_ _ _ua nstemi approach guidelines v2
TRANSCRIPT
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2014 AHA/ACC GUIDELINES FOR THEMANAGEMENT OF PATIENTS WITH
NONST-ELEVATIONACUTE CORONARY SYNDROMES
Aimee Victoria B. Dalisay, M.D.
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Circulation. 201
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EPIDEMIOLOGY
Worldwide, cardiovascular disease (CVD) isestimated to be the leading cause o death and
loss o disability!ad"usted lie years.Coronary artery disease (CAD) has assumed
e#idemic #ro#ortions globally.
By $%$%
increase by almost &' in theglobal CVD burden.
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A A*D *+-M
nstable angina (A) and the closelyrelated condition non/+!segment
elevation myocardial inarction (M)(*+-M) are very commonmaniestations o this disease and areres#onsible or a##ro0imately 1.'million hos#itali2ations each year (+#o#ulation)
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CLASSIFICATION OF
RECOMMENDATIONS ANDLEVELS OF EVIDENCE
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(Adapted from CW Hamm et al: Lancet 358:1533, 2001, anMJ Dave!: Heart 83:3"1, 2000#
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*A3 -VA3A4*A*D MA*A5-M-*
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C3*CA3 A++-++M-* A*D *A3
-VA3A4*
Pati!t" #it$ "%"&'t( ACS
"$)%*( + ,i" "t,ati.( +a"( )!t$ *i*i$))( ) ACS a!( a(,")%t')"3 t) ('i( )! t$ !(), $)"&ita*iati)! a!( a""i"t i!t$ "*'ti)! ) t,at!t )&ti)!"40-4235 L* ) Ei(!'6 73
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-M-65-*C7 D-8A6M-* 46
48A-* 9AC37 86-+-*A4*
Pati!t" #it$ "%"&'t( ACS a!(
$i8$-,i" at%," "%'$ a"')!ti!%i!8 '$"t &ai!9 ",(:"&!a9 ":!')&/&,":!')&9 ),&a*&itati)!" "$)%*( + ,,,(
i(iat*: t) t$ ED a!(t,a!"&),t( +: EMS #$! aai*a+*5(Cla!! $% Level of &vdence C#
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8645*4++: -A637 6+;+6A9CA4*
8erorm ra#id determination o li
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8645*4++: -A637 6+;+6A9CA4*
U" ,i" "')," t) a"""" &,)8!)"i" i!&ati!t" #it$ NSTE-ACS(Cla!! $#
6iscation models can be useul in
management(Class IIa)Continuous monitoring with 1$!lead -C5 maybe a reasonable alternative with initial non!diagnostic -C5 in #atients at
intermediate@high ris< or AC+(Class IIb)
7NP ), NT&,)-7NP may be considered toassess ris< in #atients with sus#ected AC+
(Class IIb)
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M 6+; +C46-
A8 ; ,i" a't)," ), CAD ai*: $i"t),: )
CAD9 $:&,t!"i)!9 $:&,'$)*"t,)*ia9(ia+t"9 ), '%,,!t "),3
P,i), '),)!a,: "t!)"i" ) ; =0?
ST-"8!t (iati)! )! ECG
At *a"t 2 a!8i!a* !t" i! &,i), 24 $)%,"
U" ) a"&i,i! i! &,i), @ (a:"
E*at( ",% 'a,(ia' +i)a,,"
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M 6+; +C46-
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56AC- 6+; M4D-3
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-A637 6+; +6A9CA4*
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B4MA6;-6+: DA5*4++
Ma"%, 'a,(ia'-"&'i.' t,)&)!i! t,)&)!i! I), T3 at &,"!tati)! a!( > < $ at,":&t) )!"t i! a** &ati!t" #it$ "%"&'t(
ACS t) i(!ti: &att,! ) a*%"(Cla!! $# O+tai! a((iti)!a* t,)&)!i! **" +:)!( < $
i! &ati!t" #it$ i!itia* !),a* ",ia*t,)&)!i!" #it$ ECG '$a!8" a!(/),i!t,(iat/$i8$ ,i" '*i!i'a* at%,"(Cla!!$#
With contem#orary tro#onin assays, C;!MB andmyoglobin are not useul or diagnosis o AC+(Class III)
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CA6DAC B4MA6;-6+
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D+CA65- 964M - -D46 C-+ 8A* *
4bserve #atients with sym#toms consistentwith AC+ without ob"ective evidence omyocardial ischemia (non!ischemic initial -C5
and normal cardiac tro#onin) in a chest #ainunit or telemetry unit with serial -C5s andcardiac tro#onin at =! to ?!hour intervals (ClassIIa)
5ive low!ris< #atients who are reerred orout#atient testing daily as#irin, short!acting*5, and other medication i a##ro#riate (e.g.,beta bloc
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EARLY HOSPITALCARE
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STANDARD MEDICALTHERAPY
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M-DCA3 MA*A5-M-*
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M-DCA3 MA*A5-M-*
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M-DCA3 MA*A5-M-*
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M-DCA3 MA*A5-M-*
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A+86*
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8$71$ *B46+
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58 B@A *B46+
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8A6-*-6A3 A*C4A53A*
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&A'L $)*A+$*&A)D $+CH&M$A
-.$D&D+/'A/&-$&+
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+C-MA!5D-D +6A-57
L)#-,i" "'), 5859 TIMI 0 ), 1B9
GRACE 10B3 L)#-,i" T!-!8ati a*
&ati!t"
Pati!t ), '*i!i'ia! &,,!' i!t$ a+"!' ) $i8$-,i" at%,"
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MM-DA- *VA+V- +6A-57
(W* $ )
R,a't),: a!8i!a
Si8!" ), ":&t)" ) HF ), !# ),
#),"!i!8 it,a* ,8%,8itati)! H)(:!ai' i!"ta+i*it:
R'%,,!t a!8i!a ), i"'$ia at ,"t ),#it$ *)#-** a'tiiti" ("&iti!t!"i (i'a* t$,a&:
S%"tai!( VT ), VF
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-A637 *VA+V- +6A-57
(W* $ )
N)! ) t$ a+)9 +%t GRACE ,i""'), 140
T&),a* '$a!8 i! T!
N# ), &,"%a+*: !# ST
(&,""i)!
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D-3A7-D *VA+V- +6A-57
(W* $'!&$ )
N)! ) t$ a+) +%t (ia+t" **it%"
R!a* i!"%'i!': GFR
3 R(%'( LV ":"t)*i' %!'ti)! EF 05403
Ea,*: &)"t-i!a,'ti)! a!8i!a
PCI #it$i! < )
P,i), CA7G
GRACE ,i" "'), 10140 TIMI "'), ;2
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+6A-5-+
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*4*!A*5*A3 8A* MA*A5-M-*
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+8-CA3 8A-* 5648+
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+8-CA3 8A-* 5648+
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+8-CA3 8A-* 5648+
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+8-CA3 8A-* 5648+
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+8-CA3 8A-* 5648+
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+8-CA3 8A-* 5648+
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A*; 74
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