2014 AHA/ACC Guideline for the€Management of Patients With Non–ST-Elevation Acute Coronary ...

43 Pages·2015·3.74 MB·English

JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL. 64, NO. 24, 2014
ª2014 BY THE AMERICAN HEART ASSOCIATION, INC., AND ISSN 0735-1097/$36.00
THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION http://dx.doi.org/10.1016/j.jacc.2014.09.016
PUBLISHED BY ELSEVIER INC.
CLINICAL PRACTICE GUIDELINE: EXECUTIVE SUMMARY
2014 AHA/ACC Guideline for
the Management of Patients With
–
Non ST-Elevation Acute Coronary Syndromes:
Executive Summary
AReportoftheAmericanCollegeofCardiology/AmericanHeartAssociation
TaskForceonPracticeGuidelines
DevelopedinCollaborationWiththeSocietyforCardiovascularAngiographyandInterventions
andtheSocietyofThoracicSurgeons
EndorsedbytheAmericanAssociationforClinicalChemistry
Writing EzraA.Amsterdam,MD,FACC,Chairy EricD.Peterson,MD,MPH,FACC,FAHA*#
Committee NanetteK.Wenger,MD,MACC,FAHA,ViceChair*y MarcS.Sabatine,MD,MPH,FACC,FAHA*y
Members* RichardW.Smalling,MD,PHD,FACC,FSCAI***
RalphG.Brindis,MD,MPH,MACC,FSCAIz SusanJ.Zieman,MD,PHD,FACCy
DonaldE.Casey,JR,MD,MPH,MBA,FACP,FAHAx
TheodoreG.Ganiats,MDk
DavidR.Holmes,JR,MD,MACCy *Writingcommitteemembersarerequiredtorecusethemselvesfrom
AllanS.Jaffe,MD,FACC,FAHA*y votingonsectionstowhichtheirspecificrelationshipswithindustryand
otherentitiesmayapply;seeAppendix1forrecusalinformation.
HaniJneid,MD,FACC,FAHA,FSCAIy yACC/AHARepresentative.zACC/AHATaskForceonPracticeGuidelines
RosemaryF.Kelly,MD{ Liaison.xAmericanCollegeofPhysiciansRepresentative.kAmerican
MichaelC.Kontos,MD,FACC,FAHA*y AcademyofFamilyPhysiciansRepresentative.{SocietyofThoracic
SurgeonsRepresentative.#ACC/AHATaskForceonPerformance
GlennN.Levine,MD,FACC,FAHAy
MeasuresLiaison.**SocietyforCardiovascularAngiographyand
PhilipR.Liebson,MD,FACC,FAHAy InterventionsRepresentative.
DebabrataMukherjee,MD,FACCy
ThewritingcommitteegratefullyacknowledgesthememoryofDr.FrancisM.Fesmire(representativeoftheAmericanCollegeofEmergencyPhy-
sicians),whodiedduringthedevelopmentofthisdocumentbutcontributedimmenselytoourunderstandingofnon–ST-elevationacutecoronary
syndromes.
ThisdocumentwasapprovedbytheAmericanCollegeofCardiologyBoardofTrusteesandtheAmericanHeartAssociationScienceAdvisoryand
CoordinatingCommitteeinAugust2014.
TheAmericanCollegeofCardiologyrequeststhatthisdocumentbecitedasfollows:AmsterdamEA,WengerNK,BrindisRG,CaseyDEJr,GaniatsTG,
HolmesDRJr,JaffeAS,JneidH,KellyRF,KontosMC,LevineGN,LiebsonPR,MukherjeeD,PetersonED,SabatineMS,SmallingRW,ZiemanSJ.2014
AHA/ACCguidelineforthemanagementofpatientswithnon–ST-elevationacutecoronarysyndromes:executivesummary:areportoftheAmerican
CollegeofCardiology/AmericanHeartAssociationTaskForceonPracticeGuidelines.JAmCollCardiol2014;64:2645–87.
ThisarticleiscopublishedinCirculation.
Copies:ThisdocumentisavailableontheWorldWideWebsitesoftheAmericanCollegeofCardiology(www.cardiosource.org)andtheAmerican
HeartAssociation(my.americanheart.org).Forcopiesofthisdocument,pleasecontacttheElsevierInc.ReprintDepartment,fax[phone],e-mail
[e-mail].
Permissions:Multiplecopies,modification,alteration,enhancement,and/ordistributionofthisdocumentarenotpermittedwithouttheexpress
permission of the American College of Cardiology. Requests may be completed online via the Elsevier site (http://www.elsevier.com/authors/
obtainingpermission-to-re-useelsevier-material).
Listentothismanuscript’saudiosummarybyJACCEditor-in-ChiefDr.ValentinFuster.
Youcanalsolistentothisissue’saudiosummarybyJACCEditor-in-ChiefDr.ValentinFuster.
