2010年9月14日 星期二

ACC/AHA 2007 Guidelines for UA/NSTEMI



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

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