2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes: Executive Summary
2014; Lippincott Williams & Wilkins; Volume: 130; Issue: 25 Linguagem: Inglês
10.1161/cir.0000000000000133
ISSN1524-4539
AutoresEzra A. Amsterdam, Nanette K. Wenger, Ralph G. Brindis, Donald E. Casey, Théodore G. Ganiats, David R. Holmes, Allan S. Jaffe, Hani Jneid, Rosemary F. Kelly, Michael C. Kontos, Glenn N. Levine, Philip R. Liebson, Debabrata Mukherjee, Eric D. Peterson, Marc S. Sabatine, Richard W. Smalling, Susan J. Zieman,
Tópico(s)Antiplatelet Therapy and Cardiovascular Diseases
ResumoHomeCirculationVol. 130, No. 252014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes: Executive Summary Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessResearch ArticlePDF/EPUB2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes: Executive SummaryA Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Ezra A. Amsterdam, MD, FACC, Nanette K. Wenger, MD, MACC, FAHA, Ralph G. Brindis, MD, MPH, MACC, FSCAI, Donald E. CaseyJr, MD, MPH, MBA, FACP, FAHA, Theodore G. Ganiats, MD, David R. HolmesJr, MD, MACC, Allan S. Jaffe, MD, FACC, FAHA, Hani Jneid, MD, FACC, FAHA, FSCAI, Rosemary F. Kelly, MD, Michael C. Kontos, MD, FACC, FAHA, Glenn N. Levine, MD, FACC, FAHA, Philip R. Liebson, MD, FACC, FAHA, Debabrata Mukherjee, MD, FACC, Eric D. Peterson, MD, MPH, FACC, FAHA, Marc S. Sabatine, MD, MPH, FACC, FAHA, Richard W. Smalling, MD, PhD, FACC, FSCAI and Susan J. Zieman, MD, PhD, FACC Ezra A. AmsterdamEzra A. Amsterdam *Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information. Search for more papers by this author , Nanette K. WengerNanette K. Wenger Search for more papers by this author , Ralph G. BrindisRalph G. Brindis Search for more papers by this author , Donald E. CaseyJrDonald E. CaseyJr §American College of Physicians Representative. Search for more papers by this author , Theodore G. GaniatsTheodore G. Ganiats ‖American Academy of Family Physicians Representative. Search for more papers by this author , David R. HolmesJrDavid R. HolmesJr †ACC/AHA Representative. Search for more papers by this author , Allan S. JaffeAllan S. Jaffe Search for more papers by this author , Hani JneidHani Jneid †ACC/AHA Representative. Search for more papers by this author , Rosemary F. KellyRosemary F. Kelly ¶Society of Thoracic Surgeons Representative. Search for more papers by this author , Michael C. KontosMichael C. Kontos Search for more papers by this author , Glenn N. LevineGlenn N. Levine †ACC/AHA Representative. Search for more papers by this author , Philip R. LiebsonPhilip R. Liebson †ACC/AHA Representative. Search for more papers by this author , Debabrata MukherjeeDebabrata Mukherjee †ACC/AHA Representative. Search for more papers by this author , Eric D. PetersonEric D. Peterson Search for more papers by this author , Marc S. SabatineMarc S. Sabatine Search for more papers by this author , Richard W. SmallingRichard W. Smalling Search for more papers by this author and Susan J. ZiemanSusan J. Zieman †ACC/AHA Representative. Search for more papers by this author Originally published23 Sep 2014https://doi.org/10.1161/CIR.0000000000000133Circulation. 2014;130:2354–2394is corrected byCorrectionOther version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2014: Previous Version 1 Table of ContentsPreamble 2356Introduction 23571.1. Methodology and Evidence Review 23571.2. Organization of the GWC 23581.3. Document Review and Approval 23581.4. Scope of the CPG 2358Overview of Acs 2358Initial Evaluation and Management: Recommendations 23583.1. Clinical Assessment and Initial Evaluation 23583.2. Emergency Department or Outpatient Facility Presentation 23583.3. Prognosis–Early Risk Stratification 23593.4. Cardiac Biomarkers and the Universal Definition of Myocardial Infarction 23623.4.1. Biomarkers: Diagnosis 23623.4.2. Biomarkers: Prognosis 23633.5. Discharge From the ED or Chest Pain Unit 2363Early Hospital Care: Recommendations 23634.1. Standard Medical Therapies 23634.1.1. Oxygen 23634.1.2. Nitrates 23634.1.3. Analgesic Therapy 23644.1.4. Beta-Adrenergic Blockers 23644.1.5. Calcium Channel Blockers 23654.1.6. Cholesterol Management 23654.2. Inhibitors of the Renin-Angiotensin-Aldosterone