to
evaluate LV function in patients with definite ACS
who are not scheduled for coronary angiography
and left ventriculography. (Level of Evidence: B)
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4. Hospital Discharge and
Post-Hospital Discharge Care
The acute phase of UA/NSTEMI is usually over within 2 months.
The risk of progression to MI or the development of recurrent
MI or death is highest during this period. Most patients then
resume a clinical course similar to that of patients with chronic,
stable coronary artery disease.
A. Medical Regimen
An effort of the entire staff (physicians, nurses, dietitians,
pharmacists, rehabilitation specialists, and physical and
occupational therapists) is often necessary to prepare the
patient for discharge. Direct patient instruction is important and
should be reinforced and documented with written instruction
sheets. Enrollment in a cardiac rehabilitation program after
discharge may enhance patient education and compliance with
the medical regimen.
Recommendations
Class I 1. Medications required in the hospital to control
ischemia should be continued after hospital
discharge in patients with UA/NSTEMI who do not
undergo coronary revascularization, patients with
unsuccessful revascularization, and patients with
recurrent symptoms after revascularization. Upward
or downward titration of the doses may be required.
(Level of Evidence: C)
31
2. All post-UA/NSTEMI patients should be given
sublingual or spray NTG and instructed in its use.
(Level of Evidence: C)
3. Before hospital discharge, patients with UA/
NSTEMI should be informed about symptoms of
worsening myocardial ischemia and MI and should
be instructed in how and when to seek emergency
care and assistance if such symptoms occur. (Level
of Evidence: C)
4. Before hospital discharge, post-UA/NSTEMI
patients and/or designated responsible caregivers
should be provided with supportable, easily
understood, and culturally sensitive instructions with
respect to medication type, purpose, dose, frequency,
and pertinent side effects. (Level of Evidence: C)
5. In post-UA/NSTEMI patients, anginal discomfort
lasting more than 2 or 3 minutes should prompt the
patient to discontinue physical activity or remove
himself or herself from any stressful event. If pain
does not subside immediately, the patient should be
instructed to take 1 dose of NTG sublingually. If the
chest discomfort/pain is unimproved or worsening
5 minutes after 1 NTG dose has been taken, it is
recommended that the patient or a family member/
friend call 9-1-1 immediately to access EMS. While
activating EMS access, additional NTG (at 5-minute
intervals 2 times) may be taken while lying down or
sitting. (Level of Evidence: C)
6. If the pattern or severity of anginal symptoms
changes, which suggests worsening myocardial
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ischemia (e.g., pain is more frequent or severe or is
precipitated by less effort or now occurs at rest), the
patient should contact his or her physician without
delay to assess the need for additional treatment or
testing. (Level of Evidence: C)
B. Convalescent and Long-Term Medical Therapy and
Secondary Prevention (UPDATED)
1. Antiplatelet Therapy (Updated)
Class I 1. Aspirin 75 to 162 mg daily should be given and
continued indefinitely for medically-treated patients
recovering from UA/NSTEMI. (Level of Evidence: A) For
patients who have undergone PCI, ASA 162 to 325
mg daily should be given for at least 1 month after
bare-metal stent implantation, 3 months after
sirolimus-eluting stent implantation, and 6 months
after paclitaxel-eluting stent implantation, after
which daily chronic ASA use should be continued
indefinitely at a dose of 75 to 162 mg. (Level of
Evidence: B)
33
2. Clopidogrel 75 mg daily (preferred) or ticlopidine
(in the absence of contraindications) should be given
to patients recovering from UA/NSTEMI when ASA
is contraindicated or not tolerated because of
hypersensitivity or gastrointestinal intolerance
(despite use of gastroprotective agents such as
proton pump inhibitors). (Level of Evidence: B)
3. The duration and maintenance dose of
thienopyridine therapy should be as follows:
a. In UA/NSTEMI patients undergoing
percutaneous coronary intervention (PCI) with a
drug-eluting stent or bare-metal stent, clopidogrel
75 mg daily or prasugrel 10 mg daily should be
given for at least 12 months. (Level of Evidence: B)
b. If the risk of morbidity because of bleeding
outweighs the anticipated benefits afforded by
thienopyridine therapy, earlier discontinuation
should be considered. (Level of Evidence: C)
c. For UA/NSTEMI patients treated medically
without stenting, clopidogrel 75 mg daily should
be prescribed for at least 1 month and ideally up
to 1 year. (Level of Evidence: B)
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Class IIa 1. For UA/NSTEMI patients in whom
the physician is concerned about
the risk of bleeding, a lower initial
ASA dose (75 to 162 mg/day) after
PCI is reasonable. (Level of Evidence: C)
Class IIb 1. Platelet function testing to determine platelet
inhibitory response in patients with UA/NSTEMI (or,
after ACS and PCI) on thienopyridine therapy may be
considered if results of testing may alter
management. (Level of Evidence: B)
2. Continuation of clopidogrel or prasugrel beyond
15 months may be considered in patients following
drug-eluting stent placement. (Level of Evidence: C)
Class III: In UA/NSTEMI patients with a prior history of stroke
Harm and/or transient ischemic attack for whom PCI is
planned, prasugrel is potentially harmful as part of a
dual-antiplatelet therapy regimen. (Level of Evidence: B)
2. Beta Blockers
Class I 1. Beta blockers are indicated for all patients recovering
from UA/NSTEMI unless contraindicated and should
be continued indefinitely. (Level of Evidence: B)
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2. Patients recovering from UA/NSTEMI with
moderate or severe LV failure should receive beta-
blocker therapy with a gradual titration scheme.
(Level of Evidence: B)
3. Inhibition of the Renin-Angiotensin-
Aldosterone System
Class I 1. ACE inhibitors should be given and continued
indefinitely for patients recovering from UA/NSTEMI
with HF, LV dysfunction (EF <0.40), hypertension, or
diabetes mellitus unless contraindicated. (Level of
Evidence: A)
2. An angiotensin receptor blocker should be
prescribed at discharge to those patients who are
intolerant of an ACE inhibitor and who have either
clinical or radiological signs of HF and LVEF less
than 0.40. (Level of Evidence: A)
3. Long-term aldosterone receptor blockade should
be prescribed for post-UA/NSTEMI patients without
significant renal dysfunction (estimated creatinine
clearance should be >30 mL per min) or
hyperkalemia (potassium should be ≤5 mEq per L)
who are already receiving therapeutic doses of an
ACE inhibitor, have an LVEF less than or equal to
0.40, and have either symptomatic HF or diabetes
mellitus. (Level of Evidence: A)
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Class IIa 1. ACE inhibitors are reasonable for patients
recovering from UA/NSTEMI in the absence of LV
dysfunction, hypertension, or diabetes mellitus
unless contraindicated. (Level of Evidence: A)
4. Nitroglycerin
Class I 1. NTG to treat ischemic symptoms is recommended.
(Level of Evidence: C)
5. Calcium Channel Blockers
Class I 1. Calcium channel blockers* are recommended for
ischemic symptoms when beta blockers are not
successful. (Level of Evidence: B)
2. Calcium channel blockers* are recommended for
ischemic symptoms when beta blockers are
contraindicated or cause unacceptable side effects.
(Level of Evidence: C)
* Short-acting dihydropyridine calcium channel blockers should
be avoided.
6. Warfarin Therapy (Updated)
Class I 1. Use of warfarin in conjunction with ASA and/or a
thienopyridine agent is associated with an increased
risk of bleeding and patients and clinicians should
watch for bleeding, especially gastrointestinal, and
seek medical evaluation for evidence of bleeding.
(Level of Evidence: A)
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Class IIb 1. Warfarin either without (international normalized
ratio 2.5 to 3.5) or with low-dose ASA (75 to 81 mg
per day; international normalized ratio 2.0 to 2.5)
may be reasonable for patients at high coronary
artery disease risk and low bleeding risk who do not
require or are intolerant of a thienopyridine. (Level of
Evidence: B)
7. Lipid Management
Class I 1. The following lipid recommendations are beneficial:
a. Lipid management should include assessment
of a fasting lipid profile for all patients, within 24
hours of hospitalization. (Level of Evidence: C)
b. Statins, in the absence of contraindications,
regardless of baseline low-density lipoprotein
(LDL)-cholesterol and diet modification, should be
given to post-UA/NSTEMI patients, including
post revascularization patients. (Level of Evidence: A)
c. For patients with elevated LDL-cholesterol
(≥100 mg per dL), cholesterol-lowering therapy
should be initiated or intensified to achieve an
LDL-cholesterol of less than 100 mg per dL. (Level
of Evidence: A)
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2. Treatment of triglycerides and non–HDL-
cholesterol is useful, including the following:
a. If triglycerides are 200 to 499 mg per dL, non–
high-density lipoprotein (HDL)-cholesterol* should
be less than 130 mg per dL. (Level of Evidence: B)
b. If triglycerides are greater than or equal to 500
mg per dL

