NSTEMI: risk stratification and management

NSTEMI: risk stratification and management


Features that help differentiate ACS from stable angina are (1) onset of symptoms at rest (or with minimal exertion) and lasting longer than 10 minutes unless treated promptly; (2) severe, oppressive pressure or chest discomfort; and (3) an accelerating pattern of symptoms that develop more frequently, occur with greater severity, or awaken the patient from sleep Clinical Assessment

Physical examination / clinical history Electrocardiogram Cardiac biomarkers Risk stratification Further investigations History

NSTE-ACS most commonly presents as a pressure-type chest pain that typically occurs at rest or with minimal exertion lasting 10 minutes Relatively uncommon in men <40 yr. and women < 50 yr Previous history of coronary heart disease(CHD)

Presence of traditional risk factors for CHD. Atypical manifestations :anginal equivalents- more prevalent in women, older adults, patients with DM2, CKD or Dementia. Unexplained new-onset or increased exertional dyspnea is the most common angina equivalent

Secondary NSTE ACS :cause is extrinsic to coronaries Increase in myocardial O2 demand: fever, tachycardia, hypertensive emergencies Decrease in supply: hypotension, anemia Pysical examianation

May be normal Audible S3 and/or S4 Hypotension, pale cool skin, cardiogenic shock To r/ o other non coronary cardiac cause/noncardiac cause ECG A 12-lead ECG should be performed and interpreted within 10 minutes of the patients arrival at an emergency facility to assess for cardiac ischemia

or injury. Changes include ST depression, transient ST-elevation, or new T-wave inversion Significant changes: 0.05mV ST Depression compare to recent ECG (In PURSUIT trial 30 day mortality was 5.1% in patient with ST depression compared to 2.1% in patient without ST depression)

Deep T wave inversion of >0.2mV Transient ST elevation lasting for <20 min A normal ECG does not exclude ACS and occurs in 1% to 6% of such patients. A normal ECG may also be associated with left circumflex or right coronary artery occlusions, which can be electrically silent.

posterior electrocardiographic leads [V7 to V9] may be helpful. Rightsided leads (V3R to V4R) Left ventricular (LV) hypertrophy, bundlebranch blocks with repolarization abnormalities, and ventricular pacing may mask signs of ischemia/injury. ECG should be repeated (e.g., at 15- to 30-minute intervals during them

first hour), especially if symptoms recur biomarkers Cardiac troponins are the most sensitive and specific biomarkers for NSTEACS. Even minor elevation in cTn levels associated with poor outcome.

Diagnosis of acute MI requires an elevation in cTnI or cTnT above the 99th percentile of the normal range for the specific assay used, a typical temporal rise and decline when serial samples are tested, and a clinical picture consistent with ACS. A negative cardiac troponin obtained with more sensitive cardiac troponin assays on admission confers a >95% negative predictive value for MI compared with high-sensitivity assays that confer a negative predictive value 99%

Newer high-sensitivity assays can, exclude myocardial necrosis if two values measured 3 hours apart are both normal. The fourth-generation cTn assays are less sensitive than the so-called high-sensitivity assays, and two negative cTn assays at least 6 to 9 hours apart are needed to exclude MI. Causes of troponin elevation other than ACS Pulmonary embolus

myocarditis Cardiac contusion Congestive heart failure Chemiotherapy (adiramycin, 5-flurouracil) Cardioversion or RFA Septic shock Extreme endurance athletics Renal failure Pro-BNP & NT-Pro BNP No diagnostic, but prognostic significance.

rise in proportion to the degree of ventricular distention and correlate with the risk for adverse events In patients with NSTE-ACS, a baseline BNP measured on average 40 hours after the onset of symptoms correlated strongly with risk for death, heart failure, and MI through 10 months in a graded fashion.

CRP & other biomarkers C-reactive protein (CRP) is a marker of inflammation that is elevated following ACS, and persistently elevated levels after discharge are associated with increased long-term cardiovascular risk. CRP provides less prognostic information than cTn & Pro BNP, routine CRP measurement after ACS is not recommended.