2646 Amsterdametal. JACC VOL. 64, NO. 24, 2014
2014AHA/ACCNSTE-ACSGuideline:ExecutiveSummary DECEMBER 23, 2014:2645–87
ACC/AHATask JeffreyL.Anderson,MD,FACC,FAHA,Chair RichardJ.Kovacs,MD,FACC,FAHA
ForceMembers JonathanL.Halperin,MD,FACC,FAHA,Chair-Elect E.MagnusOhman,MD,FACC
SusanJ.Pressler,PHD,RN,FAHA
NancyM.Albert,PHD,RN,FAHA FrankW.Sellke,MD,FACC,FAHA
BiykemBozkurt,MD,PHD,FACC,FAHA Win-KuangShen,MD,FACC,FAHA
RalphG.Brindis,MD,MPH,MACC WilliamG.Stevenson,MD,FACC,FAHAyy
LesleyH.Curtis,PHD,FAHA DumindaN.Wijeysundera,MD,PHD
DavidDeMets,PHDyy ClydeW.Yancy,MD,FACC,FAHAyy
LeeA.Fleisher,MD,FACC,FAHA
SamuelGidding,MD,FAHA
RobertA.Guyton,MD,FACCyy yyFormerTaskForcemember;currentmemberduringthe
JudithS.Hochman,MD,FACC,FAHAyy writingeffort.
TABLE OF CONTENTS
PREAMBLE.................................... 2647 4.2. InhibitorsoftheRenin-Angiotensin-Aldosterone
System.................................. 2657
1.INTRODUCTION .............................2649 4.3. InitialAntiplatelet/AnticoagulantTherapyin
PatientsWithDefiniteorLikelyNSTE-ACS .... 2657
1.1. MethodologyandEvidenceReview ..........2649
4.3.1.InitialOralandIntravenousAntiplatelet
1.2. OrganizationoftheGWC ...................2649 TherapyinPatientsWithDefiniteorLikely
NSTE-ACSTreatedWithanInitialInvasive
1.3. DocumentReviewandApproval.............2649 orIschemia-GuidedStrategy........... 2657
4.3.2.InitialParenteralAnticoagulantTherapyin
1.4. ScopeoftheCPG .........................2650 PatientsWithDefiniteNSTE-ACS .......2659
2.OVERVIEWOFACS .......................... 2650 4.4. Ischemia-GuidedStrategyVersusEarlyInvasive
Strategies ...............................2659
4.4.1.EarlyInvasiveandIschemia-Guided
3.INITIALEVALUATIONANDMANAGEMENT:
Strategies ..........................2659
RECOMMENDATIONS ........................ 2650
4.5. RiskStratificationBeforeDischargefor
3.1. ClinicalAssessmentandInitialEvaluation.....2650 PatientsWithanIschemia-GuidedStrategy
ofNSTE-ACS............................. 2661
3.2. EmergencyDepartmentorOutpatient
FacilityPresentation.......................2650
5.MYOCARDIALREVASCULARIZATION:
3.3. Prognosis—EarlyRiskStratification...........2650
RECOMMENDATIONS ........................ 2661
3.4. CardiacBiomarkersandtheUniversal
DefinitionofMyocardialInfarction...........2654 5.1. PCI—GeneralConsiderations ................ 2661
3.4.1.Biomarkers:Diagnosis ................ 2654 5.1.1.PCI—OralandIntravenousAntiplatelet
Agents ............................. 2661
3.4.2.Biomarkers:Prognosis ................ 2654 5.1.1.1. PCI—GPIIb/IIIaInhibitors ......... 2662
3.5. DischargeFromtheEDorChestPainUnit.....2655 5.1.2.AnticoagulantTherapyinPatients
UndergoingPCI...................... 2663
4.EARLYHOSPITALCARE:RECOMMENDATIONS.. 2655
5.2. TimingofUrgentCoronaryArteryBypassGraftin
4.1. StandardMedicalTherapies ................2655 PatientsWithNSTE-ACSinRelationtoUseof
AntiplateletAgents........................2663
4.1.1.Oxygen ............................ 2655
4.1.2.Nitrates ............................ 2655
6.LATEHOSPITALCARE,HOSPITALDISCHARGE,
4.1.3.AnalgesicTherapy ................... 2655
ANDPOSTHOSPITALDISCHARGECARE:
4.1.4.Beta-AdrenergicBlockers..............2656 RECOMMENDATIONS ........................ 2663
4.1.5.CalciumChannelBlockers............. 2657
6.1. MedicalRegimenandUseofMedicationsat
4.1.6.CholesterolManagement.............. 2657 Discharge................................2663
JACC VOL. 64, NO. 24, 2014 Amsterdametal 2647
DECEMBER 23, 2014:2645–87 2014AHA/ACCNSTE-ACSGuideline:ExecutiveSummary
6.2. LateHospitalandPosthospitalOralAntiplatelet AHA have shared a responsibility to translate scientific
Therapy.................................2664 evidence into clinical practice guidelines (CPGs) with
6.3. CombinedOralAnticoagulantTherapyand recommendations to standardize and improve cardio-
AntiplateletTherapyinPatientsWithNSTE-ACS..2664 vascular health. These CPGs, based on systematic
methods to evaluate and classify evidence, provide a
6.4. RiskReductionStrategiesforSecondary
Prevention...............................2664 cornerstoneofqualitycardiovascularcare.
