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2011ACC、AHA最新指南


Table 2.

Recommendations for Antiplatelet Therapy
2007 Recommendations 2011 Focused Update Recommendations 1. ASA* should be administered to UA/NSTEMI patients as soon as possible after hospital presentation and continued indefinitely in patients who tolerate it (3–10). (Level of Evidence: A) 2. Clopidogrel (loading dose followed by daily maintenance dose) should be administered to UA/NSTEMI patients who are unable to take ASA because of hypersensitivity or major gastrointestinal intolerance (11–13). (Level of Evidence: B) Comments Modified recommendation (changed wording for clarity). Modified recommendation (level of evidence changed from A to B because trials do not address the specific subgroups in this recommendation). Deleted recommendation (see ACCF/ACG/AHA PPI expert consensus document [14]). 3. Patients with definite UA/NSTEMI at medium or high risk and in whom an initial invasive strategy is selected should receive dual-antiplatelet therapy on presentation (13,15–17). (Level of Evidence: A) ASA should be initiated on presentation (3– 8,10). (Level of Evidence: A) The choice of a second antiplatelet therapy to be added to ASA on presentation includes 1 of the following: Before PCI: ● Clopidogrel (13,17) (Level of Evidence: B); or ● An IV GP IIb/IIIa inhibitor (18 –21). (Level of Evidence: A) IV eptifibatide or tirofiban are the preferred GP IIb/IIIa inhibitors. At the time of PCI: ● Clopidogrel if not started before PCI (13,17) (Level of Evidence: A); or ● Prasugrel? (22) (Level of Evidence: B); or ● An IV GP IIb/IIIa inhibitor (18,21,23,24). (Level of Evidence: A) 4. For UA/NSTEMI patients in whom an initial conservative (i.e., noninvasive) strategy is selected (see Section 3.3), clopidogrel (loading dose followed by daily maintenance dose) should be added to ASA and anticoagulant therapy as soon as possible after admission and administered for at least 1 month (13) and ideally up to 1 year (11,13). (Level of Evidence: B) Modified recommendation (modified to include prasugrel and define therapy more clearly).

Class I ASA should be administered to UA/NSTEMI patients as soon as possible after hospital presentation and continued indefinitely in patients not known to be intolerant of that medication. (Level of Evidence: A) (Figs. 7 and 8; Box A) Clopidogrel (loading dose followed by daily maintenance dose) should be administered to UA/NSTEMI patients who are unable to take ASA because of hypersensitivity or major gastrointestinal intolerance. (Level of Evidence: A) (Figs. 7 and 8; Box A)

In UA/NSTEMI patients with a history of gastrointestinal bleeding, when ASA and clopidogrel are administered alone or in combination, drugs to minimize the risk of recurrent gastrointestinal bleeding (e.g., PPI), should be prescribed concomitantly. (Level of Evidence: B) For UA/NSTEMI patients in whom an initial invasive strategy is selected, antiplatelet therapy in addition to ASA should be initiated before diagnostic angiography (upstream) with either clopidogrel (loading dose followed by daily maintenance dose) or an IV GP IIb/IIIa inhibitor. (Level of Evidence: A) Abciximab as the choice for upstream GP IIb/IIIa therapy is indicated only if there is no appreciable delay to angiography and PCI is likely to be performed; otherwise, IV eptifibatide or tirofiban is the preferred choice of GP IIb/IIIa inhibitor. (Level of Evidence: B)

For UA/NSTEMI patients in whom an initial conservative (i.e., noninvasive) strategy is selected (see Section 3.3), clopidogrel (loading dose followed by daily maintenance dose) should be added to ASA and anticoagulant therapy as soon as possible after admission and administered for at least 1 month (Level of Evidence: A) and ideally up to 1 year. (Level of Evidence: B) (Fig. 8; Box C2) For UA/NSTEMI patients in whom an initial conservative strategy is selected, if recurrent symptoms/ischemia, HF or serious arrhythmias subsequently appear, then diagnostic angiography should be performed. (Level of Evidence: A) (Fig. 8; Box D) Either an IV GP IIb/IIIa inhibitor (eptifibatide or tirofiban; Level of Evidence: A) or clopidogrel (loading dose followed by daily maintenance dose; Level of Evidence: A) should be added to ASA and anticoagulant therapy before diagnostic angiography (upstream). (Level of Evidence: C)

Modified recommendation (changed level of evidence from A to B for 1-month clopidogrel administration).

