Unstable angina non ST elevation myocardial infarction long-term medical therapy and secondary prevention: Difference between revisions
/* ACC / AHA Guidelines- Antioxidant Vitamins and Folic Acid (DO NOT EDIT) {{cite journal |author=Anderson JL, Adams CD, Antman EM, et al |title=ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial i |
Smitakohli (talk | contribs) No edit summary |
||
| Line 6: | Line 6: | ||
==Overview of Long-Term Medical Therapy and Secondary Prevention for UA / NSTEMI== | ==Overview of Long-Term Medical Therapy and Secondary Prevention for UA / NSTEMI== | ||
Similar to patients with STEMI, patients with UA/NSTEMI also require secondary prevention at the time of discharge. HEalth care team should work with patients and their families to educate them in detail regarding specific targets for LDL cholesterol and HDL cholesterol, blood pressure, body mass index (BMI), physical activity, and other appropriate lifestyle modifications. | |||
==ACC / AHA Guidelines- Antiplatelet Therapy (DO NOT EDIT) <ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, ''et al'' |title=ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine |journal=JACC |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi:10.1016/j.jacc.2007.02.013 |url=}}</ref>== | ==ACC / AHA Guidelines- Antiplatelet Therapy (DO NOT EDIT) <ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, ''et al'' |title=ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine |journal=JACC |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi:10.1016/j.jacc.2007.02.013 |url=}}</ref>== | ||
Revision as of 14:27, 9 December 2009
|
WikiDoc Resources for Unstable angina non ST elevation myocardial infarction long-term medical therapy and secondary prevention |
|
Articles |
|---|
|
Media |
|
Evidence Based Medicine |
|
Clinical Trials |
|
|
|
Guidelines / Policies / Govt |
|
|
|
Books |
|
News |
|
Commentary |
|
Definitions |
|
Patient Resources / Community |
|
|
|
Healthcare Provider Resources |
|
Continuing Medical Education (CME) |
|
International |
|
|
|
Business |
|
Experimental / Informatics |
| Cardiology Network |
 Discuss Unstable angina non ST elevation myocardial infarction long-term medical therapy and secondary prevention further in the WikiDoc Cardiology Network |
| Adult Congenital |
|---|
| Biomarkers |
| Cardiac Rehabilitation |
| Congestive Heart Failure |
| CT Angiography |
| Echocardiography |
| Electrophysiology |
| Cardiology General |
| Genetics |
| Health Economics |
| Hypertension |
| Interventional Cardiology |
| MRI |
| Nuclear Cardiology |
| Peripheral Arterial Disease |
| Prevention |
| Public Policy |
| Pulmonary Embolism |
| Stable Angina |
| Valvular Heart Disease |
| Vascular Medicine |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Please Join in Editing This Page and Apply to be an Editor-In-Chief for this topic: There can be one or more than one Editor-In-Chief. You may also apply to be an Associate Editor-In-Chief of one of the subtopics below. Please mail us [2] to indicate your interest in serving either as an Editor-In-Chief of the entire topic or as an Associate Editor-In-Chief for a subtopic. Please be sure to attach your CV and or biographical sketch.
Overview of Long-Term Medical Therapy and Secondary Prevention for UA / NSTEMI
Similar to patients with STEMI, patients with UA/NSTEMI also require secondary prevention at the time of discharge. HEalth care team should work with patients and their families to educate them in detail regarding specific targets for LDL cholesterol and HDL cholesterol, blood pressure, body mass index (BMI), physical activity, and other appropriate lifestyle modifications.