In response to published reports from the Institute of
6.5. PlanofCareforPatientsWithNSTE-ACS......2665 Medicine (1,2) and the ACC/AHA’s mandate to evaluate
new knowledge and maintain relevance at the point of
7.SPECIALPATIENTGROUPS:
care, the ACC/AHA Task Force on Practice Guidelines
RECOMMENDATIONS ........................ 2665
(Task Force) began modifying its methodology. This
7.1. NSTE-ACSinOlderPatients ................2665 modernization effort is published in the 2012 Methodol-
ogy Summit Report (3) and 2014 perspective article (4).
7.2. HeartFailureandCardiogenicShock ........2665
The latter recounts the history of the collaboration,
7.3. DiabetesMellitus.........................2667 changes over time, current policies, and planned initia-
7.4. Post–CABG ..............................2668 tives to meet the needs of an evolving healthcare envi-
ronment. Recommendations on value in proportion to
7.5. PerioperativeNSTE-ACSRelatedto
resource utilization will be incorporated as high-quality
NoncardiacSurgery.......................2668
comparative-effectiveness data become available (5).
7.6. ChronicKidneyDisease ...................2668 The relationships between CPGs and data standards,
7.7. Women ................................2668 appropriate use criteria, and performance measures are
addressedelsewhere(4).
7.8. Anemia,Bleeding,andTransfusion..........2668 IntendedUse—CPGsproviderecommendationsapplicable
7.9. CocaineandMethamphetamineUsers .......2668 to patients with or at risk of developing cardiovascular
disease. The focus is on medical practice in the United
7.10. Vasospastic(Prinzmetal)Angina ............2668
States, but CPGs developed in collaboration with other
7.11. ACSWithAngiographicallyNormalCoronary organizations may have a broader target. Although CPGs
Arteries ................................2669
maybeusedtoinformregulatoryorpayerdecisions,the
7.12. Stress(Takotsubo)Cardiomyopathy .........2669 intent is to improve the quality of care and be aligned
withthepatient’sbestinterest.
8.QUALITYOFCAREANDOUTCOMESFORACS—USE Evidence Review—Guideline writing committee (GWC)
OFPERFORMANCEMEASURESANDREGISTRIES: members are charged with reviewing the literature;
RECOMMENDATION .........................2669 weighing the strength and quality of evidence for or
against particular tests, treatments, or procedures; and
9.SUMMARYANDEVIDENCEGAPS ..............2669 estimatingexpectedhealthoutcomeswhendataexist.In
analyzing the data and developing CPGs, the GWC uses
REFERENCES ................................. 2670 evidence-based methodologies developed by the Task
Force (6). A key component of the ACC/AHA CPG meth-
APPENDIX1 odology is the development of recommendations on the
basis of all available evidence. Literature searches focus
AuthorRelationshipsWithIndustryand
OtherEntities(Relevant).......................2680 on randomized controlled trials (RCTs) but also include
registries, nonrandomized comparative and descriptive
APPENDIX2 studies, case series, cohort studies, systematic reviews,
andexpertopinion.Onlyselectedreferencesarecitedin
ReviewerRelationshipsWithIndustryand
the CPG. To ensure that CPGs remain current, new data
OtherEntities(Relevant).......................2683
arereviewedbiannuallybytheGWCsandtheTaskForce
to determine if recommendations should be updated or
PREAMBLE modified. In general, a target cycle of 5 years is planned
forfullrevisions(1).
The American College of Cardiology (ACC) and the Guideline-Directed Medical Therapy—Recognizing ad-
American Heart Association (AHA) are committed to the vances in medical therapy across the spectrum of car-
prevention and management of cardiovascular diseases diovasculardiseases,theTaskForcedesignatedtheterm
through professional education and research for clini- “guideline-directed medical therapy” (GDMT) to repre-
cians, providers, and patients. Since 1980, the ACC and sentrecommendedmedicaltherapyasdefinedmainlyby
2648 Amsterdametal. JACC VOL. 64, NO. 24, 2014
2014AHA/ACCNSTE-ACSGuideline:ExecutiveSummary DECEMBER 23, 2014:2645–87
TABLE 1 ApplyingClassificationofRecommendationsandLevelofEvidence
ArecommendationwithLevelofEvidenceBorCdoesnotimplythattherecommendationisweak.Manyimportantclinicalquestionsaddressedintheclinicalpracticeguidelinesdonot
lendthemselvestoclinicaltrials.Althoughrandomizedtrialsareunavailable,theremaybeaveryclearclinicalconsensusthataparticulartestortherapyisusefuloreffective.
*Dataavailablefromclinicaltrialsorregistriesabouttheusefulness/efficacyindifferentsubpopulations,suchassex,age,historyofdiabetesmellitus,historyofpriormyocardial
infarction,historyofheartfailure,andprioraspirinuse.