5. For UA/NSTEMI patients in whom an initial conservative strategy is selected, if recurrent symptoms/ischemia, HF, or serious arrhythmias subsequently appear, then diagnostic angiography should be performed (13,25,26). (Level of Evidence: A). Either an IV GP IIb/IIIa inhibitor (eptifibatide or tirofiban (19 –21) [Level of Evidence: A]) or clopidogrel (loading dose followed by daily maintenance dose (13,15) [Level of Evidence: B]) should be added to ASA and anticoagulant therapy before diagnostic angiography (upstream). (Level of Evidence: C) 6. A loading dose of thienopyridine is recommended for UA/NSTEMI patients for whom PCI is planned. Regimens should be 1 of the following: a. Clopidogrel 300 to 600 mg should be given as early as possible before or at the time of PCI (13,27–31) (Level of Evidence: A) or b. Prasugrel? 60 mg should be given promptly and no later than 1 hour after PCI once coronary anatomy is defined and a decision is made to proceed with PCI (22). (Level of Evidence: B) The duration and maintenance dose of thienopyridine therapy should be as follows: a. In UA/NSTEMI patients undergoing PCI, clopidogrel 75 mg daily (17) or prasugrel? 10 mg daily (22) should be given for at least 12 months (13,17). (Level of Evidence: B) b. If the risk of morbidity because of bleeding outweighs the anticipated benefits afforded by thienopyridine therapy, earlier discontinuation should be considered. (Level of Evidence: C)

Modified recommendation (changed level of evidence from A to B for clopidogrel addition).

7.

New recommendation (included to be concordant with 2009 STEMI and PCI Focused Update (32), modified for the UA/NSTEMI patient group). New recommendation (included to be concordant with 2009 STEMI and PCI Focused Update [32]).

(Continued)

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JACC Vol. 57, No. 18, 2011 May 3, 2011:xxx

UA/NSTEMI

Guideline

Wright et al. Focused Update

7

Table 2.

Continued
2007 Recommendations 2011 Focused Update Recommendations 1. For UA/NSTEMI patients in whom an initial conservative strategy is selected and who have recurrent ischemic discomfort with clopidogrel, ASA, and anticoagulant therapy, it is reasonable to add a GP IIb/IIIa inhibitor before diagnostic angiography. (Level of Evidence: C) 2. For UA/NSTEMI patients in whom an initial invasive strategy is selected, it is reasonable to omit administration of an IV GP IIb/IIIa inhibitor if bivalirudin is selected as the anticoagulant and at least 300 mg of clopidogrel was administered at least 6 hours earlier than planned catheterization or PCI (16,33,34). (Level of Evidence: B) Comments 2007 recommendation remains current.

Class IIa For UA/NSTEMI patients in whom an initial conservative strategy is selected and who have recurrent ischemic discomfort with clopidogrel, ASA, and anticoagulant therapy, it is reasonable to add a GP IIb/IIIa antagonist before diagnostic angiography. (Level of Evidence: C) For UA/NSTEMI patients in whom an initial invasive strategy is selected, it is reasonable to omit upstream administration of an IV GP IIb/IIIa antagonist before diagnostic angiography if bivalirudin is selected as the anticoagulant and at least 300 mg of clopidogrel was administered at least 6 hours earlier than planned catheterization or PCI. (Level of Evidence: B) Class IIb For UA/NSTEMI patients in whom an initial conservative (i.e., noninvasive) strategy is selected, it may be reasonable to add eptifibatide or tirofiban to anticoagulant and oral antiplatelet therapy. (Level of Evidence: B) (Fig. 8; Box C2) 1. For UA/NSTEMI patients in whom an initial conservative (i.e., noninvasive) strategy is selected, it may be reasonable to add eptifibatide or tirofiban to anticoagulant and oral antiplatelet therapy (19,20). (Level of Evidence: B) 2. Prasugrel? 60 mg may be considered for administration promptly upon presentation in patients with UA/NSTEMI for whom PCI is planned, before definition of coronary anatomy if both the risk for bleeding is low and the need for CABG is considered unlikely (22,35,36). (Level of Evidence: C) 3. The use of upstream GP IIb/IIIa inhibitors may be considered in high-risk UA/NSTEMI patients already receiving ASA and a thienopyridine who are selected for an invasive strategy, such as those with elevated troponin levels, diabetes, or significant ST- segment depression, and who are not otherwise at high risk for bleeding (19,20,25,27,37). (Level of Evidence: B) 4. In patients with definite UA/NSTEMI undergoing PCI as part of an early invasive strategy, the use of a loading dose of clopidogrel of 600 mg, followed by a higher maintenance dose of 150 mg daily for 6 days, then 75 mg daily may be reasonable in patients not considered at high risk for bleeding (28). (Level of Evidence: B) 1. Abciximab should not be administered to patients in whom PCI is not planned (21,23). (Level of Evidence: A) 2. In UA/NSTEMI patients who are at low risk for ischemic events (e.g., TIMI risk score 2) or at high risk of bleeding and who are already receiving ASA and clopidogrel, upstream GP IIb/IIIa inhibitors are not recommended (25,36 –38). (Level of Evidence: B) 1. In UA/NSTEMI patients with a prior history of stroke and/or TIA for whom PCI is planned, prasugrel is potentially harmful as part of a dual-antiplatelet therapy regimen (22). (Level of Evidence: B)

