2014 Nste Acs Slide Set

7/24/2019 2014 Nste Acs Slide Set

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2014 AHA/ACC Guideline for the

Management of Patients WithNonS!"le#ation A$ute

Coronar% S%ndromesDeveloped in Collaboration with the Society of Thoracic Surgeons and Society for

Cardiovascular Angiography and Interventions

Endorsed by the American Association for Clinical Chemistry

& Ameri$an College of Cardiolog% 'oundation and Ameri$an Heart Asso$iation


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Citation

This slide set is adapted from the 20! A"A#ACC $uideline for the%anagement of &atients 'ith (on)ST*Elevation Acute CoronarySyndromes.&ublished on September 2+, 20!, available at- Journalof the American College of Cardiology .http-##content/onlineacc/org#article/asp1doi30/04#/acc/20!/05

/067and Circulation .http-##circ/ahaournals/org#loo8up#doi#0/4#CI9/0000000000000+!7/

The full*te1t guidelines are also available on the following 'eb sites-ACC .www/cardiosource/org7 and A"A .my/americanheart/org7
http://content.onlinejacc.org/article.aspx?doi=10.1016/j.jacc.2014.09.017http://content.onlinejacc.org/article.aspx?doi=10.1016/j.jacc.2014.09.017http://circ.ahajournals.org/lookup/doi/10.1161/CIR.0000000000000134http://circ.ahajournals.org/lookup/doi/10.1161/CIR.0000000000000134http://www.cardiosource.org/http://www.my.americanheart.org/http://www.my.americanheart.org/http://www.cardiosource.org/http://circ.ahajournals.org/lookup/doi/10.1161/CIR.0000000000000134http://circ.ahajournals.org/lookup/doi/10.1161/CIR.0000000000000134http://content.onlinejacc.org/article.aspx?doi=10.1016/j.jacc.2014.09.017http://content.onlinejacc.org/article.aspx?doi=10.1016/j.jacc.2014.09.017


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E:ra A/ Amsterdam, %D, ;ACC, ChairThe TI%I ris8 score is determined by the sum of the presence of 6

variables at admissionG point is given for each of the following variables-N4H y of ageG N+ ris8 factors for CADG prior coronary stenosis NH0OG STdeviation on EC$G N2 anginal events in prior 2! hG use of aspirin in prior 6dG and elevated cardiac biomar8ers/


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G)AC" )is Model Nomogram

To convert serum creatinine level to micromoles per liter, multiply by MM/!/


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Cali.ration of Sim(lified Glo.al )egistr% of ACS

Mortalit% Model


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Cardia$ :iomarers and the 7ni#ersal ;efinition

of M

nitial "#aluation and Management


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:iomarers ;iagnosis

)e$ommendations C) *"

Cardiac*specific troponin .troponin I or T when a

contemporary assay is used7 levels should be measured atpresentation and + to 4 hours after symptom onset in allpatients who present with symptoms consistent with ACS toidentify a rising and#or falling pattern/

I A

Additional troponin levels should be obtained beyond 4hours after symptom onset in patients with normal troponinson serial e1amination when electrocardiographic changesand#or clinical presentation confer an intermediate or highinde1 of suspicion for ACS/

I A

If the time of symptom onset is ambiguous, the time ofpresentation should be considered the time of onset for

assessing troponin values/

I A

'ith contemporary troponin assays, creatine 8inasemyocardial isoen:yme .C=*%F7 and myoglobin are notuseful for diagnosis of ACS/

III- (oFenefit A


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:iomarers Prognosis


The presence and magnitude of troponin elevations are

useful for short* and long*term prognosis/ I FIt may be reasonable to remeasure troponin once on day +or day ! in patients with %I as an inde1 of infarct si:e anddynamics of necrosis/ IIb F

Jse of selected newer biomar8ers, especially F*typenatriuretic peptide, may be reasonable to provide additionalprognostic information/ IIb F


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mmediate Management

nitial "#aluation and Management


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mmediate Management


It is reasonable to observe patients with symptomsconsistent with ACS without obective evidence ofmyocardial ischemia .nonischemic initial EC$ and normalcardiac troponin7 in a chest pain unit or telemetry unit withserial EC$s and cardiac troponin at +* to 4*hour intervals/

IIa F

It is reasonable for patients with possible ACS who havenormal serial EC$s and cardiac troponins to have atreadmill EC$ .Level of Evidence: A), stress myocardialperfusion imaging, or stress echocardiography beforedischarge or within 62 hours after discharge/ (Level ofEvidence: B)

IIa

A

F


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mmediate Management +$ont-d,


In patients with possible ACS and a normal EC$, normalcardiac troponins, and no history of CAD, it is reasonable toinitially perform .without serial EC$s and troponins7coronary CT angiography to assess coronary arteryanatomy (Level of Evidence: A) or rest myocardial perfusionimaging with a technetium*55m radiopharmaceutical toe1clude myocardial ischemia/ .Level of Evidence: B7

IIa

A

F

It is reasonable to give low*ris8 patients who are referred foroutpatient testing daily aspirin, short*acting nitroglycerin,and other medication if appropriate .e/g/, beta bloc8ers7,with instructions about activity level and clinician follow*up/

IIa C


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"arl% Hos(ital Care

Guideline for NS"!ACS


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Standard Medi$al hera(ies

"arl% Hos(ital Care


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Anti!s$hemi$ and Analgesi$ Medi$ations

Nitrates


&atients with (STE*ACS with continuing ischemic painshould receive sublingual nitroglycerin .0/+ mg to 0/! mg7every H minutes for up to + doses, after which anassessment should be made about the need forintravenous nitroglycerin if not contraindicated/

I C

Intravenous nitroglycerin is indicated for patients with(STE*ACS for the treatment of persistent ischemia, ";, orhypertension/

