ACC/AHA 2007 guideline update for the

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ACC/AHA Guideline Revision 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 WRITING COMMITTEE MEMBERS Jeffrey L. Anderson, MD, FACC, FAHA, Chair; Cynthia D. Adams, RN, PhD, FAHA; Elliott M. Antman, MD, FACC, FAHA; Charles R. Bridges, ScD, MD, FACC, FAHA*; Robert M. Califf, MD, MACC; Donald E. Casey, Jr, MD, MPH, MBA, FACP†; William E. Chavey II, MD, MS‡; Francis M. Fesmire, MD, FACEP§; Judith S. Hochman, MD, FACC, FAHA; Thomas N. Levin, MD, FACC, FSCAI; A. Michael Lincoff, MD, FACC; Eric D. Peterson, MD, MPH, FACC, FAHA; Pierre Theroux, MD, FACC, FAHA; Nanette Kass Wenger, MD, FACC, FAHA; R. Scott Wright, MD, FACC, FAHA ACC/AHA TASK FORCE MEMBERS Sidney C. Smith, Jr, MD, FACC, FAHA, Chair; Alice K. Jacobs, MD, FACC, FAHA, Vice-Chair; Cynthia D. Adams, RN, PhD, FAHA; Jeffrey L. Anderson, MD, FACC, FAHA; Elliott M. Antman, MD, FACC, FAHA; Jonathan L. Halperin, MD, FACC, FAHA; Sharon A. Hunt, MD, FACC, FAHA; Harlan M. Krumholz, MD, FACC, FAHA; Frederick G. Kushner, MD, FACC, FAHA; Bruce W. Lytle, MD, FACC, FAHA; Rick Nishimura, MD, FACC, FAHA; Joseph P. Ornato, MD, FACC, FAHA#; Richard L. Page, MD, FACC, FAHA; Barbara Riegel, DNSC, RN, FAHA *Society of Thoracic Surgeons Representative. †American College of Physicians Representative. ‡American Academy of Family Physicians Representative. §American College of Emergency Physicians Representative. Society for Cardiovascular Angiography and Interventions Representative. Immediate Past Chair. #Former Task Force member during this writing effort. This document was approved by the American College of Cardiology Foundation Board of Trustees in June 2007 and by the American Heart Association Science Advisory and Coordinating Committee in June 2007. When this document is cited, the American College of Cardiology Foundation and the American Heart Association request that the following citation format be used: Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, Chavey WE II, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS. 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). Circulation. 2007;116:e148–e304. This article has been copublished online only in the August 14, 2007, issue of the Journal of the American College of Cardiology. Copies: This document is available on the World Wide Web sites of the American College of Cardiology (www.acc.org) and the American Heart Association (www.americanheart.org). To purchase Circulation reprints, call 843-216-2533 or e-mail kelle.ramsay@wolterskluwer.com. Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American College of Cardiology Foundation or the American Heart Association. Instructions for obtaining permission are located at http://www.americanheart.org/presenter.jhtml?identifier4431. A link to the “Permission Request Form” appears on the right side of the page. (Circulation. 2007;116:e148-e304.) © 2007 by the American College of Cardiology Foundation and the American Heart Association, Inc. Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIRCULATIONAHA.107.181940 Downloaded from circ.ahajournals.org e148 by on September 22, 2007
Preamble ......................................e150 1. Introduction ...............................e151 1.1. Organization of Committee and Evidence Review ...............................e151 1.2. Purpose of These Guidelines .............e153 1.3. Overview of the Acute Coronary Syndromes . . .e153 1.3.1. Definition of Terms ...............e153 1.3.2. Pathogenesis of UA/NSTEMI .......e155 1.3.3. Presentations of UA and NSTEMI . . .e156 1.4. Management Before UA/NSTEMI and Onset of UA/NSTEMI. .......................e156 1.4.1. Identification of Patients at Risk of UA/NSTEMI ....................e157 1.4.2. Interventions to Reduce Risk of UA/NSTEMI ....................e157 1.5. Onset of UA/NSTEMI ..................e158 1.5.1. Recognition of Symptoms by Patient. . .e158 1.5.2. Silent and Unrecognized Events .....e158 2. Initial Evaluation and Management ............e159 2.1. Clinical Assessment ....................e159 2.1.1. Emergency Department or Outpatient Facility Presentation. ..................e163 2.1.2. Questions to Be Addressed at the Initial Evaluation. ......................e163 2.2. Early Risk Stratification .................e163 2.2.1. Estimation of the Level of Risk .....e165 2.2.2. Rationale for Risk Stratification .....e165 2.2.3. History .........................e166 2.2.4. Anginal Symptoms and Anginal Equivalents ......................e166 2.2.5. Demographics and History in Diagnosis and Risk Stratification. ................e167 2.2.6. Estimation of Early Risk at Presentation .....................e168 2.2.6.1. Electrocardiogram .........e170 2.2.6.2. Physical Examination. ......e171 2.2.7. Noncardiac Causes of Symptoms and Secondary Causes of Myocardial Ischemia . . . .e171 2.2.8. Cardiac Biomarkers of Necrosis and the Redefinition of AMI ..............e172 2.2.8.1. Creatine Kinase-MB. .......e172 2.2.8.2. Cardiac Troponins .........e173 2.2.8.2.1. Clinical Use ......e173 2.2.8.2.1.1. Clinical Use of Marker Change Scores. . . .e175 2.2.8.2.1.2. Bedside Testing for Cardiac Markers . .e176 2.2.8.3. Myoglobin and CK-MB Subforms Compared With Troponins . .e176 2.2.8.4. Summary Comparison of Biomarkers of Necrosis: Singly and in Combination ..............e176 2.2.9. Other Markers and Multimarker Approaches ......................e176 2.2.9.1. Ischemia .................e176 2.2.9.2. Coagulation. ..............e177 2.2.9.3. Platelets. .................e177 2.2.9.4. Inflammation .............e177 2.2.9.5. B-Type Natriuretic Peptides .e178 Anderson et al ACC/AHA UA/NSTEMI Guideline Revision e149 TABLE OF CONTENTS Downloaded from circ.ahajournals.org by on September 22, 2007 2.3. Immediate Management .................e178 2.3.1. Chest Pain Units. .................e179 2.3.2. Discharge From ED or Chest Pain Unit . .e180 3. Early Hospital Care. ........................e181 3.1. Anti-Ischemic and Analgesic Therapy ......e182 3.1.1. General Care. ....................e185 3.1.2. Use of Anti-Ischemic Therapies .....e186 3.1.2.1. Nitrates ..................e186 3.1.2.2. Morphine Sulfate ..........e187 3.1.2.3. Beta-Adrenergic Blockers . . .e188 3.1.2.4. Calcium Channel Blockers . .e190 3.1.2.5. Inhibitors of the Renin-Angiotensin- Aldosterone System .........e191 3.1.2.6. Other Anti-Ischemic Therapies.e191 3.1.2.7. Intra-Aortic Balloon Pump Counterpulsation. ..........e192 3.1.2.8. Analgesic Therapy .........e192 3.2. Recommendations for