The American College of Cardiology/American Heart Association released a focused update this week to their guidelines on management of unstable angina (UA) and non-ST-elevation myocardial infarction (NSTEMI). The guidelines were originally issued in 2007.
For this update, the guideline writing committee examined areas of new research: the timing of acute interventional therapy in patients with NSTEMI; the timing, duration and application of dual-antiplatelet therapy and triple-antiplatelet therapy in high-risk patients and dual-antiplatelet therapy in low- and moderate-risk patients; the role of invasive therapies in patients with advanced renal dysfunction; and the effect of participation in a quality-of-care data registry for UA/NSTEMI on quality improvement for acute coronary syndromes.
New recommendations in the focused update include the following:
- Patients with UA/NSTEMI for whom percutaneous coronary intervention (PCI) is planned should receive a loading dose of a thienopyridine.
- Clopidogrel, 75 mg/d, or prasugrel, 10 mg/d, should be given for at least a year after PCI, unless the risk of bleeding outweighs the potential benefits.
- In patients with UA/NSTEMI who are planning to have PCI and have a history of stroke or transient ischemic attack, prasugrel may be harmful if used as dual-antiplatelet therapy.
- Platelet function testing may be considered in patients with UA/NSTEMI receiving thienopyridine therapy to evaluate platelet inhibitory response if the results of such testing might change management.
- An early invasive treatment strategy (within 12 to 24 hours of hospital admission) is considered reasonable in stabilized high-risk patients with UA/NSTEMI. A delayed invasive approach is considered reasonable for patients who are not at high risk.
- Continuing clopidogrel or prasugrel beyond 15 months after placement of a drug-eluting stent may be considered.
- Patients with chronic kidney disease who are having cardiac catheterization with contrast media should receive adequate hydration beforehand.
- Clinicians and hospitals caring for patients with UA/NSTEMI may reasonably participate in a standardized quality-of-care data registry to track and measure outcomes, complications and adherence to evidence-based care.