I F

(itrates should not be administered to patients with (STE*ACS who recently received a phosphodiesterase inhibitor,

especially within 2! hours of sildenafil or vardenafil, orwithin !M hours of tadalafil/

III-

"armF


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Analgesi$ hera(%


In the absence of contraindications, it may be reasonable toadminister morphine sulfate intravenously to patients with(STE*ACS if there is continued ischemic chest pain despitetreatment with ma1imally tolerated anti*ischemicmedications/

IIb F

(onsteroidal anti*inflammatory drugs .(SAIDs7 .e1ceptaspirin7 should not be initiated and should be discontinuedduring hospitali:ation for (STE*ACS because of theincreased ris8 of %ACE associated with their use/

III-"arm F


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:eta!Adrenergi$ :lo$ers


Pral beta*bloc8er therapy should be initiated within the first2! hours in patients who do not have any of the following-7 signs of ";, 27 evidence of low*output state, +7 increasedris8 for cardiogenic shoc8, or !7 other contraindications tobeta bloc8ade .e/g/, &9 interval Q0/2! second, second* or

third*degree heart bloc8 without a cardiac pacema8er,active asthma, or reactive airway disease7/

I A

In patients with concomitant (STE*ACS, staili!ed";, andreduced systolic function, it is recommended to continuebeta*bloc8er therapy with of the + drugs proven to reduce

mortality in patients with ";- sustained*release metoprololsuccinate, carvedilol, or bisoprolol/

I C


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:eta!Adrenergi$ :lo$ers +$ont-d,


&atients with documented contraindications to betabloc8ers in the first 2! hours of (STE*ACS should be re*evaluated to determine their subse?uent eligibility/

I C

It is reasonable to continue beta*bloc8er therapy in patientswith normal L function with (STE*ACS/ IIa C

Administration of intravenous beta bloc8ers is potentiallyharmful in patients with (STE*ACS who have ris8 factorsfor shoc8/

III-"arm F


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Cal$ium Channel :lo$ers


In patients with (STE*ACS, continuing or fre?uentlyrecurring ischemia, and a contraindication to beta bloc8ers,a nondihydropyridine calcium channel bloc8er .CCF7 .e/g/,verapamil or diltia:em7 should be given as initial therapy inthe absence of clinically significant L dysfunction,

increased ris8 for cardiogenic shoc8, &9 interval greaterthan 0/2! second, or second* or third*degreeatrioventricular bloc8 without a cardiac pacema8er/

I F

Pral nondihydropyridine calcium antagonists arerecommended in patients with (STE*ACS who have

recurrent ischemia in the absence of contraindications, afterappropriate use of beta bloc8ers and nitrates/

I C


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Cal$ium Channel :lo$ers +$ont-d,


CCFs


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Cholesterol Management


"igh*intensity statin therapy should be initiated or continuedin all patients with (STE*ACS and no contraindications toits use/

I A

It is reasonable to obtain a fasting lipid profile in patientswith (STE*ACS, preferably within 2! hours of presentation/ IIa C


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nhi.itors of )enin!Angiotensin!Aldosterone

S%stem

"arl% Hos(ital Care


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nhi.itors of )enin!Angiotensin!Aldosterone S%stem


ACE inhibitors should be started and continued indefinitelyin all patients with LE; less than 0/!0 and in those withhypertension, diabetes mellitus, or stable C=D .Section6/47, unless contraindicated/

I A

A9Fs are recommended in patients with "; or %I with

LE; less than 0/!0 who are ACE inhibitor intolerant/I A

Aldosterone bloc8ade is recommended in patients post)%Iwithout significant renal dysfunction .creatinine Q2/H mg#din men or Q2/0 mg#d in women7 or hyper8alemia .= QH/0mE?#7 who are receiving therapeutic doses of ACE

inhibitor and beta bloc8er and have a LE; 0/!0 or less,diabetes mellitus, or ";/

I A


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nhi.itors of )enin!Angiotensin!Aldosterone S%stem +$ont-d,


A9Fs are reasonable in other patients with cardiac or othervascular disease who are ACE inhibitor intolerant/ IIa F

ACE inhibitors may be reasonable in all other patients withcardiac or other vascular disease/

IIb F


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nitial Anti(latelet/Anti$oagulant hera(% in

Patients With ;efinite or *iel% NS"!ACS

"arl% Hos(ital Care


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reated With an nitial n#asi#e or s$hemia!Guided Strateg%


(on)enteric*coated, chewable aspirin .42 mg to +2H mg7

should be given to allpatients with (STE*ACS withoutcontraindications as soon as possible after presentation,and a maintenance dose of aspirin .M mg#d to 42 mg#d7should be continued indefinitely/

I A

In patients with (STE*ACS who are unable to ta8e aspirin

because of hypersensitivity or maor gastrointestinalintolerance, a loading dose of clopidogrel followed by adaily maintenance dose should be administered/

I F


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reated With an nitial n#asi#e or s$hemia!Guided Strateg% +$ont-d,


A &2R2inhibitor .either clopidogrel or ticagrelor7 in addition

to aspirin should be administered for up to 2 months to allpatients with (STE*ACS without contraindications who aretreated with either an early invasiveorischemia*guidedstrategy/ Pptions include-Clopidogrel- +00*mg or 400*mg loading dose, then 6H mg

dailyTicagrelor- M0*mg loading dose, then 50 mg twice daily

IF

F

The recommended maintenance dose of aspirin to be used with ticagrelor is M mg daily/


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reated With an nitial n#asi#e or s$hemia!Guided Strateg% +$ont-d,


It is reasonable to use ticagrelor in preference to clopidogrel

for &2R2treatment in patients with (STE*ACS whoundergo an early invasive or ischemia*guided strategy/ IIa F

In patients with (STE*ACS treated with an early invasivestrategy and dual antiplatelet therapy .DA&T7 withintermediate#high*ris8 features .e/g/, positive troponin7, a

