New guidelines for the management of UANSTEMI

1
New guidelines for the management of UA/NSTEMI

• It is encouraging that in the 21 months since
  the publication of the September 2000 guidelines,
  a considerable body of additional useful
  information about UA/NSTEMI has emerged.
  Indeed, the progress between September 2000 and
  June 2002 equals that between 1994, when the
  first guidelines were published, and September
  2000.

Braunwald et al. J Am Coll Cardiol 200240(7)
1366-1374.
2
Overview of 2002 Guideline Update

• Assess Likelihood of CAD
• Risk stratification
• Anti-ischemic Rx
• Antithrombotic Rx
• Invasive vs. Conservative Strategy
• Secondary prevention/risk factor modification

New Update in 2002
3
New recommendations for clopidogrel use

• clopidogrel recommended both for patients
  receiving conservative management and for
  patients undergoing percutaneous coronary
  intervention (PCI) who are not at high risk of
  bleeding
• caution against the use of clopidogrel a week or
  less prior to CABG, because of excess bleeding.
• clopidogrel is now the preferred thienopyridine.

4
New recommendations for GP IIb/IIIa
antagonist use

• GPIIb/IIIa antagonists (in combination with
  aspirin and heparin) recommended for patients who
  are undergoing PCI
• quadruple therapy the addition of GPIIb/IIIa
  inhibitors to clopidogrel, aspirin, and heparin
  in PCI patients, tentatively recommended.

5
Safety of LMWH in PCI

• New observational studies, including NICE-1,
  suggest that PCI can be performed safely in
  patients who have received enoxaparin
• Alternative approach LMWH during the initial
  stabilization, then withhold the agent the
  morning of the procedure. If PCI is required and
  more than 8 hours have elapsed since the last
  LMWH dose, UFH can then be used

6
Summary of Major Changes

• ACC/AHA UA/NSTEMI Guideline rapidly updated to
  incorporate new ACS trials
• Addition of clopidogrel
• Targeting IIb/IIIa inhibitors to INV strategy
• Enoxaparin (LMWH) preferred over UFH
• Invasive strategy for Tn, ST changes
• Long-term Rx add statins, clopidogrel

7
Optimal Strategy for UA/NSTEMI
RITA-3
2002
TRUCS
VANQWISH
VINO
MATE
TACTICS-TIMI 18
TIMI IIIB
FRISC II
Conservative
Invasive