Unstable angina non ST elevation myocardial infarction additional management considerations for antiplatelet and anticoagulant therapy: Difference between revisions

Jump to navigation Jump to search
← Older editNewer edit →
VisualWikitext
Kogando (talk | contribs)
nocaptcha
7,761 edits
Varun Kumar (talk | contribs)
nocaptcha
5,592 edits
No edit summary
Line 7: Line 7:
==Overview of Additional Management Considerations for Antiplatelet and Anticoagulant Therapy in UA / NSTEMI==
==Overview of Additional Management Considerations for Antiplatelet and Anticoagulant Therapy in UA / NSTEMI==


==ACC / AHA Guidelines (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 (DO NOT EDIT) <ref name="pmid21444889">{{cite journal |author=Wright RS, Anderson JL, Adams CD, Bridges CR, Casey DE, Ettinger SM, Fesmire FM, Ganiats TG, Jneid H, Lincoff AM, Peterson ED, Philippides GJ, Theroux P, Wenger NK, Zidar JP |title=2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction (Updating the 2007 Guideline): A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines |journal=[[Circulation]] |volume= |issue= |pages= |year=2011 |month=March |pmid=21444889 |doi=10.1161/CIR.0b013e31820f2f3e |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=21444889 |accessdate=2011-03-31}}</ref>==
{{cquote|   
{{cquote|   
===Class I===
===Class I===


1. For [[UA]] / [[NSTEMI]] patients in whom an initial conservative strategy is selected and no subsequent features appear that would necessitate [[diagnostic angiography]] (recurrent symptoms / [[ischemia]], [[heart failure]] or serious [[arrhythmia]]s), a [[stress test]] should be performed. (Level of Evidence: B).
'''1.''' For [[UA]] / [[NSTEMI]] patients in whom an initial conservative strategy is selected and no subsequent features appear that would necessitate [[diagnostic angiography]] (recurrent symptoms / [[ischemia]], [[heart failure]] or serious [[arrhythmia]]s), a [[stress test]] should be performed. (Level of Evidence: B).


::a. If, after [[stress test]]ing, the patient is classified as not at low risk, [[diagnostic angiography]] should be performed. (Level of Evidence: A)  
::'''a.''' If, after [[stress test]]ing, the patient is classified as not at low risk, [[diagnostic angiography]] should be performed. (Level of Evidence: A)  
::b. If, after [[stress test]]ing, the patient is classified as being at low risk, the following instructions should be used in preparation for discharge (Level of Evidence: A):
::'''b.''' If, after [[stress test]]ing, the patient is classified as being at low risk, the following instructions should be used in preparation for discharge (Level of Evidence: A):


:::* Continue [[ASA]] indefinitely. (Level of Evidence: A)
:::* Continue [[ASA]] indefinitely. (Level of Evidence: A)
:::* Continue [[clopidogrel]] for at least 1 month (Level of Evidence: A) and ideally up to 1 year. (Level of Evidence: B)  
:::* Continue [[clopidogrel]] for at least 1 month (Level of Evidence: A) and ideally up to 1 year. (Level of Evidence: B)  
:::* Discontinue intravenous [[GP IIb/IIIa inhibitor]] if started previously. (Level of Evidence: A)
:::* Discontinue intravenous [[GP IIb/IIIa inhibitor]] if started previously. (Level of Evidence: A)
:::* Continue [[UFH]] for 48 h or administer [[enoxaparin]] or [[fondaparinux]] for the duration of hospitalization, up to 8 d, and then discontinue [[anticoagulant therapy]]. (Level of Evidence: A)
:::* Continue [[UFH]] for 48 hours (Level of Evidence: A) or administer [[enoxaparin]] (Level of Evidence: A) or [[fondaparinux]] (Level of Evidence: B) for the duration of hospitalization, up to 8 days, and then discontinue [[anticoagulant therapy]]. (Level of Evidence: A)


2. For [[UA]] / [[NSTEMI]] patients in whom [[CABG]] is selected as a postangiography management strategy, the instructions noted below should be followed.  
'''2.''' For [[UA]] / [[NSTEMI]] patients in whom [[CABG]] is selected as a postangiography management strategy, the instructions noted below should be followed.  


