doi:10.1016/j.jacc.2011.02.009
published online Mar 28, 2011; J. Am. Coll. Cardiol.
Philippides, Pierre Theroux, Nanette K. Wenger, and James Patrick Zidar
Theodore G. Ganiats, Hani Jneid, A. Michael Lincoff, Eric D. Peterson, George J.
Charles R. Bridges, Donald E. Casey, Jr, Steven M. Ettinger, Francis M. Fesmire,
of Thoracic Surgeons, R. Scott Wright, Jeffrey L. Anderson, Cynthia D. Adams,
Physicians, Society for Cardiovascular Angiography and Interventions, and Society
American Academy of Family Physicians, American College of Emergency
Guidelines
Cardiology Foundation/American Heart Association Task Force on Practice
(Updating the 2007 Guideline): A Report of the American College of
Patients With Unstable Angina/Non�ST-Elevation Myocardial Infarction
2011 ACCF/AHA Focused Update of the Guidelines for the Management of
This information is current as of March 30, 2011
http://content.onlinejacc.org/cgi/content/full/j.jacc.2011.02.009v1
located on the World Wide Web at:
The online version of this article, along with updated information and services, is
by on March 30, 2011 content.onlinejacc.orgDownloaded from
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Journal of the American College of Cardiology Vol. 57, No. 18, 2011
© 2
Pub
CCF/AHA FOCUSED UPDATE
2011 ACCF/AHA Focused Update of the Guidelines
for the Management of Patients With Unstable Angina/
Non–ST-Elevation Myocardial Infarction
(Updating the 2007 Guideline)
A Report of the American College of Cardiology Foundation/
American Heart Association Task Force on Practice Guidelines
Developed in Collaboration With the American Academy of Family Physicians,
erican College of Emergency Physicians, Society for Cardiovascular Angiography and Interventions,
and Society of Thoracic Surgeons
2011 WRITING GROUP MEMBERS
. Scott Wright, MD, FACC, FAHA, Chair*; Jeffrey L. Anderson, MD, FACC, FAHA, Vice Chair*†;
Cynthia D. Adams, RN, PhD, FAHA*; Charles R. Bridges, MD, ScD, FACC, FAHA†‡;
Donald E. Casey, JR, MD, MPH, MBA, FACP, FAHA§; Steven M. Ettinger, MD, FACC�;
Francis M. Fesmire, MD, FACEP¶; Theodore G. Ganiats, MD#; Hani Jneid, MD, FACC, FAHA*;
A. Michael Lincoff, MD, FACC*†; Eric D. Peterson, MD, MPH, FACC, FAHA†**;
George J. Philippides, MD, FACC, FAHA*; Pierre Theroux, MD, FACC, FAHA*†;
Nanette K. Wenger, MD, MACC, FAHA*†; James Patrick Zidar, MD, FACC, FSCAI†††
2007 WRITING COMMITTEE MEMBERS
Jeffrey L. Anderson, MD, FACC, FAHA, Chair; Cynthia D. Adams, RN, PhD, FAHA;
Elliott M. Antman, MD, FACC, FAHA; Charles R. Bridges, MD, ScD, FACC, FAHA‡;
Robert M. Califf, MD, MACC; Donald E. Casey, JR, MD, MPH, MBA, FACP§;
William E. Chavey II, MD, MS#; Francis M. Fesmire, MD, FACEP¶;
Judith S. Hochman, MD, FACC, FAHA; Thomas N. Levin, MD, FACC, FSCAI††;
A. Michael Lincoff, MD, FACC; Eric D. Peterson, MD, MPH, FACC, FAHA;
Pierre Theroux, MD, FACC, FAHA; Nanette K. Wenger, MD, MACC, FAHA;
R. Scott Wright, MD, FACC, FAHA
CCF/AHA Representative. †Recused from voting on Section 3.2. Recommendations for Antiplatelet/Anticoagulant Therapy in Patients for Whom
gnosis of UA/NSTEMI Is Likely or Definite and Section 5.2.1. Recommendations for Antiplatelet Therapy. ‡Society of Thoracic Surgeons
resentative. §American College of Physicians Representative. �ACCF/AHA Task Force on Practice Guidelines Liaison. ¶American College of
ergency Physicians Representative. #American Academy of Family Physicians Representative. **ACCF/AHA Task Force on Performance Measures
ison. ††Society of Coronary Angiography and Interventions Representative.
his document was approved by the American College of Cardiology Foundation Board of Trustees and the American Heart Association Science
visory and Coordinating Committee in December 2010.
