Patient Care

Updated Guidelines for Management of Non-ST-Elevation Acute Coronary Syndrome


Clinical question: What is the recommended approach for management of non-ST-elevation acute coronary syndrome (NSTE-ACS)?

Background: This is the first comprehensive update from the American Heart Association/American College of Cardiology (AHA/ACC) on NSTE-ACS since 2007 and follows a focused update published in 2012.

Synopsis: This guideline provides recommendations for acute and long-term care of patients with NSTE-ACS.

Cardiac-specific troponin assays (troponin I or T) are the mainstay for ACS diagnosis. When contemporary troponin assays are used for diagnosis, other biomarkers (CK-MB, myoglobin) are not useful.

Initial hospital care for all patients with NSTE-ACS should include early initiation of beta-blockers (within the first 24 hours), high-intensity statin therapy, P2Y12 inhibitor (clopidogrel or ticagrelor) plus aspirin, and parenteral anticoagulation.

An early invasive strategy (diagnostic angiography within 24 hours with intent to perform revascularization based on coronary anatomy) is preferred to an ischemia-guided strategy, particularly in high-risk NSTE-ACS patients (Global Registry of Acute Coronary Events [GRACE] score >140).

“Ischemia-guided” strategy replaces the term “conservative management strategy,” and its focus on aggressive medical therapy is an option in selected low-risk patient populations (e.g. thrombolysis in myocardial infarction [TIMI] risk score 0 or 1, GRACE score <109, low-risk troponin-negative females). Patients managed with an ischemia-guided strategy should undergo pre-discharge noninvasive stress testing for further risk stratification.

Regardless of angiography strategy (invasive vs. ischemia-guided), post-discharge dual antiplatelet therapy (clopidogrel or ticagrelor) is recommended for up to 12 months in all patients with NSTE-ACS. Prasugrel is an appropriate P2Y12 inhibitor option for patients following percutaneous coronary intervention with stent placement.

All patients with NSTE-ACS should be referred to an outpatient comprehensive cardiovascular rehabilitation program.

Citation: Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of non-ST-elevation acute coronary syndromes. J Am Coll Cardiol. 2014;64(24):e139-228.

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