Unstable angina and NSTEMIImplementing NICE guidance

March 2010

NICE clinical guideline 94

Updated guidance

This guideline updates and replaces recommendations for the early management of unstable angina and NSTEMI from NICE technology appraisal guidance 47 and 80

What this presentation covers

Background

Scope

Key priorities for implementation

Costs and savings

Discussion

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Background 1

• Cholesterol-rich plaques form on coronary artery walls narrowing the lumen. Blood supply to myocarduim is compromised causing pain on exertion

• An unstable plaque may tear and expose underlying athermoma. This stimulates clot (thrombus) formation

• The thrombus partly blocks the artery, interrupting blood supply to heart muscle (myocardial ischaemia)

• Unstable angina – myocardial ischaemia with no evidence of heart muscle death (myocardial necrosis)

• NSTEMI – myocardial ischaemia with evidence of myocardial necrosis

Background 2

• Outcomes vary widely among patients with NSTEMI and unstable angina

• Scoring systems attempt to stratify risk of future adverse cardiovascular events

• Guideline defines patients likely to benefit from interventions

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

Key priorities for implementation

• Assess risk of adverse cardiovascular events

• Consider glycoprotein inhibitors for patients atintermediate or higher risk

• Offer angiography within 96 hours to patients at intermediate or higher risk

• Discuss revascularisation with other healthcare professionals and choice of strategy with patient

• Consider ischaemia testing before discharge

• Rehabilitation and discharge planning

As soon as the diagnosis of unstable angina or NSTEMI is made, and aspirin and antithrombin therapy have been offered, formally assess individual risk 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

Risk assessment 2

Predicted 6-month mortality Risk of future adverse cardiovascular 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

• Aspirin – offer a 300 mg loading dose as soon as possible unless there is clear evidence that a patient is allergic to it

• Clopidogrel – offer a 300 mg loading dose to patients with a predicted 6-month mortality of more than 1.5% and no contraindications

Antiplatelet therapy

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 angiographywithin 96 hours of admission

Antiplatelet therapy

Antithrombin therapy

• Fondaparinux – for patients without high bleeding risk who are not undergoing coronary angiography within 24 hours of admission

• Unfractionated heparin – for patients likely to undergo coronary angiography within 24 hours of admission

• Offer systemic unfractionated heparin in the cardiac catheter laboratory to patients receiving fondaparinux who are undergoing PCI

Antithrombin considerations• Carefully consider choice and dose of antithrombin for

patients 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 plus a 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 hours and• are not on fondaparinux or a GPI

Offer coronary angiography (with PCI if indicated) within 96 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

When the role of revascularisation or the strategy is unclear, 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

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

Before discharge offer patients advice and information about:

•diagnosis •arrangements for follow-up•cardiac rehabilitation•management of cardiovascular risk factors •drugs for secondary prevention•lifestyle changes

Rehabilitation and discharge planning

Costs and savings

The guideline on unstable angina and NSTEMI is unlikely to result in a significant change in resource use in the NHS.

However, recommendations in the following areas may result in additional costs/savings depending on local circumstances:

• Considering intravenous eptifibatide or tirofiban as part of the early management for patients

• Offering fondaparinux to patients who do not have a high bleeding risk

• Offering ischaemia testing before discharge

Discussion• Which risk-scoring system should we be using to

formally assess risk of future adverse cardiovascular events after diagnosis?

• Do we have a robust mechanism for the timely and appropriate identification and risk assessment of patients?

• How do we use eptifibatide and tirofiban and will this need to change?

• Do we need to think about wider discussion across the team when considering revascularisation?

• How do we need to update our dischargeinformation for patients?

NHS Evidence

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