$& IIb#IIIa inhibitor may be considered as part of initialantiplatelet therapy/ &referred options are eptifibatide ortirofiban/

IIb F

iti l P t l A ti l t h i P ti t With ; fi it


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nitial Parenteral Anti$oagulant hera(% in Patients With ;efinite

NS"!ACS


In patients with (STE*ACS, anticoagulation, in addition toantiplatelet therapy, is recommended for all patientsirrespective of initial treatment strategy/ Treatment optionsinclude-Eno1aparin- mg#8g subcutaneous .SC7 every 2 hours.reduce dose to mg#8g SC once daily in patients withcreatinine clearance CrClU V+0 m#min7, continued for theduration of hospitali:ation or until &CI is performed/ Aninitial intravenous loading dose is +0 mg/

I A



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NS"!ACS +$ont-d,


.contKd7Fivalirudin- 0/0 mg#8g loading dose followed by 0/2Hmg#8g per hour .only in patients managed with an earlyinvasive strategy7, continued until diagnostic angiography or&CI, with only provisional use of $& IIb#IIIa inhibitor,provided the patient is also treated with DA&T/

;ondaparinu1- 2/H mg SC daily, continued for the durationof hospitali:ation or until &CI is performed/

IF

F



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NS"!ACS +$ont-d,


.contKd7If &CI is performed while the patient is on fondaparinu1, anadditional anticoagulant with anti*IIa activity .either J;" orbivalirudin7 should be administered because of the ris8 ofcatheter thrombosis/J;" IL- initial loading dose of 40 IJ#8g .ma1imum !,000IJ7 with initial infusion of 2 IJ#8g per hour .ma1imum ,000IJ#h7 adusted per activated partial thromboplastin time tomaintain therapeutic anticoagulation according to thespecific hospital protocol, continued for !M hours or until&CI is performed/

I

F

F

In patients with (STE*ACS .i/e/, without ST elevation, trueposterior %I, or left bundle*branch bloc8 not 8nown to beold7, intravenous fibrinolytic therapy should not be used/

III-"arm A

Algorithm for Management of Patients With ;efinite or *iel% NS" ACS


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Algorithm for Management of Patients With ;efinite or *iel% NS"!ACS


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s$hemia!Guided Strateg% =ersus "arl% n#asi#e

Strategies

"arl% Hos(ital Care

" l i d h i G id d St t i


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"arl% n#asi#e and s$hemia Guided Strategies


An urgent#immediate invasive strategy .diagnostic

angiography with intent to perform revasculari:ation ifappropriate based on coronary anatomy7 is indicated inpatients .men and women7 with (STE*ACS who haverefractory angina or hemodynamic or electrical instability.without serious comorbidities or contraindications to suchprocedures7/

I A

An early invasive strategy .diagnostic angiography withintent to perform revasculari:ation if appropriate based oncoronary anatomy7 is indicated in initially stabili:ed patientswith (STE*ACS .without serious comorbidities orcontraindications to such procedures7 who have an

elevated ris8 for clinical events/

I F



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"arl% n#asi#e and s$hemia Guided Strategies +$ont-d,


It is reasonable to choose an early invasive strategy .within

2! hours of admission7 over a delayed invasive strategy.within 2H to 62 hours7 for initially stabili:ed high*ris8patients with (STE*ACS/ ;or those not at high#intermediateris8, a delayed invasive approach is reasonable/

IIa F

In initially stabili:ed patients, an ischemia*guided strategy

may be considered for patients with (STE*ACS .withoutserious comorbidities or contraindications to this approach7who have an elevated ris8 for clinical events/

IIb F

The decision to implement an ischemia*guided strategy ininitially stabili:ed patients .without serious comorbidities orcontraindications to this approach7 may be reasonable afterconsidering clinician and patient preference/

IIb C



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"arl% n#asi#e and s$hemia Guided Strategies+$ont-d,


An early invasive strategy .i/e/, diagnostic angiography with

intent to perform revasculari:ation7 is not recommended inpatients with-a/E1tensive comorbidities .e/g/, hepatic, renal, pulmonaryfailure, cancer7, in whom the ris8s of revasculari:ation andcomorbid conditions are li8ely to outweigh the benefits of

revasculari:ation/(Level of Evidence: C)

b/Acute chest pain and a low li8elihood of ACS (Level ofEvidence: C)who are troponin*negative, especially women/.Level of Evidence: B)

III- (oFenefit

C

C

F

'a$tors Asso$iated With A((ro(riate Sele$tion of "arl% n#asi#e


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'a$tors Asso$iated With A((ro(riate Sele$tion of "arl% n#asi#e

Strateg% or s$hemia!Guided Strateg% in Patients With NS"!ACS

Immediate

invasive.within 2 h7

9efractory angina

Signs or symptoms of "; or new or worsening mitral regurgitation"emodynamic instability9ecurrent angina or ischemia at rest or with low*level activities despiteintensive medical therapySustained LT or L;

Ischemia*guidedstrategy

ow*ris8 score .e/g/, TI%I 0 or U, $9ACE V05U7ow*ris8 Tn*negative female patients&atient or clinician preference in the absence of high*ris8 features

Earlyinvasive

.within 2! h7

(one of the above, but $9ACE ris8 score Q!0Temporal change in Tn .Section +/!7

(ew or presumably new ST depressionDelayedinvasive.within2H62 h7

(one of the above but diabetes mellitus9enal insufficiency .$;9 V40 m#min#/6+ mW79educed L systolic function .E; V0/!07Early postinfarction angina&CI within 4 mo

&rior CAF$


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)is Stratifi$ation :efore ;is$harge for Patients

