Management of Non-ST Elevation Myocardial Infarction (NSTE-ACS) 2021 PDF

CLINICAL PRACTICE GUIDELINES MANAGEMENT OF NON-ST ELEVATION MYOCARDIAL INFARCTION (NSTE-ACS)...

CLINICAL PRACTICE GUIDELINES MANAGEMENT OF NON-ST ELEVATION MYOCARDIAL INFARCTION (NSTE-ACS) 3RD EDITION 2021 Appendix II: ELEVATIONS OF CARDIAC TROPONIN IN THE ABSENCE OF OVERT ISCHEMIC HEART DISEASE. Damage related to secondary myocardial ischemia (MI type 2) Tachy - or bradyarrhythmias Aortic dissection and severe aortic valve disease Hypo - or hypertension, e.g. hemorrhagic shock, hypertensive emergency Acute and chronic HF without significant concomitant CAD Hypertrophic cardiomyopathy Coronary vasculitis, e.g. systemic lupus erythaematosus, Kawasaki syndrome Coronary endothelial dysfunction without significant CAD e.g., cocaine abuse Damage not related to myocardial ischemia Cardiac contusion Cardiac incisions with surgery Radiofrequency or cryoablation therapy Rhabdomyolysis with cardiac involvement Myocarditis Cardiotoxic agents, e.g. anthracyclines, Herceptin, carbon monoxide poisoning Severe burns affecting > 30% of body surface Indeterminant or multifactorial group Apical ballooning syndrome Severe pulmonary embolism or pulmonary hypertension Peripartum cardiomyopathy Renal failure Severe acute neurological disease e.g., stroke, trauma Infiltrative disease e.g., amyloidosis, sarcoidosis Extreme exertion Sepsis Acute respiratory failure Frequent defibrillator shocks Adapted from Thygesen K et al. Recommendations for the use of cardiac troponin measurement in acute cardiac care. Eur Heart J 2010; 31:2197-2204. 94 CLINICAL PRACTICE GUIDELINES MANAGEMENT OF NON-ST ELEVATION MYOCARDIAL INFARCTION (NSTE-ACS) 3RD EDITION 2021 Appendix III : HEART SCORE# ++ HEART SCORE History Highly suspicious 2 Moderately suspicious 1 Slightly suspicious 0 ECG Significant ST segment depression 2 Non-specific repolarization disturbances 1 Normal 0 Age ≥ 65 years 2 > 45 - < 65 years 1 ≤ 45 years 0 Risk Factors > 3 risk factors* or 2 history of atherosclerotic disease** 1 or 2 risk factors 1 No known risk factors 0 Troponins ≥ 3 x normal 2 > 1 - < 3 x normal 1 ≤ normal limit 0 * Risk factors include: currently treated diabetes mellitus, current or recent smoker, diagnosed and/or treated hypertension, diagnosed hypercholesterolemia, family history of coronary artery disease, obesity (body mass index >30). ** History of atherosclerotic disease include: coronary revascularization, myocardial infarction, stroke, or peripheral arterial disease, irrespective of the risk factors for coronary artery disease. #Six AJ, Backus BE, Kelder JC. Chest pain in the emergency room: value of the HEART score. Neth Heart J. 2008;16(6):191-196. + In Modified Heart Score, the hs-cTn is used instead of cardiac troponins. ++ Willems MN, van de Wijngaart DJ, Bergman H, et al. Addition of heart score to high-sensitivity troponin T versus conventional troponin T in risk stratification of patients with chest pain at the coronary emergency rooms. Neth Heart J. 2014;22:552–556. 95 CLINICAL PRACTICE GUIDELINES MANAGEMENT OF NON-ST ELEVATION MYOCARDIAL INFARCTION (NSTE-ACS) 3RD EDITION 2021 APPENDIX IV: TIMI RISK SCORE FOR UA/NSTEMI* TIMI Risk Score All-Cause Mortality, New or Recurrent MI, or Severe Recurrent Ischemia Requiring Urgent Revascularization Through 14 d After Randomization, % 0-1 4.7 2 8.3 3 13.2 4 19.9 5 26.2 6-7 40.9 * Derived from clinical trial data The TIMI risk score is determined by the sum of the presence of 7 variables at admission: 1 point is given for each of the following variables:  Age 65 y or older  At least 3 risk factors for CAD (family history of premature CAD, hypertension > 140/90 or on antihypertensives, Low HDL cholesterol (< 40 mg/dL), current cigarette smoker, diabetes mellitus)  Known CAD (coronary stenosis of ≥ 50%)  Use of aspirin in prior 7 days  ST-segment deviation (≥ 0.5mm) on ECG  At least 2 anginal episodes in prior 24 h  Elevated serum cardiac biomarkers Total Score = 7 points Low Risk : ≤ 2 point Moderate Risk : 3 - 4 points High Risk : ≥ 5 points Adapted from : Antman EM, Cohen M, Bernink PJ, et al. The TIMI risk score for unstable angina/non-ST elevation MI: a method for prognostication and therapeutic decision making. JAMA 2000; 284 : 835-42. 96 CLINICAL PRACTICE GUIDELINES MANAGEMENT OF NON-ST ELEVATION MYOCARDIAL INFARCTION (NSTE-ACS) 3RD EDITION 2021 Appendix V: GRACE PREDICTION SCORE CARD AND NOMOGRAM FOR ALL CAUSE MORTALITY FROM DISCHARGE TO 6 MONTHS* Risk Calculator for 6-Month Postdischarge Mortality After Hospitalization for Acute Coronary Syndrome Record the points for each variable at the bottom left and sum the points to calculate the total risk score. Find the total score on the x-axis of the nomogram plot. The corresponding probability on the y-axis is the estimated probability of all-cause mortality from hospital discharge to 6 monts Medical History Findings at Initial Hospital Findings During Presentation Hospitalization 1 Age in Years Points 4 Resting Heart Points 7 Initial Serum Points Rate, Beats/min Creatinine, mg/dL ≤ 29 0 ≤ 49.9 0 0 - 0.39 1 30 - 39 0 50 - 69.9 3 0.4 - 0.79 3 40 - 49 18 70 - 89.9 9 0.8 - 1.19 5 50 - 59 36 90 - 109.9 14 1.2 - 1.59 7 60 - 69 55 110 - 149.9 23 1.6 - 1.99 9 70 - 79 73 150 - 199.9 35 2 - 3.99 15 80 - 90 91 ≥ 200 43 ≥4 20 ≥ 90 100 5 Systolic Blood 8 Elevated Cardiac 15 Pressure, mm Hg 2 History of ≤ 79.9 24 Enzymes Congestive 80 - 99.9 22 Heart Failure 24 100 - 139.9 18 9 No In Hospital 120 - 139.9 14 Percutaneous 3 History of 140 - 159.9 10 Coronary Myocardial 160 - 199.9 4 Invervention 14 Infarction 12 ≥ 200 0 1 6 ST-Segment Depression 11 Predicted All-Cause Mortality From Hospital Discharge to 6 Months Points 0.50 1 0.45 2 0.40 3 0.35 4 0.30 Probability 5 0.25 6 0.20 7 0.15 8 0.10 9 0.05 Total Risk Score _______(Sum of Points) 0 Mortality Risk _______(From Plot) 70 90 110 130 150 170 190 210 Total Risk Score Derived from international registry of ACS patients *Fox KAA, Dabbous OH, Goldberg RJ, et al. Prediction of risk of death and myocardial, infarction in the six months after presentation with acute coronary syndrome: prospective multinational observational study(GRACE), BMJ, 2006:333:1091 97 CLINICAL PRACTICE GUIDELINES MANAGEMENT OF NON-ST ELEVATION MYOCARDIAL INFARCTION (NSTE-ACS) 3RD EDITION 2021 Appendix VI: PRECISE -DAPT SCORE * TIMI Major or Minor Bleeding 5 TIMI Major Bleeding >4.15 700 4 3.85 1 year bleeding rish (%) 525 3 Number of Patients 2.67 >2.05 350 1.93 2 1.84 1.27 1.38 175 0.88 1 0.99 0.60 0.42 0.71 0.51 0.37 0.26 0 0 0 5 10 15 20 25 30 35 ≥ 36 Bleeding Score 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 Points ≥12.0 11.5 11.0 10.5 ≤10.0 Haemoglobin (g/dL) ≤5 8 10 12 14 16 18 ≥20 White-Blood cell count (x103 cells per µL) ≤50 60 70 80 ≥90 Ages (years) ≥100 80 60 40 20 0 Creatinine Cleareance (mL/min) No Yes Previous Bleed *Costa F, van Klaveren D, James S, Heg D, Räber L et al. PRECISE-DAPT Study Investigators. Derivation and validation of the predicting bleeding complications in patients undergoing stent implantation and subsequent dual antiplatelet therapy (PRECISE-DAPT) score: a pooled analysis of individual-patient datasets from clinical trials. Lancet. 