Updates and Current Recommendations for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes: What It Means for Clinical Practice

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The American Heart Association (AHA) and the American College of Cardiology (ACC) have recently updated their joint guidelines for the management of patients with non–ST-elevation acute coronary syndromes (NSTE-ACS, including unstable angina [UA] and non–ST-elevation myocardial infarction [NSTEMI]). These guidelines replace the 2007 guidelines and the focused updates from 2011 and 2012 and now combine UA and NSTEMI into a new classification, NSTE-ACS, and updating the terminology around noninvasive management to ischemia-guided strategy. The latest guidelines include updated recommendations for the use of the oral antiplatelet agents (P2Y12 inhibitors) prasugrel and ticagrelor as part of dual-antiplatelet therapy—the cornerstone of treatment for these patients. This report provides a comprehensive overview of the new and modified recommendations for the management of patients with NSTE-ACS and the evidence supporting them. Also, where appropriate, similarities and differences between the current recommendations of the AHA/ACC and those of the European Society of Cardiology (ESC) are highlighted. For example, the AHA/ACC recommends the P2Y12 inhibitor ticagrelor over clopidogrel in all patients with NSTE-ACS and clopidogrel, prasugrel, or ticagrelor for patients in whom percutaneous coronary intervention is planned, whereas the ESC guidelines specifically recommend individual P2Y12 inhibitors for particular patient subgroups.

Section snippets

Antiplatelet Therapy

The AHA/ACC recommendations for the use of antiplatelet therapy in patients with a definite or likely diagnosis of NSTE-ACS, additional management strategies for patients receiving antiplatelet therapy, and the long-term use of antiplatelet therapy have been updated with respect to prasugrel and ticagrelor. The recommendations for patients who underwent treatment with an early invasive or an ischemia-guided strategy are summarized in Table 2.6, 7 Figure 1 summarizes the COR I and II

Initial Ischemia-Guided Versus Initial Invasive Strategies

The recommendations for early initial ischemia-guided versus initial invasive strategies in patients with NSTE-ACS remain unchanged from the previous guidelines, except for the inclusion of an additional recommendation, on the basis of the updated PCI guidelines.11 “It is reasonable to choose an early invasive strategy (within 24 h of admission) over a delayed invasive strategy (within 25 to 72 hours) for initially stabilized high-risk patients with NSTE-ACS. For patients not at

Diabetes mellitus

It is well established that patients with diabetes and ACS have poorer outcomes than those without diabetes; diabetes is independently associated with higher 30-day mortality after UA/NSTEMI (odds ratio 1.78, 95% CI 1.24 to 2.56) and higher mortality 1 year after UA/NSTEMI (HR, 1.65; 95% CI, 1.30 to 2.10).39 Indeed, patients with diabetes presenting with NSTE-ACS have a similar risk of death to those without diabetes presenting with STEMI at 1 year39 The AHA/ACC guidelines acknowledge the high

Future Directions

Despite the growing body of evidence about optimal management of NSTE-ACS, some key questions remain unanswered about how best to use antiplatelet therapy in this setting. One such question is the optimal timing for initiation of P2Y12 antagonist therapy in relation to PCI. The recent ACCOAST study suggested that starting prasugrel at the time of NSTE-ACS diagnosis was no more effective at preventing adverse CV outcomes than starting at the time of angiography and was associated with a

Acknowledgment

The authors acknowledge the editorial assistance of Tara N Miller, PhD, of Gardiner-Caldwell Communications in drafting the review article, funded by AstraZeneca. Views expressed in this review represent those of the authors and the authors did not receive financial compensation.

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