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UA/NSTEMI (ACCF Bundle)

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Key Points •  "Acute coronary syndrome" (ACS) has evolved as a useful operational term to refer to any constellation of clinical symptoms that are compatible with acute myocardial ischemia (Fig. 1). It encompasses myocardial infarction (MI) (ST-segment elevation and non–ST-segment elevation MI) and unstable angina (UA). •  UA/NSTEMI is defined by electrocardiographic (ECG) ST-segment depression or prominent T-wave inversion and/or positive biomarkers of necrosis (eg, troponin) in the absence of ST-segment elevation and in an appropriate clinical setting (chest discomfort or anginal equivalent). •  UA/NSTEMI often results from the disruption or erosion of an atherosclerotic plaque and a subsequent cascade of thrombotic pathological processes that decrease coronary blood flow. •  Most patients who die during UA/NSTEMI do so because of sudden death or the development (or recurrence) of acute MI. •  The initial presumptive diagnosis and optimal management of these patients must depend on the patient's initial history, ECGs, and the results of the initial cardiac biomarker tests. ▶▶ The clinical presentation of patients with a life-threatening ACS often overlaps that of patients subsequently found not to have coronary artery disease (CAD). Moreover, an acute non–ST-segment elevation MI cannot be differentiated from UA at the time of initial presentation in the absence of cardiac biomarker results. •  All practitioners should emphasize prevention and refer patients to primary care providers for appropriate long-term preventive care. Assessment Identification of Patients at Risk for UA/NSTEMI ÎÎPrimary care providers should evaluate the presence and control the status of major risk factors for coronary heart disease (CHD) for all patients at regular intervals (approximately every 3-5 years). (I-C) ÎÎTen-year risk (National Cholesterol Education Program [NCEP] global risk) of developing symptomatic CHD should be calculated for all patients who have 2 or more major risk factors to assess the need for primary prevention strategies. (I-B) ÎÎPatients with established CHD should be identified for secondary prevention efforts, and patients with a CHD risk equivalent (eg, atherosclerosis in other vascular beds, diabetes mellitus, chronic kidney disease [CKD], or 10-year risk greater than 20% as calculated by Framingham equations) should receive equally intensive risk factor intervention as those with clinically apparent CHD. (I-A) 1

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