†Forcomparative-effectivenessrecommendations(ClassIandIIa;LevelofEvidenceAandBonly),studiesthatsupporttheuseofcomparatorverbsshouldinvolvedirectcomparisons
ofthetreatmentsorstrategiesbeingevaluated.
Class I measures, generally a combination of lifestyle recommendation, which encompasses the anticipated
modificationanddrug-anddevice-basedtherapeutics.As magnitude and judged certainty of benefit in proportion
medical science advances, GDMT evolves, and hence torisk)isassignedbytheGWC.Concurrently,theLevelof
GDMT is preferred to “optimal medical therapy.” For Evidence (LOE) rates the scientific evidence supporting
GDMT and all other recommended drug treatment regi- the effect of the intervention on the basis on the type,
mens,thereadershouldconfirmthedosagewithproduct quality, quantity, and consistency of data from clinical
insert material and carefully evaluate for contraindica- trials and other reports (Table 1) (4). Unless otherwise
tions and possible drug interactions. Recommendations stated, recommendations are presented in order by the
arelimitedtotreatments,drugs,anddevicesapprovedfor COR and then the LOE. Where comparative data exist,
clinicaluseintheUnitedStates. preferred strategies take precedence. When more than 1
Class of Recommendation and Level of Evidence—Once drug,strategy,ortherapyexistswithinthesameCORand
recommendations are written, the Class of Recommen- LOEandtherearenocomparativedata,optionsarelisted
dation (COR; i.e., the strength the GWC assigns to the alphabetically.
JACC VOL. 64, NO. 24, 2014 Amsterdametal 2649
DECEMBER 23, 2014:2645–87 2014AHA/ACCNSTE-ACSGuideline:ExecutiveSummary
RelationshipsWithIndustryandOtherEntities—TheACC JeffreyL.Anderson,MD,FACC,FAHA
and AHA exclusively sponsor the work of GWCs without Chair,ACC/AHATaskForceonPracticeGuidelines
commercial support, and members volunteer their time
1. INTRODUCTION
for this activity. The Task Force makes every effort to
avoid actual, potential, or perceived conflicts of interest
that might arise through relationships with industry or 1.1. MethodologyandEvidenceReview
other entities (RWI). All GWC members and reviewers The recommendations listed in this CPG are, whenever
are required to fully disclose current industry relation- possible, evidence based. An extensive evidence review
ships or personal interests from 12 months before initia- wasconductedthroughOctober2012,andotherselected
tion of the writing effort. Management of RWI involves references published through April 2014 were reviewed
selecting a balanced GWC and requires that both the by the GWC. Literature included was derived from
chair and a majority of GWC members have no relevant researchinvolvinghumansubjects,publishedinEnglish,
RWI(seeAppendix1forthedefinitionofrelevance).GWC and indexed in MEDLINE (through PubMed), EMBASE,
membersarerestrictedwithregardtowritingorvotingon the Cochrane Library, Agency for Healthcare Research
sections to which their RWI apply. In addition, for and Quality Reports, and other selected databases rele-
transparency, GWC members’ comprehensive disclosure vant to this CPG. The relevant data are included in evi-
information is available as an online supplement. dence tables in the Online Data Supplement. Key search
Comprehensive disclosure information for the Task wordsincludedbutwerenotlimitedtothefollowing:acute
Forceisavailableasanadditionalsupplement.TheTask coronary syndrome, anticoagulant therapy, antihyperten-
Force strives to avoid bias by selecting experts from a sives, anti-ischemic therapy, antiplatelet therapy, antith-
broad array of backgrounds representing different rombotictherapy,betablockers,biomarkers,calciumchannel
geographic regions, sexes, ethnicities, races, intellectual blockers, cardiac rehabilitation, conservative management,
perspectives/biases, and scopes of clinical practice. diabetes mellitus,glycoproteinIIb/IIIainhibitors,heart fail-
Selected organizations and professional societies with ure, invasive strategy, lifestyle modification, myocardial
related interests and expertise are invited to participate infarction, nitrates, non-ST-elevation, P2Y receptor inhi-
12
aspartnersorcollaborators. bitor,percutaneouscoronaryintervention,renin-angiotensin-
IndividualizingCareinPatientsWithAssociatedConditions aldosterone inhibitors, secondary prevention, smoking
and Comorbidities—The ACC and AHA recognize the cessation,statins,stent,thienopyridines,troponins,unstable
complexityofmanagingpatientswithmultipleconditions, angina, and weight management. Additionally, the GWC
comparedwithmanagingpatientswithasingledisease,and reviewed documents related to NSTE-ACS previously
thechallengeiscompoundedwhenCPGsforevaluationor published by the ACC and AHA. References selected and
treatment of several coexisting illnesses are discordant or published in this document are representative and not
interacting(7).CPGsattempt to definepracticesthat meet all-inclusive.
theneedsofpatientsinmost,butnotall,circumstancesand
donotreplaceclinicaljudgment. 1.2. OrganizationoftheGWC
Clinical Implementation—Management in accordance The GWC was composed of clinicians, cardiologists, in-
with CPG recommendations is effective only when ternists,interventionists, surgeons,emergency medicine
followed; therefore, to enhance their commitment to specialists, family practitioners, and geriatricians. The
treatment and compliance with lifestyle adjustment, GWC included representatives from the ACC and AHA,
clinicians should engage the patient to participate American Academy of Family Physicians, American
in selecting interventions on the basis of the pa- College of Emergency Physicians, American College
tient’s individual values and preferences, taking associ- ofPhysicians,SocietyforCardiovascularAngiographyand
ated conditions and comorbidities into consideration Interventions,andSocietyofThoracicSurgeons.
