2014 Guideline for NSTE-ACS Management Has New Name, Focus

The recently released American College of Cardiology (ACC)/American Heart Association (AHA) 2014 Guideline for the Management of Patients with Non–ST-Elevation Acute Coronary Syndromes (NSTE-ACS) features a title change from the previous version as well as recognition of an alternate strategy for low-risk patients and the importance of ongoing postdischarge care.

The document, published online September 23, 2014, ahead of print in the Journal of the American College of Cardiology, is the first full revision of the recommendations since 2007; focused updates were released in 2013.

According to Writing Committee Chair Ezra A. Amsterdam, MD, of the University of California, Davis Medical Center (Sacramento, CA), the substitution of “NSTE-ACS" in the current title for “unstable angina and non–ST-segment elevation myocardial infarction” in the earlier title “emphasizes the pathophysiologic continuum” of the latter 2 conditions and their frequently indistinguishable presentations. “It’s therefore reasonable that they be considered together in the guideline,” he said in a press release.

Dr. Amsterdam observed that the document aims to be user friendly by incorporating tables and algorithms that present concise diagnostic and management strategies.

Sorin J. Brener, MD, of Weill Cornell Medical College (New York, NY), endorsed the title change, telling TCTMD in a telephone interview that the older phrasing was overly broad, capturing many patients who did not have acute events.

In addition, he suggested that rather than focus on a complete guideline revision in the future, the task force might better serve clinicians by providing yearly focused updates based on the strength of the evidence from important new ACS trials.

Strategy for Low-Risk Patients Singled Out

While an early invasive strategy is generally preferred for NSTE-ACS patients with significant CAD, the statement affirms that low-risk patients may be treated with an “ischemia-guided strategy.” According to Dr. Amsterdam, this phrase was chosen to replace the previous version’s “initial conservative management” to more clearly convey the physiologic rationale behind the approach.

The document explains that an ischemia-guided strategy “seeks to avoid the routine early use of invasive procedures unless patients experience refractory or recurrent ischemic symptoms or develop hemodynamic instability.” Nonetheless, it adds, when such a strategy is chosen, “a plan for noninvasive evaluation is required to detect severe ischemia that occurs at a low threshold of stress and to promptly refer these patients for coronary angiography and revascularization as indicated.”

The statement also recognizes that low-risk patients may substantially benefit from guideline-directed medical therapy, which “has not always been optimally utilized,” Dr. Amsterdam said. “Advances in noninvasive testing have the potential to identify patients with NSTE-ACS at low-intermediate risk to distinguish candidates for invasive versus medical therapy.”

Another update reflects evidence for the superior efficacy of newer antiplatelet agents. Ongoing P2Y12 inhibitor therapy is recommended for all NSTE-ACS patients irrespective of the initial treatment approach. But for the first time, said co-author Debabrata Mukherjee, MD, of Texas Tech University Health Sciences Center (El Paso, TX), in an email with TCTMD, the guidelines say choice of the more potent agent ticagrelor over clopidogrel is reasonable, as is use of prasugrel in stented patients who are not at high bleeding risk.

Focus on Postdischarge Care

Recognizing that acute events signal underlying chronic disease, the guidelines also offer expanded recommendations for postdischarge care, including education about symptoms, lifestyle modification, referral to cardiac rehabilitation, routine use of dual antiplatelet therapy, cholesterol management, and other guideline-directed medical therapy.

“The hospitalization period involves crisis management of ACS, which is pivotal to successful patient outcomes during the acute phase of disease,” observed Writing Committee Vice Chair Nanette K. Wenger, MD, professor emeritus at Emory University School of Medicine (Atlanta, GA), in a press release. “However, discharge planning in addition to patient and family education guide the long-term ambulatory care of the patient who has sustained [an] NSTE-ACS.”

The statement also identifies several areas where evidence gaps pose an ongoing challenge for clinicians managing patients with NSTE-ACS. One centers on whether potent antiplatelet regimens should be recommended for A-fib patients receiving a stent if they are already on an oral anticoagulant. Although such triple therapy has been reported to be safely modified by the elimination of aspirin, the finding requires confirmation, the authors observe.

Another rapidly evolving area is use of high-sensitivity cardiac troponins to diagnose NSTE-ACS. Such assays have been linked to elevated cardiac troponin levels unrelated to coronary plaque rupture. “The diagnostic quandary posed by these findings necessitates investigation to elucidate the optimal utility of this advanced biomarker,” the statement says.

In addition, older patients account for more than half of the mortality among those with NSTE-ACS, the document notes, adding, “An unmet need is to more clearly distinguish which older patients are candidates for an ischemia-guided strategy compared with an early invasive management strategy.”

Also, an appreciable proportion of NSTE-ACS patients, including many women, present with nonobstructive CAD, yet their prognoses are not benign. “Clinical advances are predicated on clarification of the pathophysiology of this challenging syndrome,” the authors write.

Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non–ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;Epub ahead of print.

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2014 Guideline for NSTE-ACS Management Has New Name, Focus

  • Drs. Amsterdam, Mukherjee, and Brener report no relevant conflicts of interest.
  • Dr. Wenger reports receiving research grants from and serving as a consultant to multiple pharmaceutical companies.