, therapeutic options to prevent
pancreatitis are fibrate

or niacin


before LDL-
lowering therapy is recommended. It is also
recommended that LDL-cholesterol be treated to
goal after triglyceride-lowering therapy.
Achievement of a non–HDL-cholesterol* less than
130 mg per dL (i.e., 30 mg per dL >LDL-
cholesterol target) if possible is recommended.
(Level of Evidence: C)
Class IIa 1. The following lipid management strategies can be
beneficial:
a. Further reduction of LDL-cholesterol to less
than 70 mg per dL is reasonable. (Level of
Evidence: A)
b. If baseline LDL cholesterol is 70 to 100 mg per
dL, it is reasonable to treat LDL-cholesterol to less
than 70 mg per dL. (Level of Evidence: B)
* Non–HDL-cholesterol = total cholesterol minus HDL-cholesterol.
† Patients with very high triglycerides should not consume alcohol. The use of bile acid sequestrants
is relatively contraindicated when triglycerides are >200 mg per dL.
‡ The combination of high-dose statin plus fibrate can increase risk for severe myopathy. Statin doses
should be kept relatively low with this combination. Dietary supplement niacin must not be used
as a substitute for prescription niacin.
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8. Blood Pressure Control
Class I 1. Blood pressure control to less than 140/90 mm Hg
(or <130/80 mm Hg if the patient has diabetes
mellitus or chronic kidney disease). (Level
of Evidence: A) Additional measures recommended to
treat and control blood pressure include the following:
a. Patients should initiate and/or maintain
lifestyle modifications, including weight control;
increased physical activity; alcohol moderation;
sodium reduction; and emphasis on increased
consumption of fresh fruits, vegetables, and low-
fat dairy products. (Level of Evidence: B)
b. For patients with blood pressure greater than or
equal to 140/90 mm Hg (or ≥130/80 mm Hg for
individuals with chronic kidney disease or
diabetes mellitus), it is useful to add blood
pressure medication as tolerated, treating initially
with beta blockers and/or ACE inhibitors, with
addition of other drugs such as thiazides as
needed to achieve target blood pressure. (Level of
Evidence: A)
9. Diabetes Mellitus (Updated)
Class I 1. Diabetes management should include lifestyle and
pharmacotherapy measures to achieve a near-
normal hemoglobin A1c level of less than 7% (Level of
Evidence: B). Diabetes management should also
include the following:
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a. Vigorous modification of other risk factors (e.g.,
physical activity, weight management, blood
pressure control, and cholesterol management) as
recommended should be initiated and maintained.
(Level of Evidence: B)
b. It is useful to coordinate the patient’s diabetic
care with the patient’s primary care physician or
endocrinologist. (Level of Evidence: C)
Class IIa 1. It is reasonable to use an insulin-based regimen
to achieve and maintain glucose levels less than 180
mg/dL while avoiding hypoglycemia* for
hospitalized patients with UA/NSTEMI with either a
complicated or uncomplicated course. (Level of
Evidence: B)
10. Chronic Kidney Disease (Updated)
Class I 1. Creatinine clearance should be estimated in UA/
NSTEMI patients and the doses of renally-cleared
medications should be adjusted according to the
pharmacokinetic data for specific medications. (Level
of Evidence: B)
2. Patients undergoing cardiac catheterization with
receipt of contrast media should receive adequate
preparatory hydration. (Level of Evidence: B)
* There is uncertainty about the ideal target range for glucose necessary to achieve an optimal
risk-benefit ratio.
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3. Calculation of the contrast volume to creatinine
clearance ratio is useful to predict the maximum
volume of contrast media that can be given without
significantly increasing the risk of contrast-associated
nephropathy. (Level of Evidence: B)
Class IIa 1. An invasive strategy is reasonable in patients with
mild (stage II) and moderate (stage III) chronic kidney
disease. (Level of Evidence: B) (There are insufficient data on
benefit/risk of invasive strategy in UA/NSTEMI patients with
advanced chronic kidney disease [stages IV, V].)
11. Smoking Cessation
Class I 1. Smoking cessation and avoidance of exposure to
environmental tobacco smoke at work and home are
recommended. Follow-up, referral to special
programs, or pharmacotherapy (including nicotine
replacement) is useful, as is adopting a stepwise
strategy aimed at smoking cessation (the 5 As: Ask,
Advise, Assess, Assist, and Arrange). (Level of Evidence: B)
12. Weight Management
Class I 1. Weight management, as measured by body mass
index and/or waist circumference, should be
assessed on each visit. A body mass index of 18.5 to
24.9 kg per m
2
and a waist circumference (measured
horizontally at the iliac crest) of less than 40 inches
for men and less than 35 inches for women is
recommended. (Level of Evidence: B)
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13. Physical Activity
Class I 1. The patient’s risk after UA/NSTEMI should be
assessed on the basis of an in-hospital
determination of risk. A physical activity history or
an exercise test to guide initial prescription is
beneficial. (Level of Evidence: B)
2. Guided/modified by an individualized exercise
prescription, patients recovering from UA/NSTEMI
generally should be encouraged to achieve physical
activity duration of 30 to 60 minutes per day,
preferably in the form of 7 (but at least 5) days per
week of moderate aerobic activity, such as brisk
walking, supplemented by an increase in daily
lifestyle activities (e.g., walking breaks at work,
gardening, and household work). (Level of Evidence: B)
3. Cardiac rehabilitation/secondary prevention
programs are recommended for patients with UA/
NSTEMI, particularly those with multiple modifiable
risk factors and/or those moderate- to high-risk
patients in whom supervised exercise training is
particularly warranted. (Level of Evidence: B)
14. Patient Education
Class I 1. Beyond the detailed instructions for daily exercise,
patients should be given specific instruction on
activities (e.g., heavy lifting, climbing stairs, yard
work, and household activities) that are permissible
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and those that should be avoided. Specific mention
should be made regarding resumption of driving,
return to work, and sexual activity. (Level of Evidence: C)
15. Influenza
Class I 1. An annual influenza vaccination is recommended
for patients with cardiovascular disease. (Level of
Evidence: B)
16. Depression
Class IIa 1. It is reasonable to consider screening UA/NSTEMI
patients for depression and refer for treatment when
indicated. (Level of Evidence: B)
17. Hormone Therapy
Class III 1. Hormone therapy with estrogen plus progestin, or
estrogen alone, should not be given de novo to
postmenopausal women after UA/NSTEMI for
secondary prevention of coronary events. (Level of
Evidence: A)
2. Postmenopausal women who are already taking
estrogen plus progestin, or estrogen alone, at the
time of UA/NSTEMI in general should not continue
hormone therapy. However, women who are more
than 1 to 2 years past the initiation of hormone
therapy who wish to continue such therapy for
another compelling indication should weigh the
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risks and benefits, recognizing the greater risk of
cardiovascular events and breast cancer
(combination therapy) or stroke (estrogen).
Hormone therapy should not be continued while
patients are on bedrest in the hospital. (Level of
Evidence: B)
18. Quality Care and Outcomes (Updated)
Class IIa 1. It is reasonable for clinicians and hospitals that
provide care to patients with UA/NSTEMI to
participate in a standardized quality-of-care data
registry designed to track and measure outcomes,
complications, and adherence to evidence-based
processes of care and quality improvement for UA/
NSTEMI. (Level of Evidence: B)
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5. Coronary Revascularization
See 2011 Percutaneous Coronary Intervention and
Coronary Artery Bypass Graft Surgery Guidelines
for the most current recommendations on
revascularization.
The ACCF/AHA would like to
acknowledge and thank our volunteer
writing committee members for their
time and contributions in support of
the missions of our organizations.
2011 ACCF/AHA WRITING GROUP
R. Scott Wright, MD, FACC, FAHA, Chair
Jeffrey L. Anderson, MD, FACC, FAHA, Vice Chair
Cynthia D. Adams, RN, PhD, FAHA
Charles R. Bridges, MD, ScD, FACC, FAHA
Donald E. Casey, Jr, MD, MPH, MBA, FACP, FAHA
Steven M. Ettinger, MD, FACC
Theodore G. Ganiats, MD
Hani Jneid, MD, FACC, FAHA
A. Michael Lincoff, MD, FACC
Eric D. Peterson, MD, MPH, FACC, FAHA
George J. Philippides, MD, FACC, FAHA
Pierre Theroux, MD, FACC, FAHA
Nanette K. Wenger, MD, MACC, FAHA
James Patrick Zidar, MD, FACC, FSCAI
2007 ACCF/AHA WRITING COMMITTEE
Jeffrey L. Anderson, MD, FACC, FAHA, Chair
Cynthia D. Adams, RN, PhD, FAHA
Elliott M. Antman, MD, FACC, FAHA
Charles R. Bridges, MD, ScD, FACC, FAHA
Robert M. Califf, MD, MACC
Donald E. Casey, JR, MD, MPH, MBA, FACP
William E. Chavey II, MD, MS
Francis M. Fesmire, MD, FACEP
Judith S. Hochman, MD, FACC, FAHA
Thomas N. Levin, MD, FACC, FSCAI
A. Michael Lincoff, MD, FACC
Eric D. Peterson, MD, MPH, FACC, FAHA
Pierre Theroux, MD, FACC, FAHA
Nanette K. Wenger, MD, MACC, FAHA
R. Scott Wright, MD, FACC, FAHA
46

© 2011 American College of Cardiology Foundation and the American Heart Association, Inc.

Initial E/M

The following material was adapted from the 2011 ACCF/ AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction. (J Am Coll Cardiol 2011;57:e215–367). This pocket guideline is available on the Web sites of the American College of Cardiology (www.cardiosource.org) and the American Heart Association (my.americanheart.org).

Hospital Care

For a copy of the full report or published executive summary, visit ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction (J Am Coll Cardiol 2007;50:e1-e157) and the 2011 ACCF/AHA Focused Update (J Am Coll Cardiol 2011;57:1920-1959).

