1 Guidance

The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance.

1.1 Provision of information

1.1.1 Offer patients clear information about the risks and benefits of the treatments offered so that they can make informed choices about management strategies. Information should be appropriate to the patient's underlying risk of a future adverse cardiovascular event and any comorbidities.

1.2 Assessment of a patient's risk of future adverse cardiovascular events

1.2.1 As soon as the diagnosis of unstable angina or NSTEMI is made, and aspirin and antithrombin therapy have been offered, formally assess individual risk of future adverse cardiovascular events using an established risk scoring system that predicts 6-month mortality (for example, Global Registry of Acute Cardiac Events [GRACE]).

1.2.2 Include in the formal risk assessment:

  • a full clinical history (including age, previous myocardial infarction [MI] and previous percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG])

  • a physical examination (including measurement of blood pressure and heart rate)

  • resting 12-lead electrocardiography (ECG) (looking particularly for dynamic or unstable patterns that indicate myocardial ischaemia)

  • blood tests (such as troponin I or T, creatinine, glucose and haemoglobin).

1.2.3 Record the results of the risk assessment in the patient's care record.

1.2.4 Use risk assessment to guide clinical management, and balance the benefit of a treatment against any risk of related adverse events in the light of this assessment.

1.2.5 Use predicted 6-month mortality to categorise the risk of future adverse cardiovascular events as follows:[3]

Predicted 6-month mortality

Risk of future adverse cardiovascular events

1.5% or below

Lowest

> 1.5 to 3.0%

Low

> 3.0 to 6.0%

Intermediate

> 6.0 to 9.0%

High

over 9.0%

Highest

1.3 Antiplatelet therapy

Aspirin

1.3.1 Offer aspirin as soon as possible to all patients and continue indefinitely unless contraindicated by bleeding risk or aspirin hypersensitivity.

1.3.2 Offer patients a single loading dose of 300 mg aspirin as soon as possible unless there is clear evidence that they are allergic to it.

1.3.3 For patients with aspirin hypersensitivity, clopidogrel monotherapy should be considered as an alternative treatment. (This recommendation is from 'MI – secondary prevention', NICE clinical guideline 172.)

Clopidogrel [4]

Recommendations in this section update and replace recommendations for the early management of unstable angina and NSTEMI from 'Clopidogrel in the treatment of non-ST-segment-elevation acute coronary syndrome', NICE technology appraisal guidance 80 (TA 80).

1.3.4 As soon as the risk of adverse cardiovascular events has been assessed, offer a loading dose of 300 mg clopidogrel in addition to aspirin to patients with a predicted 6-month mortality of more than 1.5% and no contraindications (for example, an excessive bleeding risk)[5].

1.3.5 Offer a 300-mg loading dose of clopidogrel to all patients with no contraindications who may undergo PCI within 24 hours of admission to hospital[5][6].

1.3.6 Offer clopidogrel as a treatment option for up to 12 months to people who have had an NSTEMI, regardless of treatment[7]. (This recommendation is from MI – secondary prevention, NICE clinical guideline 172.)

1.3.7 Consider discontinuing clopidogrel treatment 5 days before CABG in patients who have a low risk of adverse cardiovascular events.

1.3.8 For patients at intermediate or higher risk of adverse cardiovascular events, discuss the continuation of clopidogrel before CABG with the cardiac surgeon and base the decision on the balance of ischaemic and bleeding risk.

Glycoprotein IIb/IIIa inhibitors

Recommendations in this section update and replace recommendations for the early management of unstable angina and NSTEMI from 'Guidance on the use of glycoprotein IIb/IIIa inhibitors in the treatment of acute coronary syndrome', NICE technology appraisal guidance 47 (TA 47).

1.3.9 Consider intravenous eptifibatide or tirofiban[8] as part of the early management for patients who have an intermediate or higher risk of adverse cardiovascular events (predicted 6-month mortality above 3.0%), and who are scheduled to undergo angiography within 96 hours of hospital admission.

1.3.10 Consider abciximab as an adjunct to PCI for patients at intermediate or higher risk of adverse cardiovascular events who are not already receiving a GPI.

1.3.11 Balance the potential reduction in a patient's ischaemic risk with any increased risk of bleeding, when determining whether a GPI should be offered.

1.4 Antithrombin therapy

1.4.1 Offer fondaparinux to patients who do not have a high bleeding risk, unless coronary angiography is planned within 24 hours of admission.

1.4.2 Offer unfractionated heparin as an alternative to fondaparinux to patients who are likely to undergo coronary angiography within 24 hours of admission.

1.4.3 Carefully consider the choice and dose of antithrombin in patients who have a high risk of bleeding associated with any of the following:

  • advancing age

  • known bleeding complications

  • renal impairment

  • low body weight.

1.4.4 Consider unfractionated heparin, with dose adjustment guided by monitoring of clotting function, as an alternative to fondaparinux for patients with significant renal impairment (creatinine above 265 micromoles per litre).

1.4.5 Offer systemic unfractionated heparin (50–100 units/kg) in the cardiac catheter laboratory to patients receiving fondaparinux who are undergoing PCI[9].

