2011ACCF+AHA+不稳定型心绞痛非ST段抬高心肌梗死治疗指南

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 A Am R *A Dia Rep Em Lia T Ad T Cas AC 200 Car T C He rep P per 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 A y L. ; Ma Robe Judit A; E ; Cl TA Pre 1. I 1 1 1 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 and App and App App Ant Foc App P2Y App Rec UA/ App App Inva Ref 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 by on March 30, 2011 g up t be r to im maj Evid will quic olog part T sens late- vett pop imp Evid inte revi Spe incl • P • L • N re • S • L fi • Im n • R th s ti • N • N re In a and evid that T curr as L clin able sing was reco stan evid deve spec cert reco expe peni no expe by h clin spar the Lev sche evid the cert ACC reco is de to th com gest ativ anot adde T tial, of re the grou to d mon imp the chai rele confi by a recu docu selv RW RW staff Forc mee occu proc poli to th tivel grou clud as a Task ACC Forc excl port effor T ulat ica. 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 reco content.onlinejacc.orDownloaded from 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 by on March 30, 2011 g subj revi pati to th find T heal ing diag or c of e curr pati Tabl videnc *D myoc Many very †F direc 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 resp content.onlinejacc.orDownloaded from 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 mee ultim be m the circ be a qual prov regu men situa differen on with lves to c . ce A an rm patient care; these areas will be identified within each ective guideline when appropriate. by on March 30, 2011 g P reco Bec adve prov activ style T cons focu focu Coll full- (ww Wor guid the Coll this upd 1. 1.1 Late annu Soc Apr com to id guid co