Guideline sources The following summarized guidelines for the evaluation and management of non-ST-elevation myocardial infarction are prepared by our editorial team based on guidelines from the Society for Cardiovascular Angiography and Interventions (SCAI/AHA/ACC 2022), the U.S. Preventive Services Task Force (USPSTF 2022), the European Society of Cardiology (ESC 2021), the European Society of Cardiology (ESC/EACTS 2019), and the American Heart Association (AHA/ACC 2014; 2013). 1 2 3 4 5 6 https://web.pathway.md/diseases/recGYrMGdIRdWzUih 1/22 6/30/23, 1:17 AM Non-ST-elevation myocardial infarction Pathway Calculator Calculator Calculator ACTION score for risk of ICU ad Canadian Cardiovascular Societ Dual Antip Guidelines 1. Screening and diagnosis Diagnosis: base the diagnosis and initial short-term risk stratification on a combination of clinical history, symptoms, vital signs, other physical findings, ECG, and laboratory results including high- sensitivity cardiac troponin. B 2. Classification and risk stratification Prognostic scores: As per ESC 2021 guidelines, consider using established risk scores for prognosis estimation. C Show 6 more As per ACC 2014 guidelines, stratify patients based on the likelihood of acute coronary syndrome and adverse outcomes to decide on the need for hospitalization and assist in the selection of treatment options. B Show 2 more 3. Diagnostic investigations ECG: As per ESC 2021 guidelines, obtain a 12-lead ECG within 10 minutes after first medical contact and ensure immediate interpretation by an experienced physician. B Show 2 more As per ACC 2014 guidelines, obtain a 12-lead ECG in patients with chest pain or other symptoms suggestive of acute coronary syndrome and assess for ischemic changes within 10 minutes of the arrival at an emergency facility. B Show 2 more Cardiac biomarkers: measure cardiac troponins with high-sensitivity assays immediately after admission and obtain the results within 60 minutes of blood sampling. B Show 5 more Echocardiogram: https://web.pathway.md/diseases/recGYrMGdIRdWzUih 2/22 6/30/23, 1:17 AM Non-ST-elevation myocardial infarction Pathway Obtain echocardiography by trained physicians immediately following a 12-lead ECG in patients presenting with cardiac arrest or hemodynamic instability of presumed cardiovascular origin. B Obtain echocardiography to evaluate the regional and global LV function and to rule in or rule out differential diagnoses. B Noninvasive stress testing: obtain a noninvasive stress testing (preferably with imaging) for inducible ischemia or coronary CT angiography before deciding on an invasive approach in patients with no recurrence of chest pain, normal ECG findings, and normal levels of cardiac troponin (preferably high sensitivity), but still with a suspected acute coronary syndrome. B Coronary CT angiography: As per ESC 2021 guidelines: Obtain a noninvasive stress testing or coronary CT angiography before deciding on an invasive approach in patients with no recurrence of chest pain, normal ECG findings, and normal levels of cardiac troponin (preferably high sensitivity), but still with a suspected acute coronary syndrome. B Obtain coronary CT angiography as an alternative to invasive coronary angiography to exclude acute coronary syndrome when there is a low-to-intermediate likelihood of coronary artery disease and when cardiac troponin and/or ECG are normal or inconclusive. A As per ACC 2014 guidelines, consider obtaining initial coronary CT angiography to assess coronary artery anatomy B or rest myocardial perfusion imaging with a technetium-99m radiopharmaceutical to exclude myocardial ischemia in patients with possible acute coronary syndrome, normal ECG and cardiac troponins, and no history of coronary artery disease. C Lipid profile: consider obtaining a fasting lipid profile in patients with NSTEMI, preferably within 24 hours of presentation. C 4. Respiratory support Supplemental oxygen: administer supplemental oxygen in patients with NSTEMI with SaO < 90%, respiratory distress, or other high-risk features of hypoxemia. B Updated evidence: DETO2X-AMI In patients with suspected acute myocardial infarction and an oxygen saturation of 90% on pulse oximetry, oxygen therapy was not superior to no supplemental oxygen with respect to a all-cause death at 1 year. Hofmann R et al. N Engl J Med. 2017 Sep 28. 