Discharge/Post-Discharge

For copies of this document, please contact Elsevier Inc. Reprint Department, email: reprints@elsevier.com; phone 212-633-3813; fax 212-633-3820. Permissions: Multiple copies, modifications, alterations, enhancement and/or distribution of this document are not permitted without the express permission of the American College of Cardiology Foundation. Please contact Elsevier’s permission department at healthpermissions@elsevier.com.

Revascularization

B

Contents
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3

2. Initial Evaluation and Management

. . . . . . . . . . . . . . . . . . . . . . . . . . .

6 Initial E/M

A. Clinical Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 B. Early Risk Stratification. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 C. Immediate Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

3. Early Hospital Care

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

13 Hospital Care

A. Anti-Ischemic Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 B. Initial Conservative Versus Initial Invasive Strategies (UPDATED) . . . . . . . 15 C. Antiplatelet and Anticoagulant Therapy (UPDATED) . . . . . . . . . . . . . . . . . . 20 D. Risk Stratification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Discharge/Post-Discharge

4. Hospital Discharge and Post-Hospital Discharge Care . . . . . . . . .
B. Convalescent and Long-Term Medical Therapy and

30

A. Medical Regimen. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Secondary Prevention (UPDATED). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

5. Coronary Revascularization
Revascularization (see 2011 PCI and CABG Guidelines) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

2

1. Introduction
Coronary artery disease is the leading cause of death in the United States. Unstable angina (UA) and the closely related condition non–ST-segment elevation myocardial infarction (MI) (NSTEMI) are very common manifestations of this disease and are responsible for approximately 1.5 million hospitalizations in the United States each year. UA and NSTEMI are examples of acute coronary syndrome (ACS), which is characterized by an imbalance between myocardial oxygen supply and demand. The most common cause is the reduced myocardial perfusion that results from coronary artery narrowing caused by a nonocclusive thrombus that has developed on a disrupted atherosclerotic plaque. UA and NSTEMI are considered to be closely related conditions whose pathogenesis and clinical presentations are similar but of differing severity; they differ primarily in whether the ischemia is severe enough to cause sufficient myocardial damage to release detectable quantities of a marker of myocardial injury. The customary American College of Cardiology Foundation/ American Heart Association (ACCF/AHA) classification of recommendations and levels of evidence is used and displayed in Table 1.

Discharge/Post-discharge

3

case studies. case studies.Table 1. or standard-of-care should is recommended is indicated is useful/effective/beneficial treatment/strategy A is recommended/indicated in preference to treatment B treatment A should be chosen over treatment B is reasonable can be useful/effective/beneficial is probably recommended or indicated treatment/strategy A is probably recommended/indicated in preference to treatment B it is reasonable to choose treatment A over treatment B Comparative effectiveness phrases† 4 . Applying Classification of Recommendations and Level of Evidence† S IZ E CLASS I Benefit >>> Risk Procedure/Treatment SHOULD be performed/ administered OF T REAT M ENT CLASS IIa EF FE CT Benefit >> Risk Additional studies with focused objectives needed IT IS REASONABLE to perform procedure/administer treatment ■ Recommendation in favor of treatment or procedure being useful/effective ■ Some conflicting evidence from multiple randomized trials or meta-analyses ■ Recommendation in favor of treatment or procedure being useful/effective ■ Some conflicting evidence from single randomized trial or nonrandomized studies E S T I M AT E O F C E R TA I N T Y ( P R E C I S I O N ) O F T R E AT M E N T E F F E C T LEVEL A Multiple populations evaluated* Data derived from multiple randomized clinical trials or metaanalyses ■ Recommendation that procedure or treatment is useful/effective ■ Sufficient evidence from multiple randomized trials or meta-analyses ■ Recommendation that procedure or treatment is useful/effective ■ Evidence from single randomized trial or nonrandomized studies Hospital Care LEVEL B Limited populations evaluated* Data derived from a single randomized trial or nonrandomized studies LEVEL C Very limited populations evaluated* Only consensus opinion of experts. case studies. or standard of care Suggested phrases for writing recommendations ■ Recommendation that procedure or treatment is useful/effective ■ Only expert opinion. or standard of care ■ Recommendation in favor of treatment or procedure being useful/effective ■ Only diverging expert opinion.

† For comparative effectiveness recommendations (Class I and IIa. A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. case studies.Introduction Class IIb Benefit Risk Additional studies with broad objectives needed. history of prior myocardial infarction. such as sex. Level of Evidence A and B only). Excess Cost Harmful w/o Benefit to Patients or Harmful Greater conflicting evidence from multiple randomized trials or meta-analyses ■ Recommendation that procedure or treatment is not useful/effective and may be harmful ■ Sufficient evidence from multiple randomized trials or meta-analyses Recommendation’s usefulness/efficacy less well established ■ Greater conflicting evidence from single randomized trial or nonrandomized studies ■ Recommendation that procedure or treatment is not useful/effective and may be harmful ■ Evidence from single randomized trial or nonrandomized studies ■ Recommendation’s usefulness/efficacy less well established ■ ■ Only diverging expert opinion. Although randomized trials are unavailable. and prior aspirin use. age. history of heart failure. there may be a very clear clinical consensus that a particular test or therapy is useful or effective. additional registry data would be helpful Procedure/Treatment MAY BE CONSIDERED Recommendation’s usefulness/efficacy less well established ■ Class III No Benefit or Class III Harm Procedure/ Test COR III: No Benefit COR III: Harm ■ Not Helpful Treatment No Proven Benefit * Data available from clinical trials or registries about the usefulness/ efficacy in different subpopulations. or standard-of-care Recommendation that procedure or treatment is not useful/effective and may be harmful ■ ■ Only expert opinion. history of diabetes. studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated. case studies. or standard-of-care COR III: No Benefit is not recommended is not indicated should not be done is not useful/ beneficial/ effective COR III: Harm potentially harmful causes harm associated with excess morbidity/mortality should not be done may/might be considered may/might be reasonable usefulness/effectiveness is unknown /unclear/uncertain or not well established Discharge/Post-DIscharge Care 5 .

Patients with symptoms of ACS (chest discomfort with or without radiation to the arm[s]. lightheadedness) should be instructed to call 9-1-1 and should be transported to the hospital by ambulance rather than by friends or relatives. diaphoresis. nausea. if symptoms are significantly improved by 1 NTG. Clinical Assessment Recommendations for Initial Triage Initial E/M Class I 1. If chest discomfort/pain is unimproved or is worsening 5 minutes after 1 NTG dose has been taken. neck. Initial Evaluation and Management A. shortness of breath. it is recommended that the patient or family member/friend/caregiver call 9-1-1 immediately to access EMS before taking additional NTG. (Level of Evidence: C) 3. jaw or epigastrium. it is appropriate to instruct the patient or family 6 . Health care providers should instruct patients with suspected ACS for whom nitroglycerin (NTG) has been prescribed previously to take not more than 1 dose of NTG sublingually in response to chest discomfort/pain. back. weakness. chewed) to chest pain patients suspected of having ACS unless contraindicated or already taken by the patient. (Level of Evidence: B) 2.2. Prehospital emergency medical services (EMS) providers should administer 162 to 325 mg of aspirin (ASA. In patients with chronic stable angina.

serial ECGs. death or re-MI) that focuses on history. A 12-lead ECG should be performed and shown to an experienced emergency physician as soon as possible after ED arrival. initially at 15. including anginal symptoms. and biomarkers of cardiac injury (Table 2). (Level of Evidence: C) 4. Patients who present with chest discomfort or other ischemic symptoms should undergo early risk stratification for the risk of cardiovascular events (e. If the initial ECG is not diagnostic but the patient remains symptomatic and there is high clinical suspicion for ACS. (Level of Evidence: C) Initial E/M B. Early Risk Stratification Recommendations Class I 1.member/friend/caregiver to repeat NTG every 5 minutes for a maximum of 3 doses and call 9-1-1 if symptoms have not resolved completely. (Level of Evidence: C) 2. with a goal of within 10 minutes for all patients with symptoms suggestive of ACS. physical findings. hemodynamic instability. Patients with a suspected ACS with chest discomfort or other ischemic symptoms at rest for greater than 20 minutes.g. or recent syncope or presyncope should be referred immediately to an emergency department (ED). electrocardiogram (ECG) findings. (Level of Evidence: B) 3..to 7 .

can be useful to assist in decision making regarding treatment options in patients with suspected ACS (Table 2 and Figure 1). (Level of Evidence: B) 5. should be performed to detect the potential for development of ST-segment elevation or depression. Cardiac biomarkers should be measured in all patients who present with chest discomfort consistent with ACS.30-minute intervals. Patients with negative cardiac biomarkers within 6 hours of the onset of symptoms consistent with ACS should have biomarkers remeasured in the time frame of 8 to 12 hours after symptom onset. such as the TIMI or GRACE risk score or PURSUIT risk model. A cardiac-specific troponin is Initial E/M the preferred biomarker. (Level of Evidence: B) 4. Use of risk stratification models. (Level of Evidence: C) Class IIa 1. (Level of Evidence: B) 8 . The initial evaluation of the patient with suspected ACS should include the consideration of noncoronary causes for the development of unexplained symptoms.