::a. Continue [[ASA]]. (Level of Evidence: A)
::'''a.''' Continue [[ASA]]. (Level of Evidence: A)
::b. Discontinue [[clopidogrel]] 5 to 7 d before elective [[CABG]]. (Level of Evidence: B) More urgent surgery, if necessary, may be performed by experienced surgeons if the incremental bleeding risk is considered acceptable. (Level of Evidence: C)
::'''b.''' Discontinue [[clopidogrel]] 5 to 7 d before elective [[CABG]]. (Level of Evidence: B) More urgent surgery, if necessary, may be performed by experienced surgeons if the incremental bleeding risk is considered acceptable. (Level of Evidence: C)
::c. Discontinue intravenous [[GP IIb/IIIa inhibitor]] ([[eptifibatide]] or [[tirofiban]]) 4 h before [[CABG]]. (Level of Evidence: B)
::'''c.''' Discontinue intravenous [[GP IIb/IIIa inhibitor]] ([[eptifibatide]] or [[tirofiban]]) 4 h before [[CABG]]. (Level of Evidence: B)
::d. Anticoagulant therapy should be managed as follows:  
::'''d.''' Anticoagulant therapy should be managed as follows:  


:::* Continue [[UFH]]. (Class I Level of Evidence: B)
:::* Continue [[UFH]]. (Class I Level of Evidence: B)
Line 33: Line 33:
:::* Discontinue [[bivalirudin]] 3 h before [[CABG]] and dose with [[UFH]] per institutional practice. (Level of Evidence: B)
:::* Discontinue [[bivalirudin]] 3 h before [[CABG]] and dose with [[UFH]] per institutional practice. (Level of Evidence: B)


3. For [[UA]] / [[NSTEMI]] patients in whom [[PCI]] has been selected as a postangiography management strategy, the instructions noted below should be followed:
'''3.''' In patients taking a [[thienopyridine]] in whom [[CABG]] is planned and can be delayed, it is recommended that the drug be discontinued to allow for dissipation of the antiplatelet effect (Level of Evidence: B). The period of withdrawal should be at least 5 days in patients receiving [[clopidogrel]] (Level of Evidence: B) and at least 7 days in patients receiving [[prasugrel]] (Level of Evidence: C) unless the need for revascularization and/or the net benefit of the [[thienopyridine]] outweighs the potential risks of excess bleeding. (Level of Evidence: C)


::a. Continue [[ASA]]. (Class I Level of Evidence: A)
'''4.''' For [[UA]] / [[NSTEMI]] patients in whom [[PCI]] has been selected as a postangiography management strategy, the instructions noted below should be followed:
::b. Administer a loading dose of [[clopidogrel]] if not started before [[diagnostic angiography]]. (Level of Evidence: A)  
::'''a.''' Continue [[ASA]]. (Level of Evidence: A)
::c. Administer an intravenous [[GP IIb/IIIa inhibitor]] ([[abciximab]], [[eptifibatide]], or [[tirofiban]]) if not started before [[diagnostic angiography]] for troponin-positive and other high-risk patients (Level of Evidence: A).
::'''b.''' Administer a loading dose of a thienopyridine if not started before diagnostic angiography. (Level of Evidence: A)
::d. Discontinue [[anticoagulant therapy]] after [[PCI]] for uncomplicated cases. (Level of Evidence: B)
::'''c.''' See Class IIa, #1, in this section.
::'''d.''' Discontinue anticoagulant therapy after PCI for uncomplicated cases. (Level of Evidence: B)


4. According to angiographic findings;
'''5.''' For [[UA]] / [[NSTEMI]] patients in whom medical therapy is selected as a management strategy and in whom no significant obstructive [[CAD]] on angiography was found, [[antiplatelet]] and [[anticoagulant therapy]] should be administered at the discretion of the clinician (Level of Evidence: C). For patients in whom evidence of [[coronary atherosclerosis]] is present (e.g., luminal irregularities or intravascular ultrasound demonstrated lesions), albeit without flow-limiting stenoses, long-term treatment with [[ASA]] and other secondary prevention measures should be prescribed. (Level of Evidence: C)


