On July 16, the ACC Foundation (ACCF) and the American Heart Association (AHA) released a focused update of the guideline for the management of patients with unstable angina (UA)/non-ST-elevation myocardial infarction (NSTEMI).

The document, which addresses recent research and approvals of new drugs like ticagrelor, updates sections of the original 2007 guideline and replaces the 2011 Focused Update. While the updated guideline continues to recommend that all patients receive aspirin immediately after hospitalization, and continue as long as it is tolerated, other key recommendations include:

 

All patients with unstable angina or non-ST-elevation myocardial infarction at medium or high-risk should receive dual antiplatelet medications on admission.  After PCI, it is reasonable to use 81 mg per day of aspirin in preference to higher maintenance doses. In hospitalized patients with unstable angina or non-ST-elevation myocardial infarction, it is reasonable to use an insulin-based regimen to achieve and maintain glucose levels <180 mg/dL while avoiding hypoglycemia. An invasive strategy is reasonable in patients with mild (stage 2) and moderate (stage 3) CKD. Insufficient data on the benefits and risks of invasive strategy in patients with unstable angina or non-ST-elevation myocardial infarction with more advanced (stages 4 and 5) CKD. It is reasonable to proceed with cardiac catheterization and possible revascularization within 12 to 24 hours of admission in initially stabilized high-risk patients with unstable angina or non-ST-elevation myocardial infarction. Platelet function testing or genotyping testing for CYP2C19 loss of function allele may be considered in select patients with unstable angina or non-ST-elevation myocardial infarction who are using P2Y12 receptor inhibitors and when the results of testing may alter management.

Additional Resources 2012 ACCF/AHA Focused Update Journal Scan: Ten Points to Remember  2011 ACCF/AHA Focused Update to the 2007 Guideline PLATO Clinical Trial Summary  TRITON-TIMI 38 Trial Summary  Clopidogrel, Prasugrel, Ticagrelor: Which and When? (CardioSource Interventional News)  An Inconvenient Finding: Does Ticagrelor Work in the U.S.? (CardioSource WorldNews)

The updated guideline also recommends consideration of prasugrel and ticagrelor, approved by the FDA in 2011, as a treatment option in addition to clopidogrel. Ticagrelor was found to be superior to clopidogrel in the PLATO trial, and was studied and approved for use in all patients, including medically-treated patients and patients undergoing revascularization procedures. Prasugrel was superior to clopidogrel in the TRITON-TIMI 38 trial. It was studied and approved for use in the cardiac cath laboratory in patients in whom coronary anatomy is known and who are planned to undergo a PCI.

 

"The AHA and ACCF constantly update their guidelines so that physicians can provide patients with the most appropriate, aggressive therapy with the goal of improving health and survival," said Hani Jneid, MD, FACC, lead author of the update and an assistant professor of medicine and director of interventional cardiology research at Baylor College of Medicine, and an interventional cardiologist at the Michael E. DeBakey VA Medical Center in Houston. In the case of this update "we have put [ticagrelor] on equal footing with the two other antiplatelet medications, clopidogrel and prasugrel."

Also included in the update, the guideline authors encourage clinicians and hospitals to participate in a standardized quality-of-care data registry designed to track and measure outcomes, complications and adherence to evidence-based recommendations. They note that these registries "may prove pivotal in addressing opportunities for quality improvement at the local, regional and national level, and include the elimination of health care disparities and conduct of comparative effectiveness research."

The document was endorsed by the American College of Emergency Physicians, Society for Cardiovascular Angiography Interventions, and Society of Thoracic Surgeons.

< Back to Listings