1 / 23

UA/NSTEMI Guidelines Audio-Webcast: A Presentation & Discussion of Treatment Essentials

UA/NSTEMI Guidelines Audio-Webcast: A Presentation & Discussion of Treatment Essentials.

Antony
Download Presentation

UA/NSTEMI Guidelines Audio-Webcast: A Presentation & Discussion of Treatment Essentials

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. UA/NSTEMI Guidelines Audio-Webcast: A Presentation & Discussion of Treatment Essentials Based on the ACC/AHA Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: A Report of the ACC/AHA Task Force on Practice Guidelines Writing Committee to Revise the 2002 Guidelines for the Management of Patients with Unstable Angina/Non-ST-Elevation Myocardial Infarction. Presented by: Jeffrey L. Anderson, MD, FACC, Moderator Elliott M. Antman, MD, FACC Robert M. Califf, MD, MACCA. Michael Lincoff, MD, FACC

  2. Disclosures Jeffrey L. Anderson, MD, FACC

  3. Disclosures Elliott M. Antman, MD, FACC

  4. Disclosures Robert M. Califf, MD, MACC

  5. Disclosures Robert M. Califf, MD, MACC

  6. Disclosures Robert M. Califf, MD, MACC

  7. Disclosures A. Michael Lincoff, MD, FACC

  8. Evolution of Guidelines for ACS 2004 2007 1990 1992 1994 1996 1998 2000 2002 1990ACC/AHAAMI R. Gunnar 1994AHCPR/NHLBIUA E. Braunwald 1996 1999Rev Upd ACC/AHA AMI T. Ryan 2000 2002 2007 Rev UpdRev ACC/AHA UA/NSTEMI E. Braunwald J. Anderson Figure 1. Evolution of Guidelines for Management of Patients with AMI The first guideline published by the ACC/AHA described the management of patients with acute myocardial infarction (AMI). The subsequent three documents were the Agency for Healthcare and Quality/National Heart, Lung and Blood Institute sponsored guideline on management of unstable angina (UA), the revised/updated ACC/AHA guideline on AMI, and the revised/updated ACC/AHA guideline on unstable angina/non-ST segment myocardial infarction (UA/NSTEMI). The present guideline is a revision and deals strictly with the management of patients presenting with ST segment elevation myocardial infarction (STEMI). The names of the chairs of the writing committees for each of the guidelines are shown at the bottom of each box. Rev, Revised; Upd, Update 2004 2007 Rev Upd ACC/AHA STEMI E. Antman

  9. Hospitalizations in the U.S. Due to Acute Coronary Syndromes (ACS) Acute Coronary Syndromes* 1.57 Million Hospital Admissions - ACS UA/NSTEMI† STEMI 1.24 millionAdmissions per year .33 millionAdmissions per year Heart Disease and Stroke Statistics – 2007 Update. Circulation 2007; 115:69-171. *Primary and secondary diagnoses. †About 0.57 million NSTEMI and 0.67 million UA.

  10. Risk Stratification

  11. Risk Stratification • Integral prerequisite to decision making • Intensive initial assessment • Continuous clinical assessment • Targeted ECG and marker data • Risk based on contingent probabilities • Probability of obstructive CAD causing ischemia • Risk given presence of obstructive CAD • Risk scores should be a routine part of assessment throughout the hospital course and periodically after discharge

  12. Likelihood of obstructive CAD as cause of symptoms Dominated by acute findings Exam Symptoms Markers Traditional risk factors are of limited utility Does this patient have symptoms due to acute ischemia from obstructive CAD? Risk of bad outcome Dominated by acute findings Older age very important Hemodynamic abnormalities critical ECG, markers What is the likelihood of death, MI, heart failure? Risk Assessment Dependent on Contingent Probabilities

  13. Physiological monitoring Periodic physical exams Cardiac markers ECG Risk 24h 3-4 days 6 months Time

  14. Risk Scores

  15. Early Hospital Care

  16. Algorithm for Patients with UA/NSTEMI Managed by an Initial Invasive Strategy Diagnosis of UA/NSTEMI is Likely or Definite ASA (Class I, LOE: A) Clopidogrel if ASA intolerant (Class I, LOE: A) A Proceed with an Initial Conservative Strategy Select Management Strategy B Invasive Strategy Initiate A/C Rx (Class I, LOE: A) Acceptable options: enoxaparin or UFH (Class I, LOE: A) bivalirudin or fondaparinux (Class I, LOE: B) B1 Prior to Angiography Initiate at least one (Class I, LOE: A) or both (Class IIa, LOE: B) of the following: Clopidogrel IV GP IIb/IIIa inhibitor B2 Factors favoring admin of both clopidogrel and GP IIb/IIIa inhibitor include: Delay to Angiography High Risk Features Early recurrent ischemic discomfort Proceed to Diagnostic Angiography Anderson JL. J Am Coll Cardiol 2007;50:e1-157. Figure 7

