Latest Clinical Practice Guidelines Recommend Early Angiography and Revascularization for NSTE-ACS Patients

January 6, 2016

what-new-clinical-practice-guidelines-are-recommended-for-the-management-of-patients-with-non-st-elevation-acute-coronary-syndromes-300x201The latest update of clinical practice guidelines for the management of patients with non-ST-elevation acute coronary syndromes (NSTE-ACS) by Amsterdam et al. entitled “2014 AHA/ACC Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines” was published in Circulation in 2014 [vol 130, pages e344-e426].

The 2014 NSTE-ACS Clinical Practice Guideline is a full revision of the 2007 ACCF/AHA Clinical Practice Guideline for the management of unstable angina (UA) and non-ST-elevation myocardial infarction (NSTEMI).

The authors explain “NSTE-ACS commonly presents as a pressure type chest pain that typically occurs at rest or with minimal exertion lasting at least 10 minutes.” The guideline reviews the standard of care for patients with NSTE-ACS from initial presentation to evaluation, diagnosis, assessment of risk, and management of all levels of disease.

Why were the new Clinical Practice Guidelines developed?

The new clinical care guidelines were developed to provide optimal management for patients with NSTEMI. These guidelines were developed to advise clinicians about the newest management practices for patients with NSTEMI-ACS. They are a combination of approved drug and device-based therapeutics as well as lifestyle modifications.

How were the new Clinical Practice Guidelines developed?

A guideline writing committee reviewed the literature from October 2012 through April 2014 to determine if present recommendations should be updated or modified developed the guidelines.

The guideline writing committee was composed of clinicians, internists, interventionists, surgeons, emergency medicine specialists, family practitioners, and geriatricians. Members of the ACC and AHA, American Academy of Family Physicians, American College of Emergency Physicians, American College of Physicians, Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons also participated in this process.

What does this mean clinically?

UA and NSTEMI are related conditions with acute myocardial ischemia and/or infarction due to a sudden decrease in coronary blood flow. If ST-elevation is not present, NSTEMI is suggested. If cardiac biomarkers are elevated or show an elevated pattern of response, the patient is likely to have NSTEMI; if not, the patient’s condition is probably UA. The distinguishing difference between UA and NSTEMI is “if the ischemia is severe enough to cause myocardial damage leading to detectable quantities of myocardial injury biomarkers.” Cardiac troponin I or T are markers of myocardial necrosis.

Cardiac troponin levels rise a few hours after symptoms begin and remain elevated for several days. To assess myocardial infarction, measurement of cardiac troponin I or T is recommended at presentation and within 3 to 6 hours after symptoms begin. The authors note that “myocardial infarction is indicated by a rising or falling pattern of troponin levels.”

Treatment for NSTE-ACS follows one of two strategies: invasive (coronary angiography) or ischemia, as suggested by the algorithm presented in the paper (Figure 3). Diagnostic angiography with intent to perform revascularization is recommended for NSTE-ACS patients with refractory angina, hemodynamic instability, electrical instability, or for patients with an elevated risk of clinical events. For high risk patients with NSTE-ACS, the clinical practice guidelines recommend early coronary angiography. Coronary angiography and revascularization are also recommended for patients 75 years of age or older.

PCI is often performed in patients with NSTE-ACS, particularly UA or NSTEMI. Early angiography and revascularization are associated with fewer reports of recurrent UA, hospitalization, myocardial infarction, and death.

Next Steps:

  1. Read an executive summary of the updated guideline by Amsterdam et al (2014)
  2. Read an the updated guideline by Amsterdam et al (2014)
  3. Read the original 2011 PCI Clinical Practice Guidelines by Levine et al (2011)
  4. Learn more about the Clinical Guidelines and Protected PCI
  5. Learn more about Patient Identification and Protected PCI
  6. Learn more about the use of Impella 2.5 for PCI

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