Transcript Integration of Training Programs

ACC/AHA GUIDELINES
UA/NSTEMI 9/00
UNSTABLE ANGINA & NON–ST-SEGMENT
ELEVATION MYOCARDIAL INFARCTION
COMMITTEE MEMBERS
Eugene Braunwald, MD, Chair
Elliott M. Antman, MD
John W. Beasley, MD
Robert M. Califf, MD
Melvin D. Cheitlin, MD
Judith S. Hochman, MD
Robert H. Jones, MD
Dean Kereiakes, MD
Joel Kupersmith, MD
Thomas N. Levin, MD
Carl J. Pepine, MD
John W. Schaeffer, MD
Earl E. Smith, III, MD
David E. Steward, MD
Pierre Theroux, MD
UA/NSTEMI 9/00
ACUTE CORONARY SYNDROME
No ST Elevation
ST Elevation
NSTEMI
Unstable Angina
NQMI
QwMI
Myocardial Infarction
CAUSES OF UA/NSTEMI
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Mechanical
Obstruction
Thrombosis
.
 MVO2
Dynamic
Obstruction
Inflammation/
Infection
Mechanical
Obstruction
Thrombosis
.
 MVO2
Dynamic
Obstruction
Braunwald, Circulation
98:2219, 1998
Inflammation/
Infection
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UA/NSTEMI
THREE PRINCIPAL PRESENTATIONS
Rest Angina*
Angina occurring at rest and
prolonged, usually > 20 minutes
New-onset Angina
New-onset angina of at least CCS
Class III severity
Increasing Angina
Previously diagnosed angina that has
become distinctly more frequent,
longer in duration, or lower in
threshold (i.e., increased by > 1 CCS)
class to at least CCS Class III severity.
* Pts with NSTEMI usually present with angina at rest.
Braunwald
Circulation 80:410; 1989
Mortality at 42 Days (% of patients)
TROPONIN I LEVELS PREDICT THE
Changes
in
Focus
on
Heart
Failure
RISK
OF
MORTALITY
IN
UA/NSTEMI
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7.5
8
6.0
6
3.7
3.4
4
1.7
2
1.0
831
174
148
134
1.0 to <2.0
2.0 to <5.0
50
67
0
0 to <0.4
0.4 to <1.0
5.0 to <9.0
>9.0
Cardiac Troponin I (ng/ml)
Risk Ratio
1.0
Antman
N Engl J Med. 335:1342, 1996
1.8
3.5
3.9
6.2
7.8
PURSUIT TRIAL: DEATH OR MI
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1
0.98
0.96
0.94
0.92
0.9
0.88
0.86
0.84
0.82
0.8
0
30
60
90
120
150
180
Days
N Engl J Med. 339:436-43, 1998
TROPONINS T AND I
AS PREDICTORS OF MORTALITY
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Cardiac Mortality
6.9
Total Mortality
6.4
7
6
5.0
5
4
3
3.3
2.0
1.7
2
1
0
PTS
Trop.
No. Trials
1993
1057
Neg
Pos
6
RR
1641
792
Neg
Pos
7
RR
RECOMMENDATION
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Class I
1.
Patients with suspected ACS with chest
discomfort at rest for >20 min, hemodynamic
instability, or recent syncope or presyncope
should be referred immediately to an ED or a
specialized chest pain unit.
Other patients with a suspected ACS may be
seen initially in an ED, a chest pain unit, or
an outpatient facility.
RISK STRATIFICATION
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Class I
1. Noninvasive stress testing in low-risk pts free of
ischemia at rest or with low-level activity and of
CHF for a minimum of 12 to 24 h.
2. Noninvasive stress testing in pts at intermediate
risk who have been free of ischemia at rest or
with low-level activity and of CHF for a minimum
of 2 or 3 days.
RISK STRATIFICATION (cont’d)
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Class I
3. Choice of stress test is based on the resting ECG,
local expertise, and technologies. Treadmill exercise
in pts able to exercise in whom the ECG is free of
baseline ST-segment abnormalities, BBB, LVH,
intraventricular conduction defect, paced rhythm,
pre-excitation, and digoxin effect.
4. An imaging modality in pts with resting ST-segment
depression (>0.1 mV), LVH, BBB, IVCD, pre-excitation,
or digoxin who are able to exercise.