System 23654.3. Initial Antiplatelet/Anticoagulant Therapy in Patients With Definite or Likely NSTE-ACS 23654.3.1. Initial Oral and Intravenous Antiplatelet Therapy in Patients With Definite or Likely NSTE-ACS Treated With an Initial Invasive or Ischemia-Guided Strategy 23654.3.2. Initial Parenteral Anticoagulant Therapy in Patients With Definite NSTE-ACS 23674.4. Ischemia-Guided Strategy Versus Early Invasive Strategies 23674.4.1. Early Invasive and Ischemia-Guided Strategies 23674.5. Risk Stratification Before Discharge for Patients With an Ischemia-Guided Strategy of NSTE-ACS 2369Myocardial Revascularization: Recommendations 23695.1. PCI–General Considerations 23695.1.1. PCI–Oral and Intravenous Antiplatelet Agents 23695.1.1.1. PCI–GP llb/llla Inhibitors 23705.1.2. Anticoagulant Therapy in Patients Undergoing PCI 23705.2. Timing of Urgent Coronary Artery Bypass Graft in Patients With NSTE-ACS in Relation to Use of Antiplatelet Agents 2370Late Hospital Care, Hospital Discharge, and Posthospital Discharge Care: Recommendations 23716.1. Medical Regimen and Use of Medications at Discharge 23716.2. Late Hospital and Posthospital Oral Antiplatelet Therapy 23716.3. Combined Oral Anticoagulant Therapy and Antiplatelet Therapy in Patients With NSTE-ACS 23726.4. Risk Reduction Strategies for Secondary Prevention 23726.5. Plan of Care for Patients With NSTE-ACS 2373Special Patient Groups: Recommendations 23737.1. NSTE-ACS in Older Patients 23737.2. Heart Failure and Cardiogenic Shock 23737.3. Diabetes Mellitus 23757.4. Post-CABG 23757.5. Perioperative NSTE-ACS Related to Noncardiac Surgery 23757.6. Chronic Kidney Disease 23767.7. Women 23767.8. Anemia, Bleeding, and Transfusion 23767.9. Cocaine and Methamphetamine Users 23767.10. Vasospastic (Prinzmetal) Angina 23767.11. ACS With Angiographically Normal Coronary Arteries 23777.12. Stress (Takotsubo) Cardiomyopathy 2377Quality of Care and Outcomes For ACS–Use of Performance Measures and Registries: Recommendation 2377Summary and Evidence Gaps 2377References 2378Appendix 1.Author Relationships With Industry and Other Entities (Relevant) 2387Appendix 2.Reviewer Relationships With Industry and Other Entities (Relevant) 2390PreambleThe American College of Cardiology (ACC) and the American Heart Association (AHA) are committed to the prevention and management of cardiovascular diseases through professional education and research for clinicians, providers, and patients. Since 1980, the ACC and AHA have shared a responsibility to translate scientific evidence into clinical practice guidelines (CPGs) with recommendations to standardize and improve cardiovascular health. These CPGs, based on systematic methods to evaluate and classify evidence, provide a cornerstone of quality cardiovascular care.In response to published reports from the Institute of Medicine1,2 and the ACC/AHA’s mandate to evaluate new knowledge and maintain relevance at the point of care, the ACC/AHA Task Force on Practice Guidelines (Task Force) began modifying its methodology. This modernization effort is published in the 2012 Methodology Summit Report3 and 2014 perspective article.4 The latter recounts the history of the collaboration, changes over time, current policies, and planned initiatives to meet the needs of an evolving healthcare environment. Recommendations on value in proportion to resource utilization will be incorporated as high-quality comparative-effectiveness data become available.5 The relationships between CPGs and data standards, appropriate use criteria, and performance measures are addressed elsewhere.4Intended Use—CPGs provide recommendations applicable to patients with or at risk of developing cardiovascular disease. The focus is on medical practice in the United States, but CPGs developed in collaboration with other organizations may have a broader target. Although CPGs may be used to inform regulatory or payer decisions, the intent is to improve the quality of care and be aligned with the patient’s best interest.Evidence Review—Guideline writing committee (GWC) members are charged with reviewing the literature; weighing the strength and quality of evidence for or against particular tests, treatments, or procedures; and estimating expected