(e.g., shared decision making). Consequently, there are
circumstancesinwhichdeviationsfromtheseguidelines 1.3. DocumentReviewandApproval
areappropriate. Thisdocumentwasreviewedby2officialreviewerseach
TherecommendationsinthisCPGaretheofficialpolicy nominatedbytheACCandAHA;1reviewereachfromthe
oftheACCandAHAuntiltheyaresupersededby apub- American Academy of Family Physicians, American Col-
lished addendum, focused update, or revised full-text legeofEmergencyPhysicians,SocietyforCardiovascular
CPG. The reader is encouraged to consult the full-text Angiography and Interventions, and Society of Thoracic
CPG (8) for additional guidance and details about the Surgeons;and37individualcontentreviewers(including
management of patients with non–ST-elevation acute members of the American Association of Clinical Chem-
coronary syndrome (NSTE-ACS) because the executive istry, ACC Heart Failure and Transplant Section Leader-
summarycontainsmainlytherecommendations. ship Council, ACC Cardiovascular Imaging Section
2650 Amsterdametal. JACC VOL. 64, NO. 24, 2014
2014AHA/ACCNSTE-ACSGuideline:ExecutiveSummary DECEMBER 23, 2014:2645–87
Leadership Council, ACC Interventional Section Leader- and the supporting documentation to encourage their
ship Council, ACC Prevention of Cardiovascular Disease application.
Committee, ACC Surgeons’ Council, Association of In-
2. OVERVIEW OF ACS
ternational Governors, and Department of Health and
Human Services). Reviewers’ RWI information was
ACShasevolvedasausefuloperationaltermthatrefersto
distributedtotheGWCandispublishedinthisdocument
a spectrum of conditions compatible with acute myocar-
(Appendix2).
dialischemiaand/orinfarctionthatareusuallyduetoan
This document was approved for publication by the
abruptreductionincoronarybloodflow(Figure1).
governing bodies of the ACC and the AHA and endorsed
3. INITIAL EVALUATION AND MANAGEMENT:
by the American Association for Clinical Chemistry,
RECOMMENDATIONS
Society for Cardiovascular Angiography and Inter-
ventions,andtheSocietyofThoracicSurgeons.
3.1. ClinicalAssessmentandInitialEvaluation
1.4. ScopeoftheCPG CLASSI
The 2014 NSTE-ACS CPG is a full revision of the 2007 1. Patients with suspected ACS should be risk stratified based
ACCF/AHA CPG for the management of patients with onthelikelihoodofACSandadverseoutcome(s)todecideon
unstable angina (UA) and non–ST-elevation myocardial the need for hospitalization and assist in the selection of
treatmentoptions(40–42).(LevelofEvidence:B)
infarction(NSTEMI)andthe2012focusedupdate(9).The
new title, “Non–ST-Elevation Acute Coronary Syn-
dromes,” emphasizes the continuum between UA and 3.2. EmergencyDepartmentorOutpatientFacilityPresentation
NSTEMI. At presentation, patients with UA and NSTEMI CLASSI
can be indistinguishable and are therefore considered
1. Patients with suspected ACS and high-risk features such as
togetherinthisCPG. continuingchestpain,severedyspnea,syncope/presyncope,
In the United States, NSTE-ACS affects >625,000 pa- or palpitations should be referred immediately to the
tients annually,* or almost three fourths of all patients emergencydepartment(ED)andtransportedbyemergency
withacutecoronarysyndrome(ACS)(10).Inselectingthe medicalserviceswhenavailable.(LevelofEvidence:C)
initial approach to care, the term “ischemia-guided
strategy” has replaced the previous descriptor, “initial CLASSIIb
conservative management,” to more clearly convey the 1. Patients with less severe symptoms may be considered for
physiologicalrationaleofthisapproach. referraltotheED,achestpainunit,orafacilitycapableof
Thetaskofthe2014GWCwastoestablishacontempo- performing adequate evaluation depending on clinical cir-
rary CPG for the optimal management of patients with cumstances.(LevelofEvidence:C)
NSTE-ACS.Itincorporatesbothestablishedandnewevi-
dencefrompublishedclinicaltrials,aswellasinformation 3.3. Prognosis—EarlyRiskStratification
from basic science and comprehensive review articles.
SeeFigure2andTable3forestimationatpresentationof
These recommendations were developed to guide the
death and nonfatal cardiac ischemic events. See Table 4
clinician in improving outcomes for patients with NSTE-
forasummaryofrecommendationsfromthissection.
