Activity 4: Case Studies in ACS

The evidence-based recommendations discussed in this presentation come from the American College of Cardiology (ACC) and the American Heart Association (AHA). Strength of evidence is indicated following each recommendation. The AHA/ACC Classification of Recommendations and Level of Evidence is included at the end of this document.

• 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.
• STEMI Guidelines: 2007 Focused Updates of the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction. Circulation 2008;117;296-329.
• Prevention of Premature Discontinuation of Dual Antiplatelet Therapy in Patients with Coronary Artery Stents. Circulation 2007;115:813-8.
• Scientific Advisory: Depression and Coronary Heart Disease: Recommendations for Screening, Referral, and Treatment. Circulation 2008;118:1768-75.
• 2009 Focused Updates: ACC/AHA Guideline for the Management of Patients with ST-Elevation Myocardial Infarction (Updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (Updating the 2005 Guideline and 2007 Focused Update). Circulation 2009;120:2271-306.

Recommendation #1: Aspirin (75 mg-162 mg daily) should be started and continued indefinitely in ACS patients unless contraindicated. (IA) Patients who have undergone PCI with stent placement should initially receive higher-dose aspirin (162 mg-325 mg daily) for 1 month (BMS), 3 months (sirolimus-eluting stent), and 6 months (paclitaxel-eluting stent). (IB)

Recommendation #2: The duration of thienopyridine should be as follows: Patients receiving stents (BMS or DES) during PCI for ACS should be given clopidogrel, 75 mg daily, or prasugrel, 10 mg daily, for at least 12 months. (IB)

Recommendation #3: Continuation of clopidogrel or prasugrel beyond 15 months may be considered in patients undergoing DES implantation. (IIIbC)

Recommendation #4: Health care professionals should ensure that before patients are discharged they are thoroughly educated about the reasons they are prescribed thienopyridines and the significant risks associated with prematurely discontinuing such therapy. (Expert Consensus)

Recommendation #5: Blood pressure should be controlled to less than 140/90 mm Hg, or to less than 130/80 mm Hg in patients with diabetes or chronic kidney disease. (IA)

Recommendation #6: Care should be taken to establish effective communication between the post-ACS patient and the health care team to enhance long-term compliance with prescribed therapies and recommended lifestyle changes. (IB)

Recommendation #7: Clopidogrel (75 mg daily) in combination with aspirin should be started and ideally continued for 12 months in patients after ACS. (IB)

• UA/NSTEMI: An ARB can be a useful alternative for patients who do not tolerate ACE inhibitors, provided there are either clinical or radiological signs of HF and LVEF <40%. (IIaB)
• STEMI: An ARB is recommended for patients who are intolerant of ACE inhibitors and have HF or have had an MI with LVEF ≤40%. (IA) It is beneficial to use ARB therapy in other patients who are ACE inhibitor-intolerant and have hypertension. (IB)

Recommendation #9: A beta blocker should be started and continued indefinitely in all patients who have had MI, ACS or LV dysfunction with or without heart failure, unless contraindicated. (IA)

Recommendation #10: HMG-CoA reductase inhibitors (statins), in the absence of contraindications, should be given to patients (including post-revascularization patients) post-ACS. (IA)

Recommendation #11: Smoking cessation and avoidance of exposure to environmental tobacco smoke at work and at home are recommended. Arrange follow-up, referral to special programs or pharmacotherapy. (IB)

Recommendation #12: The opportunity to screen for and treat depression in cardiac patients should not be missed, as effective depression treatment may improve health outcomes. (Expert Consensus)

Recommendation #13: Medically supervised programs such as cardiac rehabilitation should be recommended for high-risk patients (e.g., recent ACS or revascularization, heart failure). (IB)

Recommendation #14: In patients with diabetes, lifestyle and pharmacotherapy should be initiated to achieve near-normal A1C levels (<7%). (IB)

Recommendation #15: Patients should be encouraged to aim for 30 to 60 minutes of moderate intensity aerobic activity on most, and preferably all, days of the week (minimum of 5 days a week). This should be supplemented by an increase in daily lifestyle activities as well. (IB)

Recommendation #16: The LDL cholesterol goal is <100 mg/dL in patients with CHD. (IA) Further reduction to <70 mg/dL is reasonable. (IIaA)

AHA-ACC Classification of Recommendations and Level of Evidence

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Presentation Slides for Case Studies in ACS.

Abbreviations and Acronyms

Guidelines and Scientific Statements:

1. 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. STEMI Guidelines: 2007 Focused Updates of the ACC/AHA 2004 Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction. Circulation 2008;117;296-329.
3. Prevention of Premature Discontinuation of Dual Antiplatelet Therapy in Patients with Coronary Artery Stents. Circulation 2007;115:813-8.
4. Scientific Advisory: Depression and Coronary Heart Disease: Recommendations for Screening, Referral, and Treatment. Circulation 2008;118:1768-75.
5. 2009 Focused Updates: ACC/AHA Guideline for the Management of Patients with ST-Elevation Myocardial Infarction (Updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (Updating the 2005 Guideline and 2007 Focused Update). Circulation 2009;120:2271-306.
6. Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm
7. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf

1. PHQ-2 Depression Screen:Download PDF
2. PHQ-9 Depression Screen: http://www.depression-primarycare.org/clinicians/toolkits/materials/forms/phq9/
3. ATP III Guidelines At-A-Glance Quick Desk Reference:Download PDF