health outcomes when data exist. In analyzing the data and developing CPGs, the GWC uses evidence-based methodologies developed by the Task Force.6 A key component of the ACC/AHA CPG methodology is the development of recommendations on the basis of all available evidence. Literature searches focus on randomized controlled trials (RCTs) but also include registries, nonrandomized comparative and descriptive studies, case series, cohort studies, systematic reviews, and expert opinion. Only selected references are cited in the CPG. To ensure that CPGs remain current, new data are reviewed biannually by the GWCs and the Task Force to determine if recommendations should be updated or modified. In general, a target cycle of 5 years is planned for full revisions.1Guideline-Directed Medical Therapy—Recognizing advances in medical therapy across the spectrum of cardiovascular diseases, the Task Force designated the term “guideline-directed medical therapy” (GDMT) to represent recommended medical therapy as defined mainly by Class I measures, generally a combination of lifestyle modification and drug- and device-based therapeutics. As medical science advances, GDMT evolves, and hence GDMT is preferred to “optimal medical therapy.” For GDMT and all other recommended drug treatment regimens, the reader should confirm the dosage with product insert material and carefully evaluate for contraindications and possible drug interactions. Recommendations are limited to treatments, drugs, and devices approved for clinical use in the United States.Class of Recommendation and Level of Evidence—Once recommendations are written, the Class of Recommendation (COR; ie, the strength the GWC assigns to the recommendation, which encompasses the anticipated magnitude and judged certainty of benefit in proportion to risk) is assigned by the GWC. Concurrently, the Level of Evidence (LOE) rates the scientific evidence supporting the effect of the intervention on the basis on the type, quality, quantity, and consistency of data from clinical trials and other reports (Table 1).4 Unless otherwise stated, recommendations are presented in order by the COR and then the LOE. Where comparative data exist, preferred strategies take precedence. When more than 1 drug, strategy, or therapy exists within the same COR and LOE and there are no comparative data, options are listed alphabetically.Table 1. Applying Classification of Recommendations and Level of EvidenceTable 1. Applying Classification of Recommendations and Level of EvidenceRelationships With Industry and Other Entities—The ACC and AHA exclusively sponsor the work of GWCs without commercial support, and members volunteer their time for this activity. The Task Force makes every effort to avoid actual, potential, or perceived conflicts of interest that might arise through relationships with industry or other entities (RWI). All GWC members and reviewers are required to fully disclose current industry relationships or personal interests from 12 months before initiation of the writing effort. Management of RWI involves selecting a balanced GWC and requires that both the chair and a majority of GWC members have no relevant RWI (see Appendix 1 for the definition of relevance). GWC members are restricted with regard to writing or voting on sections to which their RWI apply. In addition, for transparency, GWC members’ comprehensive disclosure information is available as an online supplement. Comprehensive disclosure information for the Task Force is available as an additional supplement. The Task Force strives to avoid bias by selecting experts from a broad array of backgrounds representing different geographic regions, sexes, ethnicities, races, intellectual perspectives/biases, and scopes of clinical practice. Selected organizations and professional societies with related interests and expertise are invited to participate as partners or collaborators.Individualizing Care in Patients With Associated Conditions and Comorbidities—The ACC and AHA recognize the complexity of managing patients with multiple conditions, compared with managing patients with a single disease, and the challenge is compounded when CPGs for evaluation or treatment of several