ACS. Table 2 lists documents deemed pertinent to this
effortandisintendedforuseasaresource,thusobviating
CLASSI
theneedtorepeatextantCPGrecommendations.
1. Inpatientswithchestpainorothersymptomssuggestiveof
The GWC abbreviated the discussion sections to
ACS,a12-leadelectrocardiogram(ECG)shouldbeperformed
include an explanation of salient information related to
and evaluated for ischemic changes within 10 minutes of
therecommendations.Incontrasttotextbookdeclaratory thepatient’sarrivalatanemergencyfacility(22).(Levelof
presentations,explanationsweresupplementedwithev- Evidence:C)
idencetables.TheGWCalsoprovidedabriefsummaryof
2. If the initial ECG is not diagnostic but the patient remains
the relevant recommendations and references related to
symptomatic and there is a high clinical suspicion for ACS,
secondary prevention rather than detailed reiteration.
serialECGs(e.g.,15-to30-minuteintervalsduringthefirst
Throughout, the goal was to provide the clinician with
hour) should be performed to detect ischemic changes.
concise,evidence-basedcontemporaryrecommendations
(LevelofEvidence:C)
3. Serial cardiac troponin I or T levels (when a contemporary
assayisused)shouldbeobtainedatpresentationand3to6
hours after symptom onset (see Section 3.4.1, Class I, #3
*Estimateincludessecondarydischargediagnoses. recommendationiftimeofsymptomonsetisunclear)inall
JACC VOL. 64, NO. 24, 2014 Amsterdametal 2651
DECEMBER 23, 2014:2645–87 2014AHA/ACCNSTE-ACSGuideline:ExecutiveSummary
TABLE 2 AssociatedCPGsandStatements
Title Organization PublicationYear(Reference)
CPGs
Stableischemicheartdisease ACC/AHA/AATS/PCNA/SCAI/STS 2014(11)*2012(12)
Atrialfibrillation AHA/ACC/HRS 2014(13)
Assessmentofcardiovascularrisk ACC/AHA 2013(14)
Heartfailure ACC/AHA 2013(15)
Lifestylemanagementtoreducecardiovascularrisk AHA/ACC 2013(16)
Managementofoverweightandobesityinadults AHA/ACC/TOS 2013(17)
ST-elevationmyocardialinfarction ACC/AHA 2013(18)
Treatmentofbloodcholesteroltoreduceatheroscleroticcardiovascularriskinadults ACC/AHA 2013(19)
AcutemyocardialinfarctioninpatientspresentingwithST-segmentelevation ESC 2012(20)
Device-basedtherapy ACC/AHA/HRS 2013(21)
Thirduniversaldefinitionofmyocardialinfarction ESC/ACC/AHA/WHF 2012(22)
AcutecoronarysyndromesinpatientspresentingwithoutpersistentST-segmentelevation ESC 2011(23)
Coronaryarterybypassgraftsurgery ACC/AHA 2011(24)
Hypertrophiccardiomyopathy ACC/AHA 2011(25)
Effectiveness-basedguidelinesforthepreventionofcardiovasculardiseaseinwomen AHA/ACC 2011(26)
Percutaneouscoronaryintervention ACC/AHA/SCAI 2011(27)
Secondarypreventionandriskreductiontherapyforpatientswithcoronary AHA/ACC 2011(28)
andotheratheroscleroticvasculardisease
Assessmentofcardiovascularriskinasymptomaticadults ACC/AHA 2010(29)
Myocardialrevascularization ESC 2010(30)
Unstableanginaandnon–ST-elevationmyocardialinfarction NICE 2010(31)†
Guidelinesforcardiopulmonaryresuscitationandemergencycardiovascular AHA 2010(32)
care—part9:postcardiacarrestcare
Seventhreportofthejointnationalcommitteeonprevention,detection, NHLBI 2003(33)
evaluation,andtreatmentofhighbloodpressure
Statements
Keydataelementsanddefinitionsformeasuringtheclinicalmanagementand ACC/AHA 2013(34)
outcomesofpatientswithacutecoronarysyndromesandcoronaryarterydisease
Practicalclinicalconsiderationsintheinterpretationoftroponinelevations ACC 2012(35)
Testingoflow-riskpatientspresentingtotheemergencydepartmentwithchestpain AHA 2010(36)
Primarypreventionofcardiovasculardiseasesinpeoplewithdiabetesmellitus AHA/ADA 2007(37)
Preventionandcontrolofinfluenza CDC 2005(38)
*Thefull-textSIHDCPGisfrom2012(12).Afocusedupdatewaspublishedin2014(11).
†Minormodificationsweremadein2013.Forafullexplanationofthechanges,seehttp://publications.nice.org.uk/unstable-angina-and-nstemi-cg94/changes-after-publication.