Modified recommendation (removed language about diagnostic angiography).

2007 recommendation remains current. New recommendation

New recommendation

New recommendation

Class III: No Benefit Abciximab should not be administered to patients in whom PCI is not planned. (Level of Evidence: A)

2007 recommendation remains current. New recommendation

Class III: Harm

New recommendation (included to be concordant with 2009 STEMI and PCI Focused Update [32]).

*Refer to the ACC/AHA/SCAI Guideline for Percutaneous Coronary Intervention for long-term dosing of ASA following stent placement. ?Patients weighing 60 kg have an increased exposure to the active metabolite of prasugrel and an increased risk of bleeding on a 10-mg once– daily maintenance dose. Consideration should be given to lowering the maintenance dose to 5 mg in patients who weigh 60 kg, although the effectiveness and safety of the 5-mg dose have not been studied prospectively. For post-PCI patients receiving a BMS or DES, a daily maintenance dose should be given for at least 12 months and for up to 15 months unless the risk of bleeding outweighs the anticipated net benefit afforded by a thienopyridine. Do not use prasugrel in patients with active pathological bleeding or a history of TIA or stroke. In patients 75 years of age, prasugrel is generally not recommended because of the increased risk of fatal and intracranial bleeding and uncertain benefit except in high-risk situations (patients with diabetes or a history of prior MI), in which its effect appears to be greater and its use may be considered. Do not start prasugrel in patients likely to undergo urgent CABG. When possible, discontinue prasugrel at least 7 days before any surgery (35). Additional risk factors for bleeding include body weight 60 kg, propensity to bleed, and concomitant use of medications that increase the risk of bleeding (e.g., warfarin, heparin, fibrinolytic therapy, or chronic use of nonsteroidal anti-inflammatory drugs) (35).

The pivotal trial (22) for prasugrel, TRITON-TIMI 38 (Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition with Prasugrel-Thrombolysis in Myocardial Infarction), focused on patients with acute coronary syndrome (ACS) who were referred for percutane- ous coronary intervention (PCI). TRITON-TIMI 38 randomly assigned 13,608 patients with moderate- to high-risk ACS, of whom

10,074 (74%) had UA/NSTEMI, to receive prasugrel (a 60-mg loading dose and a 10-mg daily maintenance dose) or clopidogrel (a 300-mg loading dose and a 75-mg daily maintenance dose) for a median follow-up of 14.5 months.

Acetylsalicylic acid (ASA) was prescribed within 24 hours of PCI. Clinical endpoints were assessed at 30 and 90 days and then at 3-month intervals for 6 to 15 months. Among patients with UA/NSTEMI undergoing PCI, a prasugrel loading dose was administered before, during, or within 1 hour after PCI but only after coronary anatomy had been defined.

Prasugrel was associated with a significant 2.2% absolute reduction and a 19% relative reduction in the primary efficacy endpoint, a composite of the rate of death due to cardiovascular causes (including arrhythmia, congestive heart failure, shock, and sudden or unwitnessed death), nonfatal myocar-

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8

Wright et al. UA/NSTEMI Guideline Focused Update

JACC Vol. 57, No. 18, 2011 May 3, 2011:xxx

Table 3.

