Unstable angina non ST elevation myocardial infarction additional management considerations for antiplatelet and anticoagulant therapy
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Overview of Additional Management Considerations for Antiplatelet and Anticoagulant Therapy in UA / NSTEMI
ACC / AHA Guidelines (DO NOT EDIT) [1]
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Class I1. 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).
2. For UA / NSTEMI patients in whom CABG is 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) 4. For UA / NSTEMI patients in whom PCI has been selected as a postangiography management strategy, the instructions noted below should be followed:
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:
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:
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 IIa1. 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 IIb1. 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 III1. 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) |
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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
- ↑ 1.0 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
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