5. Medical management https://web.pathway.md/diseases/recGYrMGdIRdWzUih 3/22 6/30/23, 1:17 AM Non-ST-elevation myocardial infarction Pathway Outpatient management: consider prescribing daily aspirin, short-acting nitroglycerin, and other medication if appropriate (such as -blockers) with instructions about activity level and clinician follow-up in low-risk patients referred for outpatient testing. C Transfer to emergency department: Refer patients with suspected acute coronary syndrome and high-risk features such as continuing chest pain, severe dyspnea, syncope/presyncope, or palpitations immediately to the emergency department and transport them by emergency medical services when available. B Consider referring patients with less severe symptoms to the emergency department, a chest pain unit, or a facility capable of performing adequate evaluation depending on clinical circumstances. C Shared-decision making: make treatment decisions based on clinical indication, regardless of gender or race or ethnicity, and reduce disparities of care in patients requiring coronary revascularization. B Show 3 more Fibrinolysis: do not administer IV fibrinolytic therapy in patients with non-ST-elevation acute coronary syndrome (without ST-elevation, true posterior myocardial infarction, or left bundle- branch block not known to be old). D Nitrates: As per ESC 2021 guidelines: Administer sublingual or IV nitrates in patients with ongoing ischemic symptoms and without contraindications. B Administer IV nitrates in patients with uncontrolled hypertension or signs of HF. B As per ACC 2014 guidelines, administer sublingual nitroglycerin (0.3-0.4 mg) every 5 minutes for up to 3 doses in patients with NSTEMI with continuing ischemic pain, thereafter assess the need for IV nitroglycerin if not contraindicated. B Show 2 more Analgesics: consider administering IV morphine sulfate in patients with NSTEMI in the absence of contraindications if there is continued ischemic chest pain despite treatment with maximally tolerated anti-ischemic medications. C Show 5 more Beta-blockers: As per ESC 2021 guidelines: Administer early -blockers in patients with ongoing ischemic symptoms and without contraindications. B Continue chronic -blocker therapy unless the patient is in overt HF. B As per ACC 2014 guidelines, initiate oral -blocker therapy within the first 24 hours in patients not having any of the following: signs of HF evidence of low-output state https://web.pathway.md/diseases/recGYrMGdIRdWzUih 4/22 6/30/23, 1:17 AM Non-ST-elevation myocardial infarction Pathway increased risk for cardiogenic shock other contraindications to -blockade (such as PR interval > 0.24 second, second- or third- degree heart block without a cardiac pacemaker, active asthma, or reactive airway disease). A Show 4 more Landmark trials: COMMIT In patients suspected of acute myocardial infarction, metoprolol was not superior to placebo with respect to death, reinfarction, or cardiac arrest. Chen ZM et al. Lancet. 2005 Nov 5. Calcium channel blockers: Administer nondihydropyridine CCBs (such as verapamil or diltiazem) as initial therapy in patients with NSTEMI, continuing or frequently recurring ischemia, contraindications to -blockers, and in the absence of the following: clinically significant LV dysfunction increased risk for cardiogenic shock PR interval > 0.24 second second- or third-degree AV block without a cardiac pacemaker. B Show 3 more ACEIs and ARBs: As per ESC 2021 guidelines, initiate ACEIs (or ARBs in case of intolerance to ACEIs) in patients with HF with reduced LVEF (< 40%), diabetes, or CKD unless contraindicated (such as severe renal impairment, hyperkalemia) to reduce all-cause and cardiovascular mortality and cardiovascular morbidity. A As per ACC 2014 guidelines, initiate ACEIs and continue indefinitely in all patients with LVEF < 0.40 and in patients with hypertension, diabetes mellitus, or stable CKD, unless contraindicated. A Show 2 more Aldosterone antagonists: As per ESC 2021 guidelines, initiate mineralocorticoid receptor antagonists in patients with HF with reduced LVEF (< 40%) to reduce all-cause and cardiovascular mortality and cardiovascular morbidity. A Landmark trials: EPHESUS In patients with acute myocardial infarction complicated by LV dysfunction and HF, eplerenone was superior to placebo with respect to cardiovascular death or hospitalization for cardiovascular events. https://web.pathway.md/diseases/recGYrMGdIRdWzUih 5/22 6/30/23, 1:17 AM Non-ST-elevation myocardial infarction Pathway Pitt B et al. N Engl J Med. 2003 Apr 3. As per ACC 2014 guidelines, initiate aldosterone blockers in patients post-myocardial infarction without significant renal dysfunction (creatinine > 2.5 mg/dL in males or > 2.0 mg/dL in females) or hyperkalemia (potassium > 5.0 mEq/L) receiving therapeutic doses of ACEIs and -blockers and having a LVEF 0.40, diabetes mellitus, or HF. A Management of cardiogenic shock: As per ESC 2021 guidelines, obtain emergency coronary angiography in patients with cardiogenic shock complicating acute coronary syndrome. B Show 8 more Landmark trials: CULPRIT-SHOCK (1 year follow-up) In patients who had acute myocardial infarction that was complicated by cardiogenic shock, culprit-lesion-only PCI was not superior to