Others , if elevated shows increased chances of CV events in both short and long terms e.g. Blood sugar level HbA1c Markers for renal dysfunctions- cystatin c, serum creatinine Emerging biomarkers Markers that predict death and/ ischemic events Growth differentiation factor 15 (GDF 15) Heart-type fatty acid binding protein (H-FABP) myeloperoxidase

Pregnancy associated plasma protein A (PAPP-A)- expressed in eroded and ruptured plaque Placental growth factor Secretory phospholipase A2 Interleukin-6 (IL-6) Chemokine ligand-5 & ligand 18 Markers that predict heart failure Midregional proadrenomedullin neopterin osteoprotegrin

ECHO useful in the assessment of left ventricular systolic and diastolic function left atrial dilation, functional mitral regurgitation, tricuspid annular plane systolic excursion, diastolic dysfunction, ventricular mechanical dyssynchrony, and ultrasound lung comets

Each of which have been associated with adverse prognosis Invasive imaging The culprit lesion in NSTE-ACS typically exhibits an eccentric stenosis with scalloped or overhanging edges and a narrow neck. CAG findings in NSTE ACS %

Multivessel with LMCA 10% TVD 35% DVD 20%

SVD 20% Normal coronaries 15% 85 %

Normal coronaries- more frequently in women and nonwhites individuals. In such patients, NSTE-ACS, if present, may be related to microvascular coronary obstruction, endothelial dysfunction, or coronary artery spasm and is generally associated with a more favourable prognosis. Objectives of stratification

Can We Identify Patients At Low, Intermediate And High Risk Of Short Term And Long Term Macce? Will It Help To Guide Treatment For Better Outcome? Acute coronary syndromes: Prognostic spectrum

Unstable angina New onset exertional angina Progressive angina Rest pain without EKG changes Rest pain with EKG changes

Rest pain troponin+ Non ST elevation MI (NSTEMI) Acute ST segment elevation MI Lea st RISK Coronary occlusion & short term death

Great est Clinical Indicators of Increased Risk in UA/NSTEMI History Clinical Presentation Advanced age (> 70 yr) Braunwald class II or III (acute or

subacute rest pain) Diabetes mellitus Postmyocardial infarction angina Prior peripheral vascular disease Prior cerebrovascular disease ECG ST segment deviation 0.05 mV T wave inversion 0.3 mV Left bundle branch block Angiogram Thrombus Multivessel disease

Left ventricular dysfunction Braunwald class B (secondary unstable angina) Heart failure/hypotension Multiple episodes of pain within 24 hr Cardiac Markers Increased troponin T or I or creatine kinase-MB Increased C-reactive protein or white blood cell count Increased B-type natriuretic peptide Elevated creatinine

Elevated glucose or hemoglobin A1C The TIMI unstable angina risk score

7 possible risk factors: Age >= 65 years Prior known CAD >= 3 coronary risk factors ( HTN, Hchol, FH, DM, current smoker) Aspirin use within 7 days ST segment deviation >= 2 episodes of angina within 24 hours Abnormal cardiac markers (MB or T) Low risk = 0-2 risk factors Intermediate risk = 4-3 risk

factors High risk = 5-7 risk factors Antman EM et al: JAMA 2000;284:83542

The TIMI risk score has been validated internally within the TIMI 11B trial and in 2 separate cohorts of patients from the ESSENCE (Efficacy and Safety of Subcutaneous Enoxaparin in NonQ-Wave Coronary Event) trial The TIMI risk index is useful in predicting 30-day and 1-year mortality in patients with NSTE-ACS The c-statistic of the TIMI score in the original trial was0.65. Risk Scores for Patients with Chest Pain: Evaluation in the EmergencyDepartment B.E. Backus1,*, A.J. Six2, J.H. Kelder3, W.B. Gibler4, F.L. Moll1 and P.A. Doevendans1 Current Cardiology Reviews, 2011, 7, 2-8

PURSUIT SCORE(018) Age, separate points for enrolment diagnosis Decade [UA (MI)] 50 60 70 80 8 (11) 9 (12) 11 (13) 12 (14)

Sex Male Female Worst CCS-class in previous 6 weeks No angina or CCS I/II CCS III/IV Signs of heart failure ST-depression on presenting ECG 1 0 0

2 2 1 Eur Heart J (May 2005) 26 (9):865-872. possible score ranging from 1 to 18. The PURSUIT score predicts the risk of death

or death/MI at 30 days after admission. According to the PURSUIT score ACS patients are divided into low, intermediate and high risk patients, with suggested therapies of early discharge, watchful waiting and aggressive antiplatelet / early invasive strategies respectively Risk Scores for Patients with Chest Pain: Evaluation in the EmergencyDepartment B.E. Backus1,*, A.J. Six2, J.H. Kelder3, W.B. Gibler4, F.L. Moll1 and P.A. Doevendans1 Current Cardiology Reviews, 2011, 7, 2-8 GRACE(0258) Age (years)