With an s$hemia!Guided Strateg% of NS"!ACS

"arl% Hos(ital Care

)i St tifi ti : f ;i h f P ti t With


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)is Stratifi$ation :efore ;is$harge for Patients With an

s$hemia!Guided Strateg% of NS"!ACS


(oninvasive stress testing is recommended in low* andintermediate*ris8 patients who have been free of ischemiaat rest or with low*level activity for a minimum of 2 to 2!hours/

I F

Treadmill e1ercise testing is useful in patients able to

e1ercise in whom the EC$ is free of resting ST changesthat may interfere with interpretation/ I C

Stress testing with an imaging modality should be used inpatients who are able to e1ercise but have ST changes onresting EC$ that may interfere with interpretation/ In

patients undergoing a low*level e1ercise test, an imagingmodality can add prognostic information/

I F


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)is Stratifi$ation :efore ;is$harge for Patients With an

s$hemia!Guided Strateg% of NS"!ACS +$ont-d,


&harmacological stress testing with imaging isrecommended when physical limitations preclude ade?uatee1ercise stress/

I C

A noninvasive imaging test is recommended to evaluate Lfunction in patients with definite ACS/ I C


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M%o$ardial )e#as$ulari8ation



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Per$utaneous Coronar% nter#ention



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General Considerations

)e$ommendation C) *"A strategy of multivessel &CI, in contrast to culpritlesiononly &CI, may be reasonable in patients undergoingcoronary revasculari:ation as part of treatment for (STE*

ACS/

IIb F

Anti(latelet and Anti$oagulant hera(%


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ral and Anti(latelet Agents


&atients already ta8ing daily aspirin before &CI should ta8eM mg to +2H mg non)enteric*coated aspirin before &CI/ I F

&atients not on aspirin therapy should be given non)enteric*coated aspirin +2H mg as soon as possible before&CI/

I F

After &CI, aspirin should be continued indefinitely at a doseof M mg to +2H mg daily/ I F



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ral and Anti(latelet Agents +$ont-d,)e$ommendations C) *"

A loading dose of a &2R2receptor inhibitor should be givenbefore the procedure in patients undergoing &CI withstenting/ (Level of Evidence: A)Pptions include-a/Clopidogrel- 400 mg (Level of Evidence: B) orb/&rasugrel-40 mg (Level of Evidence: B) orc/Ticagrelor- M0 mg(Level of Evidence: B)

I

AF

F

F

&atients should receive a loading dose of prasugrel, provided that they were notpretreated with another &2R2 receptor inhibitor/The recommended maintenance dose of aspirin to be used with ticagrelor is M mg daily/

A ti l t l t d A ti l t h


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ral and Anti(latelet Agents +$ont-d,

)e$ommendations C) *"In patients with (STE*ACS and high*ris8 features .e/g/,elevated troponin7 not ade?uately pretreated withclopidogrel or ticagrelor, it is useful to administer a $&IIb#IIIa inhibitor .abci1imab, double*bolus eptifibatide, orhigh*dose bolus tirofiban7 at the time of &CI/

I A



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In patients receiving a stent .bare*metal stent or drug*eluting stent DESU7 during &CI for (STE*ACS, &2R2inhibitor therapy should be given for at least 2 months/Pptions include-a/Clopidogrel- 6H mg daily (Level of Evidence: B) or

b/&rasugrel-

0 mg daily (Level of Evidence: B) orc/Ticagrelor- 50 mg twice daily (Level of Evidence: B)

IF

FF

&atients should receive a loading dose of prasugrel, provided that they were notpretreated with another &2R2receptor inhibitor/The recommended maintenance dose of aspirin to be used with ticagrelor is M mg daily/

A ti l t l t d A ti l t h


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It is reasonable to choose ticagrelor over clopidogrel for&2R2inhibition treatment in patients with (STE*ACStreated with an early invasive strategy and#or coronarystenting/

IIa F

It is reasonable to choose prasugrel over clopidogrel for

&2R2treatment in patients with (STE*ACS who undergo&CI who are not at high ris8 of bleeding complications/

IIa F

In patients with (STE*ACS and high*ris8 features .e/g/,elevated troponin7 treated with J;" and ade?uatelypretreated with clopidogrel, it is reasonable to administer a

$& IIb#IIIa inhibitor .abci1imab, double*bolus eptifibatide, orhigh*bolus dose tirofiban7 at the time of &CI/

IIa F

Anti(latelet and Anti$oag lant hera(


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)e$ommendations C) *"After &CI, it is reasonable to use M mg per day of aspirin inpreference to higher maintenance doses/ IIa F

If the ris8 of morbidity from bleeding outweighs theanticipated benefit of a recommended duration of &2R2inhibitor therapy after stent implantation, earlierdiscontinuation .e/g/, V2 months7 of &2R2inhibitor therapyis reasonable/

IIa C

Continuation of DA&T beyond 2 months may beconsidered in patients undergoing stent implantation/ IIb C

&rasugrel should not be administered to patients with aprior history of stro8e or transient ischemic attac8/

III-"arm F



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GP ./a nhi.itors


In patients with (STE*ACS and high*ris8 features .e/g/,elevated troponin7 and not ade?uately pretreated withclopidogrel or ticagrelor, it is useful to administer a $&IIb#IIIa inhibitor .abci1imab, double*bolus eptifibatide, orhigh*dose bolus tirofiban7 at the time of &CI/

I A

In patients with (STE*ACS and high*ris8 features .e/g/,elevated troponin7 treated with J;" and ade?uatelypretreated with clopidogrel, it is reasonable to administer a$& IIb#IIIa inhibitor .abci1imab, double*bolus eptifibatide, orhigh*dose bolus tirofiban7 at the time of &CI/

IIa F



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Anti$oagulant hera(% in Patients 7ndergoing PC


An anticoagulant should be administered to patients with(STE*ACS undergoing &CI to reduce the ris8 ofintracoronary and catheter thrombus formation/

