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Transcript of Nice Guideline Nstemi
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Unstable angina and NSTEMIImplementing NICE guidance
2nd Edition October 2011
NICE clinical guideline 94
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Updated guidance
This guideline updates and replaces
recommendations for the early management ofunstable angina and NSTEMI from NICE technologyappraisal guidance 47 and 80
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What this presentation covers
Background
Scope
Key priorities for implementationCosts and savings
Discussion
NHS Evidence
Hyperglycaemia in ACS
Find out more
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Background:1
Cholesterol-rich plaques form on coronary artery wallsnarrowing the lumen. Blood supply to myocarduim iscompromised causing pain on exertion
An unstable plaque may tear and expose underlyingathermoma. This stimulates clot (thrombus) formation
The thrombus partly blocks the artery, interrupting bloodsupply to heart muscle (myocardial ischaemia)
Unstable angina myocardial ischaemia with noevidence of heart muscle death (myocardial necrosis)
NSTEMI myocardial ischaemia withevidence of myocardial necrosis
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Background:2
Outcomes vary widely among patients with NSTEMIand unstable angina
Scoring systems attempt to stratify risk of futureadverse cardiovascular events
Guideline defines patients likely to benefit from
interventions
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Scope
This guideline covers:
Adults with a diagnosis of unstable angina or NSTEMI
This guideline does not cover:
ST-segment-elevation myocardial infarction (STEMI)
Specific complications of unstable angina and NSTEMI
such as cardiac arrest or acute heart failure
Management after discharge from hospital
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Key priorities forimplementation
Assess risk of adverse cardiovascular events
Consider glycoprotein inhibitors for patients atintermediate or higher risk
Offer angiography within 96 hours to patients atintermediate or higher risk
Discuss revascularisation with other healthcare
professionals and choice of strategy with patient
Consider ischaemia testing before discharge
Rehabilitation and discharge planning
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As soon as the diagnosis of unstable angina or
NSTEMI is made, and aspirin and antithrombin
therapy have been offered, formally assess individualrisk of future adverse cardiovascular events using an
established risk scoring system that predicts 6-month
mortality (for example, Global Registry of Acute
Cardiac Events [GRACE]).
Risk assessment: 1
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Risk assessment: 2
Predicted 6-month mortality Risk of future adversecardiovascular events
1.5% or below Lowest
> 1.5 to 3.0% Low
> 3.0 to 6.0% Intermediate
> 6.0 to 9.0% High
over 9.0% Highest
Risk categories derived from Myocardial Ischaemia National Audit Project (MINAP) database
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Aspirin offer a 300 mg loading dose as soon aspossible unless there is clear evidence that a
patient is allergic to it
Clopidogrel offer a 300 mg loading dose topatients with a predicted 6-month mortality of more
than 1.5% and no contraindications
Antiplatelet therapy: 1
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Consider intravenous eptifibatide or tirofibanas part of the early management for patients who:
have intermediate or higher risk ( 3.0%)
and
are scheduled to undergo angiography
within 96 hours of admission
Antiplatelet therapy: 2
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Antithrombin therapy
Fondaparinux for patients without high bleeding riskwho are not undergoing coronary angiography within24 hours of admission
Unfractionated heparin for patients likely to undergocoronary angiography within 24 hours of admission
Offer systemic unfractionated heparin in the cardiac
catheter laboratory to patients receiving fondaparinuxwho are undergoing PCI
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Antithrombin considerations
Carefully consider choice and dose of antithrombin forpatients with high bleeding risk associated with:
advancing age known bleeding complications
renal impairment low body weight
As an alternative to the combination of a heparin plusa GPI, consider bivalirudin for patients at intermediate
or higher risk of adverse cardiovascular events(predicted 6-month mortality above 3%), who:
have angiography scheduled within 24 hoursand
are not on fondaparinux or a GPI
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Offer coronary angiography (with PCI if indicated) within96 hours of first admission to patients with:
intermediate or higher risk (
3.0%) and no contraindications (such as comorbidity or active
bleeding)
Perform angiography as soon as possible for patients
who are: clinically unstable or at high ischaemic risk
Management strategies: 1
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When the role of revascularisation or the strategy isunclear, discuss with:
interventional cardiologist cardiac surgeon other healthcare professionals relevant to the needs
of the patient
Discuss choice of strategy with the patient
Management strategies: 2
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To detect and quantify inducible ischaemia,
consider ischaemia testing before discharge
for patients whose condition has been
managed conservatively and who have not
had coronary angiography
Testing for ischaemia
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Before discharge offer patients advice and informationabout:
diagnosis arrangements for follow-up
cardiac rehabilitation
management of cardiovascular risk factors
drugs for secondary prevention
lifestyle changes
Rehabilitation and
discharge planning
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Costs and savings
The guideline on unstable angina and NSTEMI isunlikely to result in a significant change in resourceuse in the NHS.
However, recommendations in the following areas may
result in additional costs/savings depending on localcircumstances:
Considering intravenous eptifibatide or tirofiban aspart of the early management for patients
Offering fondaparinux to patients who do not havea high bleeding risk
Offering ischaemia testing before discharge
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Discussion
Which risk-scoring system should we be using toformally assess risk of future adverse cardiovascularevents after diagnosis?
Do we have a robust mechanism for the timely and
appropriate identification and risk assessment ofpatients?
How do we use eptifibatide and tirofiban and will thisneed to change?
Do we need to think about wider discussion acrossthe team when considering revascularisation?
How do we need to update our discharge
information for patients?
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NHS EvidenceClick here to go
to the NHSEvidence website
http://www.evidence.nhs.uk/http://www.evidence.nhs.uk/http://www.evidence.nhs.uk/http://www.evidence.nhs.uk/ -
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Hyperglycaemia in ACS
Hyperglycaemia in ACS is a powerful predictor of poorersurvival and increased risk of complications while inhospital.
In October 2011 NICE published clinical guideline 130and a NICE pathway on Hyperglycaemia in ACS
The guideline and pathway cover the management ofhyperglycaemia within the first 48 hours in all patientsadmitted to hospital for acute coronary syndromes(ACS).
http://www.evidence.nhs.uk/http://www.evidence.nhs.uk/http://www.evidence.nhs.uk/http://www.evidence.nhs.uk/http://www.evidence.nhs.uk/http://www.evidence.nhs.uk/http://www.evidence.nhs.uk/http://www.evidence.nhs.uk/http://www.evidence.nhs.uk/http://www.evidence.nhs.uk/ -
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Find out more
Visit www.nice.org.uk/guidance/CG94 for:
the guideline the quick reference guide
Understanding NICE guidance
costing statement
audit support, including patient questionnaire chest pain algorithm, including clinical case scenarios
online educational tool
http://www.evidence.nhs.uk/http://www.evidence.nhs.uk/http://www.nice.org.uk/guidance/CG94http://www.nice.org.uk/guidance/CG94 -
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