<40 0 Heart rate (bpm) <70 0 4049 18

17089 7 5059 36 190109 13 6069

55 110149 23 7079 73 150199

36 80 91 >200 46 Systolic BP (mmHg) <80 18099

100119 120139 140159 160199 >200 63 58 47 37 26 11 0

Creatinine (mg/dL) Killip class Class Class Class Class I II III IV

0 21 43 64 0.0- 0.39 0.40.79 0.81.19 1.21.59 1.61.99 0.23.99 >4

2 5 8 11 14 23 31 Cardiac arrest at admission Elevated cardiac markers

ST-segment deviation Eur Heart J (May 43 15 30

The GRACE tool was developed from 11,389 patients in GRACE and validated in subsequent GRACE and GUSTO (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries) IIb cohorts determine all-cause mortality from hospital discharge to 6 months

possible score ranging from 1 to 372 Event rates increased significantly with increasing GRACE-scores, ranging from 0.2% to 52% chance of inhospital death The investigators did not divide patients into different risk categories. The c-statistic of the GRACE score in the original database was 0.83. Risk Scores for Patients with Chest Pain: Evaluation in the EmergencyDepartment B.E. Backus1,*, A.J. Six2, J.H. Kelder3, W.B. Gibler4, F.L. Moll1 and P.A. Doevendans1

Current Cardiology Reviews, 2011, 7, 2-8 The FRISC score (2004) is based on the FRISC (Fast Revascularisation in Instability in

Coronary disease) II trial. c-statistic of the FRISC score for the prediction of death was 0.77 and for death/MI 0.70. low, intermediate and high risk, based on the FRISC scores of 0-2, 3-4 and 5-7. In one study conducted over 1200 patients, the high risk group mortality reduced from 15.4 5.2%, while the composite endpoint of death and MI was reduced in both intermediate and high risk groups. The FRISC score is the only risk score that focussed on the treatment effect of early invasive strategies in ACS. Investigators recommended early invasive strategies for patients with a FRISC score 3. Risk Scores for Patients with Chest Pain: Evaluation in the EmergencyDepartment B.E. Backus1,*, A.J. Six2, J.H. Kelder3, W.B. Gibler4, F.L. Moll1 and P.A. Doevendans1 Current Cardiology Reviews, 2011, 7, 2-8

Heart scoring History ECG Age Risk factor Troponin Highly suspicious

2 Moderately suspicious 1 Slightly suspicious 0 Significant ST depression

2 Non specific repolarization disturbance 1 normal 0 65 2

46-64 1 45 0 3 risk facor or known atherosclerotic disease 2

1-2 risk factors 1 No risk fctor known 0 3x normal limit 2 1-3x normal limit

1 normal limit 0 Low risk 0-3 0.9%

Intermediate risk 4-6 12% High risk 7-10 65%

the HEART risk score (2008) was developed for chest pain patients presenting to the ED Investigator assessed endpoint of MI, Percutaneous Coronary Intervention (PCI), Coronary Artery Bypass Grafting (CABG) ordeath within 6 weeks after presentation. The c-statistic was 0.90, indicating good toexcellent

discriminative power. The HEART score divides patients into low (0-3), intermediate (4-6) or high risk groups (7-10), with mean risks of an event of 0.9%, 12% and 65%, respectively Risk Scores for Patients with Chest Pain: Evaluation in the EmergencyDepartment B.E. Backus1,*, A.J. Six2, J.H. Kelder3, W.B. Gibler4, F.L. Moll1 and P.A. Doevendans1 Current Cardiology Reviews, 2011, 7, 2-8 TIMI, PURSUIT, AND GRACE RISK SCORES: SUSTAINED PROGNOSTIC VALUE AND INTERACTION WITH REVASCULARIZATION IN NSTEACS

Pedro de Arajo Gonalves, Jorge Ferreira, Carlos Aguiar and Ricardo Seabra-Gomes Eur Heart J (May 2005) 26 (9):865872. Interaction between the admission score and the prognostic impact of myocardial revascularization performed during initial hospital stay. Eur Heart J (May 2005) 26 (9):865872. Comparison of the predictive accuracy of the risk scores

