Treatment
26
Table 18. Special Patient Groups (cont'd)
Recommendations
COR LOE
Cocaine and methamphetamine users
Patients with NSTE-ACS and a recent history of cocaine or
methamphetamine use should be treated in the same manner
as patients without cocaine- or methamphetamine-related
NSTE-ACS. e only exception is in patients with signs of acute
intoxication (e.g., euphoria, tachycardia, and/or hypertension) and
beta-blocker use, unless patients are receiving coronary vasodilator
therapy.
I C
Benzodiazepines alone or in combination with nitroglycerin
are reasonable for management of hypertension and tachycardia
in patients with NSTE-ACS and signs of acute cocaine or
methamphetamine intoxication.
IIa C
Beta blockers should NOT be administered to patients with
ACS with a recent history of cocaine or methamphetamine use
who demonstrate signs of acute intoxication due to the risk of
potentiating coronary spasm.
III:
Harm
C
Vasospastic (Prinzmetal) angina
CCBs alone or in combination with long-acting nitrates are useful
to treat and reduce the frequency of vasospastic angina.
I B
Treatment with HMG-CoA reductase inhibitor, cessation of
tobacco use, and additional atherosclerosis risk factor modification
are useful in patients with vasospastic angina.
I B
Coronary angiography (invasive or noninvasive) is recommended
in patients with episodic chest pain accompanied by transient ST
elevation to rule out severe obstructive CAD.
I C
Provocative testing during invasive coronary angiography
a
may
be considered in patients with suspected vasospastic angina
when clinical criteria and noninvasive testing fail to establish the
diagnosis.
IIb B
ACS with angiographically normal coronary arteries
If coronary angiography reveals normal coronary arteries and
endothelial dysfunction is suspected, invasive physiological
assessment such as coronary flow reserve measurement may be
considered.
IIb B
a
Provocative testing during invasive coronary angiography (e.g., using ergonovine, acetylcholine,
methylergonovine) is relatively safe, especially when performed in a controlled manner by
experienced operators. However, sustained spasm, serious arrhythmias, and even death can
also occur very infrequently. erefore, provocative testing should be avoided in patients with
significant le main disease, advanced 3-vessel disease, presence of high-grade obstructive lesions,
significant valvular stenosis, significant LV systolic dysfunction, and advanced HF.
