ACC/AHA 2007 guideline update for the

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e184 Circulation August 14, 2007 Table 13. Dosing Table for Antiplatelet and Anticoagulant Therapy in Patients With UA/NSTEMI Drug* Initial Medical Treatment Aspirin 162 to 325 mg nonenteric formulation, orally or chewed Clopidogrel LD of 300 to 600 mg orally MD of 75 mg orally per day Ticlopidine LD of 500 mg orally MD of 250 mg orally twice daily Bivalirudin 0.1 mg per kg bolus, 0.25 mg per kg per h infusion Dalteparin 120 IU per kg SC every 12 h (maximum 10,000 IU twice daily)‡ Enoxaparin LD of 30 mg IV bolus may be given MD 1 mg per kg SC every 12 h; extend dosing interval to 1 mg per kg every 24 h if estimated creatinine clearance less than 30 mL per min Fondaparinux 2.5 mg SC once daily. Avoid for creatinine clearance less than 30 mL per min Unfractionated heparin LD of 60 U per kg (max 4,000 U) as IV bolus MD of IV infusion of 12 U per kg per h (max 1,000 U per h) to maintain aPTT at 1.5 to 2.0 times control (approximately 50 to 70 s) Patient Received Initial Medical Treatment During PCI Patient Did Not Receive Initial Medical Treatment Oral Antiplatelet Therapy No additional treatment 162 to 325 mg nonenteric formulation orally or chewed A second LD of 300 mg orally may be given to supplement a prior LD of 300 mg LD of 300 to 600 mg orally After PCI At Hospital Discharge 162 to 325 mg daily should be given† for at least 1 month after BMS implantation, 3 months after SES implantation, and 6 months after PES implantation, after which daily chronic aspirin should be continued indefinitely at a dose of 75 to 162 mg For BMS: 75 mg daily for at least 1 month and ideally up to 1 year. For DES, 75 mg daily for at least 1 year (in patients who are not at high risk of bleeding) (See Fig. 11) No additional treatment LD of 500 mg orally Anticoagulants MD of 250 mg orally twice daily (duration same as clopidogrel) 0.5 mg per kg bolus, increase infusion to 1.75 mg per kg per h IV GP IIb/IIIa planned: target ACT 200 s using UFH No IV GP IIb/IIIa planned: target ACT 250 to 300 s for HemoTec; 300 to 350 s for Hemochron using UFH Last SC dose less than 8 h: no additional therapy Last SC dose greater than 8 h: 0.3 mg per kg IV bolus 50 to 60 U per kg IV bolus of UFH is recommended by the OASIS 5 Investigators IV GP IIb/IIIa planned: target ACT 200 s No IV GP IIb/IIIa planned: target ACT 250 to 300 s for HemoTec; 300 to 350 s for Hemochron 0.75 mg per kg bolus, 1.75 mg per kg per h infusion IV GP IIb/IIIa planned: 60 to 70 U per kg§ of UFH No IV GP IIb/IIIa planned: 100 to 140 U per kg of UFH 0.5 to 0.75 mg per kg IV bolus 50 to 60 U per kg IV bolus of UFH is recommended by the OASIS 5 Investigators IV GP IIb/IIIa planned: 60 to 70 U per kg§ No IV GP IIb/IIIa planned: 100 to 140 U per kg No additional treatment or continue infusion for up to4h No additional treatment No additional treatment No additional treatment No additional treatment Downloaded from circ.ahajournals.org by on September 22, 2007 162 to 325 mg daily should be given† for at least 1 month after BMS implantation, 3 months after SES implantation, and 6 months after PES implantation, after which daily chronic aspirin should be continued indefinitely at a dose of 75 to 162 mg For BMS: 75 mg daily for at least 1 month and ideally up to 1 year. For DES, 75 mg daily for at least 1 year (in patients who are not at high risk of bleeding) (See Fig. 11) MD of 250 mg orally twice daily (duration same as clopidogrel) Continued on next page
Table 13. Continued Patient Received Initial Medical Treatment During PCI to invasive cardiovascular diagnosis and therapeutic procedures. Ready access is defined as ensured, timely access to a cardiac catheterization laboratory with personnel who have appropriate credentials and experience in invasive coronary procedures, as well as to emergency or urgent cardiovascular surgery and cardiac anesthesia (2,300). The approach to the achievement of the twin goals described here includes the initiation of pharmacological management and planning of a definitive treatment strategy for the underlying disease process. Most patients are stable at presentation or stabilize after a brief period of intensive Anderson et al ACC/AHA UA/NSTEMI Guideline Revision e185 Patient Did Not Receive Initial Medical Treatment Drug* Initial Medical Treatment Intravenous Antiplatelet Therapy Abciximab Not applicable Not applicable LD of 0.25 mg per kg Continue MD infusion for IV bolus MD of 0.125 mcg per kg per min (max 10 mcg per min) 12 h Eptifibatide LD of IV bolus of 180 mcg Continue infusion LD of IV bolus of 180 Continue MD infusion for per kg mcg per