30 days 1 year P-value P-value PURSUIT vs. TIMI

0.064 0.288 0.044 0.319 GRACE vs. PURSUIT 0.057

0.332 0.086 0.04 GRACE vs. TIMI 0.121 0.054

0.130 0.004 Eur Heart J (May 2005) 26 (9):865-872. Conclusions RSs developed from Databases of clinical trials (PURSUIT and TIMI) or

Registries (GRACE) At 30 days the risk stratification by all 3 scores for patients with NSTEACS has fair to good discriminatory accuracy in predicting major adverse cardiac events at both 30 days and 1 year. The

GRACE RS was the best for predicting the risk of death or MI at 1 year after admission. Eur Heart J (May 2005) 26 (9):865-872. Risk Scores for Patients with Chest Pain: Evaluation in the EmergencyDepartment B.E. Backus1,*, A.J. Six2, J.H. Kelder3, W.B. Gibler4, F.L. Moll1 and P.A. Doevendans1 Current Cardiology Reviews, 2011, 7, 2-8 A prospective validation of the HEART score for chest pain patients at the emergency department B.E. Backus et al

International Journal of Cardiology 168 (2013) 21532158 Methods: A total of 2440 unselected patients presented with chest pain at the cardiac emergency department of ten participating hospitals in The Netherlands. The HEART score was assessed as soon as the first lab results and ECG were obtained. Primary endpoint was the

occurrence of major adverse cardiac events (MACE) within 6 weeks. Conclusion: The HEART score provides the clinician with a quick and reliable predictor of outcome, without computer-required calculating. Low HEART scores (03), exclude short-term MACE with >98% certainty. In these patients one

might consider reserved policies. In patients with high HEART scores (710) the high risk of MACE may indicate more aggressive policies. 2014 AHA/ACC GUIDELINE FOR THE MANAGEMENT OF PATIENTS WITH NONST-ELEVATION ACUTE CORONARY SYNDROMES: EXECUTIVE SUMMARY A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines

Circulation. published online September 23, 2014 INITIAL EVALUATION AND MANAGEMENT Emergency Department or Outpatient Facility Presentation Patients with suspected ACS and high-risk features such as continuing chest pain, severe dyspnea, syncope/presyncope, or palpitations should be referred

immediately to the ED and transported by EMS when available. (Class I; Level of Evidence C) Prognosis: Early Risk Stratification Perform rapid determination of likelihood of ACS, including a 12-lead ECG within 10 min of arrival at an emergency facility, in patients whose symptoms suggest ACS (Class I) Perform serial ECGs at 15- to 30-min intervals during the first hour in symptomatic patients with initial

nondiagnostic ECG (Class I) Measure cardiac troponin (cTnI or cTnT) in all patients with symptoms consistent with ACS (Class I) Measure serial cardiac troponin I or T at presentation and 36 h after symptom onset Prognosis: Early Risk Stratification Use risk scores to assess prognosis in patients with NSTE-ACS (Class I) Risk-stratification models can be useful in management (Class IIa)

Continuous monitoring with 12-lead ECG may be a reasonable alternative with initial non-diagnostic ECG in patients at intermediate/high risk for ACS (Class IIb) BNP or NTpro-BNP may be considered to assess risk in patients with suspected ACS (Class IIb) Biomarkers: Diagnosis

Measure cardiac-specific troponin (troponin I or T) at presentation and 36 h after symptom onset in all patients with suspected ACS to identify pattern of values (Class I) Obtain additional troponin levels beyond 6 h in patients with initial normal serial troponins with ECG changes and/or intermediate/high risk clinical features (Class I) With contemporary troponin assays, CK-MB and myoglobin are not useful for diagnosis of ACS (Class III)

Discharge From the ED or Chest Pain Unit Observe patients with symptoms consistent with ACS without objective evidence of myocardial ischemia (non-ischemic initial ECG and normal cardiac troponin) in a chest pain unit or telemetry unit with serial ECGs and cardiac troponin at 3- to 6-hour intervals

(Class IIa) Give low-risk patients who are referred for outpatient testing daily aspirin, short-acting NTG, and other medication if appropriate (e.g., beta blockers), with instructions about activity level and clinician follow-up (Class IIa) EARLY HOSPITAL CARE STANDARD MEDICAL THERAPIES

