Non ST segment elevation acute coronary syndromes: A simplified risk-orientated algorithm

Abstract

Non-ST segment elevation acute coronary syndromes (NSTE ACS) include a clinical spectrum that ranges from unstable angina to NSTE myocardial infarction. Management goals aim to prevent recurrent ACS and improve long-term outcomes by choosing a treatment strategy according to an estimate of the risk of an adverse outcome. Recent registry data suggest that patients with NSTE ACS frequently do not receive recommended treatment, and that risk stratification is not used to determine either the choice of treatment or the speed of access to coronary angiography. The present article evaluates the evidence for recommended treatment using information from recent trials and guidelines published by the major cardiac organizations in Europe and North America. Using this information, a multidisciplinary group developed a simplified algorithm that uses risk stratification to select an optimal early management strategy. Long-term outcomes are improved by a multi-faceted vascular protection strategy that is initiated at the time of hospitalization for NSTE ACS.

Figure 1

Management of the patient with chest pain or atypical symptoms. ACS Acute coronary syndrome

Figure 2

Algorithm for the management of non-ST segment elevation acute coronary syndromes (ACS) NOTES:

1. Very unstable patients with one of:

   1. Frequent ischemic episodes with or without pain and electrocardiogram (ECG) ST segment shift;

   2. Very high-risk ECG changes (eg, transient ST elevation or deep ST depression across many leads);

   3. Hemodynamic instability (heart failure or hypotension); or,

   4. Refractory ischemia with ECG ST shift despite acetylsalicylic acid (ASA), clopidogrel and heparin.

      Need intensive management with:

      1. Very urgent or immediate cardiac catheterization.

      2. Consider adding intravenous glycoprotein IIb/IIIa inhibitor (tirofiban or eptifibatide) to ASA, clopidogrel and unfractionated heparin (UFH).(if low-molecular-weight heparin has been started, it should be continued and not switched).

      3. Consider use of intra-aortic balloon pump to stabilize the patient before transfer for coronary angiography.

2. For patients in hospitals where cardiac catheterization will occur within 24 h, UFH should be used.

3. The stress ECG/perfusion scan ideally should be performed before hospital discharge. This is usually not practical. In patients with a higher probability of more extensive coronary artery disease (prior known coronary disease, multiterritory vascular disease, diabetes and chronic renal insufficiency), short-term admission may be necessary to facilitate early noninvasive testing. In other patients, arrangements should be made for testing in the following few days.

4. For low-risk patients with a normal stress test, the decision to use long-term vascular protective medication will depend on the patient’s risk factor profile and the clinical history of the acute event. Other causes of chest pain should be considered in many of these patients.