he American College of Cardiology Foundation requests that this document be cited as follows: Wright RS, Anderson JL, Adams CD, Bridges CR,
ey DE Jr, Ettinger SM, Fesmire FM, Ganiats TG, Jneid H, Lincoff AM, Peterson ED, Philippides GJ, Theroux P, Wenger NK, Zidar JP. 2011
CF/AHA focused update of the guidelines for the management of patients with unstable angina/non–ST-elevation myocardial infarction (updating the
7 guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll
diol 2011;57:xxx–xxx.
his article has been copublished in Circulation.
opies: This document is available on the World Wide Web sites of the American College of Cardiology (www.cardiosource.org) and the American
art Association (my.americanheart.org). For copies of this document, please contact Elsevier Inc. Reprint Department, fax (212) 633-3820, e-mail
rints@elsevier.com.
011 by the American College of Cardiology Foundation and the American Heart Association, Inc. ISSN 0735-1097/$36.00
lished by Elsevier Inc. doi:10.1016/j.jacc.2011.02.009
ermissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express
mission of the American College of Cardiology Foundation. Please contact Elsevier’s permission department at healthpermissions@elsevier.com.
by on March 30, 2011 content.onlinejacc.orgDownloaded from
ORC
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3. E
3
3
3.3.3.1. TIMING OF INVASIVE THERAPY . . . . . . . . . . . . . . . . .000
5. Late Hospital Care, Hospital Discharge, and
P
5
6. S
6
6
7. C
7
App
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App
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App
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2 Wright et al. JACC Vol. 57, No. 18, 2011
osthospital Discharge Care. . . . . . . . . . . . . . . . . . .000
.2. Long-Term Medical Therapy and
Secondary Prevention . . . . . . . . . . . . . . . . . . . . . . .000
5.2.1. Recommendations for Antiplatelet Therapy .000
5.2.6. Recommendations for Warfarin Therapy. . . .000
pecial Groups. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .000
.2. Recommendations for Diabetes Mellitus . . . . .000
6.2.1.1. INTENSIVE GLUCOSE CONTROL . . . . . . . . . . . . . . . . .000
Preamble
A primary challenge in the development of clinical practice
guidelines is keeping pace with the stream of new data on
which recommendations are based. In an effort to respond
promptly to new evidence, the American College of Cardi-
ology Foundation/American Heart Association (ACCF/AHA)
Task Force on Practice Guidelines (Task Force) has created a
“focused update” process to revise the existing guideline
recommendations that are affected by the evolving data or
ACCF/AHA TASK F
lice K. Jacobs, MD, FACC, FAHA, Chair; Jeffre
Nancy Albert, PhD, CCNS, CCRN, FAHA
Steven M. Ettinger, MD, FACC;
Jonathan L. Halperin, MD, FACC, FAHA;
Frederick G. Kushner, MD, FACC, FAH
William G. Stevenson, MD, FACC, FAHA
BLE OF CONTENTS
amble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .000
ntroduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .000
.1. Methodology and Evidence Review . . . . . . . . . .000
.2. Organization of Committee . . . . . . . . . . . . . . . . . .000
.3. Document Review and Approval . . . . . . . . . . . . .000
arly Hospital Care. . . . . . . . . . . . . . . . . . . . . . . . . . . .000
.2. Recommendations for Antiplatelet/Anticoagulant
Therapy in Patients for Whom Diagnosis of
UA/NSTEMI Is Likely or Definite . . . . . . . . . . . . . . . .000
3.2.1. Recommendations for Antiplatelet Therapy . . .000
3.2.3. Recommendations for Additional Management
of Antiplatelet and Anticoagulant Therapy . . . .000
3.2.3.1. ANTIPLATELET/ANTICOAGULANT THERAPY IN
PATIENTS FOR WHOM DIAGNOSIS OF UA/NSTEMI
IS LIKELY OR DEFINITE . . . . . . . . . . . . . . . . . . . . . . . .000
3.2.3.1.1. THIENOPYRIDINES . . . . . . . . . . . . . . . . .000
3.2.3.1.2. CHOICE OF THIENOPYRIDINE FOR PCI
IN UA/NSTEMI . . . . . . . . . . . . . . . . . . . .000
3.2.3.1.2.1. Timing of Discontinuation
of Thienopyridine Therapy
for Surgical Procedures. . .000
3.2.3.1.3. INTERINDIVIDUAL VARIABILITY IN
RESPONSIVENESS TO
CLOPIDOGREL . . . . . . . . . . . . . . . . . . . .000
3.2.3.1.4. OPTIMAL LOADING AND MAINTENANCE