I C

Intravenous J;" is useful in patients with (STE*ACSundergoing &CI/ I C

Fivalirudin is useful as an anticoagulant with or without priortreatment with J;" in patients with (STE*ACS undergoing&CI/

I F



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Anti$oagulant hera(% in Patients 7ndergoing PC +$ont-d,


An additional dose of 0/+ mg#8g IL eno1aparin should beadministered at the time of &CI to patients with (STE*ACSwho have received fewer than 2 therapeutic subcutaneousdoses .e/g/, mg#8g SC7 or received the last subcutaneouseno1aparin dose M to 2 hours before &CI/

I F

If &CI is performed while the patient is on fondaparinu1, anadditional MH IJ#8g of J;" should be given intravenouslyimmediately before &CI because of the ris8 of catheterthrombosis .40 IJ#8g IL if a $& IIb#IIIa inhibitor used withJ;" dosing based on the target*activated clotting time7/

I F

In patients with (STE*ACS, anticoagulant therapy shouldbe discontinued after &CI unless there is a compellingreason to continue such therapy/

I C



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Anti$oagulant hera(% in Patients 7ndergoing PC +$ont-d,


In patients with (STE*ACS undergoing &CI who are at highris8 of bleeding, it is reasonable to use bivalirudinmonotherapy in preference to the combination of J;" anda $& IIb#IIIa receptor antagonist/

IIa F

&erformance of &CI with eno1aparin may be reasonable in

patients treated with upstream subcutaneous eno1aparinfor (STE*ACS/ IIb F

;ondaparinu1 should not be used as the sole anticoagulantto support &CI in patients with (STE*ACS due to anincreased ris8 of catheter thrombosis/

III-"arm F

;osing of Parenteral Anti$oagulants ;uring PC


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;rug3 n Patients Who Ha#e )e$ei#edPrior Anti$oagulant hera(%

n Patients WhoHa#e Not )e$ei#edPrior Anti$oagulant

hera(%

Eno1aparin ;or prior treatment with eno1aparin, if lastSC dose was administered M2 h earlieror if V2 therapeutic SC doses ofeno1aparin have been administered, an ILdose of eno1aparin 0/+ mg#8g should be

given If the last SC dose was administeredwithin prior M h, no additional eno1aparinshould be given

0/H mg#8g)0/6Hmg#8g IL loadingdose

Fivalirudin ;or patients who have received J;", wait+0 min, then give 0/6H mg#8g IL loading

dose, then /6H mg#8g#h IL infusion ;or patients already receiving bivalirudin

infusion, give additional loading dose 0/Hmg#8g and increase infusion to /6Hmg#8g#h during &CI

0/6H mg#8g loadingdose, /6H mg#8g#h

IL infusion

;osing of Parenteral Anti$oagulants ;uring PC


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;rug3 n Patients Who Ha#e )e$ei#edPrior Anti$oagulant hera(%

n Patients Who Ha#e Not)e$ei#ed

Prior Anti$oagulant hera(%

;ondaparinu1

;or prior treatment withfondaparinu1, administeradditional IL treatment withanticoagulant possessing anti*IIa activity, considering whether$&I receptor antagonists havebeen administered

(#A

J;" IL $&I planned- additional J;"as needed .e/g/, 2,000)H,000J7 to achieve ACT of 200)2H0 s

(o IL $&I planned- additionalJ;" as needed .e/g/, 2,000)

H,000 J7 to achieve ACT of2H0)+00 s for "emoTec, +00)+H0 s for "emochron

IL $&I planned- H0)60J#8g loading dose toachieve ACT of 200)2H0 s

(o IL $&I planned- 60)00J#8g loading dose to

achieve target ACT of 2H0)+00 s for "emoTec, +00)+H0 s for "emochron

>Drugs are presented in order by the CP9 then the PE/ 'hen more than druge1ists within the same PE and there are no comparative data, then the drugs arelisted alphabetically/

M di l ) l i ti


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iming of 7rgent CA:G in Patients With

NS"!ACS in )elation to 7se of Anti(latelet

Agents


iming of 7rgent CA:G in Patients With NS"!ACS in


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(on)enteric*coated aspirin .M mg to +2H mg daily7 shouldbe administered preoperatively to patients undergoingCAF$/

I F

In patients referred for elective CAF$, clopidogrel andticagrelor should be discontinued for at least H days before

surgery (Level of Evidence: B7 and prasugrel for at least 6days before surgery/ (Level of Evidence: C)

IF

C

In patients referred for urgent CAF$, clopidogrel andticagrelor should be discontinued for at least 2! hours toreduce maor bleeding/

I F

iming of 7rgent CA:G in Patients With NS" ACS in

)elation to 7se of Anti(latelet Agents

iming of 7rgent CA:G in Patients With NS"!ACS in


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In patients referred for CAF$, short*acting intravenous $&IIb#IIIa inhibitors .eptifibatide or tirofiban7 should bediscontinued for at least 2 to ! hours before surgery .!M,!57 and abci1imab for at least 2 hours before to limitblood loss and transfusion/

I F

In patients referred for urgent CAF$, it may be reasonableto perform surgery less than H days after clopidogrel orticagrelor has been discontinued and less than 6 days afterprasugrel has been discontinued/

IIb C

iming of 7rgent CA:G in Patients With NS" ACS in

)elation to 7se of Anti(latelet Agents +$ont-d,

Guideline for NS" ACS


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*ate Hos(ital Care Hos(ital ;is$harge and

Posthos(ital ;is$harge Care


*ate Hos(ital Care Hos(ital ;is$harge and Posthos(ital


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Medi$al )egimen and 7se of Medi$ations at

;is$harge

*ate Hos(ital Care Hos(ital ;is$harge and Posthos(ital;is$harge Care

Medi$al )egimen and 7se of Medi$ations at ;is$harge


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%edications re?uired in the hospital to control ischemia

should be continued after hospital discharge in patients with(STE*ACS who do not undergo coronary revasculari:ation,patients with incomplete or unsuccessful revasculari:ation,and patients with recurrent symptoms afterrevasculari:ation/ Titration of the doses may be re?uired/