9 The TIMI risk score is determined by the sum of the presence of 7 variables at admission. TIMI Risk Score for Unstable Angina/Non–ST Elevation MI TIMI Risk Score All-Cause Mortality. Bernink PJ. JAMA 2000.2 19. ■ use of aspirin in prior 7 d.2 40. ECG. Reprinted with permission from Antman EM.Table 2. ■ ■ Prior coronary stenosis of 50% or more remained relatively insensitive to missing information and remained a significant predictor of events.7 8. ■ elevated serum cardiac biomarkers. % Initial E/M 0–1 2 3 4 5 6–7 4. 1 point is given for each of the following variables: age 65 y or older. electrocardiogram. at least 3 risk factors for CAD. 9 . et al. CAD indicates coronary artery disease.9 26. ■ prior coronary stenosis of 50% or more. MI. The TIMI risk score for unstable angina/ non-ST elevation MI: A method for prognostication and therapeutic decision making.3 13. or Severe Recurrent Ischemia Requiring Urgent Revascularization Through 14 d After Randomization. 284:835-42. ■ at least 2 anginal events in prior 24 h. New or Recurrent MI. Cohen M. myocardial infarction. ■ ST-segment deviation on ECG presentation. Copyright © 2000 American Medical Association.

..... Dabbous OH.9...35 0...............................................9 .................... Findings at Initial Hospital Presentation Findings During Hospitalization Medical History Initial E/M 1 Age in Years Points ≤ 29 ....79.....................................19.................3 70-89.... GRACE Prediction Score Card and Nomogram for All-Cause Mortality From Discharge to 6 Months Risk Calculator for 6-Month Post-Discharge Mortality After Hospitalization for Acute Coronary Syndrome Record the points for each variable at the bottom left and sum the points to calculate the total risk score.......................................... 18 50-59................. beats/min ≤ 49.......................18 120-139.... ©Copyright 2004 American Medical Association.................. Find the total score on the x-axis of the nomogram plot....................10 0...40 0........30 0... 11 Points Predicted All-Cause Mortality From Hospital Discharge to 6 Months 1 2 3 5 6 7 8 9 Total Risk Score Mortality Risk (Sum of Points) (From Plot) Probability 0...9 ............... 36 60-69.......35 ≥ 200 ...... 15 ≥ 4 .4-0...............14 110-149....................9 .........45 0..50 0..................... Lim MJ...9 ...9......25 0.................. 15 80-99. The corresponding probability on the y-axis is the estimated probability of all-cause mortality from hospital discharge to 6 months. mg/dL Points 0-0....... 10 .05 0 70 90 110 130 150 Total Risk Score 170 190 210 4 Eagle KA........ 14 6 ST-Segment Depression ........9 90-109..........................99 .... 12 Enzymes .................................23 150-199..........................14 140-159.........................9 ......... A validated prediction model for all forms of acute coronary syndrome: estimating the risk of 6-month post-discharge death in an international registry...............................................................9 ... 9 2-3........6-1. et al.... 24 Myocardial Infarction ........ 0 30-39 ...........39.............. 55 70-79 ..15 0..................... 8 Elevated Cardiac 9 No In-Hospital Heart Failure .............................Figure 1.....8-1.......59 ...9 ........ 24 7 Initial Serum Creatinine... JAMA 2004................ 7 1...........9 ..............10 160-199.......20 0................ 0 50-69..................0 Percutaneous Coronary Intervention ...... 5 1................4 ≥ 200 ... 73 80-89.... 3 0.9...... 0 40-49 .......2-1.. 291:2727-33... 1 0........9 ....... 20 2 History of Congestive 3 History of 5 Systolic Blood Pressure.... 100 4 Resting Heart Points Rate.....99 ...... 91 ≥ 90 ............................22 100-119...43 mm HG ≤ 79........

(Level of Evidence: C) Initial E/M 2. or on an outpatient basis in a timely fashion (within 72 h) as an alternative to inpatient admission. In patients with suspected ACS in whom ischemic heart disease is present or suspected. and definite ACS. a stress test (exercise or pharmacological) to provoke ischemia should be performed in the ED. specified time intervals. 12-lead ECG. if the followup 12-lead ECG and biomarker measurements are normal.C. in a chest pain unit. chronic stable angina. Immediate Management Recommendations Class I 1. (Level of Evidence: C) 11 . and initial cardiac biomarker tests should be integrated to assign patients with chest pain to 1 of 4 categories: a noncardiac diagnosis. possible ACS. physical examination. The history. Low-risk patients with a negative stress diagnostic test can be managed as outpatients. (Level of Evidence: B) 3. Patients with probable or possible ACS but whose initial 12-lead ECG and cardiac biomarker levels are normal should be observed in a facility with cardiac monitoring and repeat ECG (or continuous 12-lead ECG monitoring) and repeat cardiac biomarker measurement(s) should be obtained at predetermined.

(Level of Evidence: C) 5. In low-risk patients who are referred for outpatient stress testing (see above). Patients with definite ACS and ongoing ischemic Initial E/M symptoms. Patients with possible ACS and negative cardiac biomarkers who are unable to exercise or who have an abnormal resting ECG should undergo a pharmacological stress test. (Level of Evidence: B) 6. (Level of Evidence: C) 12 . Patients discharged from the ED or chest pain unit should be given specific instructions for activity. or a positive stress test should be admitted to the hospital for further management.g. positive cardiac biomarkers. and follow-up with a personal physician. (Level of Evidence: C) 5. ongoing ischemia/injury and hemodynamic or electrical instability. a telemetry step-down unit is reasonable.4. and/ or beta blockers) should be considered while awaiting results of the stress test. Otherwise. ASA. additional testing. hemodynamic abnormalities. new deep T-wave inversions. sublingual NTG. new STsegment deviations. Admission to the critical care unit is recommended for those with active. medications. precautionary pharmacotherapy (e..

Early Hospital Care A. The decision to administer intravenous NTG and the dose used should not preclude therapy with other proven mortality-reducing interventions such as beta blockers or angiotensin-converting enzyme (ACE) inhibitors. (Level of Evidence: B) 13 . or hypertension.3. Bed/chair rest with continuous ECG monitoring is recommended for all UA/NSTEMI patients during the early hospital phase. heart failure. Supplemental oxygen should be administered to UA/NSTEMI patients with an arterial saturation less than 90%. if not contraindicated. respiratory distress. Anti-Ischemic Therapy Recommendations Class I 1. or other high-risk features for hypoxemia.4 mg) every 5 minutes for a total of 3 doses. after which assessment should be made about the need for intravenous NTG. Intravenous NTG is indicated in the first 48 hours in patients with UA/NSTEMI for treatment of persistent ischemia. Patients with UA/NSTEMI with ongoing ischemic discomfort should receive sublingual NTG (0. (Level of Evidence: C) Hospital Care Initial E/M 4. (Level of Evidence: C) 2. (Level of Evidence: B) 3.

An angiotensin receptor blocker may be used for ACE intolerant patients. verapamil or diltiazem) should be given as initial therapy in the absence of clinically significant left ventricular (LV) dysfunction or other contraindications. a nondihydropyridine calcium channel blocker antagonist (e. In UA/NSTEMI patients with continuing or frequently recurring ischemia and in whom beta blockers are contraindicated.. Oral beta-blocker therapy within 24 hours should be administered to patients without a contraindication (Level of Evidence: B) 6.40 in the absence of hypotension (systolic blood pressure <100 mm Hg or <30 mm Hg below baseline) or known contraindications. (Level of Evidence: A) 14 . An ACE inhibitor should be administered orally within Hospital Care the first 24 hours to patients with pulmonary congestion or left ventricular ejection fraction (LVEF) less than or equal to 0. (Level of Evidence: B) 7.g.5.

An early invasive strategy (i.e.. (Level of Evidence: B) Class IIa 1. diagnostic Hospital Care angiography with intent to perform revascularization) is indicated in initially stabilized UA/NSTEMI patients (without serious comorbidities or contraindications to such procedures) who have an elevated risk for clinical events (Table 3). a delayed invasive approach is also reasonable. In women with low-risk features. (Level of Evidence: B) 15 . An early invasive strategy (i. It is reasonable to choose an early invasive strategy (within 12 to 24 h of admission) over a delayed invasive strategy for initially stabilized highrisk patients with UA/NSTEMI. a conservative strategy is recommended. For patients not at high risk. (Level of Evidence: A) 3..B. (Level of Evidence: B) 2. Initial Conservative Versus Initial Invasive Strategies (UPDATED) Recommendations Class I 1.e. diagnostic angiography with intent to perform revascularization) is indicated in UA/NSTEMI patients who have refractory angina or hemodynamic or electrical instability (without serious comorbidities or contraindications to such procedures).