coexisting illnesses are discordant or interacting.7 CPGs attempt to define practices that meet the needs of patients in most, but not all, circumstances and do not replace clinical judgment.Clinical Implementation—Management in accordance with CPG recommendations is effective only when followed; therefore, to enhance their commitment to treatment and compliance with lifestyle adjustment, clinicians should engage the patient to participate in selecting interventions on the basis of the patient’s individual values and preferences, taking associated conditions and comorbidities into consideration (eg, shared decision making). Consequently, there are circumstances in which deviations from these guidelines are appropriate.The recommendations in this CPG are the official policy of the ACC and AHA until they are superseded by a published addendum, focused update, or revised full-text CPG. The reader is encouraged to consult the full-text CPG8 for additional guidance and details about the management of patients with non–ST-elevation acute coronary syndrome (NSTE-ACS) because the executive summary contains mainly the recommendations.Jeffrey L. Anderson, MD, FACC, FAHAChair, ACC/AHA Task Force on Practice Guidelines1. Introduction1.1. Methodology and Evidence ReviewThe recommendations listed in this CPG are, whenever possible, evidence based. An extensive evidence review was conducted through October 2012, and other selected references published through April 2014 were reviewed by the GWC. Literature included was derived from research involving human subjects, published in English, and indexed in MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality Reports, and other selected databases relevant to this CPG. The relevant data are included in evidence tables in the Online Data Supplement. Key search words included but were not limited to the following: acute coronary syndrome, anticoagulant therapy, antihypertensives, anti-ischemic therapy, antiplatelet therapy, antithrombotic therapy, beta blockers, biomarkers, calcium channel blockers, cardiac rehabilitation, conservative management, diabetes mellitus, glycoprotein Ilb/IIIa inhibitors, heart failure, invasive strategy, lifestyle modification, myocardial infarction, nitrates, non-ST-elevation, P2Y12receptor inhibitor, percutaneous coronary intervention, renin-angiotensin-aldosterone inhibitors, secondary prevention, smoking cessation, statins, stent, thienopyridines, troponins, unstable angina, and weight management. Additionally, the GWC reviewed documents related to NSTE-ACS previously published by the ACC and AHA. References selected and published in this document are representative and not all-inclusive.1.2. Organization of the GWCThe GWC was composed of clinicians, cardiologists, internists, interventionists, surgeons, emergency medicine specialists, family practitioners, and geriatricians. The GWC included representatives from the ACC and AHA, American Academy of Family Physicians, American College of Emergency Physicians, American College of Physicians, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.1.3. Document Review and ApprovalThis document was reviewed by 2 official reviewers each nominated by the ACC and AHA; 1 reviewer each from the American Academy of Family Physicians, American College of Emergency Physicians, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons; and 37 individual content reviewers (including members of the American Association of Clinical Chemistry, ACC Heart Failure and Transplant Section Leadership Council, ACC Cardiovascular Imaging Section Leadership Council, ACC Interventional Section Leadership Council, ACC Prevention of Cardiovascular Disease Committee, ACC Surgeons’ Council, Association of International Governors, and Department of Health and Human Services). Reviewers’ RWI information was distributed to the GWC and is published in this document (Appendix 2).This document was approved for publication by the governing bodies of the ACC and the AHA and endorsed by the American Association for Clinical Chemistry, Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons.1.4. Scope of the CPGThe 2014 NSTE-ACS CPG is a full revision of the 2007 ACCF/AHA CPG for the management