The AHA Guidelines and Scientific Statements Handbook

The AHA Guidelines and Scientifi c Statements Handbook

Conservative Strategy

Initiate anticoagulant therapy (Class l, LOE: A):

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

or fondaparinux (Class l, LOE: B), but enoxaparin or

fondaparinux are preferable (Class IIa, LOE: B)

Select Management Strategy (see Table 2.2)

Any subsequent events necessitating angiography? (Recurrent symptoms/ischemia, heart failure,

serious arrhythmia)

Diagnosis of UA/NSTEMI is Likely or Definite

ASA (Class l, LOE: A)*

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

Initiate clopidogrel therapy (Class l, LOE: A)*

Consider adding IV eptifibatide or tirofiban (Class llb, LOE: B)*

Invasive Strategy

(Class l,

lOE: B)

(Class lla,

LOE: B)

(Class

l

LOE: B)

Stress

Test

O

(Class l, LOE: A)

Continue ASA indefinitely (Class I, LOE: A)*

Continue dopidogrel for at least 1 month (Class I, LOE: A)* and ideally up to 1 year (Class I, LOE: B)

Discontinue IV GP IIb/IIIa if started previously (Class I, LOE: A)

Discontinue anticoagulant therapy (Class I, LOE: A) (See recommendations in Section I.C3.b)

K

Not low

(Class I, LOE:A) Risk

(Class IIa, LOE: B)

E1 Low

Risk

E2

A

C1

C2

YesD

Evaluate LVEFL

EF 0.40 or

less

M

Diagnostic

Angiography

EF greaterN

than 0.40

NO

Class IIa

1 For UA/NSTEMI patients in whom an initial con-

servative strategy is selected and who have recurrent

ischemic discomfort with clopidogrel, ASA, and

anticoagulant therapy, it is reasonable to add a GP

IIb/IIIa antagonist before diagnostic angiography.

(Level of Evidence: C)

2 For UA/NSTEMI patents in whom an initial inva-

sive strategy is selected, it is reasonable to initiate

antiplatelet therapy with both clopidogrel (loading

dose plus maintenance dose) and an IV GP IIb/IIIa

inhibitor (Level of Evidence: B). Abceximab as the

choice for upstream GP IIb/IIIa therapy is indicated

only if there is no appreciable delay to angiography

and PCI is likely to be performed; otherwise IV

eptifi batide or tirofi ban is the preferred choice of a

GP IIb/IIIa inhibitor (Level of Evidence: B).

3 For UA/NSTEMI patients in whom an initial

invasive strategy is selected, it is reasonable to omit

upstream administration of an IV GP IIb/IIIa antag-

Fig. 2.9 Algorithm for patients with UA/NSTEMI managed by an initial conservative strategy.

• For dosing, see Figure 2.3 and full-text guidelines.