Recommendations for Additional Management of Antiplatelet and Anticoagulant Therapy
2007 Recommendations 2011 Focused Update Recommendations 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 (26). (Level of Evidence: B) a. If, after stress testing, the patient is classified as not at low risk, diagnostic angiography should be performed (25,26). (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 (25,26): 1. Continue ASA indefinitely (4,6,10). (Level of Evidence: A) 2. Continue clopidogrel for at least 1 month (13) and ideally up to 1 year (11,13). (Level of Evidence: B) 3. Discontinue IV GP IIb/IIIa inhibitor if started previously (19,20). (Level of Evidence: A) 4. Continue UFH for 48 hours (8,39) (Level of Evidence: A) or administer enoxaparin (40 – 42) (Level of Evidence: A) or fondaparinux (43) (Level of Evidence: B) for the duration of hospitalization, up to 8 days, and then discontinue anticoagulant therapy. For UA/NSTEMI patients in whom CABG is selected as a postangiography management strategy, the instructions noted below should be followed. a. Continue ASA (44 –48). (Level of Evidence: A) b. See Class I, #3, in this section. c. Discontinue IV GP IIb/IIIa inhibitor (eptifibatide or tirofiban) 4 hours before CABG (49 –51). (Level of Evidence: B) d. Anticoagulant therapy should be managed as follows: Continue UFH (40,52–54). (Level of Evidence: B) 1. 2. Discontinue enoxaparin 12 to 24 hours before CABG and dose with UFH per institutional practice (40,52–54). (Level of Evidence: B) 3. Discontinue fondaparinux 24 hours before CABG and dose with UFH per institutional practice (55,56). (Level of Evidence: B) 4. Discontinue bivalirudin 3 hours before CABG and dose with UFH per institutional practice (57,58). (Level of Evidence: B) Comments Modified recommendation (changed level of evidence from A to B for 1-month clopidogrel administration; clarified levels of evidence for UFH, enoxaparin, and fondaparinux).

Class I 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) (Fig. 8; Box O) a. If, after stress testing, the patient is classified as not at low risk, diagnostic angiography should be performed. (Level of Evidence: A) (Fig. 8; Box E1) b. If, after stress testing, the patient is classified as being at low risk (Fig. 8; Box E2), the instructions noted below should be followed in preparation for discharge (Fig. 8; Box K) (Level of Evidence: A): 1. Continue ASA indefinitely. (Level of Evidence: A) 2. Continue clopidogrel for at least 1 month (Level of Evidence: A) and ideally up to 1 year. (Level of Evidence: B) 3. Discontinue IV GP IIb/IIIa inhibitor if started previously. (Level of Evidence: A) 4. Continue UFH for 48 hours or administer enoxaparin or fondaparinux for the duration of hospitalization, up to 8 days, and then discontinue anticoagulant therapy. (Level of Evidence: A) For UA/NSTEMI patients in whom CABG is selected as a postangiography management strategy, the instructions noted below should be followed (Fig. 9; Box G). a. Continue ASA. (Level of Evidence: A) b. Discontinue clopidogrel 5 to 7 days 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 IV GP IIb/IIIa inhibitor (eptifibatide or tirofiban) 4 hours before CABG. (Level of Evidence: B) d. Anticoagulant therapy should be managed as follows: Continue UFH. (Level of Evidence: B) 1. 2. Discontinue enoxaparin* 12 to 24 hours before CABG and dose with UFH per institutional practice. (Level of Evidence: B) 3. Discontinue fondaparinux 24 hours before CABG and dose with UFH per institutional practice. (Level of Evidence: B) 4. Discontinue bivalirudin 3 hours before CABG and dose with UFH per institutional practice. (Level of Evidence: B) For UA/NSTEMI patients in whom CABG is selected as a postangiography management strategy, the instructions noted below should be followed (Fig. 9; Box G). b. Discontinue clopidogrel 5 to 7 days 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) For UA/NSTEMI patients in whom PCI has been selected as a postangiography management strategy, the instructions noted below should be followed (Fig. 9; Box H): 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 IV 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) For UA/NSTEMI patients in whom medical therapy is selected as a 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. (Fig. 9; Box I) (Level of Evidence: C)

2.

Modified recommendation (changed item “b” to include prasugrel and be a stand-alone recommendation; see Class I, #3, in this section).

