Unstable angina / non ST elevation myocardial infarction initial therapy


 * Associate Editor-In-Chief: Varun Kumar M.B.B.S; Lakshmi Gopalakrishnan M.B.B.S.

==ACC / AHA Guidelines for Initial Therapy (DO NOT EDIT) == {{cquote|

Class I
1. The history, physical examination, 12 lead ECG, and initial cardiac biomarker tests should be integrated to assign patients with chest pain into 1 of 4 categories: a non cardiac diagnosis, chronic stable angina, possible ACS, and definite ACS. (Level of Evidence: C)

2. Patients with probable or possible ACS but whose initial 12 lead ECG and cardiac biomarker levels are normal should be observed in a facility with cardiac monitoring (e.g., chest pain unit or hospital telemetry ward), and repeat ECG (or continuous 12-lead ECG monitoring) and repeat cardiac biomarker measurement(s) should be obtained at predetermined, specified time intervals. (Level of Evidence: B)

3. In patients with suspected ACS in whom ischemic heart disease is present or suspected, if the follow-up 12 lead ECG and cardiac biomarkers measurements are normal, a stress test (exercise or pharmacological) to provoke ischemia should be performed in the ED, in a chest pain unit, or on an outpatient basis in a timely fashion (within 72 h) as an alternative to inpatient admission. Low-risk patients with a negative diagnostic test can be managed as outpatients. (Level of Evidence: C)

4. In low-risk patients who are referred for outpatient stress testing, precautionary appropriate pharmacotherapy (e.g., ASA, sublingual NTG, and/or beta blockers) should be given while awaiting results of the stress test. (Level of Evidence: C)

5. Patients with definite ACS and ongoing ischemic symptoms, positive cardiac biomarkers, new ST-segment deviations, new deep T-wave inversions, hemodynamic abnormalities, or a positive stress test should be admitted to the hospital for further management. Admission to the critical care unit is recommended for those with active, ongoing ischemia/injury or hemodynamic or electrical instability. Otherwise, a telemetry step-down unit is reasonable. (Level of Evidence: C)

6. Patients with possible ACS and negative cardiac biomarkers who are unable to exercise or who have an abnormal resting ECG should undergo a pharmacological stress test. (Level of Evidence: B)

7. Patients with definite ACS and ST-segment elevation in leads V7 to V9 due to left circumflex artery occlusion should be evaluated for immediate reperfusion therapy. (Level of Evidence: A)

8. Patients discharged from the ED or chest pain unit should be given specific instructions for activity, medications, additional testing, and follow-up with a personal physician. (Level of Evidence: C)

Class IIa
1. In patients with suspected ACS with a low or intermediate probability of CAD, in whom the follow up 12 lead ECG and cardiac biomarkers measurements are normal, performance of a non invasive coronary imaging test (i.e., Cardiac / Coronary CT Angiography) is reasonable as an alternative to stress testing. (Level of Evidence: B)}}