Subcomponente de coberturas de la tierra

Class I

1. Drugs required in the hospital to control ischemia should be continued after hospital discharge in patients who do not undergo coronary revasculariza- tion, patients with unsuccessful revascularization, or patients with recurrent symptoms after revasculariza- tion. Upward or downward titration of the doses may be required. (Level of Evidence: C)

2. All patients should be given sublingual or spray NTG and instructed in its use. (Level of Evidence: C) 3. Before discharge, patients should be informed about

symptoms of AMI and should be instructed in how to seek help if symptoms occur. (Level of Evidence: C)

1. Long-Term Medical Therapy

Many patients with UA/NSTEMI have chronic stable angina at hospital discharge. The management of the patient with stable CAD is detailed in the ACC/AHA/ACP-ASIM Guidelines for the Management of Patients With Chronic Stable Angina (26). The following are recommendations for pharmacotherapy to prevent death and MI.

Recommendations Class I

1. Aspirin 75 to 325 mg per d in the absence of con- traindications. (Level of Evidence: A)

2. Clopidogrel 75 mg daily (in the absence of con- traindications) for patients with a contraindication to ASA. when ASA is not tolerated because of hyper- sensitivity or gastrointestinal intolerance. (Level of Evidence: AB)

3. The combination of ASA and clopidogrel for 9

months after UA/NSTEMI. (Level of Evidence: B) 43. Beta-blockers in the absence of contraindications.

(Level of Evidence: B)

54. Lipid-lowering agents and diet in post-ACS patients, including postrevascularization patients, with low- density lipoprotein (LDL) cholesterol of greater than 130 mg per dL. (Level of Evidence: A)

65. Lipid-lowering agents if LDL cholesterol level after diet is greater than 100 mg per dL. (Level of Evidence: B)

76. ACEIs for patients with CHF, LV dysfunction (EF less than 0.40), hypertension, or diabetes. (Level of Evidence: A)

A reduction in the rates of mortality and vascular events was reported in the Heart Outcomes Prevention Evaluation (HOPE) Study (163) with the long-term use of an ACEI in moderate-risk patients with CAD, many of whom had pre- served LV function, as well as patients at high risk of devel- oping CAD. Other agents that may be used in patients with chronic CAD are listed in Table 21 and are discussed in detail in the ACC/AHA/ACP-ASIM Guidelines for the Manage- ment of Patients With Chronic Stable Angina (26).

Although observational data suggest a protective effect of hormone replacement therapy (HRT) for coronary events, the only randomized trial of HRT for secondary prevention of death and MI that has been completed (Heart and Estrogen/progestin Replacement Study [HERS]) failed to demonstrate a beneficial effect (334). Disturbingly, there was an excess risk for death and MI early after HRT initiation. It is recommended that postmenopausal women who receive HRT may continue but that HRT should not be initiated for the secondary prevention of coronary events. There may, however, be other indications for HRT in postmenopausal women (e.g., prevention of flushing, osteoporosis).

B. Postdischarge Follow-Up

Class I

1. Discharge instructions should include a follow-up appointment. Low-risk medically treated patients and revascularized patients should return in 2 to 6 weeks, and higher-risk patients should return in 1 to 2 weeks. (Level of Evidence: C)

2. Patients managed initially with a conservative strate- gy who experience recurrent unstable angina or severe (CCS Class III) chronic stable angina despite medical management who are suitable for revascular- ization should undergo coronary arteriography. (Level of Evidence: B)

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ACC/AHA Practice Guidelines

Specifically, the presence and severity of angina should be ascertained. Rates of revascularization during the first year have been reported to be high (337). Long-term (7 years) fol- low-up of 282 patients with UA demonstrated high event rates during the first year (MI 11%, death 6%, PTCA 30%, CABG 27%). However, after the first year, event rates were low (337). Independent risk factors for death/MI were age greater than 70 years, diabetes, and male sex. Mental depres- sion has also been reported to be an independent risk factor for cardiac events after MI and occurs in up to 25% of such patients (338). Patients recognized to be at high risk for a car- diac event after discharge deserve earlier and more frequent follow-up than low-risk patients.