Antiplatelet/Anticoagulant Therapy in Patients for Whom Diagnosis of UA/NSTEMI Is Likely or Definite ........e192 3.2.1. Antiplatelet Therapy Recommendations ................e192 3.2.2. Anticoagulant Therapy Recommendations ................e193 3.2.3. Additional Management Considerations for Antiplatelet and Anticoagulant Therapy . .e194 3.2.4. Antiplatelet Agents and Trials (Aspirin, Ticlopidine, Clopidogrel) ...........e196 3.2.4.1. Aspirin ..................e196 3.2.4.2. Adenosine Diphosphate Receptor Antagonists and Other Antiplatelet Agents. ..................e198 3.2.5. Anticoagulant Agents and Trials .....e202 3.2.5.1. Unfractionated Heparin .....e203 3.2.5.2. Low-Molecular-Weight Heparin ..................e204 3.2.5.3. LMWH Versus UFH .......e205 3.2.5.3.1. Extended Therapy With LMWHS ........e208 3.2.5.4. Direct Thrombin Inhibitors . .e208 3.2.5.5. Factor XA Inhibitors .......e211 3.2.5.6. Long-Term Anticoagulation. .e212 3.2.6. Platelet GP IIb/IIIa Receptor Antagonists ......................e213 3.2.7. Fibrinolysis ......................e219 3.3. Initial Conservative Versus Initial Invasive Strategies .............................e219 3.3.1. General Principles ................e219 3.3.2. Rationale for the Initial Conservative Strategy ........................e220 3.3.3. Rationale for the Invasive Strategy . . .e220 3.3.4. Immediate Angiography. ...........e220 3.3.5. Deferred Angiography .............e220 3.3.6. Comparison of Early Invasive and Initial Conservative Strategies ............e220 3.3.7. Subgroups .......................e224 3.3.8. Care Objectives ..................e224 3.4. Risk Stratification Before Discharge .......e226 3.4.1. Care Objectives ..................e227 3.4.2. Noninvasive Test Selection .........e228 3.4.3. Selection for Coronary Angiography . . .e229
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maximal effect in the absence of a
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assigned to abciximab and 1,010 to
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8, and 9). It is suggested that eac
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the dose reduction to once daily af
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Table 17. Continued Trial (Referenc
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Figure 12. SYNERGY Primary Outcomes
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with provisional GP IIb/IIIa inhibi
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0.004). In a small randomized pilot
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Table 18. UA/NSTEMI Outcome of Deat
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Figure 16. Kaplan-Meier Curves Show
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3.2.7. Fibrinolysis The failure of
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disadvantage was more than compensa
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to continue to receive dalteparin o
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agents and anticoagulant agents, ha
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TIMI III registry (199), as discuss
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show similar accuracy in dichotomiz
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Figure 20. Revascularization Strate
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1.4% of patients, and the death rat
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evascularization improved survival
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and patients who undergo uncomplica
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2. Angiotensin-converting enzyme in
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mounting evidence that statin thera
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c. The initial goal of weight loss
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the time of a cardiovascular event
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cardiac deaths but that it was stil
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(727). These include such caveats a
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similar early and late results as m
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group was similar to that of men (1
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did not significantly reduce in-hos
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define the area of ischemia in post
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from intervention, but given the ab
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CLASS IIb Administration of combine
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nature of periodic angina. The spas
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chest pain that simulates UA second
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Late thrombosis of DES (400,402,403
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APPENDIX 1. Continued Committee Mem
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APPENDIX 1. Continued Committee Mem
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APPENDIX 2. RELATIONSHIPS WITH INDU
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APPENDIX 2. Continued Peer Reviewer
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APPENDIX 2. Continued Peer Reviewer
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APPENDIX 3. Continued Anderson et a
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eases. American Heart Association S
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103. Braunwald E, Antman EM, Beasle
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phy, mitral annular calcium, and ao
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256. Sallach SM, Nowak R, Hudson MP
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337. Hansen JF, Tingsted L, Rasmuss
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damage after elective stent implant
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484. Petersen JL, Mahaffey KW, Hass
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555. Eagle KA, Guyton RA, Davidoff
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630. The Veterans Administration Co
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ADverse outcomes with Early impleme
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the Spanish Multicentre Trial of tr
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868. Togna G, Tempesta E, Togna AR,
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