Guideline update for unstable angina, non-STEMI addresses newly approved drugs

Issue: August 2012

Updated guidelines from the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines now include a recommendation for ticagrelor to be considered along with older blood thinners, clopidogrel and prasugrel, for the treatment of patients who are experiencing unstable angina or non–ST-segment elevation MI.

The AHA and ACCF issue focused updates when pivotal new data are reported that may affect changes to current recommendations and meet specific criteria. One year after the last update in 2011, the biggest change is the recommendation of ticagrelor (Brilinta, AstraZeneca) and prasugrel (Effient, Lilly) as treatment options in addition to clopidogrel, according to a press release.

“The AHA and ACCF constantly update their guidelines so that physicians can provide patients with the most appropriate, aggressive therapy with the goal of improving health and survival,” Hani Jneid, MD, lead author of the update and assistant professor of medicine and director of interventional cardiology research at Baylor College of Medicine, stated in the release. In the case of this update, “we have put [ticagrelor] on equal footing with two other antiplatelet medications, clopidogrel and prasugrel.”

The update continues to recommend that all patients with unstable angina or non-STEMI receive aspirin immediately after hospitalization, continuing as long as it is tolerated. Other new recommendations include:

Patients undergoing invasive procedures should receive both aspirin and another antiplatelet medication.
Patients undergoing medical treatment only should receive aspirin indefinitely and clopidogrel or ticagrelor for up to at least 12 months.
After PCI, it is reasonable to use 81 mg per day of aspirin in preference to higher maintenance doses.
In hospitalized patients with unstable angina or non-STEMI, it is reasonable to use an insulin-based regimen to achieve and maintain glucose levels <180 mg/dL while avoiding hypoglycemia.
An invasive strategy is reasonable in patients with mild (stage 2) and moderate (stage 3) chronic kidney disease. There are insufficient data on the benefits and risks of invasive strategy in patients with unstable angina or non-STEMI with more advanced (stages 4 and 5) CKD.
It is reasonable to proceed with cardiac catheterization and possible revascularization within 12 to 24 hours of admission in initially stabilized high-risk patients with unstable angina or non-STEMI.
Platelet function testing or genotyping testing for CYP2C19 loss of function allele may be considered in select patients with unstable angina or non-STEMI who are using P2Y12 receptor inhibitors and when the results of testing may alter management.

Jneid noted: “While this focused update of the guidelines provides important guidance to clinicians, our recommendations are not substitutes for a physician’s own clinical judgments and the tailoring of therapy based on individual variability and a patient’s presentation and clinical diagnosis.”

Also included in the update, the task force encouraged clinicians and hospitals to participate in a standardized quality of care data registry designed to track and measure outcomes, complications and adherence to evidence-based recommendations. The authors note that these registries “may prove pivotal in addressing opportunities for quality improvement at the local, regional and national level, and include the elimination of health care disparities and conduct of comparative effectiveness research,” according to the press release.

The focused update is published in Circulation: Journal of the American Heart Association and Journal of the American College of Cardiology. It serves as an update to the 2007 guideline and replaces the 2011 focused update. The document was endorsed by the American College of Emergency Physicians, Society for Cardiovascular Angiography Interventions and Society of Thoracic Surgeons.

For more information:

Jneid H. Circulation. 2012;doi:10.1161/CIR.0b013e318256f1e0.

Jneid H. J Am Coll Cardiol. 2012;doi:10.1016/j.jacc.2012.06.004.

Disclosure: Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply.