ACC/AHA Unveil New Guideline for Treating Non-ST-Elevation Acute Coronary Syndromes

The new ACC/AHA 2014 Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes  (NSTE-ACS) released on Sept. 23 has a new name and new terminology that reflect current ways of thinking about this frequent and serious cardiac condition. The guideline is the first full revision since the 2007 ACC/AHA Guideline or the Management of Patients with Unstable Angina and Non–ST-Elevation Myocardial Infarction (NSTEMI) and subsequent focused updates.

According to Writing Committee Chair Ezra A. Amsterdam, MD, FACC, the new guideline title emphasizes the pathophysiologic continuum of unstable angina and NSTEMI and their frequently indistinguishable clinical presentations. Another significant change is the replacement of the term “initial conservative management” with “ischemia-guided strategy” to more clearly convey the physiologic rationale of this approach.

In terms of treatment, another notable element of the new guideline, is the recognition that while an early invasive strategy for patients with NSTE-ACS with significant coronary artery disease is generally accepted, low-risk patients can substantially benefit from guideline-directed medical therapy. “Guideline-directed medical therapy has not always been optimally utilized and advances in noninvasive testing have the potential to identify patients with NSTE-ACS at low-intermediate risk to distinguish candidates for invasive versus medical therapy,” Amsterdam said.

In addition, the guideline recognizes important, developing clinical areas requiring further research such as the utility of combined, potent antithrombotic and anticoagulant therapy in certain patient groups, appropriate application of new, high-sensitivity troponins, and the proper selection of high-risk elderly patients and women for interventional therapy. According to Nanette K. Wenger, MD, MACC, vice chair of the writing committee, the guideline also contains expanded recommendations regarding discharge, such as education about symptoms, risk modification, routine medication with dual antiplatelet therapy, cholesterol management, referral to cardiac rehabilitation, and other guideline-directed medical therapy.

"The hospitalization period involves crisis management of ACS, which is pivotal to successful patient outcomes during the acute phase of disease.  However, discharge planning in addition to patient and family education guide the long-term ambulatory care of the patient who has sustained a NSTE-ACS,” Wenger notes.

The document—a contemporary clinical practice approach for the optimal management of patients with NSTE-ACS—incorporates both established and new evidence from published clinical trials (presented in evidence summary tables), as well as information from basic science and comprehensive review articles. In addition, the guideline represents the cooperative efforts of experts from a variety of clinical and basic science fields dedicated to enhancing care of patients with NSTE-ACS, including cardiology, cardiac surgery, internal medicine, emergency medicine, pharmacology, clinical chemistry, and others.

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