nice guideline nstemi

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Unstable angina and NSTEMIImplementing NICE guidance

2nd Edition October 2011

NICE clinical guideline 94


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Updated guidance

This guideline updates and replaces

recommendations for the early management ofunstable angina and NSTEMI from NICE technologyappraisal guidance 47 and 80


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What this presentation covers

Background

Scope

Key priorities for implementationCosts and savings

Discussion

NHS Evidence

Hyperglycaemia in ACS

Find out more


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Background:1

Cholesterol-rich plaques form on coronary artery wallsnarrowing the lumen. Blood supply to myocarduim iscompromised causing pain on exertion

An unstable plaque may tear and expose underlyingathermoma. This stimulates clot (thrombus) formation

The thrombus partly blocks the artery, interrupting bloodsupply to heart muscle (myocardial ischaemia)

Unstable angina myocardial ischaemia with noevidence of heart muscle death (myocardial necrosis)

NSTEMI myocardial ischaemia withevidence of myocardial necrosis


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Background:2

Outcomes vary widely among patients with NSTEMIand unstable angina

Scoring systems attempt to stratify risk of futureadverse cardiovascular events

Guideline defines patients likely to benefit from

interventions


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Scope

This guideline covers:

Adults with a diagnosis of unstable angina or NSTEMI

This guideline does not cover:

ST-segment-elevation myocardial infarction (STEMI)

Specific complications of unstable angina and NSTEMI

such as cardiac arrest or acute heart failure

Management after discharge from hospital


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Key priorities forimplementation

Assess risk of adverse cardiovascular events

Consider glycoprotein inhibitors for patients atintermediate or higher risk

Offer angiography within 96 hours to patients atintermediate or higher risk

Discuss revascularisation with other healthcare

professionals and choice of strategy with patient

Consider ischaemia testing before discharge

Rehabilitation and discharge planning


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As soon as the diagnosis of unstable angina or

NSTEMI is made, and aspirin and antithrombin

therapy have been offered, formally assess individualrisk of future adverse cardiovascular events using an

established risk scoring system that predicts 6-month

mortality (for example, Global Registry of Acute

Cardiac Events [GRACE]).

Risk assessment: 1


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Risk assessment: 2

Predicted 6-month mortality Risk of future adversecardiovascular events

1.5% or below Lowest

> 1.5 to 3.0% Low

> 3.0 to 6.0% Intermediate

> 6.0 to 9.0% High

over 9.0% Highest

Risk categories derived from Myocardial Ischaemia National Audit Project (MINAP) database


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Aspirin offer a 300 mg loading dose as soon aspossible unless there is clear evidence that a

patient is allergic to it

Clopidogrel offer a 300 mg loading dose topatients with a predicted 6-month mortality of more

than 1.5% and no contraindications

Antiplatelet therapy: 1


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Consider intravenous eptifibatide or tirofibanas part of the early management for patients who:

have intermediate or higher risk ( 3.0%)

and

are scheduled to undergo angiography

within 96 hours of admission

Antiplatelet therapy: 2


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Antithrombin therapy

Fondaparinux for patients without high bleeding riskwho are not undergoing coronary angiography within24 hours of admission

Unfractionated heparin for patients likely to undergocoronary angiography within 24 hours of admission

Offer systemic unfractionated heparin in the cardiac

catheter laboratory to patients receiving fondaparinuxwho are undergoing PCI


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Antithrombin considerations

Carefully consider choice and dose of antithrombin forpatients with high bleeding risk associated with:

advancing age known bleeding complications

renal impairment low body weight

As an alternative to the combination of a heparin plusa GPI, consider bivalirudin for patients at intermediate

or higher risk of adverse cardiovascular events(predicted 6-month mortality above 3%), who:

have angiography scheduled within 24 hoursand

are not on fondaparinux or a GPI


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Offer coronary angiography (with PCI if indicated) within96 hours of first admission to patients with:

intermediate or higher risk (

3.0%) and no contraindications (such as comorbidity or active

bleeding)

Perform angiography as soon as possible for patients

who are: clinically unstable or at high ischaemic risk

Management strategies: 1


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When the role of revascularisation or the strategy isunclear, discuss with:

interventional cardiologist cardiac surgeon other healthcare professionals relevant to the needs

of the patient

Discuss choice of strategy with the patient

Management strategies: 2


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To detect and quantify inducible ischaemia,

consider ischaemia testing before discharge

for patients whose condition has been

managed conservatively and who have not

had coronary angiography

Testing for ischaemia


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Before discharge offer patients advice and informationabout:

diagnosis arrangements for follow-up

cardiac rehabilitation

management of cardiovascular risk factors

drugs for secondary prevention

lifestyle changes

Rehabilitation and

discharge planning


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Costs and savings

The guideline on unstable angina and NSTEMI isunlikely to result in a significant change in resourceuse in the NHS.

However, recommendations in the following areas may

result in additional costs/savings depending on localcircumstances:

Considering intravenous eptifibatide or tirofiban aspart of the early management for patients

Offering fondaparinux to patients who do not havea high bleeding risk

Offering ischaemia testing before discharge


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Discussion

Which risk-scoring system should we be using toformally assess risk of future adverse cardiovascularevents after diagnosis?

Do we have a robust mechanism for the timely and

appropriate identification and risk assessment ofpatients?

How do we use eptifibatide and tirofiban and will thisneed to change?

Do we need to think about wider discussion acrossthe team when considering revascularisation?

How do we need to update our discharge

information for patients?


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NHS EvidenceClick here to go

to the NHSEvidence website
http://www.evidence.nhs.uk/http://www.evidence.nhs.uk/http://www.evidence.nhs.uk/http://www.evidence.nhs.uk/


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Hyperglycaemia in ACS

Hyperglycaemia in ACS is a powerful predictor of poorersurvival and increased risk of complications while inhospital.

In October 2011 NICE published clinical guideline 130and a NICE pathway on Hyperglycaemia in ACS

The guideline and pathway cover the management ofhyperglycaemia within the first 48 hours in all patientsadmitted to hospital for acute coronary syndromes(ACS).
http://www.evidence.nhs.uk/http://www.evidence.nhs.uk/http://www.evidence.nhs.uk/http://www.evidence.nhs.uk/http://www.evidence.nhs.uk/http://www.evidence.nhs.uk/http://www.evidence.nhs.uk/http://www.evidence.nhs.uk/http://www.evidence.nhs.uk/http://www.evidence.nhs.uk/


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Find out more

Visit www.nice.org.uk/guidance/CG94 for:

the guideline the quick reference guide

Understanding NICE guidance

costing statement

audit support, including patient questionnaire chest pain algorithm, including clinical case scenarios

online educational tool
http://www.evidence.nhs.uk/http://www.evidence.nhs.uk/http://www.nice.org.uk/guidance/CG94http://www.nice.org.uk/guidance/CG94


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