DOSAGES OF CLOPIDOGREL . . . . . . . .000
3.2.3.1.5. PROTON PUMP INHIBITORS AND DUAL-
ANTIPLATELET THERAPY FOR ACUTE
CORONARY SYNDROME . . . . . . . . . . . .000
3.2.3.1.6. GLYCOPROTEIN IIB/IIIA RECEPTOR
ANTAGONISTS . . . . . . . . . . . . . . . . . . . .000
.3. Recommendations for Initial Conservative
Versus Initial Invasive Strategies . . . . . . . . . . . .000
UA/NSTEMI Guideline Focused Update
.5. Recommendations for Chronic
Kidney Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . .000
opin
peri
content.onlinejacc.orDownloaded from
E MEMBERS
Anderson, MD, FACC, FAHA, Chair-Elect;
rk A. Creager, MD, FACC, FAHA;
rt A. Guyton, MD, FACC;
h S. Hochman, MD, FACC, FAHA;
rik Magnus Ohman, MD, FACC;
yde W. Yancy, MD, FACC, FAHA
6.5.1. Angiography in Patients With
Chronic Kidney Disease . . . . . . . . . . . . . . . . .000
onclusions and Future Directions . . . . . . . . . . . . .000
.1. Recommendation for Quality of Care and
Outcomes for Acute Coronary Syndromes
(NEW SECTION) . . . . . . . . . . . . . . . . . . . . . . . . . . . . .000
7.1.1. Quality Care and Outcomes . . . . . . . . . . . . . .000
endix 1. Author Relationships With Industry
Other Entities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .000
endix 2. Reviewer Relationships With Industry
Other Entities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .000
endix 3. Abbreviation List. . . . . . . . . . . . . . . . . . . . .000
endix 4. Dosing Table for Antiplatelet and
icoagulant Therapy Discussed in This
used Update to Support PCI in NSTEMI . . . . . . . .000
endix 5. Comparisons Among Orally Effective
12 Inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .000
endix 6. Flow Chart for Class I and Class IIa
ommendations for Initial Management of
NSTEMI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .000
endix 7. Summary Table . . . . . . . . . . . . . . . . . . . . . .000
endix 8. Selection of Initial Treatment Strategy:
sive Versus Conservative Strategy . . . . . . . . . . .000
erences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .000
May 3, 2011:xxx
ion. Before the initiation of this focused approach,
odic updates and revisions of existing guidelines required
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3JACC Vol. 57, No. 18, 2011 Wright et al.
May 3
o 3 years to complete. Now, however, new evidence will
eviewed in an ongoing fashion to more efficiently respond
portant science and treatment trends that could have a
or impact on patient outcomes and quality of care.
ence will be reviewed at least twice a year, and updates
be initiated on an as-needed basis and completed as
kly as possible while maintaining the rigorous method-
y that the ACCF and AHA have developed during their
nership of more than 20 years.
hese updated guideline recommendations reflect a con-
us of expert opinion after a thorough review, primarily of
breaking clinical trials identified through a broad-based
ing process as being important to the relevant patient
ulation, as well as other new data deemed to have an
act on patient care (see Section 1.1, Methodology and
ence Review, for details). This focused update is not
nded to represent an update based on a full literature
ew from the date of the previous guideline publication.
cific criteria/considerations for inclusion of new data
ude the following:
ublication in a peer-reviewed journal
arge, randomized, placebo-controlled trial(s)
onrandomized data deemed important on the basis of
sults affecting current safety and efficacy assumptions
trength/weakness of research methodology and findings
ikelihood of additional studies influencing current
ndings
pact on current and/or likelihood of need to develop
ew performance measure(s)
equest(s) and requirement(s) for review and update from
e practice community, key stakeholders, and other
ources free of relationships with industry or other poten-
al bias
umber of previous trials showing consistent results
eed for consistency with a new guideline or guideline
visions
nalyzing the data and developing the recommendations
supporting text, the focused update writing group used
ence-based methodologies developed by the Task Force
are described elsewhere (1).
