Beta Blockers
ÎÎBeta blockers are indicated for all patients recovering from
UA/NSTEMI unless contraindicated. (For those at low risk, see below.)
Treatment should begin within a few days of the event, if not initiated
acutely, and should be continued indefinitely. (I-B)
ÎÎPatients recovering from UA/NSTEMI with moderate or severe LV failure
should receive beta-blocker therapy with a gradual titration scheme. (I-B)
ÎÎIt is reasonable to prescribe beta blockers to low-risk patients (ie,
normal LV function, revascularized, no high-risk features) recovering
from UA/NSTEMI in the absence of absolute contraindications. (IIa-B)
Inhibitors of the Renin-Angiotensin-Aldosterone System
ÎÎACE inhibitors should be given and continued indefinitely for patients
recovering from UA/NSTEMI with HF, LV dysfunction (LVEF less than
0.40), hypertension, or diabetes mellitus, unless contraindicated. (I-A)
ÎÎAn ARB should be prescribed at discharge to UA/NSTEMI patients
who are intolerant of an ACE inhibitor and who have either clinical or
radiological signs of HF and LVEF less than 0.40. (I-A)
ÎÎLong-term aldosterone receptor blockade should be prescribed
for UA/NSTEMI patients without significant renal dysfunction
(estimated creatinine clearance should be greater than 30 mL/min)
or hyperkalemia (potassium should be less than or equal to 5 mEq/L)
who are already receiving therapeutic doses of an ACE inhibitor, have
an LVEF less than or equal to 0.40, and have either symptomatic HF or
diabetes mellitus. (I-A)
ÎÎACE inhibitors are reasonable for patients recovering from
UA/NSTEMI in the absence of LV dysfunction, hypertension,
or diabetes mellitus unless contraindicated. (IIa-A)
ÎACE inhibitors are reasonable for patients with HF and LVEF greater than
Î
0.40. (IIa-A)
ÎÎIn UA/NSTEMI patients who do not tolerate ACE inhibitors, an
ARB can be useful as an alternative to ACE inhibitors in long-term
management provided there are either clinical or radiological signs of
HF and LVEF less than 0.40. (IIa-B)
ÎÎThe combination of an ACE inhibitor and an ARB may be considered
in the long-term management of patients recovering from UA/NSTEMI
with persistent symptomatic HF and LVEF less than 0.40a despite
conventional therapy including an ACE inhibitor or an ARB alone.
(IIb-B)
a
The safety of this combination has not been proven in patients also on aldosterone antagonists and
it is not recommended.
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