multivessel PCI with respect to death at 1 year follow-up. Holger Thiele et al. N Engl J Med. 2018 Nov 1. As per ACC 2014 guidelines, perform early revascularization in suitable patients with cardiogenic shock due to cardiac pump failure after NSTEMI. B Antiplatelet therapy, aspirin: As per ESC 2021 guidelines, administer aspirin in all patients without contraindications at an initial oral loading dose of 150-300 mg (or 75-250 mg IV) and at a maintenance dose of 75-100 mg once daily for long-term treatment. A As per ACC/AHA 2014 guidelines, administer non-enteric-coated, chewable aspirin (162-325 mg), if not contraindicated, in all patients with NSTEMI as soon as possible after the presentation and continue at a maintenance dose (81-325 mg/day) indefinitely. A Antiplatelet therapy, P2Y12 inhibitors: As per ESC 2021 guidelines, administer a P2Y12 receptor inhibitor in addition to aspirin and maintain over 12 months unless there are contraindications or an excessive risk of bleeding A : Situation Guidance 60 mg loading dose, 10 mg/day as the standard dose, 5 mg/day in patients aged 75 years or with a body weight < 60 kg B Prasugrel in P2Y12 receptor inhibitor-na ve patients proceeding to PCI 180 mg loading dose, 90 mg BID B Ticagrelor irrespective of the planned invasive or conservative treatment strategy https://web.pathway.md/diseases/recGYrMGdIRdWzUih 6/22 6/30/23, 1:17 AM Non-ST-elevation myocardial infarction Pathway 300-600 mg loading dose, 75 mg daily dose B Clopidogrel only when prasugrel and ticagrelor are not available, cannot be tolerated, or contraindicated Show 2 more As per ACC/AHA 2014 guidelines, administer a loading dose of clopidogrel followed by a daily maintenance dose in patients with NSTEMI unable to take aspirin because of hypersensitivity or major gastrointestinal intolerance. B Show 2 more Antiplatelet therapy, GP IIb/IIIa inhibitors: As per ESC 2021 guidelines: Consider administering glycoprotein IIb/IIIa antagonists for bail-out if there is evidence of no- reflow or a thrombotic complication. C Do not use glycoprotein IIb/IIIa antagonists if coronary anatomy is not known. D As per ACC/AHA 2014 guidelines, consider initiating a glycoprotein IIb/IIIa inhibitor, preferably eptifibatide or tirofiban, as part of initial antiplatelet therapy in patients with NSTEMI treated with an early invasive strategy and dual antiplatelet therapy with intermediate/high-risk features (such as positive troponin). C Anticoagulant therapy: As per ESC 2021 guidelines: Initiate parenteral anticoagulation in addition to antiplatelet therapy in all patients at the time of diagnosis and, especially, during revascularization procedures according to both ischemic and bleeding risks. A Decide on the choice of anticoagulation based on both ischemic and bleeding risks, and according to the efficacy safety profile of the chosen agent. B As per ACC 2014 guidelines, evaluate all patients with NSTEMI for the risk of bleeding. B Show 2 more Landmark trials: OASIS-5 In patients with acute coronary syndromes, fondaparinux was noninferior to enoxaparin with respect to death, myocardial infarction, or refractory ischemia at 9 days. Fifth Organization to Assess Strategies in Acute Ischemic Syndromes Investigators et al. N Engl J Med. 2006 Apr 6. Management of anticoagulant-associated bleeding: consider administering idarucizumab (specific antidote for dabigatran) in patients with dabigatran-associated ongoing life-threatening bleeding. C Show 3 more https://web.pathway.md/diseases/recGYrMGdIRdWzUih 7/22 6/30/23, 1:17 AM Non-ST-elevation myocardial infarction Pathway Maintenance dual antiplatelet therapy: As per ESC 2021 guidelines, initiate dual antiplatelet therapy with a P2Y12 receptor inhibitor on top of aspirin for 12 months in patients with NSTEMI treated with coronary stent implantation unless there are contraindications, such as excessive risk of bleeding. A Show 5 more Landmark trials: DAPT In patients who underwent a coronary stent procedure in which a drug-eluting stent was placed and who were treated with a thienopyridine drug (clopidogrel or prasugrel) and aspirin for 12 months, continued thienopyridine was superior to placebo with respect to stent thrombosis. Mauri L et al. N Engl J Med. 2014 Dec 4. As per AHA 2014 guidelines, continue aspirin indefinitely at the maintenance dose of 81 mg/day in patients treated with ticagrelor and 81-325 mg/day in all other patients. A Show 7 more Updated evidence: STOPDAPT-2 ACS In patients with acute coronary syndrome who underwent successful PCI, short dual antiplatelet therapy was not noninferior to long dual antiplatelet therapy with respect to the composite outcome of cardiovascular death, myocardial infarction, stent thrombosis, stroke, or bleeding. Hirotoshi Watanabe et al. JAMA Cardiol. 