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Contact:
Amy Murphy: ACC (202) 375-6476; amurphy@acc.org
Cathy Lewis: AHA (214) 706-1324; cathy.lewis@heart.org
UNDER EMBARGO UNTIL:
4 p.m. EDT, Monday
August 6, 2007
ACC/AHA Release Revised Guidelines for the Management
of Unstable Angina (UA) and Non-ST-Elevation Myocardial Infarction
(NSTEMI)
Several changes recommended regarding treatment
strategy, NSAIDs, hormone replacement therapy, anti-platelet
therapy after DES, use of ACE inhibitors, blood pressure and
lipid lowering
The American College of Cardiology and the American Heart
Association have jointly released revised Guidelines for the
Management of Patients with Unstable Angina (UA)/Non-ST- Elevation
Myocardial Infarction (NSTEMI). Major changes to the guidelines
include: suggesting an initial non-invasive set of preliminary
tests, such as a stress test, echocardiogram or radionuclide
angiogram; recommending the use of anti-platelet therapy clopidogrel
for at least one year after receiving a drug-eluting stent;
highlighting the importance of more intense lipid and blood
pressure control; and advising cessation of non-steroidal
anti-inflammatory drugs (NSAIDS) use for all UA/NSTEMI patients
during hospitalization.
Coronary artery disease (CAD) is the leading cause of death
in the United States, and UA and NSTEMI are acute manifestations
of this condition. In 2004, the National Center for Health
Statistics reported 669,000 hospitalizations for UA and 896,000
for myocardial infarction. Unstable angina, which causes chest
pain and discomfort, occurs when a coronary artery is partially
blocked. Myocardial infarction, or heart attack, occurs when
a coronary artery is completely blocked, cutting off blood
flow to the heart resulting in death of heart muscle.
The ability to detect and treat these conditions earlier
has greatly improved over the last several years. “New
evidence from pivotal trials over the past five years has
been gathered together in these guidelines to give physicians
up-to-date and detailed information on which treatment options
will provide the best possible outcomes for their patients,”
said Nanette K. Wenger, M.D., F.A.C.C., F.A.H.A., a member
of the guidelines writing committee and professor of medicine
in the Division of Cardiology at Emory University School of
Medicine in Atlanta. “This is a major educational document
for health professionals, and I trust it will become part
of the core teaching for medical students, residents and graduate
physicians.”
The guidelines, which were last published in 2002, have been
developed for cardiovascular specialists, emergency room physicians
and healthcare professionals who evaluate and treat patients
with acute coronary syndrome. They focus on the diagnosis,
treatment and management of patients with UA and the closely
related condition of NSTEMI.
The 2002 guidelines recommended an early invasive strategy
– diagnostic angiography and revascularization –
as the way to treat UA/NSTEMI patients. The revised guidelines
differentiate more extensively between high- and low-risk
UA/NSTEMI groups, and recommend an early invasive strategy
for unstable and high risk patients, with an initial conservative
(non-invasive) strategy – stress test, echocardiogram
or radionuclide study – as a possible treatment option
in stabilized UA/NSTEMI patients and low risk patients. Risk
status is determined by risk scores.
For clinical practitioners, the revised guidelines emphasize
secondary prevention, recommendations that should be continued
after the UA/NSTEMI patient is discharged from the hospital
to reduce risk of a recurrent heart attack. “We are
emphasizing the use of ACE inhibitors---drugs that protect
the muscle--- and prescribing aldosterone receptor blockade,
a new drug category that wasn’t available previously
for people with heart failure,” said Wenger. “High-dose
antioxidant vitamin supplements such as beta carotene, vitamins
E and C and folic acid for secondary prevention are no longer
recommended because results from clinical trials have shown
no benefit and possible harm.” There is also a greater
emphasis on smoking cessation.
Also new in the guidelines is the call for more intense lipid
and blood pressure control. More stringent LDL cholesterol-lowering
therapy and blood pressure management is recommended for UA/NSTEMI
patients. LDL (“bad” cholesterol) should be lower
than 100 mg/dL and ideally reduced to 70 mg/dL. Blood pressure
should be lower than 140/90 and for those with diabetes or
chronic kidney disease, a reading lower than 130/80 is recommended.
Because platelets are thought to play a key role in recurrent
heart attack, the anti-platelet therapy clopidogrel is now
recommended for at least one year after placement of a drug-eluting
stent and shorter term for bare metal stent and with medical
therapy. “In addition we are emphasizing the value of
intensive, long-term platelet therapy,” said Wenger.
Additional updates to the guidelines include recommendations
to discontinue the use of hormone replacement therapy in postmenopausal
women; add troponin biomarkers as markers of cardiac damage
and B-type natriuretic peptide (BNP) markers as potentially
useful for cardiac risk assessment; and stop the usage of
non-steroidal anti-inflammatory drugs (NSAIDS) for all UA/NSTEMI
patients during hospitalization.
Members of the writing committee include Jeffrey L. Anderson,
M.D., Chair; Cynthia D. Adams, R.N., Ph.D.; Elliott M. Antman,
M.D.; Charles R. Bridges, S.C.D., M.D.; Robert M. Califf,
M.D.; Donald E. Casey, Jr, M.D., M.P.H., M.B.A.; William E.
Chavey, II, M.D.; Francis M. Fesmire, M.D.; Judith S. Hochman,
M.D.; Thomas N. Levin, M.D.; A. Michael Lincoff, M.D.; Eric
D. Peterson, M.D., M.P.H.; Pierre Theroux, M.D.; Nanette Kass
Wenger, M.D. and R. Scott Wright, M.D.
Full text of the Guidelines will be published in the August
14, 2007 issues of the Journal of the American College
of Cardiology, and Circulation: Journal of the American
Heart Association, and will be posted ahead of print
on the ACC (www.acc.org)
and AHA (www.americanheart.org)
Web sites on August 6.
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About the American College of Cardiology (ACC):
The American College of Cardiology is leading the way to optimal
cardiovascular care and disease prevention. The College is
a 34,000-member nonprofit medical society and bestows the
credential Fellow of the American College of Cardiology upon
physicians who meet its stringent qualifications. The College
is a leader in the formulation of health policy, standards
and guidelines, and is a staunch supporter of cardiovascular
research. The ACC provides professional education and operates
national registries for the measurement and improvement of
quality care. For more information visit www.acc.org.
About the American Heart Association (AHA):
Founded in 1924, the American Heart Association today is the
nation’s oldest and largest voluntary health organization
dedicated to reducing disability and death from diseases of
the heart and stroke. These diseases, America’s No.
1 and No. 3 killers, and all other cardiovascular diseases
claim over 870,000 lives a year. In fiscal year 2005–06
the association invested over $543 million in research, professional
and public education, advocacy and community service programs
to help all Americans live longer, healthier lives. To learn
more, call 1-800-AHA-USA1 or visit americanheart.org.
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