ACC/AHA 2002 guideline update for the management of patients with unstable angina and non–ST-segment elevation myocardial infarction—summary article

Impact of combination evidence-based medical therapy on mortality in patients with acute coronary syndromes

“…␤-Blockers are presently indicated in all patients with ACS in the absence of contraindications. 30 The absolute cardiac contraindications for the use of ␤-blockers are severe bradycardia, preexisting highgrade AV block, sick sinus syndrome, and severe, unstable heart failure (mild to moderate heart failure is actually an indication for ␤-blockers). Asthma and bronchospasm are relative contraindications.…”

Early Invasive versus Selectively Invasive Management for Acute Coronary Syndromes

“…As a result, recent guidelines of the American College of Cardiology-American Heart Association and the European Society of Cardiology recommend an early invasive approach in high-risk patients with acute coronary syndromes without ST-segment elevation. 7,8 Despite these recommendations, it is not clear that an early invasive strategy reduces mortality in this setting. A reduction in mortality was shown in the FRISC II study, but only among men.…”

Application of Current Guidelines to the Management of Unstable Angina and Non-ST-Elevation Myocardial Infarction

“…34 Based on these trial results, it is recommended that clopidogrel be considered a first-line drug in UA/NSTEMI and added to aspirin in patients with UA/NSTEMI, except those at high risk for bleeding and those in whom the need for urgent CABG cannot be excluded. 5 Thus, clopidogrel should be administered to patients with UA/NSTEMI: (1) in whom an early noninvasive approach is planned; (2) who are known not to be candidates for urgent coronary bypass surgery based on previous knowledge of the coronary anatomy or who have contraindications to surgery; and (3) in whom catheterization will be deferred for Ͼ24 -36 h. In patients in whom a diagnostic catheterization is planned within 24 -36 h after presentation, it is reasonable to withhold clopidogrel until the findings on a coronary angiogram exclude the need for urgent …”

“…Because clopidogrel (like aspirin) is an irreversible inhibitor of platelet function, it is recommended that the drug be discontinued for 5 or preferably 7 days before elective surgery, including CABG. 4,5 An alternative view is that the extra risk of bleeding is tolerable in patients in whom angiography has not yet been performed because of the prevention of ischemic events during the waiting period. This view is bolstered by the observations within CREDO that pretreatment Ͼ6 h before PCI tended to enhance the benefit of the drug, 34 and that the combination of clopidogrel and GP IIb/IIIa inhibition appeared to be at least additive for benefit without enhancing the risk of bleeding.…”

“…On the one hand, their use is likely to be enhanced if, as recommended, the early invasive strategy is more widely adopted because this strategy includes the use of these agents in patients with UA/NSTEMI undergoing PCI. 5 On the other hand, their use is likely to be curbed by the recommendation that they are not indicated in patients who are not at high risk and in whom PCI is not planned. Most probably, the adoption of these two recommendations will result in little overall change in the use of these agents, but it is hoped that the care of patients with UA/NSTEMI will be improved by their application to patients who are most likely to benefit.…”