Oxygen Administer supplemental oxygen only with oxygen saturation <90%, respiratory distress, or other high-risk features for hypoxemia (Class I) Nitrates

Administer sublingual NTG every 5 min 3 for continuing ischemic pain and then assess need for IV NTG (Class I) Administer IV NTG for persistent ischemia, HF, or hypertension (Class I) Nitrates are contraindicated with recent use of a phosphodiesterase inhibitor (Class III)

Analgesic therapy IV morphine may be reasonable for continued ischemic chest pain despite maximally tolerated anti-ischemic medications (Class IIb) NSAIDs (except aspirin) should not be initiated and should be discontinued during hospitalization for NSTE-ACS because of the increased risk of MACE

associated with their use (Class III) Beta-adrenergic blockers Initiate oral beta blockers within the first 24 h in the absence of HF, low-output state, risk for cardiogenic shock, or other contraindications to beta blockade (Class I)

Use of sustained-release metoprolol succinate, carvedilol, or bisoprolol is recommended for beta-blocker therapy with concomitant NSTE-ACS, stabilized HF, and reduced systolic function (Class I) IV beta blockers are potentially harmful when risk factors for shock are present (Class III) CCBs

Administer initial therapy with non-DHP CCBs with recurrent ischemia and contraindications to beta blockers in the absence of LV dysfunction, increased risk for cardiogenic shock, PR interval >0.24 s, or 2ndor 3rd-degree AV block without a cardiac pacemaker (Class I) Administer oral non-DHP CCBs with recurrent ischemia after use of beta-blocker and nitrates in the absence of contraindications (Class I)

CCBs are recommended for ischemic symptoms when beta-blockers are not successful, are contraindicated, or cause unacceptable side effects (Class I) Immediate-release nifedipine is contraindicated in the absence of a beta-blocker (Class III) Inhibitors of Renin-AngiotensinAldosterone System ACE inhibitors should be started and

continued indefinitely in all patients with LVEF < 0.40 and in those with hypertension, DM, or stable CKD, unless contraindicated (Class I) ARB are recommended in patients with HF or MI with LVEF < 0.40 who are ACE inhibitor intolerant (Class I) INITIAL PARENTERAL ANTICOAGULANT THERAPY IN PATIENTS WITH DEFINITE NSTE-ACS

Aspirin Nonenteric-coated aspirin (162 mg325 mg) to all patients promptly after presentation and maintenance dose (81 mg/d162 mg/d) continued indefinitely (Class I) P2Y12 inhibitors

In patients with NSTE-ACS who are unable to take aspirin because of hypersensitivity or major gastrointestinal intolerance, a loading dose of clopidogrel followed by a daily. maintenance dose should be administeredP2Y12 inhibitor in addition to aspirin should be administered for up to 12 mo to all patients with NSTE-ACS without contraindications who are treated with either an early invasive or ischemia-guided strategy (Class I) Clopidogrel

300-mg or 600-mg loading dose, then 75 mg QD Ticagrelor 180-mg loading dose, then 90 mg BID P2Y12 inhibitor therapy continued for at least 12 mo in postPCI patients treated with coronary stents (Class I) Ticagrelor in preference to clopidogrel for patients treated

GP IIb/IIIa inhibitors GP IIb/IIIa inhibitor [Eptifibatide (Integrilin) or tirofiban (Aggrastat)] in patients treated with an early invasive strategy and dual anti-platelet therapy (DAPT) with intermediate/high-risk features (e.g., positive troponin) (Class IIb) Parenteral anticoagulant

and fibrinolytic therapy SC enoxaparin for duration of hospitalization or until PCI is performed (Class I)

1 mg/kg SC Q12H (reduce dose to 1 mg/kg/d SC in patients with CrCl <30 mL/min) Initial IV loading dose 30 mg Bivalirudin until diagnostic angiography or PCI is performed in patients with early invasive strategy only (Class I) Fondaparinux 2.5 mg SC QD for the duration of hospitalization or until PCI is performed (Class I) IV UFH for 48 h or until PCI is performed (Class I) Initial loading dose 60 IU/kg (max 4,000 IU) with initial infusion 12 IU/kg/h (max 1,000 IU/h) Adjusted to therapeutic aPTT range IV fibrinolytic treatment not recommended in patients