::a. For [[UA]] / [[NSTEMI]] patients in whom medical therapy is selected as a postangiography management strategy and in whom no significant obstructive [[coronary artery disease]] on angiography was found, [[antiplatelet]] and [[anticoagulant therapy]] should be administered at the discretion of the clinician. (Level of Evidence: C)
'''6.''' For [[UA]] / [[NSTEMI]] patients in whom medical therapy is selected as a postangiography management strategy and in whom CAD was found on angiography, the following approach is recommended:
::b. For patients in whom evidence of [[coronary atherosclerosis]] is present (e.g., luminal irregularities or [[intravascular ultrasound]] demonstrated lesions), albeit without flow limiting stenoses, long term treatment with [[ASA]] and other secondary prevention measures should be prescribed. (Level of Evidence: C)


5. For [[UA]] / [[NSTEMI]] patients in whom medical therapy is selected as a postangiography management strategy and in whom CAD was found on angiography, the following approach is recommended:
::'''a.''' Continue [[ASA]]. (Class I Level of Evidence: A)
 
::'''b.''' Administer a loading dose of [[clopidogrel]] if not given before [[diagnostic angiography]]. (Level of Evidence: B)  
::a. Continue [[ASA]]. (Class I Level of Evidence: A)
::'''c.''' Discontinue intravenous [[GP IIb/IIIa inhibitor]] if started previously. (Level of Evidence: B)
::b. Administer a loading dose of [[clopidogrel]] if not given before [[diagnostic angiography]]. (Level of Evidence: A)  
::'''d.''' Anticoagulant therapy should be managed as follows:
::c. Discontinue intravenous [[GP IIb/IIIa inhibitor]] if started previously. (Level of Evidence: B)
::d. Anticoagulant therapy should be managed as follows:


:::* Continue intravenous [[UFH]] for at least 48 h or until discharge if given before [[diagnostic angiography]]. (Level of Evidence: A)
:::* Continue intravenous [[UFH]] for at least 48 h or until discharge if given before [[diagnostic angiography]]. (Level of Evidence: A)
Line 57: Line 55:
:::* Either discontinue [[bivalirudin]] or continue at a dose of 0.25 mg per kg per h for up to 72 h at the physician’s discretion, if given before [[diagnostic angiography]]. (Level of Evidence: B)
:::* Either discontinue [[bivalirudin]] or continue at a dose of 0.25 mg per kg per h for up to 72 h at the physician’s discretion, if given before [[diagnostic angiography]]. (Level of Evidence: B)


6. For [[UA]] / [[NSTEMI]] patients in whom a conservative strategy is selected and who do not undergo [[coronary angiography]] or [[stress test]]ing, the instructions noted below should be followed:
'''7.''' For [[UA]] / [[NSTEMI]] patients in whom a conservative strategy is selected and who do not undergo [[coronary angiography]] or [[stress test]]ing, the instructions noted below should be followed:


::a. Continue [[ASA]] indefinitely. (Class I Level of Evidence: A)
::'''a.''' Continue [[ASA]] indefinitely. (Class I Level of Evidence: A)
::b. Continue [[clopidogrel]] for at least 1 month (Level of Evidence: A) and ideally up to 1 year. (Level of Evidence: B)
::'''b.''' Continue [[clopidogrel]] for at least 1 month and ideally up to 1 year. (Level of Evidence: B)
::c. Discontinue IV [[GP IIb/IIIa inhibitor]] if started previously. (Level of Evidence: A)
::'''c.''' Discontinue IV [[GP IIb/IIIa inhibitor]] if started previously. (Level of Evidence: A)
::d. Continue [[UFH]] for 48 h or administer [[enoxaparin]] or [[fondaparinux]] for the duration of hospitalization, up to 8 d, and then discontinue [[anticoagulant therapy]]. (Level of Evidence: A)
::'''d.''' Continue [[UFH]] for 48 h or administer [[enoxaparin]] or [[fondaparinux]] for the duration of hospitalization, up to 8 d, and then discontinue [[anticoagulant therapy]]. (Level of Evidence: A)


7. For [[UA]] / [[NSTEMI]] patients in whom an initial conservative strategy is selected and in whom no subsequent features appear that would necessitate [[diagnostic angiography]] (recurrent symptoms / [[ischemia]], [[HF]], or serious [[arrhythmia]]s), [[Left Ventricular Ejection Fraction]] should be measured. (Level of Evidence: B)
'''8.''' For [[UA]] / [[NSTEMI]] patients in whom an initial conservative strategy is selected and in whom no subsequent features appear that would necessitate [[diagnostic angiography]] (recurrent symptoms / [[ischemia]], [[HF]], or serious [[arrhythmia]]s), [[Left Ventricular Ejection Fraction]] should be measured. (Level of Evidence: B)