2022 Mar 2. Maintenance triple antithrombotic therapy: minimize the duration of triple antithrombotic therapy (vitamin K antagonist, aspirin, and a P2Y12 receptor inhibitor) in patients with NSTEMI to the extent possible to limit the risk of bleeding. B Show 3 more Lipid-lowering therapy: As per ESC 2021 guidelines, initiate statins in all patients with NSTEMI aiming to reduce LDL cholesterol by 50% from baseline and/or to achieve LDL cholesterol < 1.4 mmol/L (< 55 mg/dL). A Show 3 more Landmark trials: ODYSSEY OUTCOMES In patients with acute coronary syndrome 1-12 months earlier who have qualifying lipid levels and are receiving high-intensity statin therapy, alirocumab was superior to placebo with https://web.pathway.md/diseases/recGYrMGdIRdWzUih 8/22 6/30/23, 1:17 AM Non-ST-elevation myocardial infarction Pathway respect to death from coronary heart disease, nonfatal myocardial infarction, fatal or nonfatal ischemic stroke, or unstable angina requiring hospitalization. Gregory G Schwartz et al. N Engl J Med. 2018 Nov 29. As per ACC 2014 guidelines, initiate high-intensity statin therapy in all patients with NSTEMI in the absence of contraindications. A Landmark trials: PROVE IT-TIMI 22 In patients who had been hospitalized for an acute coronary syndrome within the preceding 10 days, intensive statin therapy was superior to standard statin therapy with respect to death or major cardiovascular events at 2 years. Cannon CP et al. N Engl J Med. 2004 Apr 8. 6. Inpatient care ECG monitoring: As per ESC 2021 guidelines, admit patients with NSTEMI to a monitored unit. B Show 4 more As per ACC 2014 guidelines, consider obtaining continuous 12-lead ECG monitoring in patients with initial nondiagnostic ECG deemed at intermediate/high risk of acute coronary syndrome. C Blood glucose monitoring: screen all patients with NSTEMI for diabetes and monitor blood glucose levels frequently in patients with known diabetes or admission hyperglycemia. B Show 4 more Serial troponin measurements: Consider remeasuring troponin once on day 3 or day 4 as an index of infarct size and dynamics of necrosis in patients with myocardial infarction. C Consider observing patients with symptoms consistent with acute coronary syndrome without objective evidence of myocardial ischemia (non-ischemic initial ECG and normal cardiac troponin) in a chest pain unit or telemetry unit with serial ECGs and cardiac troponin at 3-6-hour intervals. C Evaluation before discharge: obtain noninvasive stress testing in low- and intermediate-risk patients treated with an ischemia-guided strategy and being free of ischemia at rest or with low- level activity for a minimum of 12-24 hours. B Show 4 more 7. Nonpharmacologic interventions Smoking cessation: https://web.pathway.md/diseases/recGYrMGdIRdWzUih 9/22 6/30/23, 1:17 AM Non-ST-elevation myocardial infarction Pathway Offer a combination of behavioral interventions and pharmacotherapy after coronary revascularization to maximize cessation and reduce adverse cardiac events in patients using tobacco products. A Offer smoking cessation interventions during hospitalization after coronary revascularization and obtain supportive follow-up for at least 1 month after discharge to facilitate tobacco cessation and reduce morbidity and mortality in patients using tobacco products. A Psychological interventions: Consider screening for depression and refer or treat when indicated to improve quality of life and recovery in patients after coronary revascularization. C Consider offering CBT, psychological counseling, and/or pharmacotherapy to improve quality of life and cardiac outcomes in patients after coronary revascularization and having symptoms of depression, anxiety or stress. B Landmark trials: SADHART In patients with acute myocardial infarction or unstable angina and free of other life-threatening medical conditions who have major depressive disorder, sertraline was not superior to placebo with respect to LVEF at week 16. Glassman AH et al. JAMA. 2002 Aug 14. 8. Therapeutic procedures Indications for PCI: As per ACC 2022 guidelines, adopt an invasive strategy with the intent to proceed with revascularization to reduce cardiovascular events in patients with NSTEMI at elevated risk of recurrent ischemic events and being appropriate candidates for revascularization. A Show 5 more As per ESC 2021 guidelines, perform an immediate invasive procedure (< 2 hours) in patients with at least one of the following very high-risk criteria: hemodynamic instability or cardiogenic shock recurrent or refractory chest pain despite medical treatment life-threatening arrhythmias mechanical complications of myocardial infarction HF clearly related to NSTEMI presence of ST-segment depression > 1 mm in 6 leads in addition to ST-segment elevation in aVR and/or V1. B Show 3 more As per EACTS 2019 guidelines, perform