Treatment
ÎÎEvaluate patients with definite ACS and ST-segment elevation in leads
V7 to V9 due to left circumflex occlusion for immediate reperfusion
therapy. (I-A)
ÎÎGive patients discharged from the ED or chest pain unit specific
instructions for activity, medications, additional testing, and follow-up
with a personal physician. (I-C)
ÎÎIn patients with suspected ACS with a low or intermediate probability
of CAD, in whom the follow-up 12-lead ECG and cardiac biomarker
measurements are normal, performance of a noninvasive coronary
imaging test (ie, coronary CT angiography [CCTA]) is reasonable as an
alternative to stress testing. (IIa-B)
Anti-Ischemic and Analgesic Therapy
ÎÎBed/chair rest with continuous ECG monitoring is recommended for
all UA/NSTEMI patients during the early hospital phase. (I-C)
ÎÎAdminister supplemental oxygen to patients with UA/NSTEMI with an
arterial saturation less than 90%, respiratory distress, or other highrisk features for hypoxemia. (Pulse oximetry is useful for continuous
measurement of SaO2.) (I-B)
ÎÎPatients with UA/NSTEMI with ongoing ischemic discomfort
should receive sublingual NTG (0.4 mg) every 5 min for a total of
3 doses, after which assessment should be made about the need for
intravenous NTG, if not contraindicated. (I-C)
ÎÎIntravenous NTG is indicated in the first 48 h after UA/NSTEMI for
treatment of persistent ischemia, heart failure (HF), or hypertension.
The decision to administer intravenous NTG and the dose used
should not preclude therapy with other proven mortality-reducing
interventions such as beta blockers or angiotensin-converting enzyme
(ACE) inhibitors. (I-B)
ÎÎOral beta-blocker therapy should be initiated within the first 24 h for
patients who do not have any of the following: (I-B)
•
•
•
•
Signs of HF
Evidence of a low-output state
Increased risk for cardiogenic shock
Other relative contraindications to beta blockade (PR interval >0.24 s, secondor third-degree heart block, active asthma, or reactive airway disease).
ÎÎIn UA/NSTEMI patients with continuing or frequently recurring ischemia
and in whom beta blockers are contraindicated, a nondihydropyridine
calcium channel blocker (eg, verapamil or diltiazem) should be given as
initial therapy in the absence of clinically significant left ventricular (LV)
dysfunction or other contraindications. (I-B)
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