Non–ST-Elevation–ACS 2014 Guidelines

Non–ST-Elevation–ACS 2014 Guidelines from Sun YaiCheng

 

Non–ST-Elevation–ACS 2014 Guidelines

Circulation. published online September 23, 2014

Prognosis: Early Risk Stratification

• Perform rapid determination of likelihood of ACS, including a 12-lead ECG within 10 min of arrival at ED (Class I)
• Perform serial ECGs at 15- to 30-min intervals during the first hour in symptomatic patients with initial non-diagnostic ECG (Class I)
• Measure cardiac troponin (cTnI or cTnT) in all patients with symptoms consistent with ACS (Class I)
• Measure serial cardiac troponin at presentation and 3–6 h after symptom onset in all patients with symptoms consistent with ACS (Class I)

Biomarkers: Diagnosis

• Measure cardiac-specific troponin (troponin I or T) at presentation and 3─6 h after symptom onset in all patients with suspected ACS to identify pattern of values (Class I)
• Obtain additional troponin levels beyond 6 h in patients with initial normal serial troponins with ECG changes and/or intermediate/high risk clinical features (Class I)
• With contemporary troponin assays, CK-MB and myoglobin are not useful for diagnosis of ACS (Class III)

Early Hospital Care
  Oxygen

• Administer supplemental oxygen only with SpO₂ < 90,  respiratory distress, or other high-risk features for hypoxemia (Class I)

  Nitrates

• Administer sublingual NTG every 5 min × 3 for continuing ischemic pain and then assess need for IV NTG (Class I)
• Administer IV NTG for persistent ischemia, HF, or hypertension (Class I)

  Beta-adrenergic blockers

• Initiate oral beta blockers within the first 24 h in the absence of HF, low-output state, risk for cardiogenic shock, or other contraindications to beta blockade (Class I)
• Use of sustained-release metoprolol succinate, carvedilol, or bisoprolol is recommended for beta-blocker therapy with concomitant NSTE-ACS, stabilized HF, and reduced systolic function (Class I)

Anticoagulant Therapy
  Aspirin

• Non–enteric-coated aspirin (162 mg–325 mg) to all patients promptly after presentation and maintenance dose (81 mg/d–162 mg/d) continued indefinitely (Class I)

  P2Y₁₂ inhibitors

• P2Y₁₂ inhibitors in addition to aspirin should be administered for up to 12 mo to all patients with NSTE-ACS without contraindications who are treated with either an early invasive or ischemia-guided strategy (Class I)

Clopidogrel (Plavix) 300-mg or 600-mg loading dose, then 75 mg QD
Ticagrelor (Brilinta) 180-mg loading dose, then 90 mg BID

• Ticagrelor in preference to clopidogrel for patients treated with an early invasive or ischemia-guided strategy (Class IIa)

  GP IIb/IIIa inhibitors

• GP IIb/IIIa inhibitor [Eptifibatide (Integrilin) or tirofiban (Aggrastat)] in patients treated with an early invasive strategy and dual anti-platelet therapy (DAPT) with intermediate/high-risk features (e.g., positive troponin) (Class IIb)

  Parenteral anticoagulant therapy

• SC enoxaparin
• Bivalirudin
• SC Fondaparinux
• IV Heparin 

Ischemia-Guided Strategy Versus Early Invasive Strategies

1. Immediate invasive strategy (within 2 h)

• Refractory angina
• Signs or symptoms of HF or new or worsening MR
• Hemodynamic instability
• Recurrent angina or ischemia at rest or with low-level activities despite intensive medical therapy
• Sustained VT or VF

2. Ischemia-guided strategy
3. Early invasive strategy (within 24 h)
4. Delayed invasive strategy (within 25-72 h)

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Ten Points to Remember About NSTE-ACS

1. Door to ECG < 10min
2. 有症狀的病人，在第一小時，每15到30分鐘可重覆做ECG
3. Troponin 症狀開始要驗，3到6小時間要追蹤，症狀超過6小時後也要追蹤
4. 可以驗 Troponin 時，就不需同時驗 CK-MB，但可考慮驗 BNP
5. SpO₂ < 90%、呼吸窘迫或可能會低血氧的病人需給 O₂
6. Ticagrelor (Brilinta) 優於 Clopidrogel (Plavix)
7. 低風險病患安排 CV OPD F/U, 要給 aspirin, NTG & beta-blocker
8. NSTE-ACS 的處置由 Initial Invasive versus Conservative Strategy 改為 Ischemia-Guided Strategy versus Early Invasive Strategies
9. PCI 分成 Immediate invasive (< 2hr)、Early invasive (< 24hr) 和 Delayed invasive (25-72 hr) 
10. 頑固性心絞痛 ，心臟衰竭或二尖瓣脫垂症狀，血液動力學不穩定，休息時仍反覆心絞痛且藥物治療無效，sustained VT or VF, 建議 2小時內做 PCI

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