Class IIb 1. (Level of Evidence: C) Hospital Care 16 . a selectively invasive) strategy may be considered as a treatment strategy for UA/ NSTEMI patients (without serious comorbidity or contraindications) who have an elevated risk of clinical events (Table 4) including those who are troponin positive.e. In initially stabilized patients.. an initially conservative (i. (Level of Evidence B) The decision to implement an initial conservative strategy in these patients may be made considering physician and patient preference.

g. GRACE) Patient or physician preference in the absence of high-risk features CABG indicates coronary artery bypass graft surgery. troponin T. percutaneous coronary intervention. Selection of Initial Treatment Strategy: Invasive Versus Conservative Strategy (Updated) Strategy Invasive Status Patient Characteristics Generally preferred Recurrent angina or ischemia at rest or with lowlevel activities despite intensive medical therapy Elevated cardiac biomarkers (TnT or TnI) New or presumably new ST-segment depression Signs or symptoms of HF or new or worsening mitral regurgitation High-risk findings from noninvasive testing Hemodynamic instability Sustained ventricular tachycardia PCI within 6 mo Prior CABG High-risk score (e. PCI. heart failure. TnI. GRACE. left ventricular ejection fraction. Thrombolysis in Myocardial Infarction. TIMI.g. troponin I..Table 3. TIMI. GRACE) Mild to moderate renal dysfunction Diabetes mellitus Reduced left ventricular function (LVEF <40%) Hospital Care Conservative Generally preferred Low risk score (e. Global Registry of Acute Coronary Events. 17 . TIMI. HF. and TnT. LVEF..

tachycardia Age >75 y Angina at rest with transient ST-segment changes >0. Unstable Angina: Diagnosis and Management. or CK-MB (e.1 ng per mL) ECG Cardiac markers *Estimation of the short-term risks of death and nonfatal cardiac ischemic events in UA (or NSTEMI) is a complex multivariable problem that cannot be fully specified in a table such as this. most likely due to ischemia New or worsening MR murmur S3 or new/worsening rales Hypotension.10. May 1994. TnI. TnT or TnI >0. Short-Term Risk of Death or Nonfatal MI in Patients With UA/NSTEMI* High Risk At least 1 of the following features must be present: Accelerating tempo of ischemic symptoms in preceding 48 h Prolonged ongoing (>20 min) rest pain Feature History Character of pain Hospital Care Clinical findings Pulmonary edema. bradycardia. Adapted from AHCPR Clinical Practice Guidelines No. new or presumed new Sustained ventricular tachycardia Elevated cardiac TnT. 18 .Table 4. this table is meant to offer general guidance and illustration rather than rigid algorithms.5 mm Bundle-branch block.. therefore.g.

coronary artery disease. creatine kinase. with moderate or high likelihood of CAD Rest angina (>20 min) or relieved with rest or sublingual NTG Nocturnal angina New-onset or progressive CCS class III or IV angina in the past 2 wk without prolonged (>20 min) rest pain but with intermediate or high likelihood of CAD Age >70 years Low Risk No high. MR. nitroglycerin. troponin T. inferior. TnI.. or duration Angina provoked at a lower threshold New onset angina with onset 2 wk to 2 mo prior to presentation Hospital Care T-wave changes Pathological Q waves or resting ST-depression <1 mm in multiple lead groups (anterior. CK-MB. CCS. but must have 1 of the following: Prior MI. lateral) Slightly elevated cardiac TnT. unstable angina/non–ST-elevation myocardial infarction. mitral regurgitation. NTG. 19 . electrocardiogram. or CABG. MB fraction. now resolved. prior aspirin use Prolonged (>20 min) rest angina.g. peripheral or cerebrovascular disease. ECG. myocardial infarction.01 but <0. MI. or CK-MB (e. UA/NSTEMI. CAD. troponin I. Canadian Cardiovascular Society. TnT.or intermediate-risk feature but may have any of the following features: Increased angina frequency. severity. TnI.1 ng per mL) Normal or unchanged ECG Normal CABG indicates coronary artery bypass graft surgery. TnT >0.Intermediate Risk No high-risk feature.

20 . Initial Conservative Strategy or Unknown *If fondaparinux is used with an invasive strategy (Class I. Initiate anticoagulant therapy (Class I. UFH. percutaneous coronary intervention. The decision of which agents to use. LOE: B) ASA indicates aspirin. . LOE. GP glycoprotein. LOE: B) Initiate clopidogrel (Class I. level of evidence. 4. ST-elevation myocardial infarction. and 5. LOE: B) Select Management Strategy For Invasive Strategy see Figure 3. coronary artery bypass graft. LOE: A) Acceptable options include (Class IIa. STEMI. for example. 3. and UFH. LOE: A) Clopidogrel if ASA intolerant (Class I. unfractionated heparin. IV. it must be coadministered with another anticoagulant with Factor IIa activity. Figure 2. LOE: B). unstable angina/non-ST-elevation myocardial infarction.C. PCI. UA/NSTEMI. Antiplatelet and Anticoagulation Therapy (UPDATED) A growing number of antiplatelet and antithrombotic agents are now available for use in ACS. discontinue. D/C. and Table 5 for guidance. intravenous. when to administer them and at what doses is complex. Flowchart for Class I and Class IIa Recommendations for Initial Management of UA/NSTEMI (Initial Conservative Strategy) (Updated) Diagnosis of UA/NSTEMI is Likely or Definite Hospital Care ASA (Class I. CABG. See Figures 2.

CABG. clopidogrel. LOE: B). . level of evidence. D/C. coronary artery bypass graft. LOE: A)‡ *If fondaparinux is used with an invasive strategy (Class I. intravenous. unstable angina/non-ST-elevation myocardial infarction.Figure 3. LOE: B recommendation for selected high-risk patients. it must be coadministered with another anticoagulant with Factor IIa activity. Next step per triage decision at angiography CABG: Maintenance ASA (Class I. LOE: B) For Initial Conservative Strategy see Figure 2. PCI. glycoprotein inhibitors) is a Class IIb. unfractionated heparin. Select Management Strategy Invasive Strategy† Hospital Care Initiate anticoagulant therapy (Class I. and UFH. 21 . †Timing of invasive strategy generally is assumed to be 4 to 48 hours. If immediate angiography is selected. IV. ST-elevation myocardial infarction. for example. LOE. GP glycoprotein. percutaneous coronary intervention. LOE: A)* Acceptable options include Precatheterization: Add second antiplatelet agent (Class I. LOE: A) Clopidogrel if ASA intolerant (Class I. STEMI. discontinue. Flowchart for Class I and Class IIa Recommendations for Initial Management of UA/NSTEMI (Invasive Strategy) (Updated) Diagnosis of UA/NSTEMI is Likely or Definite ASA (Class I. see STEMI guidelines. LOE: A) PCI: Class I: catheterization) (LOE: A) or or inhibitor (if not begun precatheterization) (LOE: A) - Medical Therapy: D/C GP IIb/IIIa inhibitors if begun and give clopidogrel per conservative strategy ASA indicates aspirin. UFH. UA/NSTEMI. ‡Precatheterization tripleantiplatelet therapy (ASA.

loading dose. albeit without any significant. LOE: B)* Discontinue IV GP IIb/IIIa after at least 12 h if started pre angio (Class I. intravenous. LOE: A) Discontinue clopidogrel at least 5 d (Class I. LOE: B)‡ No significant obstructive CAD on angiography CAD on angiography Hospital Care Continue ASA* (Class I. LOE: B for clopidogrel administration) and bivalidrudin is selected as anticoagulant (Class IIa. LOE: B). LOE: A) or enoxaparin or fondaparinux for duration of hospitalization (Class I. percutaneous coronary intervention. unstable angina/non–ST-elevation myocardial infarction. Discontinue bivalirudin 3 h prior to CABG. Continue ASA* (Class I. discontinue fondaparinux 24 h prior to CABG. LOE: B)* and it is reasonable to give IV GP IIb/ IIa if not started pre angio (Class IIa. ‡ Additional bolus of UFH is recommended if fondaparinux is selected as anticoagulant (see Dosing Table 5). LOE: B) and prasugrel at least 7 d (Class I. long-term treatment with antiplatelet agents and other secondary prevention measures should be considered. LOE: B) * See Dosing Table 5. LOE: A)*† Discontinue anticoagulant after PCI for uncomplicated cases (Class I. 22 . LOE: B) † Evidence exists that GP IIb/IIIa inhibitors may not be necessary if the patient received a preloading dose of at least 300 mg of clopidogrel at least 6 h earlier (Class I. LOE: A) LD of a thienopyridine if not given pre angio (Class I. LOE: A). LOE: C) LD of clopidogrel if not given pre angio (Class I. Management After Diagnostic Angiography in Patients With UA/NSTEMI (Updated) Diagnostic Angiography Select Post-Angiography Management Strategy CABG PCI Medical therapy Continue ASA* (Class I. LOE: B) Continue IV UFH for at least 48 h (Class I.25 mg/kg/hr for up to 72 h at physician’s discretion (Class I. CAD. IV. coronary artery disease. GP glycoprotein. § For patients in whom the clinician believes coronary atherosclerosis is present. LD. UA/NSTEMI. . ASA indicates aspirin. LOE: B) Continue UFH (Class I. either discontinue bivalirudin or continue at a dose of 0. LOE:B). CABG. UFH. pre angio. Dose with UFH per institutional practice (Class I. LOE: A) J Antiplatelet and anticoagulant therapy at physician’s discretion§ (Class I. unfractionated heparin. LOE: C) prior to elective CABG Discontinue IV GP IIb/IIIa 4 h prior to CABG (Class I. flow-limiting stenosis. discontinue enoxaparin 12 to 24 h prior to CABG.Figure 4. before angiography. coronary artery bypass graft. PCI.

international normalized ratio. then 75 to 162 mg/d indefinitely (Class I. INR. LOE: C) ASA indicates aspirin. LOE: B) ASA* 162 to 325 mg/d§ for at least 1 mo. use ticlopidine. cerebral.Figure 5. or prasugrel. unstable angina/non–ST-elevation myocardial infarction. § When risk of bleeding is a concern. LOE: B) ASA* 162 to 325 mg/d§ for at least 3 to 6 mo. 23 . or try ASA desensitization. use clopidogrel alone (indefinitely). LV thrombus. Level of Evidence. LOE. † For clopidogrel allergic patients. Long-Term Antithrombotic Therapy at Hospital Discharge After UA/NSTEMI (Updated) UA/NSTEMI Patient Groups at Discharge Medical Therapy Without Stent Bare-Metal Stent Group Drug-Eluting Stent Group ASA* 75 to 162 mg/d indefinitely (Class I. LOE: A) & Clopidogrel† 75 mg/d for at least 1 mo and ideally up to 1 y (Class I. venous or pulmonary emboli. ‡ Continue ASA indefinitely and warfarin longer term as indicated for specific conditions such as atrial fibrillation. 250 mg by mouth twice daily. LOE: B) to maintain INR of 2–3 No Continue with dual antiplatelet therapy as above * For ASA allergic patients. then 75 to 162 mg/d indefinitely (Class I. LOE: A) & Clopidogrel† 75 mg/d or prasugrel 10 mg/d for at least 1 y (Class I. left ventricular. LV. UA/NSTEMI. LOE: B) Hospital Care Indication for Anticoagulation? Yes Add: Warfarin‡§ (Class IIb. a lower initial ASA (75 to 162 mg/d) after PCI is reasonable (Class IIa. LOE: A) & Clopidogrel† 75 mg/d or prasugrel 10 mg/d for at least 1 y (Class I.