RISK STRATIFICATION (cont’d)
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Class I
5. Pharmacological stress testing with imaging
when physical limitations (e.g., arthritis,
amputation, severe peripheral vascular disease,
severe COPD, general debility) preclude
adequate exercise stress.
6. Prompt angiography without noninvasive risk
stratification for failure of stabilization with
medical treatment.
NONINVASIVE RISK STRATIFICATION
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High risk (>3% annual mortality rate)
1. Severe LV dysfunction (LVEF < 0.35), rest or
exercise
2. High-risk treadmill score (score < -11)
3. Stress-induced large perfusion defect
4. Stress-induced multiple perfusion defects
Gibbons et al JACC 33:2092, 1999
NONINVASIVE RISK STRATIFICATION
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High risk (>3% annual mortality rate)
5. Large, fixed perfusion defect with LV dilation or
increased lung uptake
6. Stress-induced moderate perfusion defect with
LV dilation or increased lung uptake
7. Echocardiographic wall motion abnormality
(>2 segments) at a low dose of dobutamine
(< 10 mg•kg-1 •min-1) or at a low heart rate
(<120 bpm)
Gibbons et al JACC 33:2092, 1999
NONINVASIVE RISK STRATIFICATION
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Intermediate Risk (1-3% annual mortality rate)
1. Mild/moderate resting LV dysfunction (LVEF 0.350.49)
2. Intermediate-risk treadmill score (-11< score <5)
3. Stress-induced moderate perfusion defect
without LV dilation or increased lung intake
4. Echocardiographic ischemia with wall motion
abnormality involving < 2 segments only at
higher doses of dobutamine
Gibbons et al JACC 33:2092, 1999
NONINVASIVE RISK STRATIFICATION
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Low Risk (<1% annual mortality rate)
1. Low-risk treadmill score (score > 5)
2. Normal perfusion or small myocardial
perfusion defect at rest or with stress
3. Normal echocardiographic wall motion or no
change of limited resting wall motion
abnormalities during stress
Gibbons et al JACC 33:2092, 1999
DEATH OR MI AT 30 DAYS
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18
Placebo
16.7
GP IIb-IIIa Inhibitor
Percent of Patients
14.1
14
11.6
10.9
10.2
10.1
9
10
5.9
4.8
6
3.6
3.9
1.8
2
0
EPIC
CAPTURE
EPILOG
EPISTENT
PRISM-PLUS
PURSUIT
DEATH, MI OR URGENT
REVASC. @ 30 DAYS
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Placebo
GP IIb-IIIa Inhibitor
15.9
16
14.8
Percent of Patients
12.8
12.2
11.5
11.3
12
10.3
10.5
8
8
4.8
4.9
4.5
EPILOG
EPISTENT
4
0
EPIC
CAPTURE
IMPACT II
RESTORE
MEDICATIONS AT HOSPITAL DISCHARGE
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Class I
1. Aspirin 75 to 325 mg/d
2. Clopidogrel 75 mg/qd for patients with
contraindication to ASA
3. -Blocker
4. Lipid-lowering agent and diet in patients with
LDL cholesterol >130 mg/dL
5. Lipid-lowering agent if LDL cholesterol level after
diet is > 100 mg/dL
6. ACEI for patients with CHF, LV dysfunction
(EF<0.40) hypertension, or diabetes
UA/NSTEMI 9/00
INSTRUCTIONS AT HOSPITAL DISCHARGE
RISK FACTOR MODIFICATION
Class I
1. Smoking cessation and achievement or maintenance
of optimal weight, daily exercise, and diet.
2. HMG-CoA reductase inhibitor for LDL cholesterol
> 130 mg/dL.
3. Lipid-lowering agent if LDL cholesterol after diet is
> 100 mg/dL.
4. Hypertension control to a BP < 130/85 mm Hg.
5. Tight control of hyperglycemia in diabetics.
6. Consider referral of smokers to a smoking
cessation program.
EARLY INVASIVE STRATEGY
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Class I
1. Any of the following high-risk indicators:
a. Recurrent angina/ischemia at rest or with lowlevel activities despite intensive anti-ischemic therapy
b. Recurrent angina/ischemia with CHF symptoms, S3,
pulmonary edema, increasing rales, or new or
worsening MR
c. High-risk findings on noninvasive stress testing
d. Depressed LV systolic function (e.g., EF<0.40 on
noninvasive study)
e. Hemodynamic instability
EARLY INVASIVE STRATEGY (cont’d)
UA/NSTEMI 9/00
Class I
f. Sustained ventricular tachycardia
g. PCI within 6 months
h. Prior CABG
2. In the absence of these findings, either an early
conservative or an early invasive strategy in
hospitalized patients without contraindication for
revascularization.