AATSindicatesAmericanAssociationforThoracicSurgery;ACC,AmericanCollegeofCardiology;ADA,AmericanDiabetesAssociation;AHA,AmericanHeartAssociation;CDC,Centers
forDiseaseControlandPrevention;CPG,clinicalpracticeguideline;ESC,EuropeanSocietyofCardiology;HRS,HeartRhythmSociety;NHLBI,NationalHeart,Lung,andBloodInstitute;
NICE,NationalInstituteforHealthandClinicalExcellence;PCNA,PreventiveCardiovascularNursesAssociation;SCAI,SocietyforCardiovascularAngiographyandInterventions;SIHD,
stableischemicheartdisease;STS,SocietyofThoracicSurgeons;TOS,TheObesitySociety;andWHF,WorldHeartFederation.
patientswhopresentwithsymptomsconsistentwithACSto 5. Risk scores should be used to assess prognosis in patients
identifyarisingand/orfallingpatternofvalues(22,43–48). withNSTE-ACS(40–42,52–57).(LevelofEvidence:A)
(LevelofEvidence:A)
CLASSIIa
4. Additional troponin levels should be obtained beyond 6
1. Risk-stratification models can be useful in management
hours after symptom onset (see Section 3.4.1, Class I, #3
(40–42,52–58).(LevelofEvidence:B)
recommendation if time of symptom onset is unclear) in
patients with normal troponin levels on serial examination 2. Itisreasonabletoobtainsupplementalelectrocardiographic
whenchangesonECGand/orclinicalpresentationconferan leadsV toV inpatientswhoseinitialECGisnondiagnostic
7 9
intermediateorhighindexofsuspicionforACS(22,49–51). and who are at intermediate/high risk of ACS (59–61).
(LevelofEvidence:A) (LevelofEvidence:B)
2652 Amsterdametal. JACC VOL. 64, NO. 24, 2014
2014AHA/ACCNSTE-ACSGuideline:ExecutiveSummary DECEMBER 23, 2014:2645–87
FIGURE1 AcuteCoronarySyndromes
ThetophalfofthefigureillustratestheprogressionofplaqueformationandonsetandcomplicationsofNSTE-ACS,withmanagementateachstage.The
numberedsectionofanarterydepictstheprocessofatherogenesisfrom1)normalarteryto2)extracellularlipidinthesubintimato3)fibrofattystageto
4)procoagulantexpressionandweakeningofthefibrouscap.ACSdevelopswith5)disruptionofthefibrouscap,whichisthestimulusforthrombogenesis.
6)Thrombusresorptionmaybefollowedbycollagenaccumulationandsmoothmusclecellgrowth.Thrombusformationandpossiblecoronaryvasospasm
reducebloodflowintheaffectedcoronaryarteryandcauseischemicchestpain.Thebottomhalfofthefigureillustratestheclinical,pathological,
electrocardiographic,andbiomarkercorrelatesinACSandthegeneralapproachtomanagement.Flowreductionmayberelatedtoacompletelyocclusive
thrombus(bottomhalf,rightside)orsubtotallyocclusivethrombus(bottomhalf,leftside).MostpatientswithST-elevation(thickwhitearrowinbottom
panel)developQwMI,andafew(thinwhitearrow)developNQMI.ThosewithoutST-elevationhaveeitherUAorNSTEMI(thickredarrows),adistinction
basedoncardiacbiomarkers.MostpatientspresentingwithNSTEMIdevelopNQMI;afewmaydevelopQwMI.Thespectrumofclinicalpresentations
includingUA,NSTEMI,andSTEMIisreferredtoasACS.ThisNSTE-ACSCPGincludessectionsoninitialmanagementbeforeNSTE-ACS,attheonsetof
NSTE-ACS,andduringthehospitalphase.Secondarypreventionandplansforlong-termmanagementbeginearlyduringthehospitalphase.Patientswith
noncardiacetiologiesmakeupthelargestgrouppresentingtotheEDwithchestpain(dashedarrow).
*Elevatedcardiacbiomarker(e.g.,troponin),Section3.4.
ACSindicatesacutecoronarysyndrome;CPG,clinicalpracticeguideline;Dx,diagnosis;ECG,electrocardiogram;ED,emergencydepartment;MI,myocardial
infarction;NQMI,non–Q-wavemyocardialinfarction;NSTE-ACS,non–ST-elevationacutecoronarysyndromes;NSTEMI,non–ST-elevationmyocardialinfarction;
QwMI,Q-wavemyocardialinfarction;STEMI,ST-elevationmyocardialinfarction;andUA,unstableangina.
ModifiedwithpermissionfromLibbyetal.(39).
JACC VOL. 64, NO. 24, 2014 Amsterdametal 2653
DECEMBER 23, 2014:2645–87 2014AHA/ACCNSTE-ACSGuideline:ExecutiveSummary
FIGURE2 GlobalRegistryofAcuteCoronaryEventsRiskCalculatorforIn-HospitalMortalityforAcuteCoronarySyndrome
2654 Amsterdametal. JACC VOL. 64, NO. 24, 2014
2014AHA/ACCNSTE-ACSGuideline:ExecutiveSummary DECEMBER 23, 2014:2645–87
presentation and 3 to 6 hours after symptom onset in all
TABLE 3 TIMIRiskScore*forNSTE-ACS
patientswhopresentwithsymptomsconsistentwithACSto
All-CauseMortality,NeworRecurrentMI,orSevere identify a rising and/or falling pattern (22,43–48,70–74).