===Class IIa===
===Class IIa===


1. For [[UA]] / [[NSTEMI]] patients in whom [[PCI]] is selected as a post angiography management strategy, it is reasonable to omit administration of an intravenous [[GP IIb/IIIa antagonist]] if [[bivalirudin]] was selected as the [[anticoagulant]] and at least 300 mg of [[clopidogrel]] was administered at least 6 h earlier. (Level of Evidence: B)
'''1.''' For [[UA]] / [[NSTEMI]] patients in whom PCI has been selected as a postangiography management strategy, it is reasonable to administer an IV [[GP IIb/IIIa inhibitor]] ([[abciximab]], [[eptifibatide]], or [[tirofiban]]) if not started before diagnostic angiography, particularly for troponin-positive and/or other high-risk patients. (Level of Evidence: A)


2. If [[Left Ventricular Ejection Fraction]] is ≤40%, it is reasonable to perform [[diagnostic angiography]]. (Level of Evidence: B)  
'''2.''' For [[UA]] / [[NSTEMI]] patients in whom [[PCI]] is selected as a post angiography management strategy, it is reasonable to omit administration of an intravenous [[GP IIb/IIIa antagonist]] if [[bivalirudin]] was selected as the [[anticoagulant]] and at least 300 mg of [[clopidogrel]] was administered at least 6 h earlier. (Level of Evidence: B)


3. If [[Left Ventricular Ejection Fraction]] is >40%, it is reasonable to perform a [[stress test]]. (Level of Evidence: B)
'''3.''' If [[Left Ventricular Ejection Fraction]] is ≤40%, it is reasonable to perform [[diagnostic angiography]]. (Level of Evidence: B)
 
'''4.''' If [[Left Ventricular Ejection Fraction]] is >40%, it is reasonable to perform a [[stress test]]. (Level of Evidence: B)


===Class IIb===
===Class IIb===


1. For [[UA]] / [[NSTEMI]] patients in whom [[PCI]] is selected as a post angiography management strategy, it may be reasonable to omit an i.v. [[GP IIb/IIIa inhibitor]] if not started before [[diagnostic angiography]] for [[troponin]] negative patients without other clinical or angiographic high risk features. (Level of Evidence: C)
'''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.''' Genotyping for a CYP2C19 loss of function variant in patients with [[UA]] / [[NSTEMI]] (or, after [[ACS]] and with [[PCI]]) on [[clopidogrel]] therapy might be considered if results of testing may alter management. (Level of Evidence: C)


===Class III===
===Class III===


1. Intravenous [[fibrinolytic therapy]] is not indicated in patients without acute [[ST segment elevation]], a [[true posterior MI]], or a presumed new [[left bundle branch block]] ([[LBBB]]). (Level of Evidence: A)}}
'''1.''' Intravenous [[fibrinolytic therapy]] is not indicated in patients without acute [[ST segment elevation]], a [[true posterior MI]], or a presumed new [[left bundle branch block]] ([[LBBB]]). (Level of Evidence: A)}}


==See Also==
==See Also==
Line 86: Line 88:


==Sources==
==Sources==
*The ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction <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>
*2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction <ref name="pmid21444889">{{cite journal |author=Wright RS, Anderson JL, Adams CD, Bridges CR, Casey DE, Ettinger SM, Fesmire FM, Ganiats TG, Jneid H, Lincoff AM, Peterson ED, Philippides GJ, Theroux P, Wenger NK, Zidar JP |title=2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction (Updating the 2007 Guideline): A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines |journal=[[Circulation]] |volume= |issue= |pages= |year=2011 |month=March |pmid=21444889 |doi=10.1161/CIR.0b013e31820f2f3e |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=21444889 |accessdate=2011-03-31}}</ref>


==References==
==References==

Revision as of 01:20, 1 April 2011

WikiDoc Resources for Unstable angina non ST elevation myocardial infarction additional management considerations for antiplatelet and anticoagulant therapy