Class IIa
1. An early invasive strategy in pts with repeated
presentation for ACS despite therapy and without
evidence for ongoing ischemia or high risk.
EARLY INVASIVE STRATEGY (cont’d)
UA/NSTEMI 9/00
Class IIa
2. An early invasive strategy in pts >65 years or pts
with ST-segment depression or elevated cardiac
markers and no contraindication to
revascularization.
Class III
1. Coronary angiography in pts with extensive
comorbidities, in whom risks of
revascularization are not likely to outweigh
benefits, in pts with a low likelihood of ACS and
in pts who will not consent to revascularization.
UA/NSTEMI 9/00
GP IIb/IIIa Inhibition in UA/NSTEMI
CAPTURE, PURSUIT, PRISM-PLUS
All
Death or MI
10%
N = 12,296
OR = 0.66
P = 0.001
N = 2,754
OR = 0.59
P = 0.001
8%
8.0%
6%
4.9%
4.3%
4%
2.9%
2%
0%
+24h
+48h
Start GP IIb/IIIa inhibitor / placebo
Boersma et al. Circulation 100:2045, 2000
+72h
+24h
+48h
Percutaneous Coronary Intervention
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LMWH IN UNSTABLE ANGINA
EFFECT ON TRIPLE ENDPOINT*
Day
6
FRISC
(dalteparin; n = 1,482
FRAXIS
(nadroparin; n = 2,357
14
ESSENCE
(enoxaparin; n = 3,171)
(P = 0.032)
14
TIMI 11B
(enoxaparin; n = 3,910)
(P = 0.029)
14
0.75
1
LMWH better
1.5
UFH better
* Triple endpoint: death, MI, recurrent ischemia + urgent revascularization
ANTI - ISCHEMIC Rx
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Class IIa
1. Oral long-acting Ca2+ blocker for recurrent ischemia when
-blocker and nitrate fully used.
2. ACEI for all post-ACS patients.
3. Intra-aortic balloon pump counterpulsation for severe
ischemia that is continuing or recurs frequently despite
intensive medical therapy or for hemodynamic instability
in pts before or after coronary angiography.
Class IIb
1. Extended-release form of nondihydropyridine Ca2+
blocker instead of a -blocker.
2. Immediate-release dihydropyridine Ca2+ blocker in the
presence of a -blocker.
ANTI - ISCHEMIC Rx
UA/NSTEMI 9/00
Class I
1. Bed rest with continuous ECG monitoring in pts with
ongoing rest pain.
2. NTG, sublingual tablet or spray, followed by IV
administration for ongoing chest pain.
3. Supplemental O2 for pts with hypoxemia, cyanosis or
respiratory distress; finger pulse oximetry or arterial
blood gas determination to confirm SaO2>90%.
4. Morphine sulfate IV when symptoms are not immediately
relieved with NTG or when acute pulmonary congestion
and/or severe agitation is present.
ANTI - ISCHEMIC Rx (cont’d)
UA/NSTEMI 9/00
Class I
5. A -blocker with the first dose administered IV if there
is ongoing chest pain, followed by oral administration.
6. A nondihydropyridine Ca2+ blocker (e.g. verapamil or
diltiazem) as initial therapy in pts with continuing or
frequently recurring ischemia when -blocker is
contraindicated.
7. An ACEI when hypertension persists despite treatment
with NTG and a -blocker in pts with LV systolic
dysfunction or congestive heart failure and in ACS
patients with diabetes.
UA/NSTEMI
HOSPITAL MANAGEMENT
UA/NSTEMI 9/00
Monitoring (rhythm and ischemia)
 blocker
Nitrate
Heparin
GP IIb/IIIa inhibitor (?)
