The AHA Guidelines and Scientific Statements Handbook

Unstable Angina/Non-ST-Elevation

Myocardial Infarction

Jeffrey L. Anderson and Nanette Kass Wenger

2

Overview of recommendations for management of
patients with UA/NSTEMI
Initial evaluation and management
a. Clinical assessment
b. Early risk stratifi cation
c. Immediate management
Early hospital care
a. Anti-ischemic and analgesic therapy
b. Antiplatelet/anticoagulant therapy in patients for
whom diagnosis of UA/NSTEMI is likely or
defi nite
I. Antiplatelet therapy
II. Anticoagulant therapy
III. Additional management consideration
c. Initial conservative versus initial invasive strategies
Risk stratifi cation before discharge
Revascularization with PCI and CABG in patients with
UA/NSTEMI
a. Percutaneous coronary intervention
b. CABG
Late hospital care, hospital discharge, and post-hospital
discharge care
a. Medical regimen and use of medications
b. Long-term medical therapy and secondary
prevention
I. Antiplatelet therapy
II. Beta-blockers
III. Inhibition of the renin–angiotensin–
aldosterone system
IV. Nitroglycerin
V. Calcium channel blockers
VI. Lipid management

VII. Blood pressure control

VIII. Diabetes mellitus

IX. Smoking cessation

X. Weight management

XI. Physical activity

XII. Depression

b. Cardiac rehabilitation

c. Special groups: older adults

d. Special groups: chronic kidney disease

Comparison of ESC with ACC/AHA approach

Future directions

Overview of recommendations for

management of patients with UA/NSTEMI

The ACC/AHA 2007 Guidelines for the Manage-

ment of Patients with UA/NSTEMI place emphasis

on early access to medical evaluation and initial risk

assessment (see Table 2.1) [1]. New imaging modal-

ities (coronary computed tomographic [CT] angi-

ography and cardiac magnetic resonance imaging)

are now recognized as diagnostic options in selected

patients [2]. Troponins are highlighted as the domi-

nant cardiac biomarker of necrosis (Figures 2.1,

2.2). B-type natriuretic peptides have been added to

the list of biomarkers potentially useful in risk

assessment [3]. Supplemental posterior ECG leads

V7–V9 are noted to be a reasonable diagnostic tool

to rule out MI caused by left circumfl ex occlusion

[4].

Updated clinical trials data continue overall to

support an initial invasive strategy for higher-risk

and clinically unstable UA/NSTEMI patients (see

Table 2.2) [5]; nevertheless, at least one trial (ICTUS)

[6] suggested that an initial conservative (selective

invasive) strategy may be considered in initially sta-

bilized patients who have an elevated risk of clinical

The AHA Guidelines and Scientific Statements Handbook
Edited by Valentin Fuster © 2009 American Heart Association
ISBN: 978 -1-405-18463-2