I C

All patients who are post

(STE*ACS should be givensublingual or spray nitroglycerin with verbal and writteninstructions for its use/

I C

Fefore hospital discharge, patients with (STE*ACS shouldbe informed about symptoms of worsening myocardial

ischemia and %I and should be given verbal and writteninstructions about how and when to see8 emergency carefor such symptoms/

I C

g g


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Fefore hospital discharge, patients who are post

(STE*ACSand#or designated responsible caregivers should be providedwith easily understood and culturally sensitive verbal andwritten instructions about medication type, purpose, dose,fre?uency, side effects, and duration of use/

I C

;or patients who are post

(STE*ACS and have initialangina lasting more than minute, nitroglycerin . dosesublingual or spray7 is recommended if angina does notsubside within + to H minutesG call 5** immediately toaccess emergency medical services.

I C

Medi$al )egimen and 7se of Medi$ations at ;is$harge+$ont-d,


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If the pattern or severity of angina changes, suggestingworsening myocardial ischemia .e/g/, pain is more fre?uentor severe or is precipitated by less effort or occurs at rest7,patients should contact their clinician without delay toassess the need for additional treatment or testing/

I C

Fefore discharge, patients should be educated aboutmodification of cardiovascular ris8 factors/ I C




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*ate Hos(ital and Posthos(ital ral Anti(latelet

hera(%


*ate Hos(ital and Posthos(ital ral Anti(latelet hera(


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Aspirin should be continued indefinitely/ The maintenancedose should be M mg daily in patients treated withticagrelor and M mg to +2H mg daily in all other patients/

I A

In addition to aspirin, a &2R2inhibitor .either clopidogrel orticagrelor7 should be continued for up to 2 months in allpatients with (STE*ACS without contraindications who aretreated with an ischemia*guided strategy/ Pptions include-a/Clopidogrel- 6H mg dailyorb/Ticagrelor- 50 mg twice daily

IF

F

The recommended maintenance dose of aspirin to be used with ticagrelor is M mg daily/

*ate Hos(ital and Posthos(ital ral Anti(latelet hera(%


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In patients receiving a stent .bare*metal stent or DES7during &CI for (STE*ACS, &2R2inhibitor therapy shouldbe given for at least 2 months/ Pptions include-a/Clopidogrel- 6H mg dailyorb/&rasugrel- 0 mg daily or

c/Ticagrelor

- 50 mg twice daily

I

F

F

FIt is reasonable to use an aspirin maintenance dose of Mmg per day in preference to higher maintenance doses inpatients with (STE*ACS treated either invasively or withcoronary stent implantation/

IIa F

&atients should receive a loading dose of prasugrel, provided that they were notpretreated with another &2R2receptor inhibitor/The recommended maintenance dose of aspirin to be used with ticagrelor is M mg daily/

Medi$al )egimen and 7se of Medi$ations at ;is$harge

Medi$al )egimen and 7se of Medi$ations at ;is$harge + t-d,


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It is reasonable to choose ticagrelor over clopidogrel formaintenance &2R2treatment in patients with (STE*ACStreated with an early invasive strategy and#or &CI/

IIa F

It is reasonable to choose prasugrel over clopidogrel formaintenance &2R2treatment in patients with (STE*ACSwho undergo &CI who are not at high ris8 for bleedingcomplications/

IIa F

If the ris8 of morbidity from bleeding outweighs theanticipated benefit of a recommended duration of &2R2inhibitor therapy after stent implantation, earlierdiscontinuation .e/g/, V2 months7 of &2R2inhibitor therapy

is reasonable/

IIa C

Continuation of DA&T beyond 2 months may beconsidered in patients undergoing stent implantation/ IIb C




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Com.ined ral Anti$oagulant hera(% and

Anti(latelet hera(% in Patients With NS"!ACS


Com.ined ral Anti$oagulant hera(% and Anti(latelet


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The duration of triple antithrombotic therapy with a vitamin= antagonist, aspirin, and a &2R2receptor inhibitor inpatients with (STE*ACS should be minimi:ed to the e1tentpossible to limit the ris8 of bleeding/

I C

&roton pump inhibitors should be prescribed in patients with

(STE*ACS with a history of gastrointestinal bleeding whore?uire triple antithrombotic therapy with a vitamin =antagonist, aspirin, and a &2R2receptor inhibitor/

I C

g (% (

hera(% in Patients With NS"!ACS

Com.ined ral Anti$oagulant hera(% and Anti(latelet


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&roton pump inhibitor use is reasonable in patients with(STE*ACS "ithouta 8nown history of gastrointestinalbleeding who re?uire triple antithrombotic therapy with avitamin = antagonist, aspirin, and a &2R2 receptor inhibitor/

IIa C

Targeting oral anticoagulant therapy to a lower international

normali:ed ratio .e/g/, 2/0 to 2/H7 may be reasonable inpatients with (STE*ACS managed with aspirin and a &2R2inhibitor/

IIb C

hera(% in Patients With NS"!ACS +$ont-d,



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)is )edu$tion Strategies for Se$ondar%

Pre#ention


)is )edu$tion Strategies for Se$ondar% Pre#ention


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All eligible patients with (STE*ACS should be referred to acomprehensive cardiovascular rehabilitation program eitherbefore hospital discharge or during the first outpatient visit/

I F

The pneumococcal vaccine is recommended for patients 4Hyears of age and older and in high*ris8 patients withcardiovascular disease/

I F

&atients should be educated about appropriate cholesterolmanagement, blood pressure .F&7, smo8ing cessation, andlifestyle management/