kg 18 to 24 h MD of IV infusion of 2.0 followed 10 min mcg per kg per min; later by second IV reduce infusion by 50% bolus of 180 mcg in patients with per kg estimated creatinine MD of 2.0 mcg per clearance less than 50 kg per min; reduce mL per min infusion by 50% in patients with estimated creatinine clearance less than 50 mL per min Tirofiban LD of IV infusion of 0.4 Continue infusion LD of IV infusion of Continue MD infusion for mcg per kg per min for 0.4 mcg per kg 18 to 24 h 30 min per min for 30 MD of IV infusion of 0.1 min mcg per kg per min; MD of IV infusion of reduce rate of infusion 0.1 mcg per kg by 50% in patients with per min; reduce estimated creatinine rate of infusion by clearance less than 30 50% in patients mL per min with estimated creatinine clearance less than 30 mL per min After PCI At Hospital Discharge Additional considerations include the possibility that a conservatively managed patient may develop a need for PCI, in which case an intravenous bolus of 50 to 60 U per kg is recommended if fondaparinux was given for initial medical treatment; the safety of this drug combination is not well established. For conservatively managed patients in whom enoxaparin was the initial medical treatment, as noted in the table, additional intravenous enoxaparin is an acceptable option. *This list is in alphabetical order and is not meant to indicate a particular therapy preference. †In patients in whom the physician is concerned about the risk of bleeding, a lower initial ASA dose after PCI of 75 to 162 mg/d is reasonable (Class IIa, LOE: C). ‡Dalteparin was evaluated for management of patients with UA/NSTEMI in an era before the widespread use of important therapies such as stents, clopidogrel, and GP IIb/IIIa inhibitors. Its relative efficacy and safety in the contemporary management era is not well established. §Some operators use less than 60 U per kg of UFH with GP IIb/IIIa blockade, although no clinical trial data exist to demonstrate the efficacy of doses below 60 U per kg in this setting. For patients managed by an initial conservative strategy, agents such as enoxaparin and fondaparinux offer the convenience advantage of SC administration compared with an intravenous infusion of UFH. They are also less likely to provoke heparin-induced thrombocytopenia than UFH. Available data suggest fondaparinux is associated with less bleeding than enoxaparin in conservatively managed patients using the regimens listed. Personal communication, OASIS 5 Investigators, July 7, 2006. Note that this regimen has not been rigorously tested in prospective randomized trials. ACT activated clotting time; BMS bare-metal stent; GP glycoprotein; h hour; IU international unit; IV intravenous; LD loading dose; MD maintenance dose; PCI percutaneous coronary intervention; PES paclitaxel-eluting stent; SC subcutaneous; SES sirolimus-eluting stent; U units; UA/NSTEMI unstable angina/non–ST-elevation myocardial infarction; UFH unfractionated heparin. Downloaded from circ.ahajournals.org by on September 22, 2007 pharmacological management and, after appropriate counseling, will be able to participate in the choice of an approach for definitive therapy (see Section 3.3 for a full discussion of conservative vs. invasive strategy selection). A few patients will require prompt triage to emergency or urgent cardiac catheterization and/or the placement of an IABP. 3.1.1. General Care The severity of symptoms dictates some of the general care that should be given during the initial treatment. Patients should be placed on bed rest while ischemia is ongoing but
Page 1 and 2: ACC/AHA 2007 Guidelines for the Man
Page 3 and 4: Preamble ..........................
Page 5 and 6: outcomes where data exist. Patient-
Page 7 and 8: 1.2. Purpose of These Guidelines Th
Page 9 and 10: and angioscopic studies suggest tha
Page 11 and 12: cation of those risk factors can pr
Page 13 and 14: first to show that as many as half
Page 15 and 16: ment for the level of care needed b
Page 17 and 18: of use of these medications and the
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Page 35 and 36: typically done in the same sitting.
Page 37: CLASS IIa 1. It is reasonable to ad
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Page 45 and 46: mortality rates. Retrospective anal
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Page 53 and 54: maximal effect in the absence of a
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Page 73 and 74: 3.2.7. Fibrinolysis The failure of
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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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