Early invasive strategy
Immediate
angiography
12-48 hour
angiography
Early conservative strategy
Recurrent
symptoms/ischemia
Heart failure
Serious arrhythmia
Patient stabilizes
Evaluate LV function
EF<.40
EF>.40
Stress Test
Not low risk
Low risk
Medical Rx
UA/NSTEMI 9/00
UA/NSTEMI
PATHOGENESIS (NON-EXCLUSIVE)
Nonocclusive thrombus on pre-existing plaque
Dynamic obstruction (coronary spasm or
vasoconstriction)
Progressive mechanical obstruction
Inflammation and/or infection
Secondary UA
Braunwald Circulation 98:2219, 1998
UA/NSTEMI 9/00
RISK STRATIFICATION IN
EMERGENCY DEPARTMENT
HIGH RISK-FEATURES (RISK RISES WITH NUMBER)
History
Prolonged ischemic discomfort (>20 min), ongoing
rest pain, accelerating tempo of ischemia
Clinical findings
Pulmonary edema; S3 or new rales
New MR murmur
Hypotension, bradycardia, tachycardia
Age >75 years
ECG
Rest pain with transient ST-segment changes
> 0.05 mV; new bundle-branch block, new
sustained VT
Cardiac markers
Elevated (e.g. TnT or TnI>0.1 ng/mL)
ED MANAGEMENT OF UA/NSTEMI
UA/NSTEMI 9/00
ST  ?
NO
Nondiagnostic ECG
Normal serum cardiac markers
Observe
Follow-up at 4-8 hours: ECG, cardiac markers
No recurrent pain;
Neg follow-up studies
Stress study to provoke
ischemia prior to discharge
or as outpatient
Neg: nonischemic
discomfort;low-risk UA/NSTEMI
Outpatient follow-up
YES
ST and/or T wave changes
Ongoing pain
+ cardiac markers
Hemodynamic abnormalities
Evaluate
for
Reperfusion
Recurrent ischemic pain or
+ UA/NSTEMI follow-up studies
Diagnosis of UA/NSTEMI
confirmed
+ UA/NSTEMI confirmed
ADMIT
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Trials
ANTIPLATELET AND
ANTICOAGULATION Rx
Patients with event
(%)
Risk ratio (95% CI)
P-value
Active Placebo
N % Death or MI
ASA vs placebo
2448
6.4
12.5
0.0005
999
2.6
5.5
0.018
2629
2.0
5.3
0.0005
All GP IIb/IIIa + UFH + ASA
vs UFH + ASA
17044
5.1
6.2
0.0022
UFH + ASA vs ASA
LMWH + ASA
vs ASA
Active Treatment Superior
Active Treatment Inferior
ANTIPLATELET Rx
UA/NSTEMI 9/00
Class I
Possible ACS
Aspirin
Likely/Definite ACS
Definite ACS with continuing
Ischemia or Other High-Risk
Features or planned PCI
Aspirin
Aspirin
+
+
Subcutaneous LMWH
IV heparin
+
or
IV platelet GP IIb/IIIa antagonist
IV heparin
ANTIPLATELET Rx
UA/NSTEMI 9/00
Class I
1. Administer ASA as soon as possible after
presentation and continue indefinitely.
2. A thienopyridine (clopidogrel or ticlopidine) in pts
unable to take ASA.
3. Add IV UFH or subcutaneous LMWH to antiplatelet
therapy with ASA, clopidogrel, or ticlopidine.
4. Add platelet GP IIb/IIIa receptor antagonist in pts
with continuing ischemia or with other high-risk
features and in pts in whom early PCI is planned.
EVALUATION OF ACS PTS IN ED
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10,689 Pts with
suspected ACS
Pain in chest,
left arm, jaw,
epigastrium,
dyspnea,
dizziness,
palpitations
Evaluation for
acute ischemia
Neg.
7,996 pts (75%)
Selker Ann Intern Med. 129:845, 1998
Pos.
2,672 pts (25%)
TELEPHONE TRIAGE
UA/NSTEMI 9/00
Class I
1. Patients with symptoms that suggest
possible ACS should not be evaluated only
over the phone but should be referred to a
facility that allows evaluation by a physician
and the recording of a 12-lead ECG.