I C

)is )edu$tion Strategies for Se$ondar% Pre#ention

)is )edu$tion Strategies for Se$ondar% Pre#ention +$ont-d,


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&atients who have undergone &CI or CAF$ derive benefit

from ris8 factor modification and should receive counselingthat revasculari:ation does not obviate the need for lifestylechanges/

I C

Fefore hospital discharge, the patientKs need for treatmentof chronic musculos8eletal discomfort should be assessed,

and a stepped*care approach should be used for selectionof treatments/ &ain treatment before consideration of(SAIDs should begin with acetaminophen, nonacetylatedsalicylates, tramadol, or small doses of narcotics if thesemedications are not ade?uate/

I C

It is reasonable to use nonselective (SAIDs, such asnapro1en, if initial therapy with acetaminophen,nonacetylated salicylates, tramadol, or small doses ofnarcotics is insufficient/

IIa C

)is )edu$tion Strategies for Se$ondar% Pre#ention +$ont d,

)is )ed $tion Strategies for Se$ondar Pre ention + t-d,


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(SAIDs with increasing degrees of relativecycloo1ygenase*2 selectivity may be considered for painrelief only for situations in which intolerable discomfortpersists despite attempts at stepped*care therapy withacetaminophen, nonacetylated salicylates, tramadol, smalldoses of narcotics, or nonselective (SAIDs/ In all cases,

use of the lowest effective doses for the shortest possibletime is encouraged/

IIb C

Antio1idant vitamin supplements .e/g/, vitamins E, C, orbeta carotene7 should not be used for secondary preventionin patients with (STE*ACS/

III- (oFenefit A

;olic acid, with or without vitamins F4and F2, should not beused for secondary prevention in patients with (STE*ACS/

III- (oFenefit A

)is )edu$tion Strategies for Se$ondar% Pre#ention+$ont-d,

)is )edu$tion Strategies for Se$ondar% Pre#ention +$ont-d,


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"ormone therapy with estrogen plus progestin, or estrogenalone, should not be given as new drugs for secondaryprevention of coronary events to postmenopausal womenafter (STE*ACS and should not be continued in previoususers unless the benefits outweigh the estimated ris8s/

III-"arm A

(SAIDs with increasing degrees of relative

cycloo1ygenase*2 selectivity should not be administered topatients with (STE*ACS and chronic musculos8eletaldiscomfort when therapy with acetaminophen,nonacetylated salicylates, tramadol, small doses ofnarcotics, or nonselective (SAIDs provide acceptable pain

relief/

III-"arm F

)is )edu$tion Strategies for Se$ondar% Pre#ention+$ont d,

Ste((ed!Care A((roa$h to Pharma$ologi$al hera(% for

Mus$uloseletal S%m(toms in Patients With >no5n Cardio#as$ular


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Mus$uloseletal S%m(toms in Patients With >no5n Cardio#as$ular

;isease or )is 'a$tors for s$hemi$ Heart ;isease



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Plan of Care for Patients With NS"!ACS

( ( g (;is$harge Care

Plan of Care for Patients With NS"!ACS


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&osthospital systems of care designed to prevent hospitalreadmissions should be used to facilitate the transition toeffective, coordinated outpatient care for all patients with(STE*ACS/

I F

An evidence*based plan of care .e/g/, $D%T7 that promotesmedication adherence, timely follow*up with the healthcare

team, appropriate dietary and physical activities, andcompliance with interventions for secondary preventionshould be provided to patients with (STE*ACS/

I C

Plan of Care for Patients With NS" ACS

Plan of Care for Patients With NS"!ACS +$ont-d,


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In addition to detailed instructions for daily e1ercise,patients should be given specific instruction on activities.e/g/, lifting, climbing stairs, yard wor8, and householdactivities7 that are permissible and those to avoid/ Specificmention should be made of resumption of driving, return towor8, and se1ual activity/

I F

An annual influen:a vaccination is recommended forpatients with cardiovascular disease/ I C

Plan of Care for Patients With NS" ACS+$ont d,



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S(e$ial Patient Grou(s

NS"!ACS in lder Patients


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Plder patients>> with (STE*ACS should be treated with

$D%T, an early invasive strategy, and revasculari:ation asappropriate/ I A&harmacotherapy in older patients with (STE*ACS shouldbe individuali:ed and dose adusted by weight and#or CrClto reduce adverse events caused by age*related changes inpharmaco8inetics#dynamics, volume of distribution,

comorbidities, drug interactions, and increased drugsensitivity/

I A

%anagement decisions for older patients with (STE*ACSshould be patient centered, considering patientpreferences#goals, comorbidities, functional and cognitive

status, and life e1pectancy/

I F

>>Those N6H years of age/

NS"!ACS in lder Patients +$ont-d,


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Fivalirudin, rather than a $& IIb#IIIa inhibitor plus J;", isreasonable in older patients with (STE*ACS, both initiallyand at &CI, given similar efficacy but less bleeding ris8/

IIa F

It is reasonable to choose CAF$ over &CI in older patients>>with (STE*ACS who are appropriate candidates,particularly those with diabetes mellitus or comple1 +*vessel

CAD .e/g/, SR(TAX score Q227, with or without involvementof the pro1imal left anterior descending artery, to reducecardiovascular disease events and readmission and toimprove survival/

IIa F

NS" ACS in lder Patients+$ont d,

Heart 'ailure and Cardiogeni$ Sho$


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&atients with a history of "; and (STE*ACS should betreated according to the same ris8 stratification guidelinesand recommendations for patients without ";/

I F

Selection of a specific revasculari:ation strategy should bebased on the degree, severity, and e1tent of CADGassociated cardiac lesionsG the e1tent of L dysfunctionGand the history of prior revasculari:ation procedures/

I F

Early revasculari:ation is recommended in suitable patientswith cardiogenic shoc8 due to cardiac pump failure after(STE*ACS/

