Activity 3: Achieving Optimal Outcomes After ACS

All recommendations are from the 2007 Revision of the ACC/AHA Guidelines for the Management of Patients With UA/NSTEMI.

Source: ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction. J Am Coll Cardiol 2007;50:e1-e157.
Website:http://content.onlinejacc.org/cgi/content/full/50/7/e1
Strength of Evidence: Shown after each recommendation. The AHA/ACC Classification of Recommendations and Level of Evidence is included at the end of the document.

Long-term Medical Therapy and Secondary Prevention

Recommendation #1: Aspirin should be given indefinitely, unless contraindicated, in patients recovering from UA/NSTEMI. (IA)

Recommendation #2: The combination of aspirin and clopidogrel should generally be continued for 12 months after ACS. (IB)

Recommendation #3: ACE inhibitors should be given indefinitely in patients recovering from UA/NSTEMI with heart failure, left ventricular dysfunction, hypertension or diabetes, unless contraindicated. (IA)

Recommendation #4: Beta blockers are indicated for all patients recovering from UA/NSTEMI, unless contraindicated, and should be continued indefinitely. (IB)

Recommendation #5: In the absence of contraindications, statins should be given to post-UA/NSTEMI patients, regardless of baseline LDL-C. (IA)

Patient Education

Recommendation #6: Beyond detailed instructions for daily exercise, patients should receive guidance about activities that are permissible and those that should be avoided. Specific mention should be made about driving, returning to work and sexual activity. (IC)

Smoking Cessation

Recommendation #7: Smoking cessation and avoidance of exposure to environmental tobacco smoke at work and at home are recommended. Follow-up, referral to cessation programs and pharmacotherapy (including nicotine replacement) are useful. (IB)

Lipids

Recommendation #8: For patients with LDL-C greater than or equal to 100 mg per dL, cholesterol-lowering therapy should be initiated or intensified to achieve an LDL-C of less than 100 mg per dL. (IA) Treatment of triglycerides and non–HDL-C should be considered if triglycerides are 200-499 mg per dL after LDL-C goal is reached. (IB)

Blood Pressure

Recommendation #9: Blood pressure should be controlled to less than 140/90 mm Hg, or to 130/80 mm Hg in patients with diabetes or chronic kidney disease. (IA)

Cardiac Rehabilitation

Recommendation #10: Cardiac rehabilitation and secondary prevention programs are recommended for patients with UA/NSTEMI, particularly those with multiple modifiable risk factors and/or moderate- to high-risk patients in whom supervised exercise training is particularly warranted. (IB)

Physical Activity

Recommendation #11: Patients recovering from UA/NSTEMI generally should be encouraged to strive for 30-60 minutes of physical activity at least 5 days a week. (IB)

AHA-ACC Classification of Recommendations and Level of Evidence

Download PDF with Recommendations

Acute Coronary Syndrome: Overview Download PDF

Acute Coronary Syndrome: Tips for Recovering and Staying Well Download PDF

Acute Coronary Syndrome: Medicines Download PDF

• Smoking Cessation:
  • http://www.aafp.org/online/en/home/clinical/publichealth/tobacco/resources.html
  • Ask and Act tobacco cessation program: http://www.aafp.org/online/en/home/clinical/publichealth/tobacco/askandact.html
• Cardiac Rehabilitation:
  • http://www.nhlbi.nih.gov/health/dci/Diseases/rehab/rehab_whatis.html
  • Printer friendly version: http://www.nhlbi.nih.gov/health/dci/Diseases/rehab/rehab_all.html
  • http://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v:project=medlineplus&query=Cardiac+Rehabilitation
  • Tutorial http://www.nlm.nih.gov/medlineplus/tutorials/cardiacrehabilitation/htm/index.htm
• FAQs: http://familydoctor.org/online/famdocen/home/common/heartdisease/recovery/002.html

This file contains a PDA version of the lecture notes for the material covered in the AAFP LearningLink Acute Coronary Syndrome series as well as the latest ACS Guidelines.
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Presentation Slides for Achieving Optimal Outcomes After ACS.

Abbreviations and Acronyms

Guidelines:

1. Anderson JL, Adams CD, Antman EM, et al. UA/NSTEMI Guidelines: ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction. J Am Coll Cardiol 2007;50:e1-e157.
2. Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (ATP III).
   http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm
3. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7).
   http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf

Articles:

1. Antithrombotic Trialists’ (ATT) Collaboration. Aspirin in the primary prevention of vascular disease: Collaborative meta-analysis of individual participant data from randomised trials. Lancet 2009;373:1849–60.
2. Fiore M, Jaen CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Department of Health and Human Services, 2008.
   http://www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf
3. Haffner SM, Lehto S, Ronnemaa T, et al. Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction. N Engl J Med 1998;339:229-34.
4. Heart Protection Study Collaborative Group. Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomised placebo-controlled trial. Lancet 2002;360:7-22.
5. Kenfield SA, Stampfer MJ, Rosner BA, et al. Smoking and smoking cessation in relation to mortality in women. JAMA 2008;299:2037-47.
6. Law M, Morris JK, Wald NJ. Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies. BMJ 2009;338;b1665.
7. Metha SR. Aspirin and clopidogrel in patients with ACS undergoing PCI: CURE and PCI-CURE. J Invasive Cardiol 2003;15 Suppl B:17B-20B; discussion 20B-21B.
8. O'Keefe JH Jr, Cordain L, Harris WH, Moe RM, Vogel R. Optimal low-density lipoprotein is 50 to 70 mg/dL: lower is better and physiologically normal. J Am Coll Cardiol 2004;43:2142-6.
9. Sacks FM, Pfeffer MA, Moye LA, et al. The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels. N Engl J Med 1996;335:1001-9.
10. Saha SA, Molnar J, Arora RR. Tissue ACE inhibitors for secondary prevention of cardiovascular disease in patients with preserved left ventricular function: a pooled meta-analysis of randomized placebo-controlled trials. J Cardiovasc Pharmacol Ther 2007;12:192-204.
11. Scandinavian Simvastatin Survival Study Group. Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet 1994;344:1383-9.
12. The Action to Control Cardiovascular Risk in Diabetes Study Group. Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med 2008;358:2545-59.
13. The Clopidogrel in Unstable Angina to Prevent Recurrent Event Trial Investigators. Effects of clopidogrel in addition to aspirin in patients with ACS without ST-segment elevation. N Engl J Med 2001;345:494–502.
14. The Long-Term Intervention with Pravastatin in Ischaemic Disease (LIPID) Study Group. Prevention of cardiovascular events and death with pravastatin in patients with coronary heart disease and a broad range of initial cholesterol levels. N Engl J Med 1998:339:1349-57.

1. PHQ-2: Download PDF
2. PHQ-9: http://www.depression-primarycare.org/clinicians/toolkits/materials/forms/phq9/
3. GRACE: http://www.outcomes-umassmed.org/grace/acs_risk/acs_risk_content.html
4. ATP III Guidelines At-A-Glance Quick Desk Reference: http://www.nhlbi.nih.gov/guidelines/cholesterol/atglance.pdf