24
Treatment
Table 18. Special Patient Groups
Recommendations
COR LOE
NSTE-ACS in older patients
Older patients
a
with NSTE-ACS should be treated with GDMT,
an early invasive strateg y, and revascularization as appropriate.
I A
Pharmacotherapy in older patients
a
with NSTE-ACS should be
individualized and dose adjusted by weight and/or CrCl to reduce
adverse events caused by age-related changes in pharmacokinetics/
dynamics, volume of distribution, comorbidities, drug interactions,
and increased drug sensitivity.
I A
Management decisions for older patients
a
with NSTE-ACS
should be patient centered, considering patient preferences/goals,
comorbidities, functional and cognitive status, and life expectancy.
I B
Bivalirudin, rather than a GPI plus UFH, is reasonable in older
patients
a
with NSTE-ACS, both initially and at PCI, given similar
efficacy but less bleeding risk.
IIa B
It is reasonable to choose CABG over PCI in older patients
a
with
NSTE-ACS who are appropriate candidates, particularly those
with diabetes mellitus or complex 3-vessel CAD (e.g., SYNTAX
score >22), with or without involvement of the proximal le
anterior descending artery, to reduce cardiovascular disease events
and readmission and to improve survival.
IIa B
HF and cardiogenic shock
Patients with a history of HF and NSTE-ACS should be
treated according to the same risk stratification guidelines and
recommendations for patients without HF.
I B
Selection of a specific revascularization strateg y should be based
on the degree, severity, and extent of CAD; associated cardiac
lesions; the extent of LV dysfunction; and the history of prior
revascularization procedures.
I B
Early revascularization is recommended in suitable patients with
cardiogenic shock due to cardiac pump failure aer NSTE-ACS.
I B
Diabetes mellitus
Medical treatment in the acute phase of NSTE-ACS and decisions
to perform stress testing, angiography, and revascularization should
be similar in patients with and without diabetes mellitus.
I A
Post–CABG
Patients with prior CABG and NSTE-ACS should receive
antiplatelet and anticoagulant therapy according to GDMT and
should be strongly considered for early invasive strateg y because of
their increased risk.
I B
a
ose ≥75 years of age.
