ACC/AHA 2007 Guidelines for UA/NSTEMI

ACC/AHA 2007 Guidelines for UA & NSTEMI from Sun YaiCheng

ACC/AHA 2007 Guidelines for the Management of Patients with Unstable Angina/Non-ST-Elevation Myocardial Infarction  Circulation. 2007;116;e148-e304 J. Am. Coll. Cardiol. 2007;50;652-726  Initial Evaluation and Management of UA/NSTEMI  Clinical Assessment

• 12-lead ECG should be performed and shown to EP as soon as possible, with a goal of within 10 min of ED arrival for all patients with chest discomfort or symptoms suggestive of ACS.
• If initial ECG is not diagnostic but patient remains symptomatic and there is high clinical suspicion for ACS, serial ECGs, initially at 15- to 30-min intervals, should be performed to detect the potential for development of ST-segment elevation or depression. 

Early Risk Stratification TIMI Risk Score

• Age ≥ 65 years
• At least 3 risk factors for CAD (family history of CAD, hypertension, hypercholesterolemia, diabetes, or current smoker)
• Prior coronary stenosis of ≥ 50%
• ST-segment deviation on ECG
• At least 2 anginal events in prior 24 hours
• Use of aspirin in prior 7 days
• Elevated serum cardiac biomarkers 

GRACE risk score

Selection of Initial Treatment Strategy Initial Invasive versus Conservative Strategy Invasive

• Recurrent angina/ischemia at rest with low-level activities despite intensive medical therapy
• Elevated cardiac biomarkers (TnT or TnI)
• New/presumably new ST-segment depression
• Signs/symptoms of HF or new/worsening MR
• High-risk findings from noninvasive testing
• Hemodynamic instability
• Sustained VT 
• PCI within 6 months 
• Prior CABG 
• High risk score (e.g., TIMI, GRACE)
• Reduced left ventricular function (LVEF < 40%)

Conservative

• Low risk score (e.g., TIMI, GRACE)
• Patient/physician presence in the absence of high-risk features 

Stepped-Care Approach to Pharmacological Therapy for Musculoskeletal Symptoms with Known Cardiovascular Disease or Risk Factors for Ischemic Heart Disease
   

ED Management Strategies: Guidelines at a Glance