2012 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction (Updating the 2007 Guideline and Replacing the 2011 Focused Update): A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines

Perspective:

The following are 10 points to remember about this guideline update:

1. Aspirin should be administered to unstable angina (UA)/non–ST-segment elevation myocardial infarction (NSTEMI) patients as soon as possible after hospital presentation and continued indefinitely in patients who tolerate it.

2. A loading dose of P2Y12 receptor inhibitor therapy is recommended for UA/NSTEMI patients for whom percutaneous coronary intervention (PCI) is planned.

3. Prasugrel should not be administered routinely to patients with UA/NSTEMI before angiography, such as in an emergency department, or used in patients with UA/NSTEMI who have not undergone PCI.

4. Patients with definite UA/NSTEMI at medium or high risk and in whom an initial invasive strategy is selected should receive dual antiplatelet therapy on presentation. Either clopidogrel or ticagrelor can be used before PCI, while clopidogrel, prasugrel, or ticagrelor are options at the time of PCI. For UA/NSTEMI patients in whom an initial conservative strategy is selected, clopidogrel or ticagrelor (loading dose followed by daily maintenance dose) should be added to aspirin and anticoagulant therapy as soon as possible after admission and administered for up to 12 months.

5. In patients taking a P2Y12 receptor inhibitor in whom coronary artery bypass grafting (CABG) is planned and can be delayed, it is recommended that the drug be discontinued to allow for dissipation of the antiplatelet effect. The period of withdrawal should be at least 5 days in patients receiving clopidogrel or ticagrelor and at least 7 days in patients receiving prasugrel unless the need for revascularization and/or the net benefit of the P2Y12 receptor inhibitor therapy outweighs the potential risks of excess bleeding.

6. An early invasive strategy (i.e., diagnostic angiography with intent to perform revascularization) is indicated in UA/NSTEMI patients who have refractory angina or hemodynamic or electrical instability (without serious comorbidities or contraindications to such procedures).

7. For UA/NSTEMI patients in whom an initial conservative strategy is selected, if recurrent symptoms/ischemia, heart failure, or serious arrhythmias subsequently appear, then diagnostic angiography should be performed.

8. Use of warfarin in conjunction with aspirin and/or P2Y12 receptor inhibitor therapy is associated with an increased risk of bleeding, and patients and clinicians should watch for bleeding, especially gastrointestinal, and seek medical evaluation for evidence of bleeding.

9. Creatinine clearance should be estimated in UA/NSTEMI patients and the doses of renally cleared medications should be adjusted according to the pharmacokinetic data for specific medications.

10. The development of regional systems of UA/NSTEMI care is a matter of utmost importance. This includes encouraging the participation of key stakeholders in collaborative efforts to evaluate care using standardized performance and quality-improvement measures, such as those endorsed by the American College of Cardiology and the American Heart Association for UA/NSTEMI.

Clinical Topics: Anticoagulation Management, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Aortic Surgery, Cardiac Surgery and Heart Failure, Acute Heart Failure

Keywords: Myocardial Infarction, Warfarin, Heart Failure, Creatinine, Coronary Artery Bypass, Percutaneous Coronary Intervention


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