TIMIRisk RecurrentIschemiaRequiringUrgentRevascularization
(LevelofEvidence:A)
Score Through14dAfterRandomization,%
0–1 4.7 2. Additional troponin levels should be obtained beyond 6
2 8.3 hoursaftersymptomonsetinpatientswithnormaltroponins
3 13.2 on serial examination when electrocardiographic changes
and/or clinical presentation confer an intermediate or
4 19.9
high index of suspicion for ACS (22,49–51,75). (Level of
5 26.2
Evidence:A)
6–7 40.9
3. If the time of symptom onset is ambiguous, the time of
*The TIMI risk score is determined by the sum of the presence of 7 variables at
admission;1pointisgivenforeachofthefollowingvariables:$65yofage;$3risk presentation should be considered the time of onset for
factorsforCAD;priorcoronarystenosis$50%;STdeviationonECG;$2anginalevents assessingtroponinvalues(44,45,49).(LevelofEvidence:A)
inprior24h;useofaspirininprior7d;andelevatedcardiacbiomarkers.
CAD indicates coronary artery disease; ECG, electrocardiogram; MI, myocardial
infarction;NSTE-ACS,non–ST-elevationacutecoronarysyndromes;andTIMI,Throm- CLASSIII:NOBENEFIT
bolysisInMyocardialInfarction. 1. With contemporary troponin assays, creatine kinase
ModifiedwithpermissionfromAntmanetal.(40).
myocardialisoenzyme(CK-MB)andmyoglobinarenotuseful
CLASSIIb fordiagnosisofACS(76–82).(LevelofEvidence:A)
1. Continuous monitoring with 12-lead ECG may be a
reasonablealternativeinpatientswhoseinitialECGisnon-
diagnostic and who are at intermediate/high risk of ACS 3.4.2. Biomarkers:Prognosis
(62,63).(LevelofEvidence:B) CLASSI
2. MeasurementofB-typenatriureticpeptideorN-terminalpro– 1. The presence and magnitude of troponin elevations are
B-typenatriureticpeptidemaybeconsideredtoassessriskin useful for short- and long-term prognosis (48,50,83,84).
patientswithsuspectedACS(64–68).(LevelofEvidence:B) (LevelofEvidence:B)
3.4. CardiacBiomarkersandtheUniversalDefinitionof CLASSIIb
MyocardialInfarction 1. Itmaybereasonabletoremeasuretroponinonceonday3or
SeeTable5forasummaryofrecommendationsfromthis day4inpatientswithamyocardialinfarction(MI)asanin-
section. dexofinfarctsizeanddynamicsofnecrosis(82,83).(Level
ofEvidence:B)
3.4.1. Biomarkers:Diagnosis
2. Use of selected newer biomarkers, especially B-type
CLASSI natriuretic peptide, may be reasonable to provide
1. Cardiac-specific troponin (troponin I or T when a contem- additional prognostic information (64,65,85–89). (Level of
porary assay is used) levels should be measured at Evidence:B)
TABLE 4 SummaryofRecommendationsforPrognosis:EarlyRiskStratification
Recommendations COR LOE References
PerformrapiddeterminationoflikelihoodofACS,includinga12-leadECGwithin10minofarrivalatan I C (22)
emergencyfacility,inpatientswhosesymptomssuggestACS
PerformserialECGsat15-to30-minintervalsduringthefirsthourinsymptomaticpatientswith I C N/A
initialnondiagnosticECG
Measurecardiactroponin(cTnIorcTnT)inallpatientswithsymptomsconsistentwithACS* I A (22,43–48)
MeasureserialcardiactroponinIorTatpresentationand3–6haftersymptomonset*inallpatients I A (22,49–51)
withsymptomsconsistentwithACS
UseriskscorestoassessprognosisinpatientswithNSTE-ACS I A (40–42,52–57)
Risk-stratificationmodelscanbeusefulinmanagement IIa B (40–42,52–58)
ObtainsupplementalelectrocardiographicleadsV7toV9inpatientswithinitialnondiagnostic IIa B (59–61)
ECGatintermediate/highriskforACS
Continuousmonitoringwith12-leadECGmaybeareasonablealternativewithinitialnondiagnostic IIb B (62,63)
ECGinpatientsatintermediate/highriskforACS
BNPorNT–pro-BNPmaybeconsideredtoassessriskinpatientswithsuspectedACS IIb B (64–68)
*SeeSection3.4.1,ClassI,#3recommendationiftimeofsymptomonsetisunclear.
ACSindicatesacutecoronarysyndromes;BNP,B-typenatriureticpeptide;COR,ClassofRecommendation;cTnI,cardiactroponinI;cTnT,cardiactroponinT;ECG,electrocardiogram;
LOE,LevelofEvidence;N/A,notavailable;NSTE-ACS,non(cid:2)ST-elevationacutecoronarysyndromes;andNT–pro-BNP,N-terminalpro–B-typenatriureticpeptide.