emergency PCI of the culprit lesion in patients with cardiogenic shock due to non-ST-elevation acute coronary syndrome independent of the time https://web.pathway.md/diseases/recGYrMGdIRdWzUih 10/22 6/30/23, 1:17 AM Non-ST-elevation myocardial infarction Pathway delay of symptom onset, if coronary anatomy is amenable to PCI. B Technical considerations for PCI, arterial approach: As per SCAI/AHA/ACC 2022 guidelines, prefer radial approach over femoral approach for PCI to reduce the risk of death, vascular complications, and bleeding in patients with acute coronary syndrome. A As per ESC 2021 guidelines, use radial access as the standard approach unless there are overriding procedural considerations. A Technical considerations for PCI, strategy: As per ESC 2021 guidelines, decide on revascularization strategy (ad hoc culprit lesion PCI/multivessel PCI/CABG) based on the patient's clinical status and comorbidities, as well as their disease severity (the distribution and angiographic lesion characteristics, such as SYNTAX score) according to the principles for stable coronary artery disease. Perform immediate PCI of the culprit stenosis without heart team consultation. B Show 3 more Landmark trials: TIMACS In patients with acute coronary syndromes, early intervention was not superior to delayed intervention with respect to death, myocardial infarction, or stroke at 6 months. Mehta SR et al. N Engl J Med. 2009 May 21. As per ACC/AHA 2014 guidelines, proceed with an urgent/immediate invasive strategy (diagnostic angiography with the intent to perform revascularization if appropriate based on coronary anatomy, without serious comorbidities or contraindications to such procedures) in patients with NSTEMI with refractory angina or hemodynamic or electrical instability. A Show 4 more Landmark trials: TACTICS-TIMI 18 In patients with unstable angina and myocardial infarction without ST-segment elevation who were treated with aspirin, heparin, and the glycoprotein IIb/IIIa inhibitor tirofiban, early invasive coronary artery catheterization was superior to conservative coronary artery catheterization with respect to death, nonfatal MI, or rehospitalization for an acute coronary syndrome at 6 months. Cannon CP et al. N Engl J Med. 2001 Jun 21. Technical considerations for PCI, choice of stent: As per SCAI/AHA/ACC 2022 guidelines, prefer drug-eluting stents over bare-metal stents to prevent restenosis, myocardial infarction, or acute stent thrombosis in patients undergoing PCI. A https://web.pathway.md/diseases/recGYrMGdIRdWzUih 11/22 6/30/23, 1:17 AM Non-ST-elevation myocardial infarction Pathway As per ESC 2021 guidelines, prefer drug-eluting stents over bare-metal stents for any PCI irrespective of clinical presentation, lesion type, planned non-cardiac surgery, anticipated duration of dual antiplatelet therapy, or concomitant anticoagulant therapy. A Technical considerations for PCI, intravascular imaging: As per SCAI/AHA/ACC 2022 guidelines, consider obtaining intravascular ultrasound for procedural guidance to reduce ischemic events in patients undergoing coronary stent implantation, particularly in cases of left main or complex coronary artery stenting. C Show 2 more As per ESC 2021 guidelines, consider obtaining intracoronary imaging to diagnose spontaneous coronary artery dissection if suspected. C Technical considerations for PCI (hemodynamic support device): consider performing elective insertion of an appropriate hemodynamic support device in selected high-risk patients as an adjunct to PCI to prevent hemodynamic compromise during PCI. C Peri-PCI antiplatelet therapy, aspirin: As per SCAI/AHA/ACC 2022 guidelines, administer a loading dose of aspirin followed by daily dosing to reduce ischemic events in patients undergoing PCI. B As per ACC/AHA 2014 guidelines: Administer non-enteric-coated aspirin 81-325 mg before PCI in patients already taking daily aspirin. Administer non-enteric-coated aspirin 325 mg as soon as possible before PCI in patients not on aspirin therapy. B Continue aspirin at a dose of 81-325 mg daily indefinitely after PCI. B Peri-PCI antiplatelet therapy, P2Y12 inhibitors: As per SCAI/AHA/ACC 2022 guidelines, administer a loading dose of P2Y12 inhibitor followed by daily dosing to reduce ischemic events in patients undergoing PCI. B Show 5 more As per ESC 2021 guidelines: Consider preferring prasugrel over ticagrelor in patients with NSTEMI undergoing PCI. C Consider administering cangrelor in P2Y12 inhibitor-na ve patients undergoing PCI. B Landmark trials: CHAMPION PHOENIX In patients who were undergoing either urgent or elective PCI and were receiving guideline- recommended therapy, cangrelor was superior to clopidogrel with respect to stent thrombosis at 48 hours. Bhatt DL et al. N Engl J Med. 2013 Apr 4. As per ACC/AHA 2014 