Articles

Most recent articles on Unstable angina non ST elevation myocardial infarction additional management considerations for antiplatelet and anticoagulant therapy

Most cited articles on Unstable angina non ST elevation myocardial infarction additional management considerations for antiplatelet and anticoagulant therapy

Review articles on Unstable angina non ST elevation myocardial infarction additional management considerations for antiplatelet and anticoagulant therapy

Articles on Unstable angina non ST elevation myocardial infarction additional management considerations for antiplatelet and anticoagulant therapy in N Eng J Med, Lancet, BMJ

Media

Powerpoint slides on Unstable angina non ST elevation myocardial infarction additional management considerations for antiplatelet and anticoagulant therapy

Images of Unstable angina non ST elevation myocardial infarction additional management considerations for antiplatelet and anticoagulant therapy

Photos of Unstable angina non ST elevation myocardial infarction additional management considerations for antiplatelet and anticoagulant therapy

Podcasts & MP3s on Unstable angina non ST elevation myocardial infarction additional management considerations for antiplatelet and anticoagulant therapy

Videos on Unstable angina non ST elevation myocardial infarction additional management considerations for antiplatelet and anticoagulant therapy

Evidence Based Medicine

Cochrane Collaboration on Unstable angina non ST elevation myocardial infarction additional management considerations for antiplatelet and anticoagulant therapy

Bandolier on Unstable angina non ST elevation myocardial infarction additional management considerations for antiplatelet and anticoagulant therapy

TRIP on Unstable angina non ST elevation myocardial infarction additional management considerations for antiplatelet and anticoagulant therapy

Clinical Trials

Ongoing Trials on Unstable angina non ST elevation myocardial infarction additional management considerations for antiplatelet and anticoagulant therapy at Clinical Trials.gov

Trial results on Unstable angina non ST elevation myocardial infarction additional management considerations for antiplatelet and anticoagulant therapy

Clinical Trials on Unstable angina non ST elevation myocardial infarction additional management considerations for antiplatelet and anticoagulant therapy at Google

Guidelines / Policies / Govt

US National Guidelines Clearinghouse on Unstable angina non ST elevation myocardial infarction additional management considerations for antiplatelet and anticoagulant therapy

NICE Guidance on Unstable angina non ST elevation myocardial infarction additional management considerations for antiplatelet and anticoagulant therapy

NHS PRODIGY Guidance

FDA on Unstable angina non ST elevation myocardial infarction additional management considerations for antiplatelet and anticoagulant therapy

CDC on Unstable angina non ST elevation myocardial infarction additional management considerations for antiplatelet and anticoagulant therapy

Books

Books on Unstable angina non ST elevation myocardial infarction additional management considerations for antiplatelet and anticoagulant therapy

News

Unstable angina non ST elevation myocardial infarction additional management considerations for antiplatelet and anticoagulant therapy in the news

Be alerted to news on Unstable angina non ST elevation myocardial infarction additional management considerations for antiplatelet and anticoagulant therapy

News trends on Unstable angina non ST elevation myocardial infarction additional management considerations for antiplatelet and anticoagulant therapy

Commentary

Blogs on Unstable angina non ST elevation myocardial infarction additional management considerations for antiplatelet and anticoagulant therapy

Definitions

Definitions of Unstable angina non ST elevation myocardial infarction additional management considerations for antiplatelet and anticoagulant therapy

Patient Resources / Community

Patient resources on Unstable angina non ST elevation myocardial infarction additional management considerations for antiplatelet and anticoagulant therapy

Discussion groups on Unstable angina non ST elevation myocardial infarction additional management considerations for antiplatelet and anticoagulant therapy

Patient Handouts on Unstable angina non ST elevation myocardial infarction additional management considerations for antiplatelet and anticoagulant therapy

Directions to Hospitals Treating Unstable angina non ST elevation myocardial infarction additional management considerations for antiplatelet and anticoagulant therapy

Risk calculators and risk factors for Unstable angina non ST elevation myocardial infarction additional management considerations for antiplatelet and anticoagulant therapy

Healthcare Provider Resources

Symptoms of Unstable angina non ST elevation myocardial infarction additional management considerations for antiplatelet and anticoagulant therapy

Causes & Risk Factors for Unstable angina non ST elevation myocardial infarction additional management considerations for antiplatelet and anticoagulant therapy