UA/NSTEMI 9/00
BIOCHEMICAL CARDIAC MARKERS IN PTS
WITH SUSPECTED ACS WITHOUT STE
Disadvantages
CK-MB
Myoglobin
Troponins
1. Lack of specificity
with skeletal
muscle
disease/injury
1. Very low specificity
with skeletal
muscle injury or
disease
1. Low sensitivity in
early phase of MI
(<6 h after
symptom onset)
2. Low sensitivity
during early MI (<6
h) or late (>36 h)
after symptom
onset and for minor
myocardial damage
2. Rapid return to
normal
2. Limited ability to
detect late minor
reinfarction
UA/NSTEMI 9/00
BIOCHEMICAL CARDIAC MARKERS IN
PTS WITH SUSPECTED ACS WITHOUT STE
Advantages
CK-MB
1. Rapid, costefficient, accurate
assays
2. Ability to detect
early reinfarction
Myoglobin
Troponins
1. High sensitivity
1. Powerful for stratification
2. Useful in early
detection of MI
2. Greater sensitivity and
specificity than CK-MB
3. Detection of
reperfusion
3. Detection of recent MI up
to 2 weeks after onset
4. Most useful in
ruling out MI
4. Useful for selection of
therapy
5. Detection of reperfusion
UA/NSTEMI 9/00
RISK STRATIFICATION IN
EMERGENCY DEPARTMENT
HIGH RISK-FEATURES (RISK RISES WITH NUMBER)
History
Prolonged ischemic discomfort (>20 min), ongoing
rest pain, accelerating tempo of ischemia
Clinical findings
Pulmonary edema; S3 or new rales
New MR murmur
Hypotension, bradycardia, tachycardia
Age >75 years
ECG
Rest pain with transient ST-segment changes
> 0.05 mV; new bundle-branch block, new
sustained VT
Cardiac markers
Elevated (e.g. TnT or TnI>0.1 ng/mL)
UA/NSTEMI 9/00
UA/NSTEMI:
A MAJOR MEDICAL PROBLEM
•
5.32m ED visits for chest pain
•
1.43m hospitalizations/year (1o diagnosis)
•
60% > 65 years, 46% women
National Center for Health Statistics
ANTI - ISCHEMIC Rx
UA/NSTEMI 9/00
Class I
1. Bed rest with continuous ECG monitoring in pts with
ongoing rest pain.
2. NTG, sublingual tablet or spray, followed by IV
administration for ongoing chest pain.
3. Suplemental O2 for pts with hypoxemia, cyanosis or
respiratory distress; finger pulse oximetry or arterial
blood gas determination to confirm SaO2>90%.
4. Morphine sulfate IV when symptoms are not
immediately relieved with NTG or when acute pulmonary
congestion and/or severe agitation is present.
ANTI - ISCHEMIC Rx (cont’d)
UA/NSTEMI 9/00
Class I
5. A -blocker with the first dose administered IV if
there is ongoing chest pain, followed by oral
administration.
6. A nondihydropyridine Ca2+ blocker (e.g.
verapamil or diltiazem) as initial therapy in pts
with continuing or frequently recurring ischemia
when -blocker is contraindicated.
7. An ACEI when hypertension persists despite
treatment with NTG and a -blocker in pts with
LV systolic dysfunction or congestive heart
failure and in ACS patients with diabetes.
ANTI - ISCHEMIC Rx
UA/NSTEMI 9/00
Class Ila
1. Oral long-acting Ca2+ blocker for recurrent
ischemia when -blocker and nitrate fully used.
2. ACEI for all post-ACS patients.
3. Intra-aortic balloon pump counterpulsation for
severe ischemia that is continuing or recurs
frequently despite intensive medical therapy or
for hemodynamic instability in pts before or after
coronary angiography.
UA/NSTEMI 9/00
INTERMEDIATE LIKELIHOOD THAT UA/NSTEMI
IS CAUSED BY OBSTRUCTIVE CAD
History
Chest or left arm pain reproducing prior
reproducing prior documented angina.