guidelines, administer a loading dose of any of the following P2Y12 receptor inhibitors before PCI with stenting: A clopidogrel 600 mg B https://web.pathway.md/diseases/recGYrMGdIRdWzUih 12/22 6/30/23, 1:17 AM Non-ST-elevation myocardial infarction Pathway prasugrel 60 mg B ticagrelor 180 mg. B Show 4 more Landmark trials: TRITON-TIMI 38 In patients with moderate-to-high-risk acute coronary syndromes with scheduled PCI, prasugrel was superior to clopidogrel with respect to death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke. Wiviott SD et al. N Engl J Med. 2007 Nov 15. Peri-PCI antiplatelet therapy, GP IIb/IIIa inhibitors: As per SCAI/AHA/ACC 2022 guidelines, consider administering IV glycoprotein IIb/IIIa inhibitors to improve procedural success in patients with acute coronary syndrome undergoing PCI with large thrombus burden, no-reflow, or slow flow. C As per ACC/AHA 2014 guidelines: Consider administering a glycoprotein IIb/IIIa inhibitor (abciximab, double-bolus eptifibatide, or high-dose bolus tirofiban) at the time of PCI in patients with NSTEMI and high-risk features (such as elevated troponin) not adequately pretreated with clopidogrel or ticagrelor. B Consider administering a glycoprotein IIb/IIIa inhibitor (abciximab, double-bolus eptifibatide, or high-dose bolus tirofiban) at the time of PCI in patients with NSTEMI and high-risk features (such as elevated troponin) treated with UFH and adequately pretreated with clopidogrel. C Landmark trials: RAPPORT In patients with acute myocardial infarction of < 12 hours duration undergoing PCI in the pre- drug eluting stent era, abciximab was superior to placebo with respect to death, reinfarction, or urgent target vessel revascularization at 6 months. Brener SJ et al. Circulation. 1998 Aug 25. Peri-PCI anticoagulant therapy: As per AHA 2022 guidelines, consider administering IV UFH to reduce ischemic events in patients undergoing PCI. B Show 3 more As per ESC 2021 guidelines, administer parenteral anticoagulation in addition to antiplatelet therapy in all patients at the time of diagnosis and, especially, during revascularization procedures according to both ischemic and bleeding risks. A Show 7 more https://web.pathway.md/diseases/recGYrMGdIRdWzUih 13/22 6/30/23, 1:17 AM Non-ST-elevation myocardial infarction Pathway As per ACC 2014 guidelines, administer an anticoagulant agent - IV UFH B or bivalirudin B with or without pretreatment with UFH - to reduce the risk of intracoronary and catheter thrombus formation in patients with NSTEMI undergoing PCI. B Show 5 more Blood transfusion: As per ESC 2021 guidelines, consider administering blood transfusion in patients with anemia (Hgb level < 8 g/dL or hematocrit < 25%), compromised hemodynamic status, and no evidence of active bleeding. C As per ACC 2014 guidelines, do not administer blood transfusion routinely in hemodynamically stable patients with NSTEMI and Hgb levels > 8 g/dL. D Updated evidence: REALITY In adult patients with myocardial infarction and anemia, a restrictive strategy was noninferior to a liberal strategy with respect to the composite outcome of death, stroke, recurrent myocardial infarction, or emergency revascularization prompted by ischemia at 30 days. Gregory Ducrocq et al. JAMA. 2021 Feb 9. 9. Perioperative care General principles: Establish multidisciplinary, evidence-based perioperative management programs to optimize analgesia, minimize opioid exposure, prevent complications and to reduce time to extubation, length of stay, and healthcare costs in patients undergoing CABG. B Ensure a comprehensive approach to reduce sternal wound infection in patients undergoing CABG. B Perioperative beta-blockers: consider administering preoperative -blockers, if not contraindicated, to reduce the incidence of postoperative AF in patients undergoing CABG. C Show 3 more Perioperative amiodarone: consider administering preoperative amiodarone to reduce the incidence of postoperative AF in patients undergoing CABG. C Perioperative management of antithrombotics: As per ACC 2022 guidelines, continue aspirin until the time of surgery to reduce ischemic events in patients undergoing CABG already taking daily aspirin preoperatively. B Show 7 more As per ACC 2014 guidelines, administer non-enteric-coated aspirin (81-325 mg daily) preoperatively in patients undergoing CABG. B Show 4 more https://web.pathway.md/diseases/recGYrMGdIRdWzUih 14/22 6/30/23, 1:17 AM Non-ST-elevation myocardial infarction Pathway As per AHA 2013 guidelines, do not discontinue aspirin before urgent CABG. D Show 4 more Intraoperative insulin infusion: administer intraoperative continuous insulin infusion to maintain serum glucose level < 180 mg/dL to reduce sternal wound infection in patients undergoing CABG. B Show 2 more 10. Surgical interventions Indications for CABG: calculate