The Living Guidelines: UA/NSTEMI Recommendations for Anti Ischemic Therapy Polling Results for 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)

 UA/NSTEMI Guidelines Class I Recommendation 1 for Anti Ischemic Therapy should be: CLASS I CLASS IIa CLASS IIb CLASS III

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)

 UA/NSTEMI Guidelines Class I Recommendation 2 for Anti Ischemic Therapy should be: CLASS I CLASS IIa CLASS IIb CLASS III

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)

 UA/NSTEMI Guidelines Class I Recommendation 3 for Anti Ischemic Therapy should be: CLASS I CLASS IIa CLASS IIb CLASS III

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)

 UA/NSTEMI Guidelines Class I Recommendation 4 for Anti Ischemic Therapy should be: CLASS I CLASS IIa CLASS IIb CLASS III

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:

1) Signs of Heart Failure,

2) Evidence of a low-output state,

3) Increased risk for cardiogenic shock, or

4) 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)

 UA/NSTEMI Guidelines Class I Recommendation 5 for Anti Ischemic Therapy should be: CLASS I CLASS IIa CLASS IIb CLASS III

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)

 UA/NSTEMI Guidelines Class I Recommendation 6 for Anti Ischemic Therapy should be: CLASS I CLASS IIa CLASS IIb CLASS III

7. An Angiotensin Converting Enzyme (ACE) inhibitor 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)

 UA/NSTEMI Guidelines Class I Recommendation 7 for Anti Ischemic Therapy should be: CLASS I CLASS IIa CLASS IIb CLASS III

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)

 UA/NSTEMI Guidelines Class I Recommendation 8 for Anti Ischemic Therapy should be: CLASS I CLASS IIa CLASS IIb CLASS III

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)

 UA/NSTEMI Guidelines Class I Recommendation 9 for Anti Ischemic Therapy should be: CLASS I CLASS IIa CLASS IIb CLASS III

Reference

 * Anderson JL, Adams CD, Antman EM et. al, ACC/AHA 2007 Guidelines for the Management of Patients with Unstable Angina/Non ST-Elevation Myocardial Infarction. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation Myocardial Infarction). Circulation published online Aug 6, 2007; DOI: 10.1161/CIRCULATION AHA.107.181940