of patients with unstable angina (UA) and non–ST-elevation myocardial infarction (NSTEMI) and the 2012 focused update.9 The new title, “Non–ST-Elevation Acute Coronary Syndromes,” emphasizes the continuum between UA and NSTEMI. At presentation, patients with UA and NSTEMI can be indistinguishable and are therefore considered together in this CPG.In the United States, NSTE-ACS affects >625 000 patients annually,* or almost three fourths of all patients with acute coronary syndrome (ACS).10 In selecting the initial approach to care, the term “ischemia-guided strategy” has replaced the previous descriptor, “initial conservative management,” to more clearly convey the physiological rationale of this approach.The task of the 2014 GWC was to establish a contemporary CPG for the optimal management of patients with NSTE-ACS. It incorporates both established and new evidence from published clinical trials, as well as information from basic science and comprehensive review articles. These recommendations were developed to guide the clinician in improving outcomes for patients with NSTE-ACS. Table 2 lists documents deemed pertinent to this effort and is intended for use as a resource, thus obviating the need to repeat extant CPG recommendations.Table 2. Associated CPGs and StatementsTitleOrganizationPublication Year/ReferenceCPGsStable ischemic heart diseaseACC/AHA/AATS/PCNA/SCAI/STS201411* 201212Atrial fibrillationAHA/ACC/HRS201413Assessment of cardiovascular riskACC/AHA201314Heart failureACC/AHA201315Lifestyle management to reduce cardiovascular riskAHA/ACC201316Management of overweight and obesity in adultsAHA/ACC/TOS201317ST-elevation myocardial infarctionACC/AHA201318Treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adultsACC/AHA201319Acute myocardial infarction in patients presenting with ST-segment elevationESC201220Device-based therapyACC/AHA/HRS 1201321Third universal definition of myocardial infarctionESC/ACC/AHA/WHF201222Acute coronary syndromes in patients presenting without persistent ST-segment elevationESC201123Coronary artery bypass graft surgeryACC/AHA201124Hypertrophic cardiomyopathyACC/AHA201125Effectiveness-based guidelines for the prevention of cardiovascular disease in womenAHA/ACC201126Percutaneous coronary interventionACC/AHA/SCAI201127Secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular diseaseAHA/ACC201128Assessment of cardiovascular risk in asymptomatic adultsACC/AHA201029Myocardial revascularizationESC201030Unstable angina and non–ST-elevation myocardial infarctionNICE201031†Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care—part 9: postcardiac arrest careAHA201032Seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressureNHLBI200333StatementsKey data elements and definitions for measuring the clinical management and outcomes of patients with acute coronary syndromes and coronary artery diseaseACC/AHA201334Practical clinical considerations in the interpretation of troponin elevationsACC201235Testing of low-risk patients presenting to the emergency department with chest painAHA201036Primary prevention of cardiovascular diseases in people with diabetes mellitusAHA/ADA200737Prevention and control of influenzaCDC200538*The full-text SIHD CPG is from 2012.12 A focused update was published in 2014.11†Minor modifications were made in 2013. For a full explanation of the changes, see http://publications.nice.org.uk/unstable-angina-and-nstemi-cg94/changes-after-publication.AATS indicates American Association for Thoracic Surgery; ACC, American College of Cardiology; ADA, American Diabetes Association; AHA, American Heart Association; CDC, Centers for Disease Control and Prevention; CPG, clinical practice guideline; ESC, European Society of Cardiology; HRS, Heart Rhythm Society; NHLBI, National Heart, Lung, and Blood Institute; NICE, National Institute for Health and Clinical Excellence; PCNA, Preventive Cardiovascular Nurses Association; SCAI, Society for Cardiovascular Angiography and Interventions; SIHD, stable ischemic heart disease; STS, Society of Thoracic Surgeons; TOS, The Obesity Society; and WHF, World Heart Federation.The GWC abbreviated the discussion sections to include an explanation of salient information related to the