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

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Class I Guidelines
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, heart failure or serious arrhythmias), a stress test should be performed. (Class I Level of Evidence: B).


 * a. If, after stress testing, the patient is classified as not at low risk, diagnostic angiography should be performed. (Class I Level of Evidence: A)
 * b. If, after stress testing, the patient is classified as being at low risk, the following instructions should be used in preparation for discharge (Class I Level of Evidence: A):


 * Continue ASA indefinitely. (Class I Level of Evidence: A)
 * Continue clopidogrel for at least 1 month (Level of Evidence: A) and ideally up to 1 year. (Class I Level of Evidence: B)
 * Discontinue intravenous GP IIb/IIIa inhibitor if started previously. (Class I 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. (Class I 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. (Class I 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. (Class I Level of Evidence: C)
 * c. Discontinue intravenous GP IIb/IIIa inhibitor (eptifibatide or tirofiban) 4 h before CABG. (Class I Level of Evidence: B)
 * d. Anticoagulant therapy should be managed as follows:


 * Continue UFH. (Class I Level of Evidence: B)
 * Discontinue enoxaparin 12 to 24 h before CABG and dose with UFH per institutional practice. (Class I Level of Evidence: B)
 * Discontinue fondaparinux 24 h before CABG and dose with UFH per institutional practice. (Class I Level of Evidence: B)
 * Discontinue bivalirudin 3 h before CABG and dose with UFH per institutional practice. (Class I 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. (Class I Level of Evidence: A)
 * b. Administer a loading dose of clopidogrel if not started before diagnostic angiography. (Class I 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 (Class I Level of Evidence: A).
 * d. Discontinue anticoagulant therapy after PCI for uncomplicated cases. (Class I Level of Evidence: B)

4. According to angiographic findings;


 * a. For UA / NSTEMI patients in whom medical therapy is selected as a postangiography management strategy and in whom no significant obstructive coronary artery disease on angiography was found, antiplatelet and anticoagulant therapy should be administered at the discretion of the clinician. (Class I Level of Evidence: C)
 * b. 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. (Class I 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. (Class I Level of Evidence: A)
 * b. Administer a loading dose of clopidogrel if not given before diagnostic angiography. (Class I Level of Evidence: A)
 * c. Discontinue intravenous GP IIb/IIIa inhibitor if started previously. (Class I 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. (Class I Level of Evidence: A)
 * Continue enoxaparin for duration of hospitalization, up to 8 d, if given before diagnostic angiography. (Class I Level of Evidence: A)
 * Continue fondaparinux for duration of hospitalization, up to 8 d, if given before diagnostic angiography. (Class I 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. (Class I Level of Evidence: B)

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


 * a. Continue ASA indefinitely. (Class I 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. (Class I 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. (Class I 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), Left Ventricular Ejection Fraction should be measured. (Class I Level of Evidence: B)