the STS risk score to help stratify patient risk in candidates for CABG. B Show 2 more Bypass conduits: use a radial artery in preference to a saphenous vein conduit to graft the second most important, significantly stenosed, non-left anterior descending vessel to improve long-term cardiac outcomes in patients undergoing isolated CABG. B Show 2 more Cardiopulmonary bypass: Consider using techniques (performed by experienced surgeons) to avoid aortic manipulation, such as off-pump techniques or beating heart, to decrease the incidence of perioperative stroke in patients with significant calcification of the aorta undergoing CABG. C Consider performing off-pump surgery (performed by experienced surgeons) to reduce perioperative risk in patients with significant pulmonary disease undergoing CABG. C Landmark trials: OPTIMAL In adult patients undergoing cardiac surgery with cardiopulmonary bypass, high-dose tranexamic acid regimen was superior to low-dose tranexamic acid regimen with respect to allogeneic RBC transfusion. Jia Shi et al. JAMA. 2022 Jul 26. 11. Specific circumstances Elderly patients: As per ESC 2021 guidelines: Apply the same diagnostic and interventional strategies in older patients as for younger patients. B Adapt the choice of antithrombotic agent and dosage and secondary preventions to renal function and specific contraindications. B https://web.pathway.md/diseases/recGYrMGdIRdWzUih 15/22 6/30/23, 1:17 AM Non-ST-elevation myocardial infarction Pathway Updated evidence: SECURE In elderly patients with myocardial infarction within the previous 6 months, polypill strategy was superior to usual care with respect to the composite outcome of cardiovascular death, nonfatal type 1 myocardial infarction, nonfatal ischemic stroke, or urgent revascularization. Jose M Castellano et al. N Engl J Med. 2022 Sep 15. As per ACC 2014 guidelines, manage older patients with NSTEMI with guideline-directed medical therapy, an early invasive strategy, and revascularization as appropriate. A Show 4 more Female patients: manage female patients with NSTEMI with the same pharmacological therapy as for male patients for acute care and for secondary prevention, with attention to weight and/or renally calculated doses of antiplatelet and anticoagulant agents to reduce bleeding risk. B Show 2 more Pregnant patients: As per ACC 2022 guidelines, consider adopting an invasive strategy in pregnant patients with NSTEMI if medical therapy is ineffective for the management of life-threatening complications. C As per AHA 2014 guidelines, consider performing myocardial revascularization in pregnant patients with NSTEMI if an ischemia-guided strategy is ineffective for the management of life- threatening complications. C Patients with diabetes mellitus: initiate medical treatment in the acute phase of NSTEMI and decide on stress testing, angiography, and revascularization in patients with diabetes mellitus similarly to patients without diabetes mellitus. A Patients with chronic kidney disease: As per ACC 2022 guidelines, take measures to minimize the risk of contrast-induced AKI in patients with CKD undergoing contrast media injection for coronary angiography. B Show 2 more As per ESC 2021 guidelines, apply the same diagnostic and therapeutic strategies in patients with CKD (dose adjustment may be necessary) as for patients with normal renal function. B Show 5 more As per AHA 2014 guidelines, assess the CrCl in patients with NSTEMI and adjust the doses of medications excreted by kidneys according to the pharmacokinetic data for specific medications. B Show 2 more Landmark trials: ACT In patients undergoing an intravascular angiographic procedure with at least 1 risk factor for contrast-induced AKI (age > 70 years, renal failure, diabetes mellitus, HF, or hypotension), https://web.pathway.md/diseases/recGYrMGdIRdWzUih 16/22 6/30/23, 1:17 AM Non-ST-elevation myocardial infarction Pathway acetylcysteine was not superior to placebo with respect to a contrast-induced AKI. ACT Investigators. Circulation. 2011 Sep 13. Patients with atrial fibrillation: Discontinue aspirin therapy after 1-4 weeks while maintaining P2Y12 inhibitors in addition to a non-vitamin K OAC (rivaroxaban, dabigatran, apixaban, or edoxaban) or warfarin to reduce the risk of bleeding in patients with AF undergoing PCI and taking OACs. B Prefer a non-vitamin K OAC over warfarin to reduce the risk of bleeding in patients with AF undergoing PCI, taking OACs and treated with dual antiplatelet therapy or a P2Y12 inhibitor monotherapy. B Patients with preexisting heart failure: treat patients with a history of HF and NSTEMI according to the same risk stratification guidelines and recommendations as for patients without HF. B Show 2 more Patients with previous CABG: initiate antiplatelet and anticoagulant therapy according