recommendations. In contrast to textbook declaratory presentations, explanations were supplemented with evidence tables. The GWC also provided a brief summary of the relevant recommendations and references related to secondary prevention rather than detailed reiteration. Throughout, the goal was to provide the clinician with concise, evidence-based contemporary recommendations and the supporting documentation to encourage their application.2. Overview of ACSACS has evolved as a useful operational term that refers to a spectrum of conditions compatible with acute myocardial ischemia and/or infarction that are usually due to an abrupt reduction in coronary blood flow (Figure 1).Download figureDownload PowerPointFigure 1. Acute Coronary Syndromes. The top half of the figure illustrates the progression of plaque formation and onset and complications of NSTE-ACS, with management at each stage. The numbered section of an artery depicts the process of atherogenesis from 1) normal artery to 2) extracellular lipid in the subintima to 3) fibrofatty stage to 4) procoagulant expression and weakening of the fibrous cap. ACS develops with 5) disruption of the fibrous cap, which is the stimulus for thrombogenesis. 6) Thrombus resorption may be followed by collagen accumulation and smooth muscle cell growth. Thrombus formation and possible coronary vasospasm reduce blood flow in the affected coronary artery and cause ischemic chest pain. The bottom half of the figure illustrates the clinical, pathological, electrocardiographic, and biomarker correlates in ACS and the general approach to management. Flow reduction may be related to a completely occlusive thrombus (bottom half, right side) or subtotally occlusive thrombus (bottom half, left side). Most patients with ST-elevation (thick white arrow in bottom panel) develop QwMI, and a few (thin white arrow) develop NQMI. Those without ST-elevation have either UA or NSTEMI (thick red arrows), a distinction based on cardiac biomarkers. Most patients presenting with NSTEMI develop NQMI; a few may develop QwMI. The spectrum of clinical presentations including UA, NSTEMI, and STEMI is referred to as ACS. This NSTE-ACS CPG includes sections on initial management before NSTE-ACS, at the onset of NSTE-ACS, and during the hospital phase. Secondary prevention and plans for long-term management begin early during the hospital phase. Patients with noncardiac etiologies make up the largest group presenting to the ED with chest pain (dashed arrow). *Elevated cardiac biomarker (eg, troponin), Section 3.4. ACS indicates acute coronary syndrome; CPG, clinical practice guideline; Dx, diagnosis; ECG, electrocardiogram; ED, emergency department; Ml, myocardial infarction; NQMI, non–Q-wave myocardial infarction; NSTE-ACS, non-ST-elevation acute coronary syndromes; NSTEMI, non–ST-elevation myocardial infarction; QwMI, Q-wave myocardial infarction; STEMI, ST-elevation myocardial infarction; and UA, unstable angina. Modified with permission from Libby et al.393. Initial Evaluation and Management: Recommendations3.1. Clinical Assessment and Initial EvaluationClass IPatients with suspected ACS should be risk stratified based on the likelihood of ACS and adverse outcome(s) to decide on the need for hospitalization and assist in the selection of treatment options.40–42(Level of Evidence: B)3.2. Emergency Department or Outpatient Facility PresentationClass IPatients with suspected ACS and high-risk features such as continuing chest pain, severe dyspnea, syncope/presyncope, or palpitations should be referred immediately to the emergency department (ED) and transported by emergency medical services when available. (Level of Evidence: C)Class IIbPatients with less severe symptoms may be considered for referral to the ED, a chest pain unit, or a facility capable of performing adequate evaluation depending on clinical circumstances. (Level of Evidence: C)3.3. Prognosis—Early Risk StratificationSee Figure 2 and Table 3 for estimation at presentation of death and nonfatal cardiac ischemic events. See Table 4 for a summary of recommendations from this section.Table 3. TIMI Risk Score* for NSTE-ACSTIMI Risk ScoreAll-Cause Mortality, New or Recurrent Ml, or Severe