Summary of Recommendations for Initial Antiplatelet/Anticoagulant Therapy in Patients With Definite or Likely NSTE-ACS and PCI ISCHEMIA-GUIDED STRATEGY VERSUS EARLY INVASIVE STRATEGIES EARLY INVASIVE AND ISCHEMIA-GUIDED STRATEGIES

Risk Stratification Before Discharge for Patients With an Ischemia-Guided Strategy of NSTE-ACS: Recommendations CLASS I Noninvasive stress testing is recommended in low- and intermediaterisk patients who have been free of ischemia at rest or with low-level activity for a minimum of 12 to 24 hours. Treadmill exercise testing is useful in patients able to exercisem in whom the ECG is free of resting ST changes that may interfere with interpretation.

Stress testing with an imaging modality should be used in patients who are able to exercise but have ST changes on resting ECG that may interfere with interpretation. In patients undergoing a low-level exercise test, an imaging modality can add prognostic information.

Pharmacological stress testing with imaging is recommended when physical limitations preclude adequate exercise stress. A noninvasive imaging test is recommended to evaluate LV function in patients with definite ACS. PCIGeneral Considerations: Recommendation CLASS 2B A strategy of multivessel PCI, in contrast to culprit lesion only PCI, may be

reasonable in patients undergoing coronary revascularization as part of treatment for NSTEACS PCI-Oral and Intravenous Antiplatelet Agents: Recommendations CLASS I Patients already taking daily aspirin before PCI should take 81 mg to 325 mg nonenteric-coated aspirin before PCI. Patients not on aspirin therapy should be given nonenteric coated aspirin 325 mg

as soon as possible before PCI. After PCI, aspirin should be continued indefinitely at a dose of 81 mg to 325 mg daily. CLASS 1 A loading dose of a P2Y12 receptor inhibitor should be given before the procedure in patients undergoing PCI with stenting Options include: a. Clopidogrel: 600 mg b. Prasugrel: 60 mg c. Ticagrelol: 180 mg

In patients with NSTE-ACS and high-risk features (e.g., elevated troponin) not adequately pretreated with clopidogrel or ticagrelor, it is useful to administer a GP IIb/IIIa inhibitor (abciximab, double-bolus eptifibatide, or high-dose bolus tirofiban) at the time of PCI ( In patients receiving a stent (bare-metal stent or drugeluting stent [DES]) during PCI for NSTE-ACS, P2Y12 inhibitor therapy

should be given for at least 12 months. Options include: a. Clopidogrel: 75 mg daily b. Prasugrel: 10 mg daily c. Ticagrelol: 90 mg twice daily CLASS IIa It is reasonable to choose ticagrelor over clopidogrel for P2Y12 inhibition treatment in patients with NSTEACStreated with an early invasive strategy and/or coronary stenting. It is reasonable to choose prasugrel over clopidogrel for P2Y12 treatment in patients with NSTE-ACS who undergo

PCI who are not at high risk of bleeding complications. In patients with NSTE-ACS and high-risk features (e.g., elevated troponin) treated with UFH and adequately pretreated with clopidogrel, it is reasonable to administer a GP IIb/IIIa inhibitor (abciximab, double-bolus eptifibatide, or high-bolus dose tirofiban) at the time of PCI After PCI, it is reasonable to use 81 mg per day of aspirin in preference to higher

maintenance doses. If the risk of morbidity from bleeding outweighs the anticipated benefit of a recommended duration of P2Y12 inhibitor therapy after stent implantation, earlier discontinuation (e.g., <12 months) of P2Y12 inhibitor therapy is reasonable. CLASS IIb Continuation of DAPT beyond 12 months may be considered in patients undergoing stent implantation. CLASS III: HARM

Prasugrel should not be administered to patients with a prior history of stroke or transient ischemic attack. Timing of Urgent CABG in Patients With NSTEACS in Relation to Use of Antiplatelet Agents: Recommendations CLASS I Nonenteric-coated aspirin (81 mg to 325 mg daily) should be administered preoperatively to patients undergoing CABG. In patients referred for elective CABG, clopidogrel and ticagrelor should be discontinued for at least

