ACC/AHA Issue Guidelines to Improve NSTE-ACS
 Treatment

September 23, 2014—The American College of Cardiology (ACC) and the American Heart Association (AHA) announced that an updated guideline on the management of patients with non–ST-elevation acute coronary syndromes (NSTE-ACS) has a new name and new terminology that reflect current ways of thinking about this frequent and serious cardiac condition. 

The “2014 ACC/AHA Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes” is the first full revision since the “2007 ACC/AHA Guideline or the Management of Patients with Unstable Angina and Non–ST-Elevation Myocardial Infarction (NSTEMI)” and focused updates published in 2013.

The 2014 guideline has been published online ahead of print in the AHA’s Circulation and in the Journal of the American College of Cardiology.

According to the society’s announcement, the guideline’s new title emphasizes the pathophysiologic continuum of unstable angina and NSTEMI and their frequently indistinguishable clinical presentations. Guidelines writing committee chair Ezra A. Amsterdam, MD, stated, “It’s therefore reasonable that they be considered together in the guideline.”

Dr. Amsterdam emphasized that the guideline represents the cooperative efforts of experts from a variety of clinical and basic science fields dedicated to enhancing care of patients with NSTE-ACS, including cardiology, cardiac surgery, internal medicine, emergency medicine, pharmacology, clinical chemistry, and others. 

Another significant change in the guideline is replacing the term “initial conservative management” with “ischemia-guided strategy” to more clearly convey the physiologic rationale of this approach, noted Dr. Amsterdam. 

Regarding treatment, the guideline states that although an early invasive strategy for patients with NSTE-ACS with significant coronary artery disease is generally accepted, low-risk patients can substantially benefit from guideline-directed medical therapy. Dr. Amsterdam said, “Guideline-directed medical therapy has not always been optimally utilized, and advances in noninvasive testing have the potential to identify patients with NSTE-ACS at low-intermediate risk to distinguish candidates for invasive versus medical therapy.”

In addition, the guideline recognizes important, developing clinical areas requiring further research, such as the utility of combined, potent antithrombotic and anticoagulant therapy in certain patient groups; appropriate application of new, high-sensitivity troponins; and the proper selection of high-risk elderly patients and women for interventional therapy. Dr. Amsterdam advised, “This is an important area of current research—as it is often more challenging to treat elderly patients because they frequently have multiple comorbidities.” 



According to Nanette K. Wenger, MD, vice chair of the writing committee, the guideline contains expanded recommendations regarding discharge, such as education about symptoms, risk modification, routine medication with dual-antiplatelet therapy, cholesterol management, referral to cardiac rehabilitation, and other guideline-directed medical therapy.

In the ACC/AHA announcement, Dr. Wenger commented, “The hospitalization period involves crisis management of ACS, which is pivotal to successful patient outcomes during the acute phase of disease. However, discharge planning in addition to patient and family education guide the long-term ambulatory care of the patient who has sustained a NSTE-ACS.”

The document—a contemporary clinical practice approach for the optimal management of patients with NSTE-ACS—incorporates both established and new evidence from published clinical trials (presented in evidence summary tables), as well as information from basic science and comprehensive review articles. 



Dr. Amsterdam further stated, “There have been tremendous advances in the diagnosis and management of NSTE-ACS since the last guideline. We attempted to improve the utility of the guidelines with a focused method that eliminated repetition of ancillary information.”

According to the ACC/AHA press release, the guideline remains an extensive and comprehensive document, but it is now more direct and succinct. While the document aims to guide clinicians, it is not intended to replace their individual judgment in treating their patients. Dr. Amsterdam stated, “The science of medicine is founded on evidence. The art of medicine is based on optimal application of that evidence to the individual patient.” Dr. Amsterdam further noted that a goal of the writing committee was to make the document user friendly. He said, “Readers are aided by tables and algorithms which present diagnostic and management approaches in a concise manner.”