The Living Guidelines: UA/NSTEMI Recomendations for Additional Management Considerations for Antiplatelet and Anticoagulant Therapy Suggest Revisions to the CLASS I Guidelines

Click on the edit button above to make suggested revisions to the guidelines.


 * CLASS I

1. For UA/NSTEMI patients in whom an initial conservative strategy is selected and no subsequent features appear that would necessitate diagnostic angiography (recurrent symptoms/ischemia, HF, or serious arrhythmias), a stress test should be performed. (Level of Evidence: B).

a. If, after stress testing, the patient is classified as not at low risk, diagnostic angiography should be performed. (Level of Evidence: A)

b. If, after stress testing, the patient is classified as being at low risk, the instructions noted below should be followed in preparation for discharge (Level of Evidence: A):

-Continue ASA indefinitely. (Level of Evidence: A)

-Continue clopidogrel for at least 1 month (Level of Evidence: A) and ideally up to 1 year. (Level of Evidence: B)

-Discontinue intravenous GP IIb/IIIa inhibitor if started previously. (Level of Evidence: A)

-Continue UFH for 48 h or administer enoxaparin or fondaparinux for the duration of hospitalization, up to 8 d, and then discontinue anticoagulant therapy. (Level of Evidence: A)

2. For UA/NSTEMI patients in whom CABG is selected as a postangiography management strategy, the instructions noted below should be followed.

a. Continue ASA. (Level of Evidence: A)

b. Discontinue clopidogrel 5 to 7 d before elective CABG. (Level of Evidence: B) More urgent surgery, if necessary, may be performed by experienced surgeons if the incremental bleeding risk is considered acceptable. (Level of Evidence: C)

c. Discontinue intravenous GP IIb/IIIa inhibitor (eptifibatide or tirofiban) 4 h before CABG. (Level of Evidence: B)

d. Anticoagulant therapy should be managed as follows:

-Continue UFH. (Level of Evidence: B)

-Discontinue enoxaparin* 12 to 24 h before CABG and dose with UFH per institutional practice. (Level of Evidence: B)

-Discontinue fondaparinux 24 h before CABG and dose with UFH per institutional practice. (Level of Evidence: B)

-Discontinue bivalirudin 3 h before CABG and dose with UFH per institutional practice. (Level of Evidence: B)

3. For UA/NSTEMI patients in whom PCI has been selected as a postangiography management strategy, the instructions noted below should be followed:

a. Continue ASA. (Level of Evidence: A)

b. Administer a loading dose of clopidogrel† if not started before diagnostic angiography. (Level of Evidence: A)

c. Administer an intravenous GP IIb/IIIa inhibitor (abciximab, eptifibatide, or tirofiban) if not started before diagnostic angiography for troponin-positive and other high-risk patients (Level of Evidence: A). See Class IIa recommendation below if bivalirudin was selected as the anticoagulant.

d. Discontinue anticoagulant therapy after PCI for uncomplicated cases. (Level of Evidence: B)

4. For UA/NSTEMI patients in whom medical therapy is selected as a postangiography management strategy and in whom no significant obstructive CAD on angiography was found, antiplatelet and anticoagulant therapy should be administered at the discretion of the clinician. (Level of Evidence: C) For patients in whom evidence of coronary atherosclerosis is present (e.g., luminal irregularities or intravascular ultrasound-demonstrated lesions), albeit without flow-limiting stenoses, long-term treatment with ASA and other secondary prevention measures should be prescribed. (Level of Evidence: C)

5. For UA/NSTEMI patients in whom medical therapy is selected as a postangiography management strategy and in whom CAD was found on angiography, the following approach is recommended:

a. Continue ASA. (Level of Evidence: A)

b. Administer a loading dose of clopidogrel† if not given before diagnostic angiography. (Level of Evidence: A)

c. Discontinue intravenous GP IIb/IIIa inhibitor if started previously. (Level of Evidence: B)

d. Anticoagulant therapy should be managed as follows:

-Continue intravenous UFH for at least 48 h or until discharge if given before diagnostic angiography. (Level of Evidence: A)

-Continue enoxaparin for duration of hospitalization, up to 8 d, if given before diagnostic angiography. (Level of Evidence: A)

-Continue fondaparinux for duration of hospitalization, up to 8 d, if given before diagnostic angiography. (Level of Evidence: B)

-Either discontinue bivalirudin or continue at a dose of 0.25 mg per kg per h for up to 72 h at the physician’s discretion, if given before diagnostic angiography. (Level of Evidence: B)

6. For UA/NSTEMI patients in whom a conservative strategy is selected and who do not undergo angiography or stress testing, the instructions noted below should be followed:

a. Continue ASA indefinitely. (Level of Evidence: A)

b. Continue clopidogrel for at least 1 month (Level of Evidence: A) and ideally up to 1 year. (Level of Evidence: B)

c. Discontinue IV GP IIb/IIIa inhibitor if started previously. (Level of Evidence: A)

d. Continue UFH for 48 h or administer enoxaparin or fondaparinux for the duration of hospitalization, up to 8 d, and then discontinue anticoagulant therapy. (Level of Evidence: A)

7. For UA/NSTEMI patients in whom an initial conservative strategy is selected and in whom no subsequent features appear that would necessitate diagnostic angiography (recurrent symptoms/ischemia, HF, or serious arrhythmias), LVEF should be measured. (Level of Evidence: B)