The American College of Cardiology

(ACC)/American Heart Association (AHA) Task

Force on Practice Guidelines was formed to make
recommendations regarding the diagnosis and
treatment of patients with known or suspected
cardiovascular disease. Coronary artery disease
(CAD) is the leading cause of death in the United
States. Unstable angina (UA) and the closely
related condition nonST-segment elevation
myocardial infarction (NSTEMI) are very common
manifestations of this disease. These lifethreatening disorders are a major cause of
emergency medical care and hospitalizations in
the United States. In 1996, the National Center for
Health Statistics reported 1 433 000

 the National Center for Health Statistics reported

1 433 000 hospitalizations for UA or NSTEMI. In
recognition of the importance of the management
of this common entity and of the rapid advances
in the management of this condition, the need to
revise guidelines published by the Agency for
Health Care Policy and Research (AHCPR) and the
National Heart, Lung and Blood Institute in 1994
was evident. This Task Force therefore formed the
current committee to develop guidelines for the
management of UA and NSTEMI. The present
guidelines supersede the 1994 guidelines.

Classification
Class I:Conditions for which there is evidence and/or
general agreement that a given procedure or treatment is
useful and effective.
Class II:Conditions for which there is conflicting evidence
and/or a divergence of opinion about the
usefulness/efficacy of a procedure or treatment.
Class IIa:Weight of evidence/opinion is in favor of
usefulness/efficacy.
Class IIb:Usefulness/efficacy is less well established by
evidence/opinion.
Class III:Conditions for which there is evidence and/or
general agreement that the procedure/treatment is not
useful/effective and in some cases may be harmful.

II. INITIAL EVALUATION AND MANAGEMENT

Recommendations for Initial Triage

Class I

A. CLINICAL ASSESSMENT

Recommendations for
Initial Triage
1. Patients with symptoms that suggest
possible ACS should not be evaluated solely
over the telephone but should be referred to
a facility that allows evaluation by a
physician and the recording of a 12-lead
electrocardiogram (ECG). (Level of Evidence:
C)

 2. Patients with a suspected ACS with chest

discomfort at rest for >20 minutes,
hemodynamic instability, or recent syncope
or presyncope should be strongly
considered for immediate referral to an
emergency department (ED) or a specialized
chest pain unit. Other patients with a
suspected ACS may be seen initially in an
ED, a chest pain unit, or an outpatient
facility. (Level of Evidence: C)