Skip to main content
SpringerLink
Log in

Revised guidelines for the management of non-ST-segment elevation acute coronary syndromes

  • Published:
Current Cardiology Reports Aims and scope Submit manuscript

Abstract

Unstable angina (UA) and non-ST-segment elevation myocardial infarction (NSTEMI) refer to a spectrum of acute severe cardiac disorders characterized by myocardial oxygen demand and supply mismatch, caused by atherosclerotic coronary artery disease. Patients presenting with acute coronary syndromes represent a major medical problem, accounting for 2.5 million hospitalizations and 500,000 deaths annually in the United States alone. Of these, 1.5 million have a final diagnosis of UA, and myocardial infarction (ST-segment and non-ST-segment elevation) accounts for the remaining 1 million. The management of UA/NSTEMI presents a challenge to the cardiologist because treatment strategies continue to evolve. A number of trials have now assessed the safety and efficacy of early revascularization strategies in the treatment of patients with UA/NSTEMI, whereas others have focused on pharmacologic adjunctive therapy. An optimal single strategy encompassing most patients’ needs is not clear. This review focuses on the revised American College of Cardiology/ American Heart Association guidelines for the management of patients presenting with UA/NSTEMI.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

References and Recommended Reading

  1. Boersma E, Pieper KS, Steyerberg EW, et al.: Predictors of outcome in patients with acute coronary syndromes without persistent ST-segment elevation. Results from an international trial of 9461 patients. The PURSUIT Investigators. Circulation 2000, 101:2557–2567. Important baseline determinants of death in patients with UA/ NSTEMI were age, heart rate, systolic blood pressure, ST-segment depression, signs of heart failure, and elevated cardiac enzymes.

    PubMed  CAS  Google Scholar 

  2. Antman EM, Cohen M, Bernink PJ, et al.: The TIMI risk score for unstable angina/non-ST elevation MI: a method for prognostication and therapeutic decision making. JAMA 2000, 284:835–842. The TIMI risk score (age > 65 years, > three coronary risk factors, prior angiographic coronary obstruction, ST-segment deviation, > two angina episodes within 24 hours, use of aspirin within 7 days, and elevated cardiac markers) is a simple prognostication scheme that categorizes a patient’s risk of death and ischemic events.

    Article  PubMed  CAS  Google Scholar 

  3. Cannon CP, Weintraub WS, Demopoulos LA, et al.: Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban. N Engl J Med 2001, 344:1879–1887. Patients with UA/NSTEMI treated with the GP IIb/IIIa inhibitor tirofiban, and subsequent use of an early invasive strategy had a significant reduction in the incidence of major cardiac events (22% relative reduction in death, MI, and rehospitalization).

    Article  PubMed  CAS  Google Scholar 

  4. Yusuf S, Zhao F, Mehta SR, et al.: Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med 2001, 345:494–502. Clopidogrel is significantly beneficial in patients with UA/NSTEMI (20% relative reduction in death from cardiovascular causes, nonfatal MI, or stroke). However, the risk of major bleeding is increased among patients treated with clopidogrel.

    Article  PubMed  CAS  Google Scholar 

  5. Wood AJ: When increased therapeutic benefit comes at increased cost. N Engl J Med 2002, 346:1819–1821.

    Article  PubMed  Google Scholar 

  6. Gaspoz JM, Coxson PG, Goldman PA, et al.: Cost effectiveness of aspirin, clopidogrel, or both for secondary prevention of coronary heart disease. N Engl J Med 2002, 346:1800–1806.

    Article  PubMed  Google Scholar 

  7. Hongo RH, Ley J, Dick SE, Yee RR: The effect of clopidogrel in combination with aspirin when given before coronary artery bypass grafting. J Am Coll Cardiol 2002, 40:231–237.

    Article  PubMed  CAS  Google Scholar 

  8. Hirsh J, Anand SS, Halperin JL, Fuster V: Guide to anticoagulant therapy: Heparin: a statement for healthcare professionals from the American Heart Association. Circulation 2001, 103:2994–3018.

    PubMed  CAS  Google Scholar 

  9. Barrowcliffe T, Johnson E, Thomas D: Low Molecular Weight Heparin. Chicester, UK: John Wiley & Sons; 1992.

    Google Scholar 

  10. Bounameaux H: Low molecular weight heparins in prophylaxis and therapy of thromboembolic disease. New York: Marcel Dekker; 1994.

    Google Scholar 

  11. Cosmi B, Fredenburgh JC, Rischke J, et al.: Effect of nonspecific binding to plasma proteins on the antithrombin activities of unfractionated heparin, low-molecular-weight heparin, and dermatan sulfate. Circulation 1997, 95:118–124.

    PubMed  CAS  Google Scholar 

  12. Cohen M, Demers C, Gurfinkel EP, et al.: A comparison of lowmolecular-weight heparin with unfractionated heparin for unstable coronary artery disease. Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q-Wave Coronary Events Study Group. N Engl J Med 1997, 337:447–452.

    Article  PubMed  CAS  Google Scholar 

  13. Antman EM, Cohen M, Radley D, et al.: Assessment of the treatment effect of enoxaparin for unstable angina/non-Qwave MI. TIMI 11B-ESSENCE meta-analysis. Circulation 1999, 100:1602–1608. Enoxaparin was associated with a 20% reduction in death and serious cardiac ischemic events within the first few days of treatment, and was sustained through 43 days. It was not associated with an increase in major hemorrhage during the acute phase of therapy, but there was an increase in the rate of minor hemorrhage.

