The AHA Guidelines and Scientific Statements Handbook

Chapter 2 Unstable Angina/Non-ST-Elevation Myocardial Infarction

3 In UA/NSTEMI patients with a history of gastro-
intestinal bleeding, when ASA and clopidogrel are
administered alone or in combination, drugs to
minimize the risk of recurrent gastrointestinal
bleeding (e.g., proton-pump inhibitors) should be
prescribed concomitantly. (Level of Evidence: B)
4 For UA/NSTEMI patients in whom an initial invasive
strategy is selected, antiplatelet therapy in addition to
aspirin should be initiated before diagnostic angiography
(upstream) with either clopidogrel (loading dose followed
by daily maintenance dose) or an IV GP IIb/IIIa inhibitor
(Level of Evidence: A) Abciximab as the choice for upstream
GP IIb/IIIa therapy is indicated only if there is no appre-
ciable delay to angiography and PCI is likely to be per-
formed; otherwise, IV eptifi batide or tirofi ban is the
preferred GP IIb/IIIa inhibitor. (Level of Evidence: B).
5 For UA/NSTEMI patients in whom an initial con-
servative (i.e., noninvasive) strategy is selected,

clopidogrel (loading dose followed by daily mainte-

nance dose) should be added to ASA and anticoagu-

lant therapy as soon as possible after admission and

administered for at least 1 month (Level of Evidence:

A) and ideally up to 1 year (Level of Evidence: B)

(Figure 2.9; Box C2).

6 For UA/NSTEMI patients in whom an initial

conservative strategy is selected, if recurrent

symptoms/ischemia, HF, or serious arrhythmias

subsequently appear, diagnostic angiography should

be performed (Level of Evidence: A) (Figure 2.9;

Box D). Either an IV GP IIb/IIIa inhibitor

(eptifi batide or tirofi ban; Level of Evidence: A) or

clopidogrel (loading dose followed by daily

maintenance dose; Level of Evidence: A) should be

added to ASA and antico-agulant therapy before

diagnostic angiography (upstream). (Level of

Evidence: C)

Fig. 2.8 Algorithm for patients with UA/NSTEMI managed by an initial invasive strategy.

• For dosing, see Figure 2.3 and full-text guidelines.
  ‡ GP IIb/IIIa inhibitors may not be necessary if patient received a preloading dose of at least 300 mg clopidogrel at least 6 h earlier
  (Class I, LOE: B for clopidogrel administration) and bivalirudin was selected as the anticoagulant (Class IIa, LOE: B).

B1

A

Invasive Strategy

Initiate anticoagulant therapy (Class l, LOE: A)

Acceptable options: enoxaparin or UFH (Class l, LOE: A)

bivalirudin or fondaparinux (Class I, LOE:B)

Select Management Strategy (see Table 2.2)

Diagnosis of UA/NSTEMI is Likely or Definite

ASA (Class l, LOE: A)*

Clopidogrel if ASA intolerant (Class l, LOE: A)

Prior to Angiography B2

Initiate at least one (Class I, LOE:A) or

both (Class lla, LOE B) of the following:

Clopidogrel*‡

IV GP llb/llIa inhibitor*‡

Factors favoring administration of both clopidogrel and

GP IIb/IIIa inhibitor include:

Delay to Anglography

High Risk Features

Early recurrent ischemic discomfort

Diagnostic Angiography

Initial

Conservative Strategy