Diagnostic studies for Unstable angina non ST elevation myocardial infarction additional management considerations for antiplatelet and anticoagulant therapy

Treatment of Unstable angina non ST elevation myocardial infarction additional management considerations for antiplatelet and anticoagulant therapy

Continuing Medical Education (CME)

CME Programs on Unstable angina non ST elevation myocardial infarction additional management considerations for antiplatelet and anticoagulant therapy

International

Unstable angina non ST elevation myocardial infarction additional management considerations for antiplatelet and anticoagulant therapy en Espanol

Unstable angina non ST elevation myocardial infarction additional management considerations for antiplatelet and anticoagulant therapy en Francais

Business

Unstable angina non ST elevation myocardial infarction additional management considerations for antiplatelet and anticoagulant therapy in the Marketplace

Patents on Unstable angina non ST elevation myocardial infarction additional management considerations for antiplatelet and anticoagulant therapy

Experimental / Informatics

List of terms related to Unstable angina non ST elevation myocardial infarction additional management considerations for antiplatelet and anticoagulant therapy

Cardiology Network

Discuss Unstable angina non ST elevation myocardial infarction additional management considerations for antiplatelet and anticoagulant therapy 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 Additional Management Considerations for Antiplatelet and Anticoagulant Therapy in UA / NSTEMI

ACC / AHA Guidelines (DO NOT EDIT) [1]

“

Class I

1. For UA / NSTEMI patients in whom an initial conservative strategy is selected and no subsequent features appear that would necessitate diagnostic angiography (recurrent symptoms / ischemia, heart failure or serious arrhythmias), a stress test should be performed. (Level of Evidence: B).

a. If, after stress testing, the patient is classified as not at low risk, diagnostic angiography should be performed. (Level of Evidence: A)
b. If, after stress testing, the patient is classified as being at low risk, the following instructions should be used in preparation for discharge (Level of Evidence: A):
  • Continue ASA indefinitely. (Level of Evidence: A)
  • Continue clopidogrel for at least 1 month (Level of Evidence: A) and ideally up to 1 year. (Level of Evidence: B)
  • Discontinue intravenous GP IIb/IIIa inhibitor if started previously. (Level of Evidence: A)
  • Continue UFH for 48 hours (Level of Evidence: A) or administer enoxaparin (Level of Evidence: A) or fondaparinux (Level of Evidence: B) for the duration of hospitalization, up to 8 days, and then discontinue anticoagulant therapy. (Level of Evidence: A)

2. For UA / NSTEMI patients in whom CABG is selected as a postangiography management strategy, the instructions noted below should be followed.

a. Continue ASA. (Level of Evidence: A)
b. Discontinue clopidogrel 5 to 7 d before elective CABG. (Level of Evidence: B) More urgent surgery, if necessary, may be performed by experienced surgeons if the incremental bleeding risk is considered acceptable. (Level of Evidence: C)
c. Discontinue intravenous GP IIb/IIIa inhibitor (eptifibatide or tirofiban) 4 h before CABG. (Level of Evidence: B)
d. Anticoagulant therapy should be managed as follows:
  • Continue UFH. (Class I Level of Evidence: B)
  • Discontinue enoxaparin 12 to 24 h before CABG and dose with UFH per institutional practice. (Level of Evidence: B)
  • Discontinue fondaparinux 24 h before CABG and dose with UFH per institutional practice. (Level of Evidence: B)
  • Discontinue bivalirudin 3 h before CABG and dose with UFH per institutional practice. (Level of Evidence: B)

3. In patients taking a thienopyridine in whom CABG is planned and can be delayed, it is recommended that the drug be discontinued to allow for dissipation of the antiplatelet effect (Level of Evidence: B). The period of withdrawal should be at least 5 days in patients receiving clopidogrel (Level of Evidence: B) and at least 7 days in patients receiving prasugrel (Level of Evidence: C) unless the need for revascularization and/or the net benefit of the thienopyridine outweighs the potential risks of excess bleeding. (Level of Evidence: C)

4. For UA / NSTEMI patients in whom PCI has been selected as a postangiography management strategy, the instructions noted below should be followed:

a. Continue ASA. (Level of Evidence: A)
b. Administer a loading dose of a thienopyridine if not started before diagnostic angiography. (Level of Evidence: A)
c. See Class IIa, #1, in this section.
d. Discontinue anticoagulant therapy after PCI for uncomplicated cases. (Level of Evidence: B)