  17. Algorithm for Patients with UA/NSTEMI Managed by an Initial Conservative Strategy Diagnosis of UA/NSTEMI is Likely or Definite ASA (Class I, LOE: A) Clopidogrel if ASA intolerant (Class I, LOE: A) A Proceed with Invasive Strategy Select Management Strategy Conservative Strategy Initiate A/C Rx (Class I, LOE: A): Acceptable options: enoxaparin or UFH (Class I, LOE: A) or fondaparinux (Class I, LOE: B),but enoxaparin or fondaparinux are preferable (Class IIA, LOE: B) C1 Initiate clopidogrel (Class I, LOE: A) Consider adding IV eptifibatide or tirofiban (Class IIb, LOE: B) C2 (Continued) Anderson JL. J Am Coll Cardiol 2007;50:e1-157.Figure 8

  18. Algorithm for Patients with UA/NSTEMI Managed by an Initial Conservative Strategy (Continued) Any subsequent events necessitating angiography? D Yes No (Class I, LOE: B) L Evaluate LVEF M (Class I, LOE: B) (Class IIa, LOE: B) N EF 0.40 or less O EF greater than 0.40 Stress Test (Class IIa, LOE: B) E-1 E-2 Proceed to Dx Angiography Not Low Risk Low Risk (Class I, LOE: A) (Class I, LOE: A) K Cont ASA indefinitely (Class I, LOE A) Cont clopidogrel for at least one month (Class I, LOE A) and ideally up to 1 yr (Class I, LOE B) DC IV GP IIb/IIIa if started previously (Class I, LOE A) DC A/C Rx (Class I, LOE A) Anderson JL. J Am Coll Cardiol 2007;50:e1-157.Figure 8

  19. Revascularization and Late Hospital Care

  20. Management after Diagnostic Angiography in Patients with UA/NSTEMI Dx Angiography F Select Post Angiography Management Strategy CABG PCI Medical therapy G CAD on angiography H No significant obstructive CAD on angiography • Cont ASA (Class I, LOE: A) • DC clopidogrel 5 to 7 d prior to elective CABG (Class I, LOE: B) • DC IV GP IIb/IIIa 4 h prior to CABG (Class I, LOE: B) • Cont UFH (Class I, LOE: B); DC enoxaparin 12 to 24 h prior to CABG; DC fondaparinux 24 h prior to CABG; DC bivalirudin 3 h prior to CABG. Dose with UFH per institutional practice (Class I, LOE: B) • Cont ASA (Class I, LOE A) • LD of clopidogrel if not given pre angio (Class I, LOE: A) • & • IV GP IIb/IIIa if not started pre angio (Class I, LOE: A) • DC A/C Rx after PCI for uncomplicated cases (Class I, LOE: B) J • Cont ASA (Class I, LOE: A) • LD of clopidogrel if not given pre angio (Class I, LOE A)* • DC IV GP IIb/IIIa after at least 12 h if started pre angio (Class I, LOE: B) • Cont IV UFH for at least 48 h (Class I, LOE: A) or enoxaparin or fondaparinux for dur of hosp (LOE: A); either DC bivalirudin or cont at a dose of 0.25 mg/kg/hr for up to 72 h at physician‘s discretion (Class I, LOE: B) I Antiplatelet and A/C Rx at physician’s discretion (Class I, LOE: C) Anderson JL. J Am Coll Cardiol 2007;50:e1-157.In press. Figure 9

  21. Long-Term Antithrombotic Therapy at Hospital Discharge after UA/NSTEMI UA/NSTEMI Patient Groups at Discharge Medical Tx w/o Stent Bare Metal Stent Drug Eluting Stent ASA 162 to 325 mg/d for at least 3 to 6 months, then 75 to 162 mg/d indefinitely (Class I LOE: A) & Clopidogrel 75 mg/d for at least 1 yr (Class I LOE: B) ASA 75 to 162 mg/d indefinitely (Class I LOE: A) & Clopidogrel 75 mg/d at least 1 mo (Class I LOE: A) and up to 1 yr (Class I LOE: B) ASA 162 to 325 mg/d for at least 1 mo, then 75 to 162 mg/d indefinitely (Class I LOE: A) & Clopidogrel 75 mg/d for at least 1 mo and up to 1 yr (Class I LOE:B) Indication for Anticoagulation? Yes No Continue with dual antiplatelet tx as above. Add: Warfarin (INR 2.0 to 2.5) (Class IIb LOE: B) Anderson JL. J Am Coll Cardiol 2007;50:e1-157.Figure 11.

  22. Preparation for Discharge After UA/NSTEMI • Antiplatelet Rx • ASA 75 - 162 mg/day • Clopidogrel 75 mg/day • Beta Blocker • ACEI / ARB • Especially if DM, HF, EF <40%, HTN • Statin • LDL <100 mg/dL(ideally <70 mg/dL) • Secondary Prevention Measures • Smoking Cessation • BP <140/90 mm HG or <130/80 mm HG for DM or chronic kidney disease • HbA1C <7% • BMI 18.5-24.9 • Physical Exercise 30-60 min at least 5 days/wk

  23. Panel Discussion

More Related