LOE: A) Eptifibatide Of uncertain benefit LD of 180 mcg/kg IV bolus followed 10 min later by second IV bolus of 180 mcg/kg MD of 2.25 mg/kg IV bolus MD of 0. LOE: B) 24 .15 mcg/kg per min.0 mcg/kg per min. LOE: C) Prasugrel‡ No data are available to guide decision making LD of 300-600 mg orally (Class I.125 mcg/kg per min (maximum 10 mcg/ min) (Class I.Table 5. then no additional treatment A second LD of 300 mg may be given orally to supplement a prior LD of 300 mg (Class I. reduce infusion by 50% in patients with estimated creatinine clearance <50 mL/min (Class I. reduce rate of infusion by 50% in patients with estimated creatinine clearance <30 mL/min (Class I. LOE: B) LD of 60 mg orally MD of 10 mg orally per d (Class I. LOE: B) Hospital Care Thienopyridines Clopidogrel† If 600 mg given orally. LOE: A) MD of 75 mg orally per d (Class I. Dosing Table for Selected Antiplatelet and Anticoagulant Therapies (Updated) During PCI Drug* Patient Received Initial Medical Treatment (With a Thienopyridine) Patient Did Not Receive Initial Medical Treatment (With a Thienopyridine) Glycoprotein IIb/IIIa Receptor Antagonists Abciximab Of uncertain benefit LD of 0. LOE: A) Tirofiban Of uncertain benefit LD of 25 mcg/kg IV bolus MD of IV infusion of 0. started after first bolus. LOE: A) An MD of 150 mg orally per d for initial 6 d may be considered (Class IIb.

➤ Continue for up to 18 h at the discretion of the physician. ➤ There is a recommended duration of therapy for all post-PCI patients receiving a BMS or DES. (For full explanations. (For full explanations. ➤ Dose for patients >75 y of age has not been established.) 25 . see footnote.4 mcg/kg per min for 30 min MD of a continuous infusion of 0. ➤ MD of 5 mg orally per d in special circumstances. ➤ A LD of eptifibatide is FDA approved when the medication is initiated in UA/NSTEMI patients who are started on medical therapy and when there is an appreciable delay in angiography/PCI: LD of 180 mcg/kg IV bolus followed by MD of 2.. ➤ Optimum LD requires clinical consideration.1 mcg/kg per min. ➤ Contraindicated for use in patients with prior history of TIA or stroke. ➤ Period of withdrawal before surgery should be at least 5 d. Continue the infusion through angiography and for 12 to 24 h after angioplasty or atherectomy. ➤ There is a recommended duration of therapy for all post-PCI patients receiving a BMS or DES. 48 h): LD of 50 mcg/mL administered at an initial rate of 0. LOE: B) ➤ Infusion should be continued for 12 to 18 h at the discretion of the physician.g.Comments ➤ All Patients to Receive ASA (162–325 mg) ➤ Continue for up to 12 h at the discretion of the physician. ➤ Caution should be exercised for use with a PPI. ➤ Special dosing for patients <60 kg or >75 y of age. see footnote. ➤ A lower-dose regimen for tirofiban is FDA approved and has been shown to be effective when used to treat UA/NSTEMI patients who are started on medical therapy and when there is a substantial delay to angiography/PCI (e.) ➤ There are no data for treatment with prasugrel before PCI.0 mcg/kg per min started after bolus reduce infusion by 50% in patients with estimated creatinine clearance <50 mL/min (Class I. Hospital Care ➤ Increased dosing over previous recommendation.

diminished platelet inhibition. This drug table does not make recommendations for combinations of listed drugs. wait 30 min. 26 . LOE: B) 0. 300–350 s for Hemochron (Class I. LOE:B) * This list is in alphabetical order and is not meant to indicate a particular therapy preference.75 mg/kg bolus. Dosing Table for Selected Antiplatelet and Anticoagulant Therapies continued from previous page During PCI Drug* Patient Received Initial Medical Treatment (With a Thienopyridine) Patient Did Not Receive Initial Medical Treatment (With a Thienopyridine) Parenteral Anticoagulants Bivalirudin For patients who have received UFH. It is only meant to indicate an approved or recommended dosage if a drug is chosen for a given situation. 300–350 s for Hemochron (Class I. The period of withdrawal should be at least 5 d in patients receiving clopidogrel. † For post-PCI patients receiving a DES or BMS.Table 5. including stent thrombosis. it is reasonable to discontinue the clopidogrel to allow for dissipation of the antiplatelet effect unless the urgency for revascularization and/or the net benefit of clopidogrel outweigh the potential risks of excess bleeding. and a higher rate of MACE. 1.75 mg/kg bolus.75 mg/kg per h infusion (Class I. In NSTEMI patients taking clopidogrel for whom CABG is planned and can be delayed. then give 0.75 mg/kg per h infusion UFH Hospital Care IV GP IIb/IIIa planned: 50–70 U/kg bolus to achieve an ACT of 200–250 s No IV GP IIb/IIIa planned: 70–100 U/kg bolus to achieve target ACT of 250–300 s for HemoTec. a daily MD should be given for at least 12 mo unless the risk of bleeding outweighs the anticipated net benefit afforded by a thienopyridine. LOE: B) IV GP IIb/IIIa planned: target ACT 200–250 s No IV GP IIb/IIIa planned: target ACT 250–300 s for HemoTec. then 1. The necessity for giving an LD of clopidogrel before PCI is driven by the pharmacokinetics of clopidogrel. for which a period of several hours is required to achieve desired levels of platelet inhibition. Patients who have a reduced-function CYP2C19 allele have significantly lower levels of the active metabolite of clopidogrel.

concomitant use of medications that increase the risk of bleeding (e. Consider lowering the MD to 5 mg in patients who weigh <60 kg. subcutaneous. heparin. loading dose. In patients ≥75 years of age. IV. Hospital Care ‡ Patients weighing <60 kg have an increased exposure to the active metabolite of prasugrel and an increased risk of bleeding on a 10-mg once-daily MD. ➤ In UA/NSTEMI patients undergoing PCI who are at high risk of bleeding. except in high-risk situations (patients with diabetes or a history of prior MI). unfractionated heparin. SC. BMS. for which its effect appears to be greater and its use may be considered. discontinue prasugrel at least 7 d before any surgery. For post-PCI patients receiving a DES or BMS. MD. SES.Comments ➤ All Patients to Receive ASA (162–325 mg) ➤ Bivalirudin may be used to support PCI and UA/NSTEMI with or without previously administered UFH with the addition of 600 mg of clopidogrel. GP glycoprotein. prasugrel is generally not recommended because of the increased risk of fatal and intracranial bleeding and uncertain benefit. fibrinolytic therapy. percutaneous coronary intervention. international unit. sirolimus-eluting stent. bivalirudin anticoagulation is reasonable. PCI. LD. ACT indicates activated clotting time. intravenous. PES. . When possible. Additional risk factors for bleeding include body weight <60 kg. paclitaxel-eluting stent. units. a daily MD should be given for at least 12 and up to 15 mo unless the risk of bleeding outweighs the anticipated net benefit afforded by a thienopyridine. Do not start prasugrel in patients likely to undergo urgent CABG. unstable angina/non–ST-elevation myocardial infarction. maintenance dose. U. UA/NSTEMI. bare-metal stent. The effectiveness and safety of the 5-mg dose have not been studied prospectively. Do not use prasugrel in patients with active pathological bleeding or a history of TIA or stroke. propensity to bleed.g.. warfarin. or long-term use of nonsteroidal anti-inflammatory drugs). UFH. IU. 27 .

local expertise. bundlebranch block. (Level of Evidence: B) 4. In patients undergoing a low-level exercise test. An imaging modality should be added in patients with resting ST-segment depression (≥0.D. general debility) preclude adequate exercise stress. (Level of Evidence: B) 28 .10 mV). intraventricular conduction defect. and technologies available. or digoxin who are able to exercise. Choice of stress test is based on the resting ECG. severe chronic obstructive pulmonary disease. Treadmill exercise is useful in patients able to exercise in whom the ECG is free Hospital Care of baseline ST-segment abnormalities. intraventricular conduction defect. bundle-branch block. preexcitation. (Level of Evidence: C) 3. Noninvasive stress testing is recommended in low. arthritis. preexcitation. amputation. paced rhythm. an imaging modality can add sensitivity.. Pharmacological stress testing with imaging is recommended when physical limitations (e. ability to perform exercise.and intermediate-risk patients who have been free of ischemia at rest or with low-level activity and of heart failure for a minimum of 12 to 24 hours (Level of Evidence: C) 2. LV hypertrophy. LV hypertrophy. Risk Stratification Recommendations Class I 1. severe peripheral vascular disease. and digoxin effect.g.

