Perspective:

The following are 10 points to remember about these updated guidelines for the management of patients with unstable angina (UA)/non–ST-elevation myocardial infarction (NSTEMI):

1. Aspirin should be administered to UA/NSTEMI patients as soon as possible after hospital presentation, and continued indefinitely in patients who tolerate it.

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

3. In UA/NSTEMI patients undergoing PCI, clopidogrel 75 mg daily or prasugrel 10 mg daily should be given for at least 12 months.

4. For UA/NSTEMI patients in whom an initial conservative strategy is selected and no subsequent features appear that would necessitate diagnostic angiography (recurrent symptoms/ischemia, heart failure, or serious arrhythmias), a stress test should be performed and left ventricular ejection fraction should be measured.

5. In patients taking a thienopyridine 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 and at least 7 days in patients receiving prasugrel unless the need for revascularization and/or the net benefit of the thienopyridine 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. Medical treatment in the acute phase of UA/NSTEMI and decisions on whether to perform stress testing, angiography, and revascularization should be similar in patients with and without diabetes mellitus.

8. For patients with UA/NSTEMI and multivessel disease, CABG with use of the internal mammary arteries can be beneficial over PCI in patients being treated for diabetes mellitus.

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. It is reasonable for clinicians and hospitals that provide care to patients with UA/NSTEMI to participate in a standardized quality-of-care data registry designed to track and measure outcomes, complications, and adherence to evidence-based processes of care and quality improvement for UA/NSTEMI.