Non-ST-elevation myocardial infarction
New US guideline on coronary artery revascularization recommends a shorter 1- to 3-month duration of dual antiplatelet therapy after percutaneous coronary intervention in select patients
A new guideline on coronary artery revascularization has been published by the American Heart Association and American College of Cardiology in partnership with the Society for Cardiovascular Angiography.
The guideline provides recommendations on treatment strategies for patients undergoing percutaneous coronary intervention (PCI), including the following.
A shorter 1- to 3-month duration of dual antiplatelet therapy (DAPT) following PCI is recommended for selected patients, with subsequent transition to P2Y12 inhibitor monotherapy, to reduce the risk of bleeding events. Previously, DAPT was recommended for 6 to 12 months following PCI.
Anticoagulation therapy (subcutaneous low molecular weight heparin, intravenous unfractionated heparin, or the alternative agent bivalirudin) should be started on earliest recognition of non-ST-elevation myocardial infarction in patients undergoing PCI. Fondaparinux alone is no longer recommended due to a higher incidence of guiding-catheter thrombosis.
PCI using radial artery access is preferred for suitable patients over femoral artery access when a clinician experienced in radial access is available as it decreases procedural site complications.
Summary
Definition
History and exam
Key diagnostic factors
- chest pain
- diaphoresis
Other diagnostic factors
- shortness of breath
- weakness
- anxiety
- nausea and vomiting
- abdominal pain
- hypertension
- early morning onset
- syncope
- hypotension
- arrhythmias
- abnormal heart sounds
Risk factors
- atherosclerosis (history of angina, myocardial infarction, stroke, transient ischemic attack, peripheral vascular disease)
- diabetes
- smoking
- dyslipidemia
- family history of premature coronary artery disease (CAD)
- age >65 years
- hypertension
- obesity and metabolic syndrome phenotype
- physical inactivity
- cocaine use
- depression
- stent thrombosis or restenosis
- chronic kidney disease
- surgical procedures (including intraoperative and postoperative periods)
- sleep apnea
Diagnostic investigations
1st investigations to order
- ECG
- cardiac biomarkers
- echocardiography
- CBC
- BUN and serum creatinine
- electrolytes
- LFTs
- blood glucose
- chest x-ray
Investigations to consider
- lipids
- brain natriuretic peptide (BNP) or N-terminal pro-BNP (NT-pro-BNP)
- angiography/cardiac catheterization
- stress testing
- coronary CT angiography (CCTA)
Treatment algorithm
acute presentation
post-stabilization
Contributors
Authors
Cody S. Deen, MD
Assistant Professor of Medicine
Director of Cardiology
Hillsborough Hospital
University of North Carolina
Hillsborough
NC
Disclosures
CSD was previously the Director of Cardiac Rehab for Chatham Hospital, which was financially set up as a consultancy relationship, until 2017. CSD has spoken (unpaid) at the Update in Cardiology and Update in Internal Medicine Conferences at UNC for the last 5 years. CSD has served as the PI for the Dal-GeneE (site now closed) and the ACCELERATE Trials at the University of North Carolina (trial now completed). Each trial required paid travel to an investigator meeting.
Acknowledgements
Dr Cody S. Deen would like to gratefully acknowledge Dr Sripal Bangalore, Dr Mina Owlia, Dr Thomas Vanhecke, and Dr Dena Krishnan, the previous contributors to this topic.
Disclosures
SB, MO, TV, and DK declare that they have no competing interests.
Peer reviewers
Syed Wamique Yusuf, MBBS, FRCPI
Professor of Medicine
Department of Cardiology
University of Texas
MD Anderson Cancer Center
Houston
TX
Disclosures
SWY declares that he has no competing interests.
Differentials
- Aortic dissection
- Pulmonary embolism
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