The overall long-term risk for death or MI 2 months after an episode of UA/NSTEMI is similar to that of other CAD patients with similar characteristics. van Domburg et al. (337) reported low rates of admission for recurrent chest pain (5%, 4%, 3%, and 2% at 1, 3, 5, and 7 years, respectively). When the patient has returned to the baseline level, typically 6 to 8 weeks after hospitalization, arrangements should be made for long-term regular follow-up visits, as for stable CAD. Cardiac catheterization with coronary angiography is recommended for any of the following situations: 1) signifi- cant increase in anginal symptoms, including recurrent UA;

3. Patients who have tolerable stable angina or no anginal symptoms at follow-up visits should be managed with long-term medical therapy for stable CAD. (Level of Evidence: B)

The risk of death within 1 year can be predicted on the basis of clinical information and the ECG. For 515 survivors of hospitalization for NSTEMI, risk factors include persist- ent ST-segment depression, CHF, advanced age, and ST-seg- ment elevation at discharge (335). Patients with all high-risk markers present had a 14-fold greater mortality rate than did patients with all markers absent. Elevated cardiac TnT levels have also been demonstrated to provide independent prog- nostic information for cardiac events at 1 to 2 years. For patients with all ACS in a GUSTO-IIa substudy, age, ST- segment elevation on admission, prior CABG, TnT, renal insufficiency, and severe COPD were independently associ- ated with risk of death at 1 year (100,336). For UA/NSTEMI patients, prior MI, TnT positivity, accelerated angina before admission, and recurrent pain or ECG changes were inde- pendently associated with risk of death at 2 years. Patients managed with an initial conservative strategy (see Section III) should be reassessed at the time of return visits for the need for cardiac catheterization and revascularization.

Table 21. Medications Used for Stabilized UA/NSTEMI Anti-Ischemic and Antithrombotic/

Antiplatelet Agent Drug Action Class/Level of Evidence

Aspirin Antiplatelet I/A

Clopidogrel* or ticlopidine Antiplatelet when aspirin is

contraindicated I/A

Beta-blockers Anti-ischemic I/A

ACEI EF less than 0.40 or CHF EF greater than 0.40 I/A IIa/AB

Nitrates Antianginal I/C For ischemic symptoms Calcium antagonists (short-acting Antianginal I For ischemic symptoms

dihydropyridine antagonists should When beta-blockers are not

be avoided) successful (level of

evidence: B) or contraindicated Or cause unacceptable side

effects (level of evidence: C)

Warfarin low intensity with or Antithrombotic IIb/B without aspirin

Dipyridamole Antiplatelet III/A

Agent Risk Factor Class/Level of Evidence

HMG-CoA reductase inhibitors LDL cholesterol greater than 130 mg/dL I/A HMG-CoA reductase inhibitors LDL cholesterol 100–130 mg/dL IIa/BC Gemfibrozil HDL cholesterol less than 40 mg/dL IIa/B Niacin HDL cholesterol less than 40 mg/dL IIa/B Niacin or gemfibrozil Triglycerides greater than 200 mg/dL IIa/B

Folate Elevated homocysteine IIb/C

Antidepressant Treatment of depression IIb/C Treatment of hypertension Blood pressure greater than 135/85 mm Hg I/A HRT (initiation)† Postmenopausal state III/B HRT (continuation)† Postmenopausal state IIa/C

ACEI indicates angiotensin-converting enzyme inhibitor; CHF, congestive heart failure; EF, ejection fraction; HDL, high-density lipoprotein; HRT, hormone replacement therapy; LDL, low-density lipoprotein; NSTEMI, non–ST-segment elevation myocardial infarction; UA, unstable angina.

*Preferred to ticlopidine.

62 ACC/AHA Practice Guidelines American Heart Association - www.americanheart.org 2) high-risk pattern (e.g., greater than or equal to 2-mm ST-

segment depression, systolic blood pressure decline of greater than or equal to 10 mm Hg) on exercise test; 3) CHF; 4) angina with mild exertion (inability to complete Stage 2 of the Bruce protocol for angina); and 5) survivors of sudden cardiac death. Revascularization is recommended based on the coronary anatomy and ventricular function (see Section IV and ACC/AHA/ACP-ASIM Guidelines for the Management of Patients With Chronic Stable Angina [26]).

C. Use of Medications