he committee reviewed and ranked evidence supporting
ent recommendations, with the weight of evidence ranked
evel A if the data were derived from multiple randomized
ical trials or meta-analyses. The committee ranked avail-
evidence as Level B when data were derived from a
le randomized trial or nonrandomized studies. Evidence
ranked as Level C when the primary source of the
mmendation was consensus opinion, case studies, or
dard of care. In the narrative portions of these guidelines,
ence is generally presented in chronological order of
lopment. Studies are identified as observational, retro-
tive, prospective, or randomized when appropriate. For
ain conditions for which inadequate data are available,
mmendations are based on expert consensus and clinical
rience and ranked as Level C. An example is the use of
cillin for pneumococcal pneumonia, for which there are
, 2011:xxx
randomized trials and treatment is based on clinical
rience. When recommendations at Level C are supported
Am
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istorical clinical data, appropriate references (including
ical reviews) are cited if available. For issues where
se data are available, a survey of current practice among
clinicians on the writing committee was the basis for
el C recommendations and no references are cited. The
ma for classification of recommendations and level of
ence is summarized in Table 1, which also illustrates how
grading system provides an estimate of the size and the
ainty of the treatment effect. A new addition to the
F/AHA methodology is a separation of the Class III
mmendations to delineate whether the recommendation
termined to be of “no benefit” or associated with “harm”
e patient. In addition, in view of the increasing number of
parative effectiveness studies, comparator verbs and sug-
ed phrases for writing recommendations for the compar-
e effectiveness of one treatment/strategy with respect to
her for Class I and IIa, Level A or B only have been
d.
he Task Force makes every effort to avoid actual, poten-
or perceived conflicts of interest that may arise as a result
lationships with industry and other entities (RWI) among
writing group. Specifically, all members of the writing
p, as well as peer reviewers of the document, are asked
isclose all current relationships and those existing 12
ths before initiation of the writing effort. In response to
lementation of a newly revised RWI policy approved by
ACC and AHA, it is also required that the writing group
r plus a majority of the writing group (50%) have no
vant RWI. All guideline recommendations require a
dential vote by the writing group and must be approved
consensus of the members voting. Members who were
sed from voting are noted on the title page of this
ment and in Appendix 1. Members must recuse them-
es from voting on any recommendation to which their
I apply. Any writing group member who develops a new
I during his or her tenure is required to notify guideline
in writing. These statements are reviewed by the Task
e and all members during each conference call and/or
ting of the writing group and are updated as changes
r. For detailed information about guideline policies and
edures, please refer to the ACCF/AHA methodology and
cies manual (1). Authors’ and peer reviewers’ RWI pertinent
is guideline are disclosed in Appendixes 1 and 2, respec-
y. Additionally, to ensure complete transparency, writing
p members’ comprehensive disclosure information—in-
ing RWI not pertinent to this document—is available online
supplement to this document. Disclosure information for the
Force is also available online at www.cardiosource.org/
/About-ACC/Leadership/Guidelines-and-Documents-Task-
es.aspx. The work of the writing group was supported
usively by the ACCF and AHA without commercial sup-
. Writing group members volunteered their time for this
t.
he ACCF/AHA practice guidelines address patient pop-
ions (and healthcare providers) residing in North Amer-
As such, drugs that are currently unavailable in North
UA/NSTEMI Guideline Focused Update
erica are discussed in the text without a specific class of
mmendation. For studies performed in large numbers of
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4 Wright et al. JACC Vol. 57, No. 18, 2011
ects outside of North America, each writing group
ews the potential impact of different practice patterns and
ent populations on the treatment effect and the relevance
e ACCF/AHA target population to determine whether the
ings should inform a specific recommendation.
he ACCF/AHA practice guidelines are intended to assist
thcare providers in clinical decision making by describ-
a range of generally acceptable approaches for the
nosis, management, and prevention of specific diseases
onditions. These practice guidelines represent a consensus
xpert opinion after a thorough review of the available
e 1. Applying Classification of Recommendation and Level of E
ata available from clinical trials or registries about the usefulness/efficacy in
ardial infarction, history of heart failure, and prior aspirin use. A recommendati
important clinical questions addressed in the guidelines do not lend themse
clear clinical consensus that a particular test or therapy is useful or effective
or comparative effectiveness recommendations (Class I and IIa; Level of Eviden
t comparisons of the treatments or strategies being evaluated.
UA/NSTEMI Guideline Focused Update
ent scientific evidence and are intended to improve
ent care. The guidelines attempt to define practices that
info
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t the needs of most patients in most circumstances. The
ate judgment regarding care of a particular patient must
ade by the healthcare provider and patient in light of all
circumstances presented by that patient. Thus, there are
umstances in which deviations from these guidelines may
ppropriate. Clinical decision making should consider the
ity and availability of expertise in the area where care is
ided. When these guidelines are used as the basis for
latory or payer decisions, the goal should be improve-
t in quality of care. The Task Force recognizes that
tions arise for which additional data are needed to better
e
t subpopulations, such as sex, age, history of diabetes, history of prior
Level of Evidence B or C does not imply that the recommendation is weak.
linical trials. Although randomized trials are unavailable, there may be a
d B only), studies that support the use of comparator verbs should involve
May 3, 2011:xxx
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ective guideline when appropriate.
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