2017; 389(10073):1025-1034 Available at : http://www.precisedaptscore.com/predapt/webcalculator.html 98 CLINICAL PRACTICE GUIDELINES MANAGEMENT OF NON-ST ELEVATION MYOCARDIAL INFARCTION (NSTE-ACS) 3RD EDITION 2021 Appendix VII: P2Y12 INHIBITORS* Clopidogrel Prasugrel Ticagrelor Chemical class Thienopyridine Thienopyridine Cyclopentyl- triazolopyrimidine Administration Oral Oral Oral Dose 300 - 600mg orally 60mg orally then 180mg orally then then 75mg a day 10mg a day 90mg twice a day Dosing in CKD  Stage 3 No dose No dose No dose (eGFR 30–59 mL/min/1.73m2) adjustment adjustment adjustment  Stage 4 No dose No dose No dose (eGFR 15–29 mL/min/1.73m2) adjustment adjustment adjustment  Stage 5 Use only for Not Not (eGFR 10 cigarettes daily: Start 21 mg daily for Smokers with time-to-first 6 wk, then reduce to cigarette (TTFC) of 14 mg daily for 2 wk; finish 30 minutes or less may w/7 mg daily for 2 wk. benefit from putting the patch immediately before Nicorette® : 25,15 and 10 mg sleeping. Heavy smoker - One 25-mg Remove the patch after patch/16 hr daily for 1st 8 wk, 16 or 24 hours. Rotate and then one 15-mg patch/16 hr avoid using the same site of daily for the next 2 wk & one application for ~ 1 week. 10-mg patch/16 hr daily for the final 2 wk. Light smoker - One 15-mg patch/16 hr daily for 1st 8 wk then one 10-mg patch/16 hr daily for the final 4 wk. Nicotine NiQuitin®: 4mg: suitable for Should not be chewed or Nausea, vomiting, Lozenge smokers who have their time swallowed. Do not eat or dyspepsia, (2 mg, 4 mg) to first cigarette is < 30 drink while lozenge is in the hiccups, flatulence, minutes after waking up. mouth. oral discomfort. 2mg: suitable for smokers who have their time to first One lozenge should be cigarette is > 30 minutes placed in the mouth and after waking up. allowed to dissolve. Dosage regimen: Periodically, the lozenge Week 1-6: 1 lozenge 1-2 should be moved from one hourly. Min: 9 lozenge/day. side of the mouth to the Week 7-9: 1 lozenge 2-4 other, and repeated until the hourly. Week 10-12: lozenge is completely 1 lozenge 4-8 hourly. dissolved (approximately Max: 15 lozenge/day. 20-30 minutes for standard Max duration: 24 wk lozenges). References: Nicotine gum: https://www.mims.com/malaysia/drug/info/nicotine (Accessed 27/11/2020) https://www.mims.com/malaysia/drug/info/nicorette%20icy%20mint%20gum (Accessed 27/11/2020) https://www.uptodate.com/contents/nicotine-drug-information?- search=nicorette+gum&source=search_result&selectedTitle=1%7E150&usage_type=default&display_rank=1 (Accessed 27/11/2020) Nicotine Patch: Niquitin® : 21, 14 and 7 mg - https://quest3plus.bpfk.gov.my/front-end/attachment/66/pharma/223639/V_888_20170714_074615_D4.pdf (Accessed 27/11/2020) Nicorette®: https://www.mims.com/malaysia/drug/info/nicorette%20invisi%20transdermal%20patch (Accessed 27/11/2020) https://www.mims.com/malaysia/drug/info/nicotine (Accessed 27/11/2020) Nicotine Lozenge: NiQuitin Mint Lozenges PIL Booklet - https://quest3plus.bpfk.gov.my/front-end/attachment/66/pharma/211166/V_3818_20170714_084514_D3.pdf (Accessed 27/11/2020) 109 CLINICAL PRACTICE GUIDELINES MANAGEMENT OF NON-ST ELEVATION MYOCARDIAL INFARCTION (NSTE-ACS) 3RD EDITION 2021 Table D: Pharmacological Intervention - Non-Nicotine Based Smoking Cessation Drugs Drug Dosage Prescribing Instructions Precautions Side Effects Varenicline Days 1-3: 0.5 mg once daily; Start 1-2 weeks before quit Renal insufficiency, and Nausea, headache, (0.5mg, 1mg) Days 4-7: 0.5 mg twice daily; date. Best taken with a bit of lactating women. insomnia and Day 8-end of treatment: food. abnormal dreams. 1 mg twice daily. Dosing renal impairment: Administer after eating and CrCl