3. In patients taking a thienopyridine in whom CABG is planned and can be delayed, it is recommended that the drug be discontinued to allow for dissipation of the antiplatelet effect (13) (Level of Evidence: B) The period of withdrawal should be at least 5 days in patients receiving clopidogrel (13,18,59) (Level of Evidence: B) and at least 7 days in patients receiving prasugrel* (35) (Level of Evidence: C) unless the need for revascularization and/or the net benefit of the thienopyridine outweighs the potential risks of excess bleeding (60). (Level of Evidence: C) 4. 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 (4,6,10). (Level of Evidence: A) b. Administer a loading dose of a thienopyridine if not started before diagnostic angiography (12,29,31,61,62). (Level of Evidence: A) c. See Class IIa, #1, in this section. d. Discontinue anticoagulant therapy after PCI for uncomplicated cases (40,41,63– 65). (Level of Evidence: B)

Modified recommendation (changed to include prasugrel and update length of withdrawal period; from Class I, #2, in this section). Modified recommendation (included language to allow for prasugrel as choice of thienopyridine; class of item “c” changed from I to IIa).

2007 recommendation remains current. 5. For UA/NSTEMI patients in whom medical therapy is selected as a 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)

(Continued)

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JACC Vol. 57, No. 18, 2011 May 3, 2011:xxx

UA/NSTEMI

Guideline

Wright et al. Focused Update

9

Table 3.

Continued
2007 Recommendations 2011 Focused Update Recommendations 6. For UA/NSTEMI patients in whom medical therapy is selected as a management strategy and in whom CAD was found on angiography, the following approach is recommended: a. Continue ASA (4,6,10). (Level of Evidence: A) b. Administer a loading dose of clopidogrel if not given before diagnostic angiography (13). (Level of Evidence: B) c. Discontinue IV GP IIb/IIIa inhibitor if started previously (16,19,20,38). (Level of Evidence: B) d. Anticoagulant therapy should be managed as follows: 1. Continue IV UFH for at least 48 hours or until discharge if given before diagnostic angiography (8,39,40). (Level of Evidence: A) 2. Continue enoxaparin for duration of hospitalization, up to 8 days, if given before diagnostic angiography (40 – 42,56). (Level of Evidence: A) 3. Continue fondaparinux for duration of hospitalization, up to 8 days, if given before diagnostic angiography (43). (Level of Evidence: B) 4. Either discontinue bivalirudin or continue at a dose of 0.25 mg/kg per hour for up to 72 hours at the physician’s discretion if given before diagnostic angiography (34,67,68). (Level of Evidence: B) 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 (4,6,10). (Level of Evidence: A) b. Continue clopidogrel for at least 1 month (13) and ideally up to 1 year (11,13,121). (Level of Evidence: B) c. Discontinue IV GP IIb/IIIa inhibitor if started previously (19,20). (Level of Evidence: A) d. Continue UFH for 48 hours (8,39) (Level of Evidence: A) or administer enoxaparin (40 – 42) (Level of Evidence: A) or fondaparinux (Level of Evidence: B) for the duration of hospitalization, up to 8 days (43), and then discontinue anticoagulant therapy. Comments Modified recommendation (changed level of evidence from A to B for clopidogrel loading dose).

For UA/NSTEMI patients in whom medical therapy is selected as a management strategy and in whom CAD was found on angiography, the following approach is recommended (Fig. 9; Box J): 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 IV GP IIb/IIIa inhibitor if started previously. (Level of Evidence: B) d. Anticoagulant therapy should be managed as follows: 1. Continue IV UFH for at least 48 hours or until discharge if given before diagnostic angiography. (Level of Evidence: A) 2. Continue enoxaparin for duration of hospitalization, up to 8 days, if given before diagnostic angiography. (Level of Evidence: A) 3. Continue fondaparinux for duration of hospitalization, up to 8 days, if given before diagnostic angiography. (Level of Evidence: B) 4. Either discontinue bivalirudin or continue at a dose of 0.25 mg/kg per hour for up to 72 hours at the physician’s discretion, if given before diagnostic angiography. (Level of Evidence: B) 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 (Fig. 8; Box K): 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 hours or administer enoxaparin or fondaparinux for the duration of hospitalization, up to 8 days, and then discontinue anticoagulant therapy. (Level of Evidence: A)

7.