5 days before surgery (Level of Evidence: B) and prasugrel for at least 7 days before surgery In patients referred for urgent CABG, clopidogrel and ticagrelor should be discontinued for at least 24 hours to reduce major bleeding In patients referred for CABG, short-acting intravenous GPnIIb/IIIa inhibitors (eptifibatide or tirofiban) should be discontinued for at least 2 to 4 hours before surgery and abciximab for at least 12 hours before to limit blood loss and transfusion CLASS 2B

In patients referred for urgent CABG, it may be reasonable to perform surgery less than 5 days after clopidogrel or ticagrelor has been discontinued and less than 7 days after prasugrel has been discontinued LATE HOSPITAL CARE, HOSPITAL DISCHARGE, AND POSTHOSPITAL DISCHARGE CARE

CLASS I Medications required in the hospital to control ischemia should be continued after hospital discharge in patients with NSTE-ACS who do not undergo coronary revascularization, patients with incomplete or unsuccessful revascularization and patients with recurrent symptoms after revascularization. Titration of the doses may be required. All patients who are postNSTE-ACS should be given sublingual or spray nitroglycerin with verbal and written instructions for its use.

Before hospital discharge, patients with NSTE-ACS should be informed about symptoms of worsening myocardial ischemia and MI and should be given verbal and written instructions about how and when to seek emergency care for such symptoms. Before hospital discharge, patients who are post NSTE-ACS and/or designated responsible caregivers should be provided with easily

understood and culturally sensitive verbal and written instructions about medication type, purpose, dose, frequency, side effects, and duration of use. For patients who are postNSTE-ACS and have initial angina lasting more than 1 minute, nitroglycerin (1

dose sublingual or spray) is recommended if angina does not subside within 3 to 5 minutes; call 9-1-1 immediately to access emergency medical services. If the pattern or severity of angina changes, suggesting worsening myocardial ischemia (e.g., pain is more frequent or severe or is precipitated by less effort or occurs at rest), patients should contact their clinician without delay to assess the need for additional treatment or testing. Before discharge, patients should be educated about modification of cardiovascular risk factors Late Hospital and Posthospital Oral Antiplatelet

Therapy: Recommendations CLASS I Aspirin should be continued indefinitely. The maintenance dose should be 81 mg daily in patients treated with ticagrelor and 81 mg to 325 mg daily in all other patients. In addition to aspirin, a P2Y12 inhibitor (either clopidogrel or ticagrelor) should be continued for up to 12 months in all patients with NSTE-ACS without contraindications who are treated with an ischemia-guided strategy.

Options include: Clopidogrel: 75mg daily Ticagrelor: 90 mg twice daily In patients receiving a stent (bare-metal stent or DES) during PCI for NSTE-ACS,

P2Y12 inhibitor therapy should be given for at least 12 months . Options include: Clopidogrel: 75 mg daily Prasugrel: 10 mg daily Ticagrelor: 90mg twice daily Special population Clinical Presentation Anginal pain in NSTE-ACS patients may have the following presentations:

Prolonged (.20 min) anginal pain at rest; New onset (de novo) angina (class II or III of the Canadian Cardiovascular Society classification); Recent destabilization of previously stable angina with at least Canadian Cardiovascular Society Class

III angina characteristics (crescendo angina); or Post-MI angina. Diagnosis 0 h/3 h rule-out algorithm of non-ST-elevation acute coronary syndromes using highsensitivity cardiac troponin assays

New: 0 h/1 h rule-in & rule-out algorithm of non-ST-elevation acute coronary syndromes using high-sensitivity cardiac troponin assays Recommendations Recommendations for antiischaemic drugs in the acute phase Recommendati ons in DAPT

Recommendati ons in DAPT NE W Dosing of glycoprotein IIb/IIIa inhibitors in patients with normal and impaired renal function Dosing of anticoagulants in patients with normal and impaired renal function

Recommendation NE s for W anticoagulation Suggested strategies to reduce bleeding risk related to PCI NE W Antithrombotic strategies in patients

with NSTEMI and non-valvular A. Fib Recommendations for combining antiplatelet agents and anticoagulants in NSTEMI patients requiring chronic oral anticoagulation Risk criteria mandating invasive strategy in NSTE-ACS Selection of treatment strategy and timing according to initial risk stratification.

Recommendations for perioperative management of antiplatelet therapy patients requiring CABG Recommendations for invasive coronary angiography and revascularization

Recommendations for the management of patients with heart failure NSTEMI Recommendations for longterm management after non-ST-elevation acute coronary syndromes To do and not to do messages from the guidelines

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