ACC / AHA Guidelines- Antiplatelet Therapy (DO NOT EDIT) [1]
| “ |
Class I1. For UA/NSTEMI patients treated medically without stenting, aspirin (75 to 162 mg per day) should be prescribed indefinitely (Level of Evidence: A) clopidogrel (75 mg per day) should be prescribed for at least 1 month (Level of Evidence: A) and ideally for up to 1 year. (Level of Evidence: B) 2. For UA/NSTEMI patients treated with bare-metal stents, aspirin 162 to 325 mg per day should be prescribed for at least 1 month (Level of Evidence: B), then continued indefinitely at a dose of 75 to 162 mg per day (Level of Evidence: A); clopidogrel should be prescribed at a dose of 75 mg per day for a minimum of 1 month and ideally for up to 1 year (unless the patient is at increased risk of bleeding, then it should be given for a minimum of 2 weeks). (Level of Evidence: B) 3. For UA/NSTEMI patients treated with DES, aspirin 162 to 325 mg per day should be prescribed for at least 3 months after sirolimus-eluting stent implantation and 6 months after paclitaxel-eluting stent implantation then continued indefinitely at a dose of 75 to 162 mg per day. (Level of Evidence: B) Clopidogrel 75 mg daily should be given for at least 12 months to all post-PCI patients receiving DES. (Level of Evidence: B) 4. 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 (but with gastroprotective agents such as proton-pump inhibitors). (Level of Evidence: A) Class IIa1. For UA/NSTEMI patients in whom the physician is concerned about the risk of bleeding, a lower initial aspirin dose after PCI of 75 to 162 mg per day is reasonable. (Level of Evidence: C) Class IIb1. For UA/NSTEMI patients who have an indication for anticoagulation, add warfarin to maintain an international normalization ratio of 2.0 to 3.0. (Level of Evidence: B) Class III1. Dipyridamole is not recommended as an antiplatelet agent in post-UA/NSTEMI patients because it has not been shown to be effective. (Level of Evidence: A) |
” |
ACC / AHA Guidelines- Beta Blockers (DO NOT EDIT) [1]
| “ |
Class I1. Beta blockers are indicated for all patients recovering from UA / NSTEMI unless contraindicated. Treatment should begin within a few days of the event, if not initiated acutely, and should be continued indefinitely. (Level of Evidence: B) 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) Class IIa1. It is reasonable to prescribe beta blockers to low-risk patients (i.e., normal LV function, revascularized, no high risk features) recovering from UA / NSTEMI in the absence of absolute contraindications. (Level of Evidence: B) |
” |
ACC / AHA Guidelines- Inhibition Of The Renin-Angiotensin-Aldosterone System (DO NOT EDIT) [1]
| “ |
Class I1. Angiotensin-converting enzyme inhibitors should be given and continued indefinitely for patients recovering from UA / NSTEMI with HF, LV dysfunction (LVEF <40%), hypertension, or diabetes mellitus, unless contraindicated. (Level of Evidence: A) 2. An angiotensin receptor blocker should be prescribed at discharge to those UA / NSTEMI patients who are intolerant of an ACE inhibitor and who have either clinical or radiological signs of HF and LVEF <40%. (Level of Evidence: A) 3. Long term Aldosterone Receptor Blockade should be prescribed for UA / NSTEMI patients without significant renal dysfunction (estimated creatinine clearance should be >30 mL/min) or hyperkalemia (potassium should be ≤5 mEq/liter) who are already receiving therapeutic doses of an ACE inhibitor, have an LVEF ≤40%, and have either symptomatic heart failure or diabetes mellitus. (Level of Evidence: A) Class IIa1. Angiotensin-converting enzyme 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) 2. Angiotensin-converting enzyme inhibitors are reasonable for patients with HF and LVEF >40%. (Level of Evidence: A) 3. In UA / NSTEMI patients who do not tolerate ACE inhibitors, an angiotensin receptor blocker can be useful as an alternative to ACE inhibitors in long term management provided there are either clinical or radiological signs of HF and LVEF <40%. (Level of Evidence: B) Class IIb1. The combination of an ACE inhibitor and an angiotensin receptor blocker may be considered in the long-term management of patients recovering from UA / NSTEMI with persistent symptomatic HF and LVEF <40% despite conventional therapy including an ACE inhibitor or an angiotensin receptor blocker alone. (Level of Evidence: B) |
” |
ACC / AHA Guidelines- Nitroglycerin (DO NOT EDIT) [1]
| “ |
Class I1. Nitroglycerin to treat ischemic symptoms is recommended. (Level of Evidence: C) |
” |
ACC / AHA Guidelines- Calcium Channel Blockers (DO NOT EDIT) [1]
| “ |
Class I1. 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) |
” |
ACC / AHA Guidelines- Warfarin Therapy (DO NOT EDIT) [1]
| “ |
Class I1. Use of warfarin in conjunction with ASA and/or clopidogrel is associated with an increased risk of bleeding and should be monitored closely. (Level of Evidence: A) Class IIb1. Warfarin either without (INR 2.5 to 3.5) or with low-dose ASA (75 to 81 mg per d; INR 2.0 to 2.5) may be reasonable for patients at high CAD risk and low bleeding risk who do not require or are intolerant of clopidogrel. (Level of Evidence: B) |