Recurrent Ischemia Requiring Urgent Revascularization Through 14 d After Randomization, %0–14.728.3313.2419.9525.26–740.9*The TIMI risk score is determined by the sum of the presence of 7 variables at admission; 1 point is given for each of the following variables: ≥65 y of age; ≥3 risk factors for CAD; prior coronary stenosis ≥50%; ST deviation on ECG; ≥2 anginal events in prior 24 h; use of aspirin in prior 7 d; and elevated cardiac biomarkers.CAD indicates coronary artery disease; ECG, electrocardiogram; Ml, myo cardial infarction; NSTE-ACS, non–ST-elevation acute coronary syndromes; and TIMI, Thrombolysis In Myocardial Infarction.Modified with permission from Antman et al.40Table 4. Summary of Recommendations for Prognosis: Early Risk StratificationTable 4. Summary of Recommendations for Prognosis: Early Risk StratificationDownload figureDownload PowerPointFigure 2. Global Registry of Acute Coronary Events Risk Calculator for In-Hospital Mortality for Acute Coronary Syndrome.Class IIn patients with chest pain or other symptoms suggestive of ACS, a 12-lead electrocardiogram (ECG) should be performed and evaluated for ischemic changes within 10 minutes of the patient’s arrival at an emergency facility.22(Level of Evidence: C)If the initial ECG is not diagnostic but the patient remains symptomatic and there is a high clinical suspicion for ACS, serial ECGs (eg, 15- to 30-minute intervals during the first hour) should be performed to detect ischemic changes. (Level of Evidence: C)Serial cardiac troponin I or T levels (when a contemporary assay is used) should be obtained at presentation and 3 to 6 hours after symptom onset (see Section 3.4.1, Class I, #3 recommendation if time of symptom onset is unclear) in all patients who present with symptoms consistent with ACS to identify a rising and/or falling pattern of values.22,43–48(Level of Evidence: A)Additional troponin levels should be obtained beyond 6 hours after symptom onset (see Section 3.4.1, Class I, #3 recommendation if time of symptom onset is unclear) in patients with normal troponin levels on serial examination when changes on ECG and/or clinical presentation confer an intermediate or high index of suspicion for ACS.22,49–51(Level of Evidence: A)Risk scores should be used to assess prognosis in patients with NSTE-ACS.40–42,52–57(Level of Evidence: A)Class IIaRisk-stratification models can be useful in management.40–42,52–58 (Level of Evidence: B)It is reasonable to obtain supplemental electrocardiographic leads V7 to V9 in patients whose initial ECG is nondiagnostic and who are at intermediate/high risk of ACS.59–61(Level of Evidence: B)Class IIbContinuous monitoring with 12-lead ECG may be a reasonable alternative in patients whose initial ECG is non–diagnostic and who are at intermediate/high risk of ACS.62,63 (Level of Evidence: B)Measurement of B-type natriuretic peptide or N-terminal pro–B-type natriuretic peptide may be considered to assess risk in patients with suspected ACS.64–68 (Level of Evidence: B)3.4. Cardiac Biomarkers and the Universal Definition of Myocardial InfarctionSee Table 5 for a summary of recommendations from this section.Table 5. Summary of Recommendations for Cardiac Biomarkers and the Universal Definition of MITable 5. Summary of Recommendations for Cardiac Biomarkers and the Universal Definition of MI3.4.1. Biomarkers: DiagnosisClass ICardiac-specific troponin (troponin I or T when a contemporary assay is used) levels should be measured at presentation and 3 to 6 hours after symptom onset in all patients who present with symptoms consistent with ACS to identify a rising and/or falling pattern.22,43–48,70–74(Level of Evidence: A)Additional troponin levels should be obtained beyond 6 hours after symptom onset in patients with normal troponins on serial examination when electrocardiographic changes and/or clinical presentation confer an intermediate or high index of suspicion for ACS.22,49–51,75(Level of Evidence: A)If the time of symptom onset is ambiguous, the time of presentation should be considered the time of onset for assessing troponin values.44,45,49(Level of Evidence: A)Class III: No BenefitWith contemporary troponin as
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