NICE releases guidlines to better manage unstable angina and NSTEMI

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A 360-page guideline handbook that better addresses how to properly manage patient care for those diagnosed with unstable angina (UA) and non-ST-segment-elevation myocardial infarction (NSTEMI), has been put forth by the National Institute for Health and Clinical Excellence (NICE).

According to NICE, “When myocardial ischemia is present, but without evidence of actual myocardial necrosis (normal serum troponin level), the clinical syndrome is described as UA.”

If left untreated, these aforementioned diagnoses can produce high mortality rates. “Appropriate triage, risk assessment and timely use of acute pharmacological or invasive interventions are critical for the prevention of future adverse cardiovascular events (myocardial infarction, stroke, repeat revascularization or death),” the guidelines stated.

While NICE reported that the rates of mortality from MI and other cardiovascular causes have improved, the number of patients diagnosed with non ST-segment elevation ACS has not.

“With worrying trends in the incidence of obesity and diabetes, and lifestyles that involve less exercise, the management of these conditions remains a high priority,” NICE wrote.

According to the Institute, the evidence-based guidelines:

  • Offer the best clinical care advice for the treatment of acute coronary syndrome (ACS) in adults;
  • Take into account patient choice and informed decision making;
  • Define the components of National Health Service (NHS) care provisions for ACS;
  • Define areas of uncertainty or controversy requiring further research; and
  • Provide variant guideline versions for various audiences.

The guidelines state that “clinicians should take a more rigorous approach toward the assessment of a patient’s underlying risk.”

NICE said that patients diagnosed with UA or NSTEMI should be assessed for the risk of adverse cardiovascular (CV) events using a risk scoring system that has the ability to predict six-month mortality. This assessment should be performed only after a dose of aspirin and antithrobin therapy is administered.

Risk score systems such as the Global Registry of Acute Cardiac Events (GRACE) should be used for evaluation of these CV risks, according to NICE.

Additionally, NICE recommends that physicians record a patient's full clinical history including MI, PCI and CABG, along with a physical examination, a 12-lead ECG and blood tests.

The guidelines state that a 300 mg dose of clopidogrel may be given to these patients, who have no contraindications, and will undergo PCI within 24 hours of hospital admission.

Additionally, NICE recommends that physicians weigh the benefits of administering an injection of eptifibatide or tirofiban in patients at intermediate or high-risk of developing adverse CV events and due for angiography 96 hours after admission.

The guidelines said that for patients with predicated six-month mortality above 3 percent, angiography should be offered within the first 96 hours of admission, as well as for patients who are “unstable” or at “high ischemic risk.”

Lastly, NICE recommends that physicians offer the following information to UA or NSTEMI patients prior to hospital discharge:

  • Arrangements and diagnosis for follow-up;
  • Cardiac rehabilitation;
  • Management of CV risk factors and drug therapy for prevention; and
  • Lifestyle changes.

“This guidance addresses an important part of this ‘patient pathway’ but not the entire pathway itself. Best practice should continue beyond the scope of this guideline and with particular reference to earlier guidance on secondary prevention,” the authors concluded.