The Living Guidelines: UA/NSTEMI Recommendations for Anti Ischemic Therapy Suggest Revisions to the CLASS I Guidelines

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==Class I Guidelines ==


 * 1) Bed/chair rest with continuous ECG monitoring is recommended for all UA / NSTEMI patients during the early hospital phase. (Level of Evidence: C)
 * 2) Supplemental oxygen should be administered to patients with UA / NSTEMI with an arterial saturation <90%, respiratory distress, or other high risk features for hypoxemia. (Pulse oximetry is useful for continuous measurement of SaO²) (Level of Evidence: B)
 * 3) Patients with UA / NSTEMI with ongoing ischemic discomfort should receive sublingual NTG (0.4 mg) every 5 min for a total of 3 doses, after which assessment should be made about the need for intravenous NTG, if not contraindicated. (Level of Evidence: C)
 * 4) Intravenous NTG is indicated in the first 48 h after UA / NSTEMI for treatment of persistent ischemia, Heart failure, or hypertension. The decision to administer intravenous NTG and the dose used should not preclude therapy with other proven mortality reducing interventions such as beta blockers or ACE inhibitors. (Level of Evidence: B)
 * 5) Oral beta blocker therapy should be initiated within the first 24 h for patients who do not have 1 or more of the following: a- Signs of Heart Failure, b- Evidence of a low-output state, c- Increased risk for cardiogenic shock, or d- Other relative contraindications to beta blockade (PR interval >0.24 sec, second or third degree heart block, active asthma, or reactive airway disease). (Level of Evidence: B)
 * 6) In UA / NSTEMI patients with continuing or frequently recurring ischemia and in whom beta blockers are contraindicated, a non dihydropyridine calcium channel blocker (e.g., verapamil or diltiazem) should be given as initial therapy in the absence of clinically significant Left Ventricular dysfunction or other contraindications. (Level of Evidence: B)
 * 7) An Angiotensin Converting Enzyme inhibitor  (ACE) should be administered orally within the first 24 h to UA / NSTEMI patients with pulmonary congestion or LV ejection fraction (LVEF) ≤40%, in the absence of hypotension (systolic blood pressure <100 mmHg or <30 mmHg below baseline) or known contraindications to that class of medications. (Level of Evidence: A)on).'' J Am Coll Cardiol. 2008 Mar 4; 51(9): 974. PMID 17692738
 * 8) An angiotensin receptor blocker should be administered to UA / NSTEMI patients who are intolerant of ACE inhibitors and have either clinical or radiological signs of HF or LVEF ≤40%. (Level of Evidence: A)
 * 9) Because of the increased risks of mortality, reinfarction, hypertension, HF, and myocardial rupture associated with their use, non steroidal anti-inflammatory drugs (NSAIDs), except for ASA, whether non selective or cyclo oxygenase (COX)-2–selective agents, should be discontinued at the time a patient presents with UA / NSTEMI. (Level of Evidence: C)