Modified recommendation (changed level of evidence from A to B for 1-month clopidogrel administration).

2007 recommendation remains current.

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) (Fig. 8; Box L) Class IIa

8. 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 (25,69 –72). (Level of Evidence: B) 1. For UA/NSTEMI patients in whom PCI has been selected as a postangiography management strategy, it is reasonable to administer an IV GP IIb/IIIa inhibitor (abciximab, eptifibatide, or tirofiban) if not started before diagnostic angiography, particularly for troponin-positive and/or other high-risk patients (25,27). (Level of Evidence: A) 2. For UA/NSTEMI patients in whom PCI is selected as a management strategy, it is reasonable to omit administration of an IV GP IIb/IIIa inhibitor if bivalirudin was selected as the anticoagulant and at least 300 mg of clopidogrel was administered at least 6 hours earlier (16,25). (Level of Evidence: B) 3. If LVEF is 0.40, it is reasonable to perform diagnostic angiography (69 –72). (Level of Evidence: B)

Modified recommendation (see Class I, #4, in this section).

For UA/NSTEMI patients in whom PCI is selected as a management strategy, it is reasonable to omit administration of an IV GP IIb/IIIa antagonist if bivalirudin was selected as the anticoagulant and at least 300 mg of clopidogrel was administered at least 6 hours earlier. (Level of Evidence: B) (Fig. 9) If LVEF is 0.40, it is reasonable to perform diagnostic angiography. (Level of Evidence: B) (Fig. 8; Box M) If LVEF is greater than 0.40, it is reasonable to perform a stress test. (Level of Evidence: B) (Fig. 8; Box N) Class IIb For UA/NSTEMI patients in whom PCI is selected as a management strategy, it may be reasonable to omit an IV GP IIb/IIIa inhibitor if not started before diagnostic angiography for troponin-negative patients without other clinical or angiographic high-risk features. (Level of Evidence: C)

2007 recommendation remains current.

2007 recommendation remains current. 2007 recommendation remains current. Deleted recommendation

4. If LVEF is greater than 0.40, it is reasonable to perform a stress test (69). (Level of Evidence: B)

New recommendation

1. Platelet function testing to determine platelet inhibitory response in patients with UA/NSTEMI (or, after ACS and PCI) on thienopyridine therapy may be considered if results of testing may alter management (73–77). (Level of Evidence: B) Class III: No Benefit IV fibrinolytic therapy is not indicated in patients without acute ST-segment elevation, a true posterior MI, or a presumed new left bundle-branch block. (Level of Evidence: A) 2. Genotyping for a CYP2C19 loss of function variant in patients with UA/NSTEMI (or, after ACS and with PCI) on clopidogrel therapy might be considered if results of testing may alter management (78 – 84). (Level of Evidence: C) 1. IV fibrinolytic therapy is not indicated in patients without acute ST-segment elevation, a true posterior MI, or a presumed new left bundle-branch block (85). (Level of Evidence: A)

New recommendation

2007 recommendation remains current.

*Patients weighing 60 kg have an increased exposure to the active metabolite of prasugrel and an increased risk of bleeding on a 10-mg once– daily maintenance dose. Consideration should be given to lowering the maintenance dose to 5 mg in patients who weigh 60 kg, although the effectiveness and safety of the 5-mg dose have not been studied prospectively. For post-PCI patients receiving a bare-metal stent (BMS) or drug-eluting stent (DES), a daily maintenance dose should be given for at least 12 months and for up to 15 months unless the risk of bleeding outweighs the anticipated net benefit afforded by a thienopyridine. Do not use prasugrel in patients with active pathological bleeding or a history of TIA or stroke. In patients 75 years of age, prasugrel is generally not recommended because of the increased risk of fatal and intracranial bleeding and uncertain benefit except in high-risk situations (patients with diabetes or a history of prior MI), in which its effect appears to be greater and its use may be considered. Do not start prasugrel in patients likely to undergo urgent CABG. When possible, discontinue prasugrel at least 7 days before any surgery (35). Additional risk factors for bleeding include body weight 60 kg, propensity to bleed, and concomitant use of medications that increase the risk of bleeding (e.g., warfarin, heparin, fibrinolytic therapy, or chronic use of nonsteroidal anti-inflammatory drugs) (35).

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