” |
ACC / AHA Guidelines- Lipid Management (DO NOT EDIT) [1]
| “ |
Class I1. The following lipid recommendations are beneficial:
2. Treatment of triglycerides and non-HDL-C is useful, including the following:
Class IIa1. The following lipid management strategies can be beneficial:
Class IIb1. Encouraging consumption of omega-3 fatty acids in the form of fish or in capsule form (1 g per d) for risk reduction may be reasonable. For treatment of elevated triglycerides, higher doses (2 to 4 g per d) may be used for risk reduction. (Level of Evidence: B) |
” |
ACC / AHA Guidelines- Blood Pressure Control (DO NOT EDIT) [1]
| “ |
Class I1. Blood pressure control according to JNC 7 guidelines is recommended (i.e., blood pressure <140/90 mmHg or <130/80 mmHg 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:
|
” |
ACC / AHA Guidelines- Diabetes Mellitus (DO NOT EDIT) [1]
| “ |
Class I1. Diabetes management should include lifestyle and pharmacotherapy measures to achieve a near-normal HbA1c level of <7%. (Level of Evidence: B) Diabetes management should also include the following:
|
” |
ACC / AHA Guidelines- Smoking Cessation (DO NOT EDIT) [1]
| “ |
Class I1. 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 A’s are: Ask, Advise, Assess, Assist, and Arrange). (Level of Evidence: B) |
” |
ACC / AHA Guidelines- Weight Management (DO NOT EDIT) [1]
| “ |
Class I1. 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/m² and a waist circumference (measured horizontally at the iliac crest) of <40 inches for men and <35 inches for women is recommended. (Level of Evidence: B) Additional weight management practices recommended include the following:
|
” |
ACC / AHA Guidelines- Physical Activity (DO NOT EDIT) [1]
| “ |
Class I1. 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 min/day, preferably 7 (but at least 5) day/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) Class IIb1. The expansion of physical activity to include resistance training on 2 day per week may be reasonable. (Level of Evidence: C) |
” |
ACC / AHA Guidelines- Patient Education (DO NOT EDIT) [1]
| “ |
Class I1. 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 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) |
” |
ACC / AHA Guidelines- Influenza Vaccination (DO NOT EDIT) [1]
| “ |
Class I1. An annual influenza vaccination is recommended for patients with cardiovascular disease. (Level of Evidence: B) |
” |
ACC / AHA Guidelines- Depression (DO NOT EDIT) [1]
| “ |
Class IIa1. It is reasonable to consider screening UA / NSTEMI patients for depression and refer/treat when indicated. (Level of Evidence: B) |
” |
ACC / AHA Guidelines- Nonsteroidal Anti-Inflammatory Drugs (DO NOT EDIT) [1]
| “ |
Class I1. At the time of preparation for hospital discharge, the patient’s need for treatment of chronic musculoskeletal discomfort should be assessed, and a stepped-care approach to treatment should be used for selection of treatments. Pain relief should begin with acetaminophen, small doses of narcotics, or non acetylated salicylates. (Level of Evidence: C) Class IIa1. It is reasonable to use nonselective NSAIDs, such as naproxen, if initial therapy with acetaminophen, small doses of narcotics, or non acetylated salicylates is insufficient. (Level of Evidence: C) Class IIb1. Non steroidal anti inflammatory drugs with increasing degrees of relative COX-2 selectivity may be considered for pain relief only for situations in which intolerable discomfort persists despite attempts at stepped-care therapy with acetaminophen, small doses of narcotics, non acetylated salicylates, or non selective NSAIDs. In all cases, the lowest effective doses should be used for the shortest possible time. (Level of Evidence: C) Class III1. Non steroidal anti inflammatory drugs with increasing degrees of relative COX-2 selectivity should not be administered to UA / NSTEMI patients with chronic musculoskeletal discomfort when therapy with acetaminophen, small doses of narcotics, non acetylated salicylates, or non selective NSAIDs provides acceptable levels of pain relief. (Level of Evidence: C) |
” |
ACC / AHA Guidelines- Hormone Therapy (DO NOT EDIT) [1]
| “ |
Class III1. 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 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 bed rest in the hospital. (Level of Evidence: B) |
” |
ACC / AHA Guidelines- Antioxidant Vitamins and Folic Acid (DO NOT EDIT) [1]
| “ |
Class III1. Antioxidant vitamin supplements (e.g., vitamin E, vitamin C, or beta carotene) should not be used for secondary prevention in UA / NSTEMI patients. (Level of Evidence: A) 2. Folic acid, with or without vitamin B6 and vitamin B12, should not be used for secondary prevention in UA / NSTEMI patients. (Level of Evidence: A) |
” |
See Also
Sources
- The ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction [1]
References
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 Anderson JL, Adams CD, Antman EM; et al. (2007). "ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine". JACC. 50 (7): e1–e157. PMID 17692738. Text "doi:10.1016/j.jacc.2007.02.013 " ignored (help); Unknown parameter
|month=ignored (help)