Known history of CAD, including MI
Examination
Transient MR, hypotension, diaphoresis,
pulmonary edema, or rales
ECG
New, or presumably new, transient STsegment deviation (0.05 mV) or T-wave
inversion (0.2 mV) with symptoms
Cardiac markers
Elevated cardiac Tnl, TnT, or CK-MB
UA/NSTEMI 9/00
INTERMEDIATE LIKELIHOOD THAT UA/NSTEMI
IS CAUSED BY OBSTRUCTIVE CAD
Absence of high-likelihood features and presence
of any of the following:
History
Chest or left arm pain or discomfort
Age > 70
Male sex
Diabetes mellitus
Examination
Extracardiac vascular disease
ECG
Fixed Q waves
Abnormal ST segments or T
waves not documented to be new
Cardiac markers
Normal
UA/NSTEMI 9/00
UA/NSTEMI
EMERGENCY ROOM TRIAGE
• Chest pain or severe epigastric pain, typical of
myocardial ischemia or MI:
• Substernal compression or crushing chest pain
• Pressure, tightness, heaviness, cramping,
•
•
aching sensation
Unexplained indigestion, belching, epigastric pain
Radiating pain to neck, jaw, shoulders, back or to
one or both arms
• Associated dyspnea, nausea and/or vomiting,
diaphoresis
IF THESE SYMPTOMS ARE PRESENT, OBTAIN STAT ECG
UA/NSTEMI 9/00
FEATURE
HIGH OR INTERMEDIATE LIKELIHOOD THAT
UA/NSTEMI IS CAUSED BY OBSTRUCTIVE CAD
HIGH LIKELIHOOD
INTERMEDIATE LIKELIHOOD
Absence of high-likelihood features
and presence of any of the following:
History
Chest or left arm pain
reproducing prior
documented angina. Known
history of CAD, including MI
Examination Transient MR, hypotension,
diaphoresis, pulmonary
edema, or rales
Chest or left arm pain or
discomfort
Age > 70
Male sex
Diabetes mellitus
Extracardiac vascular
disease
UA/NSTEMI 9/00
FEATURE
HIGH OR INTERMEDIATE LIKELIHOOD THAT
UA/NSTEMI IS CAUSED BY OBSTRUCTIVE CAD
HIGH LIKELIHOOD
INTERMEDIATE LIKELIHOOD
Absence of high-likelihood features
and presence of any of the following:
ECG
New transient STsegment deviation or
T-wave inversion
(0.2 mV) with symptoms
Fixed Q waves
Abnormal ST segments
or T waves not
documented to be new
Cardiac
markers
Elevated cardiac Tnl, TnT,
or CK-MB
Normal
UA/NSTEMI 9/00
REVASCULARIZATION
STRATEGY IN UA/NSTEMI
Cardiac
Catheterization
Coronary Artery
Disease
No
Discharge from
Protocol
Yes
CABG
Yes
Left Main Disease
No
1 or 2 VD
3 VD or 2 VD with
proximal LAD
LV Dysfunction
or Diabetes
No
Medical Therapy
PCI or CABG
PCI or CABG
No
CABG
UA/NSTEMI 9/00
UA/NSTEMI
MODE OF REVASCULARIZATION
Extent of Disease
Treatment
Class/Level
of Evidence
Left main disease, candidate
for CABG
CABG
I/A
PCI
IIb/C
CABG
I/A
Left main disease not candidate
for CABG
Three-vessel disease with EF <0.50
Multivessel disease including proximal CABG
LAD with EF <0.50 or treated diabetes
PCI
Multivessel disease with EF >0.50 and
without diabetes
PCI
I/A
IIb/B
I/A
UA/NSTEMI MODE
UA/NSTEMI 9/00
OF REVASCULARIZATION (CONT’D)
Extent of Disease
Treatment Class/Level
of Evidence
One- or 2 -vessel disease without
proximal LAD but with large areas of
myocardial ischemia or high-risk
criteria on noninvasive testing
CABG
or PCI
I/B
One-vessel disease with proximal LAD
CABG
or PCI
IIa/B
One- or 2-vessel disease without
proximal LAD, with small area of
ischemia or no ischemia on
noninvasive testing
CABG
or PCI
III/C
Insignificant coronary stenosis
CABG
or PCI
III/C
UA/NSTEMI 9/00
SPECIAL GROUPS
DIABETES
Class I
1. Tight glucose control. CABG with use of the
IMA preferred over PCI.
Class IIa
1. PCI for pts with diabetes with 1-vessel
disease and inducible ischemia.
2. Abciximab for diabetics treated with
coronary stenting.
UA/NSTEMI 9/00
SPECIAL GROUPS
POST CABG PATIENTS
Class I
1. Because of many anatomic possibilities that
may be responsible for recurrent ischemia, the
threshold for angiography in post-CABG
patients with UA/NSTEMI should be low.
Class IIa
1. Repeat CABG for multiple SVG stenoses,
especially when there is significant stenosis of
a graft that supplies the LAD. PCI for a focal
saphenous vein stenosis.
2. Stress testing should involve imaging.
COCAINE
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CLINICAL CHARACTERISTICS
 Ischemic chest pain
 Usually male < 40 years
 Cigarette smokers, but no other risk factors for
atherosclerosis
 Associated with all routes of administration
 Not dose dependent
 Often associated with use of cigarettes and/or
alcohol
Adapted from Pitts et al.