A noninvasive test (echocardiogram or radionuclide angiogram) is recommended to evaluate LV function in patients with definite ACS who are not scheduled for coronary angiography and left ventriculography. (Level of Evidence: B) 6.5. (Level of Evidence: B) Hospital Care 29 . Prompt angiography without noninvasive risk stratification should be performed for failure of stabilization with intensive medical treatment.

Recommendations Class I 1. The risk of progression to MI or the development of recurrent MI or death is highest during this period. pharmacists. nurses. Direct patient instruction is important and should be reinforced and documented with written instruction sheets. patients with unsuccessful revascularization. dietitians. (Level of Evidence: C) 30 . Upward or downward titration of the doses may be required. and patients with recurrent symptoms after revascularization. rehabilitation specialists. Medications required in the hospital to control ischemia should be continued after hospital discharge in patients with UA/NSTEMI who do not undergo coronary revascularization. A. stable coronary artery disease. Most patients then resume a clinical course similar to that of patients with chronic. Enrollment in a cardiac rehabilitation program after discharge may enhance patient education and compliance with Discharge/Post-Discharge the medical regimen.4. and physical and occupational therapists) is often necessary to prepare the patient for discharge. Medical Regimen An effort of the entire staff (physicians. Hospital Discharge and Post-Hospital Discharge Care The acute phase of UA/NSTEMI is usually over within 2 months.

anginal discomfort lasting more than 2 or 3 minutes should prompt the patient to discontinue physical activity or remove himself or herself from any stressful event. the patient should be instructed to take 1 dose of NTG sublingually. (Level of Evidence: C) 4. which suggests worsening myocardial 31 Discharge/Post-Discharge . and pertinent side effects. dose. Before hospital discharge. purpose. In post-UA/NSTEMI patients. additional NTG (at 5-minute intervals 2 times) may be taken while lying down or sitting. Before hospital discharge.2. If the pattern or severity of anginal symptoms changes. patients with UA/ NSTEMI should be informed about symptoms of worsening myocardial ischemia and MI and should be instructed in how and when to seek emergency care and assistance if such symptoms occur. If the chest discomfort/pain is unimproved or worsening 5 minutes after 1 NTG dose has been taken. and culturally sensitive instructions with respect to medication type. While activating EMS access. easily understood. (Level of Evidence: C) 5. (Level of Evidence: C) 3. it is recommended that the patient or a family member/ friend call 9-1-1 immediately to access EMS. If pain does not subside immediately. (Level of Evidence: C) 6. All post-UA/NSTEMI patients should be given sublingual or spray NTG and instructed in its use. post-UA/NSTEMI patients and/or designated responsible caregivers should be provided with supportable. frequency.

. pain is more frequent or severe or is precipitated by less effort or now occurs at rest).g. Antiplatelet Therapy (Updated) Class I 1. and 6 months after paclitaxel-eluting stent implantation. the patient should contact his or her physician without delay to assess the need for additional treatment or testing. ASA 162 to 325 mg daily should be given for at least 1 month after bare-metal stent implantation. (Level of Evidence: A) For patients who have undergone PCI. 3 months after Discharge/Post-Discharge sirolimus-eluting stent implantation. Aspirin 75 to 162 mg daily should be given and continued indefinitely for medically-treated patients recovering from UA/NSTEMI. (Level of Evidence: B) 32 . Convalescent and Long-Term Medical Therapy and Secondary Prevention (UPDATED) 1. after which daily chronic ASA use should be continued indefinitely at a dose of 75 to 162 mg.ischemia (e. (Level of Evidence: C) B.

(Level of Evidence: B) Discharge/Post-Discharge 33 . (Level of Evidence: B) b. (Level of Evidence: B) 3. The duration and maintenance dose of thienopyridine therapy should be as follows: a. (Level of Evidence: C) c. clopidogrel 75 mg daily should be prescribed for at least 1 month and ideally up to 1 year.2. earlier discontinuation should be considered. If the risk of morbidity because of bleeding outweighs the anticipated benefits afforded by thienopyridine therapy. For UA/NSTEMI patients treated medically without stenting. In UA/NSTEMI patients undergoing percutaneous coronary intervention (PCI) with a drug-eluting stent or bare-metal stent. Clopidogrel 75 mg daily (preferred) or ticlopidine (in the absence of contraindications) should be given to patients recovering from UA/NSTEMI when ASA is contraindicated or not tolerated because of hypersensitivity or gastrointestinal intolerance (despite use of gastroprotective agents such as proton pump inhibitors). clopidogrel 75 mg daily or prasugrel 10 mg daily should be given for at least 12 months.

Platelet function testing to determine platelet inhibitory response in patients with UA/NSTEMI (or. Beta blockers are indicated for all patients recovering from UA/NSTEMI unless contraindicated and should be continued indefinitely. a lower initial ASA dose (75 to 162 mg/day) after PCI is reasonable. (Level of Evidence: C) Class III: Harm In UA/NSTEMI patients with a prior history of stroke and/or transient ischemic attack for whom PCI is planned. (Level of Evidence: B) 34 . Beta Blockers Class I Revascularization Discharge/Post-Discharge 1. For UA/NSTEMI patients in whom the physician is concerned about the risk of bleeding. (Level of Evidence: B) 2. after ACS and PCI) on thienopyridine therapy may be considered if results of testing may alter management. Continuation of clopidogrel or prasugrel beyond 15 months may be considered in patients following drug-eluting stent placement. (Level of Evidence: C) Class IIb 1. prasugrel is potentially harmful as part of a dual-antiplatelet therapy regimen.Class IIa 1. (Level of Evidence: B) 2.

2. Inhibition of the Renin-AngiotensinAldosterone System Class I 1. (Level of Evidence: A) 2. have an LVEF less than or equal to 0. or diabetes mellitus unless contraindicated. (Level of Evidence: A) Discharge/Post-Discharge 35 .40). An angiotensin receptor blocker should be prescribed at discharge to those patients who are intolerant of an ACE inhibitor and who have either clinical or radiological signs of HF and LVEF less than 0. LV dysfunction (EF <0. and have either symptomatic HF or diabetes mellitus. Patients recovering from UA/NSTEMI with moderate or severe LV failure should receive betablocker therapy with a gradual titration scheme. Long-term aldosterone receptor blockade should be prescribed for post-UA/NSTEMI patients without significant renal dysfunction (estimated creatinine clearance should be >30 mL per min) or hyperkalemia (potassium should be ≤5 mEq per L) who are already receiving therapeutic doses of an ACE inhibitor. hypertension.40.40. (Level of Evidence: A) 3. ACE inhibitors should be given and continued indefinitely for patients recovering from UA/NSTEMI with HF. (Level of Evidence: B) 3.

Calcium channel blockers* are recommended for ischemic symptoms when beta blockers are contraindicated or cause unacceptable side effects. (Level of Evidence: C) 5. especially gastrointestinal. (Level of Evidence: C) * Short-acting dihydropyridine calcium channel blockers should be avoided. Calcium channel blockers* are recommended for ischemic symptoms when beta blockers are not successful. hypertension.Class IIa 1. or diabetes mellitus unless contraindicated. ACE inhibitors are reasonable for patients recovering from UA/NSTEMI in the absence of LV dysfunction. (Level of Evidence: B) 2. (Level of Evidence: A) 36 . 6. Calcium Channel Blockers Class I 1. and seek medical evaluation for evidence of bleeding. Warfarin Therapy (Updated) Revascularization Discharge/Post-Discharge Class I 1. Nitroglycerin Class I 1. NTG to treat ischemic symptoms is recommended. Use of warfarin in conjunction with ASA and/or a thienopyridine agent is associated with an increased risk of bleeding and patients and clinicians should watch for bleeding. (Level of Evidence: A) 4.

5 to 3. cholesterol-lowering therapy should be initiated or intensified to achieve an LDL-cholesterol of less than 100 mg per dL. in the absence of contraindications. Lipid Management Class I 1.5) may be reasonable for patients at high coronary artery disease risk and low bleeding risk who do not require or are intolerant of a thienopyridine.5) or with low-dose ASA (75 to 81 mg per day. The following lipid recommendations are beneficial: a. (Level of Evidence: A) c.Class IIb 1. within 24 hours of hospitalization. (Level of Evidence: A) Discharge/Post-Discharge 37 . For patients with elevated LDL-cholesterol (≥100 mg per dL). should be given to post-UA/NSTEMI patients. international normalized ratio 2. including postrevascularization patients. Statins. (Level of Evidence: B) 7. Warfarin either without (international normalized ratio 2. Lipid management should include assessment of a fasting lipid profile for all patients. (Level of Evidence: C) b.0 to 2. regardless of baseline low-density lipoprotein (LDL)-cholesterol and diet modification.

