Unstable angina non ST elevation myocardial infarction long-term medical therapy and secondary prevention ACC/AHA guidelines for lipid management

Acute Coronary Syndrome Main Page
Unstable angina / NSTEMI Microchapters
Home
Patient Information
Overview
Classification
Pathophysiology
Unstable Angina
Non-ST Elevation Myocardial Infarction
Differentiating Unstable Angina/Non-ST Elevation Myocardial Infarction from other Disorders
Epidemiology and Demographics
Risk Stratification
Natural History, Complications and Prognosis
Special Groups
Women
Heart Failure and Cardiogenic Shock
Perioperative NSTE-ACS Related to Noncardiac Surgery
Stress (Takotsubo) Cardiomyopathy
Diabetes Mellitus
Post CABG Patients
Older Adults
Chronic Kidney Disease
Angiographically Normal Coronary Arteries
Variant (Prinzmetal's) Angina
Substance Abuse
Cardiovascular "Syndrome X"
Diagnosis
History and Symptoms
Physical Examination
Laboratory Findings
Blood Studies
Biomarkers
Electrocardiogram
Chest X Ray
Echocardiography
Coronary Angiography
Treatment
Primary Prevention
Immediate Management
Anti-Ischemic and Analgesic Therapy
Cholesterol Management
Antitplatelet Therapy
Antiplatelet therapy recommendations
Aspirin
Thienopyridines
Glycoprotein IIb/IIIa Inhibitor
Anticoagulant Therapy
Additional Management Considerations for Antiplatelet and Anticoagulant Therapy
Risk Stratification Before Discharge for Patients With an Ischemia-Guided Strategy of NSTE-ACS
Mechanical Reperfusion
Initial Conservative Versus Initial Invasive Strategies
PCI
CABG
Complications of Bleeding and Transfusion
Discharge Care
Medical Regimen
Post-Discharge Follow-Up
Cardiac Rehabilitation
Long-Term Medical Therapy and Secondary Prevention
ICD implantation within 40 days of myocardial infarction
ICD within 90 days of revascularization
Cost-Effectiveness of Therapy
Future or Investigational Therapies
Case Studies
Case #1
Unstable angina non ST elevation myocardial infarction long-term medical therapy and secondary prevention ACC/AHA guidelines for lipid management On the Web
Most recent articles
Most cited articles
Review articles
CME Programs
Powerpoint slides
Images
Ongoing Trials at Clinical Trials.gov
US National Guidelines Clearinghouse
NICE Guidance
FDA on Unstable angina non ST elevation myocardial infarction long-term medical therapy and secondary prevention ACC/AHA guidelines for lipid management
CDC onUnstable angina non ST elevation myocardial infarction long-term medical therapy and secondary prevention ACC/AHA guidelines for lipid management
Unstable angina non ST elevation myocardial infarction long-term medical therapy and secondary prevention ACC/AHA guidelines for lipid management in the news
Blogs on Unstable angina non ST elevation myocardial infarction long-term medical therapy and secondary prevention ACC/AHA guidelines for lipid management
to Hospitals Treating Unstable angina non ST elevation myocardial infarction long-term medical therapy and secondary prevention ACC/AHA guidelines for lipid management
Risk calculators and risk factors for Unstable angina non ST elevation myocardial infarction long-term medical therapy and secondary prevention ACC/AHA guidelines for lipid management

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-in-Chief: Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.; Maheep Sangha, M.B.B.S..

2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non -ST-Elevation Myocardial Infarction (DO NOT EDIT)

Lipid Management (DO NOT EDIT)

Class I

"1. The following lipid recommendations are beneficial:

a) Lipid management should include assessment of a fasting lipid profile for all patients, within 24 h of hospitalization. (Level of Evidence: C)

b) Hydroxymethyl glutaryl-coenzyme A reductase inhibitors (statins), in the absence of contraindications, regardless of baseline LDL-C and diet modification, should be given to post-UA/NSTEMI patients, including postrevascularization patients. (Level of Evidence: A)

c) For hospitalized patients, lipid-lowering medications should be initiated before discharge. (Level of Evidence: A)

d) For UA/NSTEMI patients with elevated LDL-C (greater than or equal to 100 mg per dL), cholesterol-lowering therapy should be initiated or intensified to achieve an LDL-C of less than 100 mg per dL. (Level of Evidence: A) Further titration to less than 70 mg per dL is reasonable. (Class IIa, Level of Evidence: A)

e) Therapeutic options to reduce non–HDL-C* are recommended, including more intense LDL-C–lowering therapy. (Level of Evidence: B)

f) Dietary therapy for all patients should include reduced intake of saturated fats (to less than 7% of total calories), cholesterol (to less than 200 mg per d), and trans fat (to less than 1% of energy). (Level of Evidence: B)

g) Promoting daily physical activity and weight management are recommended. (Level of Evidence: B)"

"2. Treatment of triglycerides and non-HDL-C is useful, including the following:

a) If triglycerides are 200 to 499 mg per dL, non-HDL-C* should be less than 130 mg per dL. (Level of Evidence: B)

b) If triglycerides are greater than or equal to 500 mg per dL<, therapeutic options to prevent pancreatitis are fibrate† or niacin† before LDL-lowering therapy is recommended. It is also recommended that LDL-C be treated to goal after triglyceride-lowering therapy. Achievement of a non-HDL-C* less than 130 mg per dL (i.e., 30 mg per dL greater than LDL-C target) if possible is recommended. (Level of Evidence: C)"

Class IIa

"1. The following lipid management strategies can be beneficial:

a) Further reduction of LDL-C to less than 70 mg per dL is reasonable. (Level of Evidence: A)

b) If baseline LDL cholesterol is 70 to 100 mg per dL, it is reasonable to treat LDL-C to less than 70 mg per dL. (Level of Evidence: B)

c) Further reduction of non-HDL-C* to less than 100 mg per dL is reasonable; if triglycerides are 200 to 499 mg per dL, non-HDL-C target is less than 130 mg per dL. (Level of Evidence: B)

d) Therapeutic options to reduce non-HDL-C* (after LDL-C lowering) include niacin† or fibrate< therapy.

e) Nicotinic acid (niacin)† and fibric acid derivatives (fenofibrate, gemfibrozil)**< can be useful as therapeutic options (after LDL-C–lowering therapy) for HDL-C less than 40 mg per dL. (Level of Evidence: B)

f) Nicotinic acid (niacin)† and fibric acid derivatives (fenofibrate, gemfibrozil)**< can be useful as therapeutic options (after LDL-C–lowering therapy) for triglycerides greater than 200 mg per dL. (Level of Evidence: B)

g) The addition of plant stanol/sterols (2 g per d) and viscous fiber (more than 10 g per d) is reasonable to further lower LDL-C. (Level of Evidence: A)"

* Non-HDL-C = total cholesterol minus HDL-C.

^† The combination of high-dose statin plus fibrate can increase risk for severe myopathy. Statin doses should be kept relatively low with this combination. Dietary supplement niacin must not be used as a substitute for prescription niacin.

** Patients with very high triglycerides should not consume alcohol. The use of bile acid sequestrants is relatively contraindicated when triglycerides are greater than 200 mg per dL.

See Also

• The UA / NSTEMI Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines

Sources

• The ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction