Guidelines for Unstable Angina or Non-STEMI Add Conservative Option

DALLAS, Aug. 8 -- Patients with non-ST elevation segment myocardial infarction or less severe unstable angina can begin with a conservative noninvasive treatment strategy, according to updated guidelines from two major heart groups.
An early echocardiogram should be considered to identify left ventricular dysfunction, according to the updated guidelines, posted online by the American Heart Association and American College of Cardiology ahead of publication in Circulation and the Journal of the American College of Cardiology.
The AHA/ACC guideline panel, chaired by Jeffrey L. Anderson, M.D., of the University of Utah, recommended an exercise or pharmacologic stress test before or soon after discharge to identify patients with latent ischemia that might benefit from revascularization.
The recommendations represent a substantive departure from the 2002 version of the guidelines, which emphasized an early, invasive strategy for most patients with non-STEMI or unstable angina. Five years later, a conservative approach is a reasonable option for more patients because "use of aggressive anticoagulant and antiplatelet agents has reduced the incidence of adverse outcomes inpatients managed conservatively," the authors said.
The choice between an early invasive or conservative noninvasive strategy hinges on a physician's ability to make an accurate estimate of a patient's risk. The guidelines set forth two criteria for establishing low risk:
A low-risk score on a recognized scale, such as TIMI or GRACE
The patient or physician prefers an invasive strategy in the absence of high-risk features
The guidelines panel pointed out that the "primary objective in selecting a treatment strategy is to yield the best long-term clinical outcome." General patient characteristics, such as those outlined in the guidelines, can help physicians in the decision-making process but ultimately "individual judgment is required."
Other revisions to the guidelines focused on more aggressive treatment of cardiac risk factors. The AHA and ACC recommended a target LDL level of less than 100 mg/dL for all patients and cited 70 mg/dL as the ideal level. Blood pressure should be treated to less than 140/90 mm Hg, and patients with diabetes or chronic kidney disease should have a blood pressure of less than 130/80 mm Hg.
Secondary prevention strategies should emphasize aggressive use of ACE inhibitors. Patients with heart failure should receive an aldosterone receptor antagonist, a class of medication that was not available when the guidelines were revised in 2002.
Other recommendations incorporated into the update include:
12 months of treatment with the antiplatelet agent clopidogrel after placement of a drug-eluting coronary stent and six months of treatment for patients who receive bare-metal stents.
Discontinuation of hormone replacement therapy in postmenopausal women.
Use of assays for cardiac troponin and B-type natriuretic peptide in the evaluation and monitoring of patients
Discontinuation of NSAIDs during hospitalization for unstable angina or non-STEMI.
Dr. Anderson reported grants from AstraZenica and Bristol-Myers Squibb, and that he is on the speaker's bureau of Merck. He also reported relationships with Sanofi and ThromboVision. Other members of the writing committee also reported relationships with various pharmaceutical firms. Additional source: Journal of the American College of CardiologySource reference: Anderson JL et al. "http://circ.ahajournals.org/cgi/content/abstract/CIRCULATIONAHA.107.185752v1" 20target="">ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction-executive summary. A report of the American College of Cardiology/American Heart Association 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).">
ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction-executive summary. A report of the American College of Cardiology/American Heart Association 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