I F

Heart 'ailure and Cardiogeni$ Sho$

;ia.etes Mellitus


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)e$ommendation C) *"

%edical treatment in the acute phase of (STE*ACS anddecisions to perform stress testing, angiography, andrevasculari:ation should be similar in patients with andwithout diabetes mellitus/

I A

;ia.etes Mellitus

Post CA:G


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&atients with prior CAF$ and (STE*ACS should receiveantiplatelet and anticoagulant therapy according to $D%Tand should be strongly considered for early invasivestrategy because of their increased ris8/

I F

Post!CA:G

Perio(erati#e NS"!ACS )elated to Non$ardia$ Surger%


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&atients who develop (STE*ACS following noncardiacsurgery should receive $D%T as recommended for patientsin the general population but with the modifications imposedby the specific noncardiac surgical procedure and theseverity of (STE*ACS/

I C

In patients who develop (STE*ACS after noncardiacsurgery, management should be directed at the underlyingcause/

I C

( g %

Chroni$ >idne% ;isease


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CrCl should be estimated in patients with (STE*ACS, anddoses of renally cleared medications should be adustedaccording to the pharmaco8inetic data for specificmedications/

I F

&atients undergoing coronary and L angiography shouldreceive ade?uate hydration/ I C

An invasive strategy is reasonable in patients with mild.stage 27 and moderate .stage +7 C=D/ IIa F

%

Women


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'omen with (STE*ACS should be managed with the same

pharmacological therapy as that for men for acute care andfor secondary prevention, with attention to weight and#orrenally*calculated doses of antiplatelet and anticoagulantagents to reduce bleeding ris8/

I F

'omen with (STE*ACS and high*ris8 features .e/g/,

troponin positive7 should undergo an early invasive strategy/

I A

%yocardial revasculari:ation is reasonable in pregnantwomen with (STE*ACS if an ischemia*guided strategy isineffective for management of life*threateningcomplications/

IIa C

'omen with (STE*ACS and low*ris8 features .see Section+/+/ in the full*te1t C&$7 should not undergo early invasivetreatment because of the lac8 of benefit and the possibilityof harm/

III- (oFenefit F

Anemia :leeding and ransfusion


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All patients with (STE*ACS should be evaluated for the ris8

of bleeding/ I CAnticoagulant and antiplatelet therapy should be weight*based where appropriate and should be adusted whennecessary for C=D to decrease the ris8 of bleeding inpatients with (STE*ACS/

I F

A strategy of routine blood transfusion in hemodynamicallystable patients with (STE*ACS and hemoglobin levelsgreater than M g#d is not recommended/

III- (oFenefit F

Co$aine and Metham(hetamine 7sers


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&atients with (STE*ACS and a recent history of cocaine or

methamphetamine use should be treated in the samemanner as patients without cocaine* or methamphetamine*related (STE*ACS/ The only e1ception is in patients withsigns of acute into1ication .e/g/, euphoria, tachycardia,and#or hypertension7 and beta*bloc8er use, unless patientsare receiving coronary vasodilator therapy/

I C

Fen:odia:epines alone or in combination with nitroglycerinare reasonable for management of hypertension andtachycardia in patients with (STE*ACS and signs of acutecocaine or methamphetamine into1ication/

IIa C

Feta bloc8ers should not be administered to patients with

ACSwith a recent history of cocaine or methamphetamineuse who demonstrate signs of acute into1ication due to theris8 of potentiating coronary spasm/

III-"arm C

=asos(asti$ +Prin8metal, Angina


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CCFs alone or in combination with long*acting nitrates are

useful to treat and reduce the fre?uency of vasospasticangina/ I FTreatment with "%$*CoA reductase inhibitor, cessation oftobacco use, and additional atherosclerosis ris8 factormodification are useful in patients with vasospastic angina/

I F

Coronary angiography .invasive or noninvasive7 isrecommended in patients with episodic chest painaccompanied by transient ST elevation to rule out severeobstructive CAD/

I C

=asos(asti$ +Prin8metal, Angina+$ont-d,


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&rovocative testing during invasive coronary angiography


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If coronary angiography reveals normal coronary arteriesand endothelial dysfunction is suspected, invasivephysiological assessment such as coronary flow reservemeasurement may be considered/

IIb F

Stress +aotsu.o, Cardiom%o(ath%


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Stress .Ta8otsubo7 cardiomyopathy should be considered inpatients who present with apparent ACS and nonobstructiveCAD at angiography/

I C

Imaging with ventriculography, echocardiography, ormagnetic resonance imaging should be performed toconfirm or e1clude the diagnosis of stress .Ta8otsubo7

cardiomyopathy/

I F

&atients should be treated with conventional agents .ACEinhibitors, beta bloc8ers, aspirin, and diuretics7 as otherwiseindicated if hemodynamically stable/

I C

Anticoagulation should be administered in patients who

develop L thrombi/ I C

Stress +aotsu.o, Cardiom%o(ath% +$ont-d,


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It is reasonable to use catecholamines for patients withsymptomatic hypotension if outflow tract obstruction is notpresent/

IIa C

The use of an intra*aortic balloon pump is reasonable forpatients with refractory shoc8/ IIa C

It is reasonable to use beta bloc8ers and alpha*adrenergic

agents in patients with outflow tract obstruction/ IIa C&rophylactic anticoagulation may be considered to inhibitthe development of L thrombi/ IIb C



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?ualit% of Care and ut$omes for ACS!7se of

Performan$e Measures and )egistries

?ualit% of Care and ut$omes for ACS!7se of


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)e$ommendation C) *"&articipation in a standardi:ed ?uality*of*care data registrydesigned to trac8 and measure outcomes, complications,and performance measures can be beneficial in improvingthe ?uality of (STE*ACS care/

IIa F

%

Performan$e Measures and )egistries

2014 Nste Acs Slide Set

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