ACC/AHA 2007 guideline update for the

e194 Circulation August 14, 2007
Figure 8. Algorithm for Patients With UA/NSTEMI Managed by an Initial Conservative Strategy
When multiple drugs are listed, they are in alphabetical order and not in order of preference (e.g., Boxes C1 and C2). *See dosing Table 13. †See Table 11 for selection of
management strategy. ‡Recurrent symptoms/ischemia, heart failure, serious arrhythmia. ASA aspirin; EF ejection fraction; GP glycoprotein; IV intravenous; LOE
level of evidence; LVEF left ventricular ejection fraction; UA/NSTEMI unstable angina/non–ST-elevation myocardial infarction; UFH unfractionated heparin.
3.2.3. Additional Management Considerations for
Antiplatelet and Anticoagulant Therapy
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, HF, or
serious arrhythmias), a stress test should be performed. (Level of
Evidence: B) (Fig. 8; Box O)
a. If, after stress testing, the patient is classified as not at low risk,
diagnostic angiography should be performed. (Level of Evidence:
A) (Fig. 8; Box E1)
b. If, after stress testing, the patient is classified as being at low
risk (Fig. 8; Box E2), the instructions noted below should be
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followed in preparation for discharge (Fig. 8; Box K) (Level of
Evidence: A):
1. Continue ASA indefinitely. (Level of Evidence: A)
2. Continue clopidogrel for at least 1 month (Level of Evidence:
A) and ideally up to 1 year. (Level of Evidence: B)
3. Discontinue intravenous GP IIb/IIIa inhibitor if started previously.
(Level of Evidence: A)
4. 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)
2. For UA/NSTEMI patients in whom CABG is selected as a postangiography
management strategy, the instructions noted below
should be followed (Fig. 9; Box G).