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Information

Population: Adults experiencing NSTEMI or unstable angina.

Organizations

ImagesACC/AHA 2014, ESC 2015, ACC/AHA/SCAI 2021

Recommendations

–Include in initial evaluation an ECG, cardiac troponin I or T levels (obtained at symptom onset and 3–6 h later, with levels beyond 6 h if ECG or clinical presentation suggests a high probability of ACS), and assess prognosis with risk scores such as TIMI1 or GRACE.2

–Give sublingual nitroglycerin q5min ×3 for ongoing ischemic pain. Use IV nitroglycerin for persistent ischemia, HF, or hypertension.

–Give dual antiplatelet therapy in likely or definite NSTE-ACS. Aspirin (325 mg, non-enteric-coated) and clopidogrel (300–600 mg loading dose, then maintenance) or ticagrelor (180 mg loading dose, then maintenance). After stabilization, consider dual antiplatelet therapy (clopidogrel or ticagrelor in addition to aspirin) “up to” 12 mo if not stented, and for “at least” 12 mo if stented.

–Anticoagulate, in addition to dual antiplatelet therapy. Use unfractionated heparin, enoxaparin, or fondaparinux. The strongest evidence supports enoxaparin.

–Give oral beta-blockers in the first 24 h, unless signs of HF, low output state, risk factors for cardiogenic shock, or other contraindications to beta-blockade. If contraindicated or if ischemia persists despite beta-blockers and nitrates, give nondihydropyridine calcium channel blocker.

–If patients are already on beta-blockers with normal LVEF or stable reduced LVEF, continue home dose of long-acting metoprolol succinate, carvedilol, or bisoprolol.

–Block the renin-angiotensin-aldosterone system with an ACE inhibitor. Continue after stabilization if LVEF < 40%, HTN, DM, or stable CKD.

–Start or continue high-intensity statin, unless contraindicated, and continue indefinitely.

–Give supplemental oxygen if SaO2 90% or respiratory distress.

–Give IV morphine for analgesia if anti-ischemic medications have been maximized. Do not give NSAIDs.

–After stabilization, continue aspirin (81–325 mg/d) indefinitely.

–Refer for cardiac catheterization in the following scenarios:

• Cardiogenic shock, refractory angina, or hemodynamic or electrical instability: immediate cardiac catheterization.

• High risk of clinical events (eg, GRACE score > 140): cardiac catheterization within 24 h.

• Stabilized patients at lower risk for clinical events: cardiac catheterization prior to hospital discharge.

Sources

Eur Heart J. 2016;37(3):267-315. https://academic.oup.com/eurheartj/article/37/3/267/2466099

J Am Coll Cardiol. 2014;64(24):e139-e228. http://content.onlinejacc.org/article.aspx?articleid=1910086

J Am Coll Cardiol. 2016;68(10):1082-1115. http://content.onlinejacc.org/article.aspx?articleid=2507082