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The early management of unstable angina and NSTEMI

The UK’s National Institute for Clinical Excellence has produced evidence based guidelines on the early management of unstable angina and NSTEMI
Their ‘key priorities for implementation’ are:

  • As soon as the diagnosis of unstable angina or NSTEMI is made, and aspirin and antithrombin therapy have been offered, formally assess individual risk 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]).
  • Consider intravenous eptifibatide or tirofiban as part of the early management for patients who have an intermediate or higher risk of adverse cardiovascular events (predicted 6-month mortality above 3.0%), and who are scheduled to undergo angiography within 96 hours of hospital admission.
  • Offer coronary angiography (with follow-on PCI if indicated) within 96 hours of first admission to hospital to patients who have an intermediate or higher risk of adverse cardiovascular events (predicted 6-month mortality above 3.0%) if they have no contraindications to angiography (such as active bleeding or comorbidity). Perform angiography as soon as possible for patients who are clinically unstable or at high ischaemic risk.
  • When the role of revascularisation or the revascularisation strategy is unclear, resolve this by discussion involving an interventional cardiologist, cardiac surgeon and other healthcare professionals relevant to the needs of the patient. Discuss the choice of the revascularisation strategy with the patient.
  • 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.
  • Before discharge offer patients advice and information about:

– their diagnosis and arrangements for follow-up

– cardiac rehabilitation

– management of cardiovascular risk factors and drug therapy for secondary prevention

– lifestyle changes

One of the most potentially confusing areas is the choice of antithrombin therapy. Whereas the low molecular weight heparin enoxaparin is currently widely used, the guideline recommends the following:

The guideline summary is here and the full guideline is here