A new guideline has been published by the National Institute for Health and Clinical Excellence (NICE) and the National Clinical Guidelines Centre for Acute and Chronic Conditions on the early management of unstable angina and non-ST elevation myocardial infarction (NSTEMI).
They note that although cardiovascular deaths are declining, there were still over 40,000 patients with NSTEMI acute coronary syndromes admitted to hospital in England and Wales in 2009. With worrying increases in the incidence of key risk factors – obesity, diabetes, and the tendency for people to take less exercise – the management of these conditions remains a high priority.
As its starting point, the guideline recommends that as soon as a diagnosis of unstable angina or NSTEMI has been made, and aspirin and antithrombin drugs have been offered, patients should be formally assessed for their individual risk of future adverse cardiovascular events using an established risk scoring system that predicts six-month mortality, such as the GRACE (Global Registry of Acute Coronary Events) score. Then treatments should be given according to whether the patient is at high, intermediate or low risk of future events, taking into account the risk of adverse events (particularly bleeding).
The guideline also advises that angiography should be conducted (if no contra-indications), with follow-on percutaneous coronary intervention (PCI) within 96 hours of first admission to hospital in patients who have an intermediate or higher risk of cardiac events (predicted six-month mortality above 3.0%). Angiography should be performed as soon as possible for patients who are clinically unstable or at high ischaemic risk.
Ischaemia testing should be considered before discharge for patients whose condition has been managed conservatively and who have not had coronary angiography.
The guideline also emphasises the importance of providing patients with comprehensive information about their diagnosis and arrangements for follow-up. It further recommends that patients are given advice about the provision of cardiac rehabilitation programmes and about how lifestyle changes, such as giving up smoking, being physically active and eating a Mediterranean diet, can help prevent a future cardiovascular event.
For full guidance, visit http://guidance.nice.org.uk/CG94. This guideline updates and replaces recommendations for the early management of unstable angina and NSTEMI from NICE technology appraisal guidance 47 and 80.