Prog. Cardiovasc. Dis. 40:65, 1997
UA/NSTEMI 9/00
SPECIAL GROUPS
COCAINE
Class I
1. NTG and oral Ca2+ blocker for pts with ST
deviation that accompanies ischemic chest
discomfort.
2. Immediate coronary arteriography in pts with ST
elevation after NTG and Ca2+ blocker;
thrombolysis if a thrombus is detected.
UA/NSTEMI 9/00
SPECIAL GROUPS
COCAINE
Class IIa
1. Ca2+ blocker for pts with ST deviation suggestive
of ischemia.
2. -blocker for pts with SBP>150 mm Hg and/or
HR > 100 min.
3. Fibrinolytic therapy if ST elevated despite NTG
and Ca2+ blocker and coronary arteriography is
not possible.
4. Coronary arteriography, if available, for pts with
new ST depression or T-wave inversion
unresponsive to NTG and Ca2+ blocker.
UA/NSTEMI 9/00
SPECIAL GROUPS
PRINZMETAL’S ANGINA
Class I
1. Coronary arteriography in pts with episodic chest
pain and ST elevation that resolves with NTG and/or
Ca2+ blocker.
2. Treatment with nitrates and Ca2+ blocker in pts with
normal coronary arteriogram.
Class IIa
1. Provocative testing in pts with a nonobstructive
lesion on coronary arteriography, the clinical picture
of coronary spasm, and transient ST elevation.
UA/NSTEMI 9/00
SPECIAL GROUPS
PRINZMETAL’S ANGINA
Class IIb
1. Provocative testing without coronary arteriography.
2. In the absence of significant CAD on arteriography,
provocative testing with methylergonovine,
acetylcholine, or methacholine when coronary
spasm is suspected but there is no transient ST.
elevation.
Class III
1. Provocative testing in pts with high-grade
obstructive lesions on coronary arteriography.
POST-HOSPITAL DISCHARGE CARE
UA/NSTEMI 9/00
A
B
C
D
E
Aspirin and Anticoagulants
Beta blockers and Blood Pressure
Cholesterol and Cigarettes
Diet and Diabetes
Education and Exercise
UA/NSTEMI 9/00
FEATURES NOT CHARACTERISTIC
OF MYOCARDIAL ISCHEMIA
Pleuritic pain (i.e., sharp or knife-like pain
brought on by respiratory movements or cough)
Primary or sole location of discomfort in the
middle or lower abdominal region
Pain that may be localized at the tip of 1 finger,
particularly over the LV apex
UA/NSTEMI 9/00
FEATURES NOT CHARACTERISTIC
OF MYOCARDIAL ISCHEMIA (CONT’D)
 Pain reproduced with movement or palpation
of the chest wall or arms
 Very brief episodes of pain that last a few
seconds or less
 Pain that radiates into the lower extremities
UA/NSTEMI 9/00
ANTIPLATELET AND
ANTICOAGULATION RX
All ASA vs placebo
2448
6.4
12.5
All UFH vs ASA
999
2.6
5.5
2629
2.0
5.3
0.0005
17044
5.1
6.2
0.0022
All hep. or LMWH vsv ASA
All GPllb/llla vs UFH
0.0005
0.018
GP IIB/IIIA INHIBITION IN UA/NSTEMI
UA/NSTEMI 9/00
CAPTURE
10%
8%
N = 1,239
OR = 0.46
P = 0.009
N = 1,265
OR = 0.37
P = 0.032
6%
4%
2%
2.8%
1.3%
0%
2.8%
N = 1,228
OR = 0.71
P = 0.105
PURSUIT
10%
8%
N = 9,461
OR = 0.72
P = 0.003
6%
Death or MI
5.8%
10.3%
7.6%
4.4%
3.2%
4%
2%
0%
PRISM-PLUS
10%
8%
6%
4%
2%
0%
N = 1,570
OR = 0.45
P = 0.016
N = 287
OR = 0.35
P = 0.062
8.0%
3.8%
1.8%
2.9%
All
10%
8%
6%
N = 2,754
OR = 0.59
P = 0.001
N = 12,296
OR = 0.66
P = 0.001
8.0%
4.9%
4.3%
2.9%
4%
2%
0%
+24h
+48h
Start GP IIb/IIIa inhibitor / placebo
+72h
+24h
+48h
Percutaneous Coronary Intervention
Boersma, E et al.
Circulation
100:2045, 2000