    PubMed  CAS  Google Scholar 

  14. Organisation to Assess Strategies for Ischemic Syndromes (OASIS-2) Investigators: Effects of recombinant hirudin (lepirudin) compared with heparin on death, myocardial infarction, refractory angina, and revascularisation procedures in patients with acute myocardial ischaemia without ST elevation: a randomised trial. Lancet 1999, 353:429–438.

    Article  Google Scholar 

  15. Carswell CI, Plosker GL: Bivalirudin: a review of its potential place in the management of acute coronary syndromes. Drugs 2002, 62:841–870.

    Article  PubMed  CAS  Google Scholar 

  16. Antman EM, McCabe CH, Braunwald E: Bivalirudin as a replacement for unfractionated heparin in unstable angina/ non-ST-elevation myocardial infarction: observations from the TIMI 8 trial. The Thrombolysis in Myocardial Infarction. Am Heart J 2002, 143:229–234.

    Article  PubMed  CAS  Google Scholar 

  17. The GUSTO IV-ACS Investigators: Effect of glycoprotein IIb/IIIa receptor blocker abciximab on outcome in patients with acute coronary syndromes without early coronary revascularization: the GUSTO-IV ACS randomised trial. Lancet 2001, 357:1915–1924. The GUSTO-IV trial was designed to examine the efficacy of abciximab as medical therapy alone in ACS patients. For the 30-day outcome of death or MI, no significant differences were observed between patients receiving abciximab versus placebo. Therefore, abciximab alone as medical therapy for ACS without PCI is not recommended.

    Article  Google Scholar 

  18. Boersma E, Harrington RA, Moliterno DJ, et al.: Platelet glycoprotein IIb/IIIa inhibitors in acute coronary syndromes: a meta-analysis of all major randomised clinical trials. Lancet 2002, 359:189–198. Intravenous GP IIb/IIIa inhibitors reduce the occurrence of death or MI in patients with UA/NSTEMI not undergoing early revascularization. The event reduction is greatest in patients at high risk of thrombotic complications, such as individuals with elevated biomarkers.

    Article  PubMed  CAS  Google Scholar 

  19. Schwartz GG, Olsson AG, Ezekowitz MD, et al.: Effects of atorvastatin on early recurrent ischemic events in acute coronary syndromes: the MIRACL study: a randomized controlled trial. JAMA 2001, 285:1711–1718. For patients with UA/NSTEMI, lipid-lowering therapy with atorvastatin (80 mg/d) reduces recurrent ischemic events in the first 16 weeks, primarily recurrent symptomatic ischemia requiring rehospitalization.

    Article  PubMed  CAS  Google Scholar 

  20. Aronow HD, Topol EJ, Roe MT, et al.: Effect of lipid-lowering therapy on early mortality after acute coronary syndromes: an observational study. Lancet 2001, 357:1063–1068.

    Article  PubMed  CAS  Google Scholar 

  21. Effects of tissue plasminogen activator and a comparison of early invasive and conservative strategies in unstable angina and non-Q-wave myocardial infarction. Results of the TIMI IIIB Trial. Thrombolysis in Myocardial Ischemia. Circulation 1994, 89:1545–1556.

  22. Boden WE, O’Rourke RA, Crawford MH, et al.: Outcomes in patients with acute non-Q-wave myocardial infarction randomly assigned to an invasive as compared with a conservative management strategy. Veterans Affairs Non-Q-Wave Infarction Strategies in Hospital (VANQWISH) Trial Investigators. N Engl J Med 1998, 338:1785–17892.

    Article  PubMed  CAS  Google Scholar 

  23. Invasive compared with non-invasive treatment in unstable coronary-artery disease: FRISC II prospective randomised multicentre study. FRagmin and Fast Revascularisation during InStability in Coronary artery disease Investigators. Lancet 1999, 354:708–715. The early invasive approach was significantly beneficial in patients with unstable CAD who have signs of ischemia on angiocardiogram or raised biochemical markers of myocardial damage.

  24. Braunwald E, Antman E, Beasley J, et al.: ACC/AHA 2002 guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina). Circulation 2002, 106:1893–1900. The revised guidelines recommend clopidogrel in all patients with UA/NSTEMI for at least 1 month and up to 9 months, enoxaparin as the antithrombotic agent of choice, and consideration of early invasive strategy in several high-risk groups.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Division of Cardiology, University of Michigan Health System, 3910 Taubman Center, 1500 East Medical Center Drive, 48103, Ann Arbor, MI, USA

    Debabrata Mukherjee MD & Kim A. Eagle MD

Authors
  1. Debabrata Mukherjee MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Kim A. Eagle MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Rights and permissions

Reprints and permissions

About this article

Cite this article

Mukherjee, D., Eagle, K.A. Revised guidelines for the management of non-ST-segment elevation acute coronary syndromes. Curr Cardiol Rep 5, 289–295 (2003). https://doi.org/10.1007/s11886-003-0065-5

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11886-003-0065-5

Search

Navigation