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WASHINGTON (Sept. 23, 2014)—An updated guideline on the management of patients with non-ST-elevation acute coronary syndromes (NSTE-ACS) has a new name and new terminology that reflect current ways of thinking about this frequent and serious cardiac condition.
Released today by the American College of Cardiology and the American Heart Association, the 2014 Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes, 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 focused updates published in 2013. The new title emphasizes the pathophysiologic continuum of unstable angina and NSTEMI and their frequently indistinguishable clinical presentations. “It’s therefore reasonable that they be considered together in the guideline,” said writing committee chair Ezra A. Amsterdam, MD, FACC. He emphasized that 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.
Another significant change in the guideline is replacing the term “initial conservative management” with “ischemia-guided strategy” to more clearly convey the physiologic rationale of this approach, said Amsterdam, who is Distinguished Professor, Internal Medicine, Associate Chief of Cardiology for Academic Affairs, and Master Clinician Educator at the University of California (Davis) School of Medicine in Sacramento.
Regarding treatment, the guideline states 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.
“This is an important area of current research—as it is often more challenging to treat elderly patients because they frequently have multiple comorbidities,” Amsterdam said.
According to Nanette K. Wenger, MD, MACC, MACP, FAHA, vice chair of the writing committee, the guideline 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,” said Dr. Wenger, a Professor of Medicine (Cardiology) Emeritus, Emory University School of Medicine Consultant, Emory Heart and Vascular Center, Atlanta.
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.
According to Dr. Amsterdam, “There have been tremendous advances in the diagnosis and management of NSTE-ACS since the last guideline. We attempted to improve the utility of the guidelines with a focused method that eliminated repetition of ancillary information.” Although still an extensive and comprehensive document, it is now more direct and succinct.
While the document aims to guide clinicians, it is not intended to replace their individual judgment in treating their patients. “The science of medicine is founded on evidence; the art of medicine is based on optimal application of that evidence to the individual patient,” Dr. Amsterdam said.
A goal of the writing committee was to make the document user friendly. “Readers are aided by tables and algorithms which present diagnostic and management approaches in a concise manner,” Dr. Amsterdam said.
The Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes will be published online today on the websites of the American College of Cardiology (www.cardiosource.org) and the American Heart Association (www.heart.org).
The work of the writing committee was supported exclusively by the ACC and AHA, without commercial support.
About the American College of Cardiology
The mission of the American College of Cardiology is to transform cardiovascular care and improve heart health. The College is a 47,000-member medical society comprised of physicians, surgeons, nurses, physician assistants, pharmacists and practice managers. The College is a leader in the formulation of health policy, standards and guidelines. The ACC provides professional education, operates national registries to measure and improve quality of care, disseminates cardiovascular research, and bestows credentials upon cardiovascular specialists who meet stringent qualifications. For more information, visit www.cardiosource.org.
About the American Heart Association
The American Heart Association is devoted to saving people from heart disease and stroke – America’s No. 1 and No. 4 killers. We team with millions of volunteers to fund innovative research, fight for stronger public health policies, and provide lifesaving tools and information to prevent and treat these diseases. The Dallas-based association is the nation’s oldest and largest voluntary organization dedicated to fighting heart disease and stroke. To learn more or to get involved, call 1-800-AHA-USA1, visit heart.org or call any of our offices around the country. Follow us on Facebook and Twitter.