. 30 mg per dL >LDLcholesterol target) if possible is recommended. (Level of Evidence: C) Class IIa 1. If triglycerides are 200 to 499 mg per dL. (Level of Evidence: B) * Non–HDL-cholesterol = total cholesterol minus HDL-cholesterol. 38 . (Level of Evidence: B) b. The following lipid management strategies can be beneficial: a. Statin doses should be kept relatively low with this combination. non– high-density lipoprotein (HDL)-cholesterol* should be less than 130 mg per dL. Treatment of triglycerides and non–HDLcholesterol is useful. If baseline LDL cholesterol is 70 to 100 mg per dL. including the following: a. † Patients with very high triglycerides should not consume alcohol. therapeutic options to prevent pancreatitis are fibrate‡ or niacin‡ before LDLlowering therapy is recommended. Dietary supplement niacin must not be used as a substitute for prescription niacin. Achievement of a non–HDL-cholesterol* less than 130 mg per dL (i. If triglycerides are greater than or equal to 500 mg per dL†. it is reasonable to treat LDL-cholesterol to less Revascularization Discharge/Post-Discharge than 70 mg per dL. It is also recommended that LDL-cholesterol be treated to goal after triglyceride-lowering therapy.2. (Level of Evidence: A) b.e. The use of bile acid sequestrants is relatively contraindicated when triglycerides are >200 mg per dL. ‡ The combination of high-dose statin plus fibrate can increase risk for severe myopathy. Further reduction of LDL-cholesterol to less than 70 mg per dL is reasonable.

(Level of Evidence: A) Additional measures recommended to treat and control blood pressure include the following: a. Diabetes management should include lifestyle and pharmacotherapy measures to achieve a nearnormal hemoglobin A1c level of less than 7% (Level of Evidence: B). alcohol moderation. sodium reduction. and lowfat dairy products. with addition of other drugs such as thiazides as needed to achieve target blood pressure. Blood Pressure Control Class I 1. Diabetes management should also include the following: 39 .8. (Level of Evidence: B) b. and emphasis on increased consumption of fresh fruits. Blood pressure control to less than 140/90 mm Hg (or <130/80 mm Hg if the patient has diabetes mellitus or chronic kidney disease). including weight control. it is useful to add blood pressure medication as tolerated. treating initially with beta blockers and/or ACE inhibitors. vegetables. increased physical activity. Patients should initiate and/or maintain lifestyle modifications. For patients with blood pressure greater than or equal to 140/90 mm Hg (or ≥130/80 mm Hg for individuals with chronic kidney disease or diabetes mellitus). Diabetes Mellitus (Updated) Discharge/Post-Discharge Class I 1. (Level of Evidence: A) 9.

Vigorous modification of other risk factors (e. It is reasonable to use an insulin-based regimen to achieve and maintain glucose levels less than 180 mg/dL while avoiding hypoglycemia* for hospitalized patients with UA/NSTEMI with either a complicated or uncomplicated course. Patients undergoing cardiac catheterization with Revascularization Discharge/Post-Discharge receipt of contrast media should receive adequate preparatory hydration. Chronic Kidney Disease (Updated) Class I 1. (Level of Evidence: B) 2. blood pressure control. (Level of Evidence: C) Class IIa 1. It is useful to coordinate the patient’s diabetic care with the patient’s primary care physician or endocrinologist. weight management. (Level of Evidence: B) b. 40 .. Creatinine clearance should be estimated in UA/ NSTEMI patients and the doses of renally-cleared medications should be adjusted according to the pharmacokinetic data for specific medications.g.a. physical activity. (Level of Evidence: B) 10. (Level of Evidence: B) * There is uncertainty about the ideal target range for glucose necessary to achieve an optimal risk-benefit ratio. and cholesterol management) as recommended should be initiated and maintained.

and Arrange). Weight Management Class I 1. (Level of Evidence: B) 41 . (Level of Evidence: B) Class IIa 1. (Level of Evidence: B) 12. Assist. as measured by body mass Discharge/Post-Discharge index and/or waist circumference. Weight management.5 to 24. Smoking Cessation Class I 1. or pharmacotherapy (including nicotine replacement) is useful. An invasive strategy is reasonable in patients with mild (stage II) and moderate (stage III) chronic kidney disease. Smoking cessation and avoidance of exposure to environmental tobacco smoke at work and home are recommended.3. A body mass index of 18. V]. Assess. Advise. should be assessed on each visit.9 kg per m2 and a waist circumference (measured horizontally at the iliac crest) of less than 40 inches for men and less than 35 inches for women is recommended. (Level of Evidence: B) (There are insufficient data on benefit/risk of invasive strategy in UA/NSTEMI patients with advanced chronic kidney disease [stages IV. referral to special programs.) 11. Calculation of the contrast volume to creatinine clearance ratio is useful to predict the maximum volume of contrast media that can be given without significantly increasing the risk of contrast-associated nephropathy. as is adopting a stepwise strategy aimed at smoking cessation (the 5 As: Ask. Follow-up.

yard work.to high-risk patients in whom supervised exercise training is particularly warranted. heavy lifting.. (Level of Evidence: B) 3.g. walking breaks at work. A physical activity history or an exercise test to guide initial prescription is beneficial. patients recovering from UA/NSTEMI generally should be encouraged to achieve physical activity duration of 30 to 60 minutes per day. Physical Activity Class I 1. supplemented by an increase in daily lifestyle activities (e. such as brisk walking. preferably in the form of 7 (but at least 5) days per week of moderate aerobic activity.. Cardiac rehabilitation/secondary prevention programs are recommended for patients with UA/ NSTEMI.13. The patient’s risk after UA/NSTEMI should be assessed on the basis of an in-hospital determination of risk. Guided/modified by an individualized exercise prescription. Beyond the detailed instructions for daily exercise.g. gardening. particularly those with multiple modifiable risk factors and/or those moderate. and household activities) that are permissible 42 . (Level of Evidence: B) 2. (Level of Evidence: B) 14. patients should be given specific instruction on activities (e. Patient Education Revascularization Discharge/Post-Discharge Class I 1. and household work). climbing stairs.

It is reasonable to consider screening UA/NSTEMI patients for depression and refer for treatment when indicated. or estrogen alone. return to work. Depression Class IIa 1. should not be given de novo to postmenopausal women after UA/NSTEMI for secondary prevention of coronary events. (Level of Evidence: B) 17. (Level of Evidence: B) 16. Specific mention should be made regarding resumption of driving. An annual influenza vaccination is recommended for patients with cardiovascular disease. Postmenopausal women who are already taking estrogen plus progestin. (Level of Evidence: C) 15. Hormone Therapy Class III 1. at the time of UA/NSTEMI in general should not continue hormone therapy. However.and those that should be avoided. women who are more than 1 to 2 years past the initiation of hormone therapy who wish to continue such therapy for another compelling indication should weigh the 43 Discharge/Post-Discharge . Hormone therapy with estrogen plus progestin. or estrogen alone. (Level of Evidence: A) 2. and sexual activity. Influenza Class I 1.

Quality Care and Outcomes (Updated) Class IIa 1. (Level of Evidence: B) Revascularization Discharge/Post-Discharge 44 .risks and benefits. Hormone therapy should not be continued while patients are on bedrest in the hospital. recognizing the greater risk of cardiovascular events and breast cancer (combination therapy) or stroke (estrogen). and adherence to evidence-based processes of care and quality improvement for UA/ NSTEMI. complications. It is reasonable for clinicians and hospitals that provide care to patients with UA/NSTEMI to participate in a standardized quality-of-care data registry designed to track and measure outcomes. (Level of Evidence: B) 18.

5. Revascularization 45 . Coronary Revascularization See 2011 Percutaneous Coronary Intervention and Coronary Artery Bypass Graft Surgery Guidelines for the most current recommendations on revascularization.

FAHA. Levin. FAHA Donald E. Peterson. FACC. MACC Donald E. FAHA Pierre Theroux. Anderson. Chair Cynthia D. MD. MS Francis M. FAHA Steven M. Califf. MPH. FAHA A. FACEP Judith S. MD. MD. FACC Theodore G. 2011 ACCF/AHA WRITING GROUP R. Hochman. MD. MD. FAHA Elliott M. MD. Fesmire. FAHA. JR. ScD. MD. MPH. PhD. FAHA George J. FACC. MACC. FAHA Nanette K. Wenger. FACC. Scott Wright. Michael Lincoff. FACC Eric D. MD. PhD. MPH. Vice Chair Cynthia D. FACC. FACP William E. Ganiats. FACC. Wenger.The ACCF/AHA would like to acknowledge and thank our volunteer writing committee members for their time and contributions in support of the missions of our organizations. MPH. FAHA Charles R. FAHA Nanette K. MD. MD. FAHA Pierre Theroux. MD Hani Jneid. MD. FACC. MD. Anderson. FACC. FACC. Ettinger. MD. MD. MD. FAHA James Patrick Zidar. FSCAI 2007 ACCF/AHA WRITING COMMITTEE Jeffrey L. MD. Casey. FACC. FACC. FACC. FAHA Thomas N. FAHA 46 . MBA. MD. MD. Adams. Michael Lincoff. ScD. FACP. FAHA R. FSCAI A. MD. MD. MBA. MD. MD. FACC. FACC Eric D. Bridges. RN. FACC. MD. Scott Wright. Adams. MD. FACC. RN. FACC. FAHA Charles R. Peterson. FAHA. Chair Jeffrey L. Casey. Jr. MACC. MD. FAHA Robert M. MD. Bridges. Philippides. Chavey II. Antman. FACC.

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