5. For UA / NSTEMI patients in whom medical therapy is selected as a management strategy and in whom no significant obstructive CAD on angiography was found, antiplatelet and anticoagulant therapy should be administered at the discretion of the clinician (Level of Evidence: C). For patients in whom evidence of coronary atherosclerosis is present (e.g., luminal irregularities or intravascular ultrasound demonstrated lesions), albeit without flow-limiting stenoses, long-term treatment with ASA and other secondary prevention measures should be prescribed. (Level of Evidence: C)

6. For UA / NSTEMI patients in whom medical therapy is selected as a postangiography management strategy and in whom CAD was found on angiography, the following approach is recommended:

a. Continue ASA. (Class I Level of Evidence: A)
b. Administer a loading dose of clopidogrel if not given before diagnostic angiography. (Level of Evidence: B)
c. Discontinue intravenous GP IIb/IIIa inhibitor if started previously. (Level of Evidence: B)
d. Anticoagulant therapy should be managed as follows:

7. For UA / NSTEMI patients in whom a conservative strategy is selected and who do not undergo coronary angiography or stress testing, the instructions noted below should be followed:

a. Continue ASA indefinitely. (Class I Level of Evidence: A)
b. Continue clopidogrel for at least 1 month and ideally up to 1 year. (Level of Evidence: B)
c. Discontinue IV GP IIb/IIIa inhibitor if started previously. (Level of Evidence: A)
d. Continue UFH for 48 h or administer enoxaparin or fondaparinux for the duration of hospitalization, up to 8 d, and then discontinue anticoagulant therapy. (Level of Evidence: A)

8. For UA / NSTEMI patients in whom an initial conservative strategy is selected and in whom no subsequent features appear that would necessitate diagnostic angiography (recurrent symptoms / ischemia, HF, or serious arrhythmias), Left Ventricular Ejection Fraction should be measured. (Level of Evidence: B)

Class IIa

1. For UA / NSTEMI patients in whom PCI has been selected as a postangiography management strategy, it is reasonable to administer an IV GP IIb/IIIa inhibitor (abciximab, eptifibatide, or tirofiban) if not started before diagnostic angiography, particularly for troponin-positive and/or other high-risk patients. (Level of Evidence: A)

2. For UA / NSTEMI patients in whom PCI is selected as a post angiography management strategy, it is reasonable to omit administration of an intravenous GP IIb/IIIa antagonist if bivalirudin was selected as the anticoagulant and at least 300 mg of clopidogrel was administered at least 6 h earlier. (Level of Evidence: B)

3. If Left Ventricular Ejection Fraction is ≤40%, it is reasonable to perform diagnostic angiography. (Level of Evidence: B)

4. If Left Ventricular Ejection Fraction is >40%, it is reasonable to perform a stress test. (Level of Evidence: B)

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. Genotyping for a CYP2C19 loss of function variant in patients with UA / NSTEMI (or, after ACS and with PCI) on clopidogrel therapy might be considered if results of testing may alter management. (Level of Evidence: C)

Class III

1. Intravenous fibrinolytic therapy is not indicated in patients without acute ST segment elevation, a true posterior MI, or a presumed new left bundle branch block (LBBB). (Level of Evidence: A)

”

See Also

Sources

  • 2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction [1]

References

  1. ↑ 1.0 1.1 Wright RS, Anderson JL, Adams CD, Bridges CR, Casey DE, Ettinger SM, Fesmire FM, Ganiats TG, Jneid H, Lincoff AM, Peterson ED, Philippides GJ, Theroux P, Wenger NK, Zidar JP (2011). "2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction (Updating the 2007 Guideline): A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". Circulation. doi:10.1161/CIR.0b013e31820f2f3e. PMID 21444889. Retrieved 2011-03-31. Unknown parameter |month= ignored (help)

Template:SIB

Template:WH Template:WS

Retrieved from "https://www.wikidoc.org/index.php?title=Unstable_angina_non_ST_elevation_myocardial_infarction_additional_management_considerations_for_antiplatelet_and_anticoagulant_therapy&oldid=573278"