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Non–ST-Elevation Acute Coronary Syndromes

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Treatment 22 Table 16. Late Hospital Care, Hospital Discharge, and Posthospital Discharge Care (cont'd) Recommendations COR LOE Risk reduction strategies for secondary prevention All eligible patients with NSTE-ACS should be referred to a comprehensive cardiovascular rehabilitation program either before hospital discharge or during the first outpatient visit. I B e pneumococcal vaccine is recommended for patients ≥65 years of age and in high-risk patients with cardiovascular disease. I B Patients should be educated about appropriate cholesterol management, BP, smoking cessation, and lifestyle management. I C Patients who have undergone PCI or CABG derive benefit from risk factor modification and should receive counseling that revascularization does not obviate the need for lifestyle changes. I C Before hospital discharge, the patient's need for treatment of chronic musculoskeletal discomfort should be assessed, and a stepped-care approach should be used for selection of treatments. Pain treatment before consideration of NSAIDs should begin with acetaminophen, nonacetylated salicylates, tramadol, or small doses of narcotics if these medications are not adequate. I C It is reasonable to use nonselective NSAIDs, such as naproxen, if initial therapy with acetaminophen, nonacetylated salicylates, tramadol, or small doses of narcotics is insufficient. IIa C NSAIDs with increasing degrees of relative cyclooxygenase-2 selectivity may be considered for pain relief only for situations in which intolerable discomfort persists despite attempts at stepped- care therapy with acetaminophen, nonacetylated salicylates, tramadol, small doses of narcotics, or nonselective NSAIDs. In all cases, use of the lowest effective doses for the shortest possible time is encouraged. IIb C Antioxidant vitamin supplements (e.g., vitamins E, C, or beta carotene) should NOT be used for secondary prevention in patients with NSTE-ACS. III: No Benefit A Folic acid, with or without vitamins B 6 and B 12 , should NOT be used for secondary prevention in patients with NSTE-ACS. III: No Benefit A Hormone therapy with estrogen plus progestin, or estrogen alone, should NOT be given as new drugs for secondary prevention of coronary events to postmenopausal women aer NSTE-ACS and should NOT be continued in previous users unless the benefits outweigh the estimated risks. III: Harm A NSAIDs with increasing degrees of relative cyclooxygenase-2 selectivity should NOT be administered to patients with NSTE- ACS and chronic musculoskeletal discomfort when therapy with acetaminophen, nonacetylated salicylates, tramadol, small doses of narcotics, or nonselective NSAIDs provide acceptable pain relief. III: Harm B

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