1.4.6 As an alternative to the combination of a heparin plus a GPI, consider bivalirudin for patients who:

  • are at intermediate or higher risk of adverse cardiovascular events (predicted 6-month mortality above 3%), and

  • are not already receiving a GPI or fondaparinux, and

  • are scheduled to undergo angiography (with follow-on PCI if indicated) within 24 hours of admission.

1.4.7 As an alternative to the combination of a heparin plus a GPI, consider bivalirudin for patients undergoing PCI who:

  • are at intermediate or higher risk of adverse cardiovascular events, and

  • are not already receiving a GPI or fondaparinux.

1.5 Management strategies

Early invasive versus conservative management

1.5.1 Offer coronary angiography (with follow-on PCI if indicated) within 96 hours of first admission to hospital to patients who have an intermediate or higher risk of adverse cardiovascular events (predicted 6-month mortality above 3.0%) if they have no contraindications to angiography (such as active bleeding or comorbidity). Perform angiography as soon as possible for patients who are clinically unstable or at high ischaemic risk.

1.5.2 Offer conservative management without early coronary angiography to patients with a low risk of adverse cardiovascular events (predicted 6-month mortality 3.0% or less).

1.5.3 Offer coronary angiography (with follow-on PCI if indicated) to patients initially assessed to be at low risk of adverse cardiovascular events (predicted 6-month mortality 3.0% or less) if ischaemia is subsequently experienced or is demonstrated by ischaemia testing.

Percutaneous coronary intervention versus coronary artery bypass grafting

1.5.4 When advising patients about the choice of revascularisation strategy (PCI or CABG), take account of coronary angiographic findings, comorbidities, and the benefits and risks of each intervention.

1.5.5 When the role of revascularisation or the revascularisation strategy is unclear, resolve this by discussion involving an interventional cardiologist, cardiac surgeon and other healthcare professionals relevant to the needs of the patient. Discuss the choice of revascularisation strategy with the patient.

Testing for ischaemia

1.5.6 To detect and quantify inducible ischaemia, consider ischaemia testing before discharge for patients whose condition has been managed conservatively and who have not had coronary angiography.

Assessing left ventricular function

1.5.7 Assessment of left ventricular function is recommended in all patients who have had an MI. (This recommendation is from 'MI – secondary prevention', NICE clinical guideline 172.)

1.5.8 Consider assessing left ventricular function in all patients with unstable angina.

1.5.9 Record measures of left ventricular function in the patient's care record and in correspondence with the primary healthcare team and the patient.

Rehabilitation and discharge planning

1.5.10 Before discharge offer patients advice and information about:

  • their diagnosis and arrangements for follow-up (in line with 'MI – secondary prevention', NICE clinical guideline 172)

  • cardiac rehabilitation (in line with 'MI – secondary prevention', NICE clinical guideline 172)

  • management of cardiovascular risk factors and drug therapy for secondary prevention (in line with 'MI – secondary prevention', NICE clinical guideline 172, and 'Lipid modification', NICE clinical guideline 67)

  • lifestyle changes (in line with 'MI – secondary prevention', NICE clinical guideline 172).

1.5.11 Make cardiac rehabilitation equally accessible and relevant to all people after an MI, particularly people from groups that are less likely to access this service. These include people from black and minority ethnic groups, older people, people from lower socioeconomic groups, women, people from rural communities, people with a learning disability and people with mental and physical health conditions. (This recommendation is from MI – secondary prevention, NICE clinical guideline 172.)

1.5.12 All patients who smoke should be advised to quit and be offered support and advice, and referral to an intensive support service (for example, the NHS Stop Smoking Services) in line with 'Brief interventions and referral for smoking cessation in primary care and other settings' (NICE public health guidance 1). (This recommendation is adapted from 'MI – secondary prevention', NICE clinical guideline 172.)



[3] Categories of risk are derived from the Myocardial Ischaemia National Audit Process (MINAP) database. More details are in the full guideline.

[4] In this guideline, clopidogrel refers to clopidogrel hydrogen sulphate.

[5] In line with 'Prasugrel for the treatment of acute coronary syndromes with percutaneous coronary intervention' (NICE technology appraisal guidance 182), prasugrel in combination with aspirin is an option for patients undergoing PCI who have diabetes or have had stent thrombosis with clopidogrel treatment.

[6] There is emerging evidence about the use of a 600-mg loading dose of clopidogrel for patients undergoing PCI within 24 hours of admission. Clopidogrel does not have UK marketing authorisation for use at doses above 300 mg. The GDG was not able to formally review all the evidence for a 600-mg loading dose and was therefore not able to recommend this at the time of publication (March 2010).

[7] This recommendation updates and replaces recommendation 1.3 in Clopidogrel in the treatment of non-ST-segment-elevation acute coronary syndrome (NICE technology appraisal guidance 80).

[8] Eptifibatide and tirofiban are licensed for use with aspirin and unfractionated heparin. They do not have UK marketing authorisation for use with clopidogrel. This recommendation is therefore for an off-label use of these drugs. Informed consent should be obtained and documented before they are used in combination with clopidogrel.

[9] Unfractionated heparin is not licensed for use during angiography and PCI. Such use is an off-label use. Informed consent should be obtained and documented before it is used during angiography and PCI.

  • National Institute for Health and Care Excellence (NICE)