Unstable angina / non ST elevation myocardial infarction long-term medical therapy and secondary prevention

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Unstable Angina
Non-ST Elevation Myocardial Infarction

Differentiating Unstable Angina/Non-ST Elevation Myocardial Infarction from other Disorders

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Women
Heart Failure and Cardiogenic Shock
Perioperative NSTE-ACS Related to Noncardiac Surgery
Stress (Takotsubo) Cardiomyopathy
Diabetic Mellitus
Post CABG Patients
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Risk Stratification Before Discharge for Patients With an Ischemia-Guided Strategy of NSTE-ACS

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Long-Term Medical Therapy and Secondary Prevention

ICD implantation within 40 days of myocardial infarction

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-in-Chief: Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.

Overview

Similar to patients with STEMI, patients with UA/NSTEMI also require secondary prevention at the time of discharge. Patients and their families should be educated regarding the specific targets for LDL cholesterol and HDL cholesterol, blood pressure, body mass index (BMI), physical activity, and other appropriate lifestyle modifications.

You can read in greater detail about each of the ACC/AHA guidelines for long term medical therapy and risk factor modification after UA/NSTEMI by clicking on the links below:[1]

Identifying and, when present, treating Category I risk factors can be an optimal secondary prevention strategy in patients with UA/NSTEMI. You can read more about general coronary heart disease secondary prevention HERE

2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes (DO NOT EDIT) [2]

Hormone Therapy

Class III (No Benefit)
"1. Hormone therapy with estrogen plus progestin, or estrogen alone, should not be given as new drugs for secondary prevention of coronary events to postmenopausal women after NSTE-ACS and should not be continued in previous users unless the benefits outweigh the estimated risks. (Level of Evidence: A)"

Antioxidant Vitamins and Folic Acid

Class III (No Benefit)
"1. Antioxidant vitamin supplements (e.g., vitamins E, C, or beta carotene) should not be used for secondary prevention in patients with NSTE-ACS. (Level of Evidence: A)"
"2. Folic acid, with or without vitamins B6 and B12, should not be used for secondary prevention in patients with NSTE-ACS. (Level of Evidence: A)"

Plan of Care for Patients With NSTE-ACS

Class I
"1. Posthospital systems of care designed to prevent hospital readmissions should be used to facilitate the transition to effective, coordinated outpatient care for all patients with NSTE-ACS. (Level of Evidence: B)"
"2. An evidence-based plan of care (e.g., GDMT) that promotes medication adherence, timely follow up with the healthcare team, appropriate dietary and physical activities, and compliance with interventions for secondary prevention should be provided to patients with NSTE-ACS. (Level of Evidence: C)"
"3. On activities (e.g., lifting, climbing stairs, yard work, and household activities) that are permissible and those to avoid. Specific mention should be made of resumption of driving, return to work, and sexual activity. (Level of Evidence: B)"
"4. An annual influenza vaccination is recommended for patients with cardiovascular disease. (Level of Evidence: C)"

References

  1. 2012 Writing Committee Members. Jneid H, Anderson JL, Wright RS, Adams CD, Bridges CR; et al. (2012). "2012 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction (Updating the 2007 Guideline and Replacing the 2011 Focused Update): A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.". Circulation. 126 (7): 875–910. PMID 22800849. doi:10.1161/CIR.0b013e318256f1e0. 
  2. Ezra A. Amsterdam, MD, FACC; Nanette K. Wenger, MD et al.2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. JACC. September 2014 (ahead of print)



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