to guideline-directed medical therapy in patients with prior CABG and NSTEMI, and proceed with an early invasive strategy because of the increased risk. B Patients with postoperative myocardial infarction: Initiate guideline-directed medical therapy in patients with NSTEMI following noncardiac surgery as recommended in patients in the general population but with modifications imposed by the specific noncardiac surgical procedure and the severity of the NSTEMI. B Direct management of patients with NSTEMI following noncardiac surgery to the underlying cause. B Updated evidence: MANAGE In patients who had undergone noncardiac surgery and were within 35 days of myocardial injury after noncardiac surgery, dabigatran was superior to placebo with respect to major vascular complications. Devereaux PJ et al. Lancet. 2018 Jun 9. Patients with spontaneous coronary artery dissection: Consider performing revascularization if feasible in patients with spontaneous coronary artery dissection with hemodynamic instability or ongoing ischemia despite conservative therapy. C Do not perform routine revascularization for spontaneous coronary artery dissection. D Patients with stress cardiomyopathy: suspect stress (Takotsubo) cardiomyopathy in patients presenting with apparent acute coronary syndrome and nonobstructive coronary artery disease at angiography. B Show 7 more https://web.pathway.md/diseases/recGYrMGdIRdWzUih 17/22 6/30/23, 1:17 AM Non-ST-elevation myocardial infarction Pathway Patients with MINOCA: follow a diagnostic algorithm to differentiate true MINOCA from alternative diagnoses in all patients with an initial working diagnosis of MINOCA. B Show 3 more Patients with microvascular angina: consider obtaining invasive physiological assessment, such as coronary flow reserve measurement, if coronary angiography reveals normal coronary arteries and endothelial dysfunction is suspected. C Patients with vasospastic angina: As per ESC 2021 guidelines, consider administering CCBs and nitrates in patients with suspected/confirmed vasospastic angina. Avoid using -blockers. C As per AHA 2014 guidelines, consider administering CCBs alone or in combination with long- acting nitrates to treat and reduce the frequency of vasospastic angina. B Administer long- acting CCBs and nitrates in patients with coronary artery vasospasm. B Show 3 more Cocaine and methamphetamine users: manage patients with NSTEMI and a recent history of cocaine or methamphetamine use in the same manner as patients without cocaine- or methamphetamine-related NSTEMI, except for patients with signs of acute intoxication (such as euphoria, tachycardia, and/or hypertension) and -blocker use unless receiving coronary vasodilator therapy. B Show 2 more 12. Patient education Counseling before discharge: inform patients with NSTEMI about symptoms of worsening myocardial ischemia and myocardial infarction and provide verbal and written instructions on how and when to seek emergency care for such symptoms. B Show 3 more 13. Preventative measures Statin therapy: initiate statins for primary prevention of CVDs in 40-75 years old adults with 1 CVD risk factors (dyslipidemia, diabetes, hypertension, or smoking) and an estimated 10-year CVD risk 10%. B Show 2 more Immunizations: As per ESC 2021 guidelines, offer annual influenza vaccination to improve morbidity in patients with coronary artery disease, especially in older patients. B As per ACC 2014 guidelines: Offer pneumococcal vaccination in patients 65 years of age and in high-risk patients with CVD. B Offer annual influenza vaccination in patients with CVD. B https://web.pathway.md/diseases/recGYrMGdIRdWzUih 18/22 6/30/23, 1:17 AM Non-ST-elevation myocardial infarction Pathway Hormone therapy: do not use hormone therapy with estrogen plus progestin or estrogen alone as new drugs for secondary prevention of coronary events in postmenopausal patients after NSTEMI and discontinue in previous users unless the benefits outweigh the estimated risks. D Vitamin supplements: Do not offer antioxidant vitamin supplements (such as vitamins E, C, or -carotene) for secondary prevention in patients with NSTEMI. D Do not offer folic acid, with or without vitamins B6 and B12, for secondary prevention in patients with NSTEMI. D 14. Follow-up and surveillance Discharge from hospital: use posthospital systems of care designed to prevent hospital readmissions to facilitate the transition to effective, coordinated outpatient care for all patients with NSTEMI. B Show 5 more Cardiac rehabilitation: As per ACC 2022 guidelines: Offer a comprehensive home-based or center-based cardiac rehabilitation program either before hospital discharge or during the first outpatient visit in patients undergone revascularization, to reduce deaths and hospital readmissions and improve quality of life. A