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2012 ACCF/AHA Focused Update Incorporated Into the ACCF/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial InfarctionA Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines
Circulation. 2013;127:e663-e828, originally published June 10, 2013
https://doi.org/10.1161/CIR.0b013e31828478ac

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2012 ACCF/AHA Focused Update Incorporated Into the ACCF/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction
Circulation June 2013, 127 (23) e663-e828; DOI: https://doi.org/10.1161/CIR.0b013e31828478ac

Table 1.
Applying Classification of Recommendations and Level of EvidenceShow More

Applying Classification of Recommendations and Level of EvidenceShow Less
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2012 ACCF/AHA Focused Update Incorporated Into the ACCF/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction
Circulation June 2013, 127 (23) e663-e828; DOI: https://doi.org/10.1161/CIR.0b013e31828478ac

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Table 2.
Guidelines for the Identification of ACS Patients by ED Registration Clerks or Triage NursesShow More

Guidelines for the Identification of ACS Patients by ED Registration Clerks or Triage NursesShow Less
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2012 ACCF/AHA Focused Update Incorporated Into the ACCF/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction
Circulation June 2013, 127 (23) e663-e828; DOI: https://doi.org/10.1161/CIR.0b013e31828478ac

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Table 3.
Causes of UA/NSTEMI*Show More

Causes of UA/NSTEMI*Show Less
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2012 ACCF/AHA Focused Update Incorporated Into the ACCF/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction
Circulation June 2013, 127 (23) e663-e828; DOI: https://doi.org/10.1161/CIR.0b013e31828478ac

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Table 4.
Three Principal Presentations of UAShow More

Three Principal Presentations of UAShow Less
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2012 ACCF/AHA Focused Update Incorporated Into the ACCF/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction
Circulation June 2013, 127 (23) e663-e828; DOI: https://doi.org/10.1161/CIR.0b013e31828478ac

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Table 5.
Grading of Angina Pectoris According to CCS ClassificationShow More

Grading of Angina Pectoris According to CCS ClassificationShow Less
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2012 ACCF/AHA Focused Update Incorporated Into the ACCF/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction
Circulation June 2013, 127 (23) e663-e828; DOI: https://doi.org/10.1161/CIR.0b013e31828478ac

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Table 6.
Likelihood That Signs and Symptoms Represent an ACS Secondary to CADShow More

Likelihood That Signs and Symptoms Represent an ACS Secondary to CADShow Less
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2012 ACCF/AHA Focused Update Incorporated Into the ACCF/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction
Circulation June 2013, 127 (23) e663-e828; DOI: https://doi.org/10.1161/CIR.0b013e31828478ac

Figure 1.
Acute Coronary Syndromes. The top half of the figure illustrates the chronology of the interface between the...
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Acute Coronary Syndromes. The top half of the figure illustrates the chronology of the interface between the patient and the clinician through the progression of plaque formation, onset, and complications of UA/NSTEMI, along with relevant management considerations at each stage. The longitudinal section of an artery depicts the “timeline” of atherogenesis from (1) a normal artery to (2) lesion initiation and accumulation of extracellular lipid in the intima, to (3) the evolution to the fibrofatty stage, to (4) lesion progression with procoagulant expression and weakening of the fibrous cap. An acute coronary syndrome (ACS) develops when the vulnerable or high-risk plaque undergoes disruption of the fibrous cap (5); disruption of the plaque is the stimulus for thrombogenesis. Thrombus resorption may be followed by collagen accumulation and smooth muscle cell growth (6). After disruption of a vulnerable or high-risk plaque, patients experience ischemic discomfort that results from a reduction of flow through the affected epicardial coronary artery. The flow reduction may be caused by a completely occlusive thrombus (bottom half, right side) or subtotally occlusive thrombus (bottom half, left side). Patients with ischemic discomfort may present with or without ST-segment elevation on the ECG. Among patients with ST-segment elevation, most (thick white arrow in bottom panel) ultimately develop a Q-wave MI (QwMI), although a few (thin white arrow) develop a non–Q-wave MI (NQMI). Patients who present without ST-segment elevation are suffering from either unstable angina (UA) or a non–ST-segment elevation MI (NSTEMI) (thick red arrows), a distinction that is ultimately made on the basis of the presence or absence of a serum cardiac marker such as CK-MB or a cardiac troponin detected in the blood. Most patients presenting with NSTEMI ultimately develop a NQMI on the ECG; a few may develop a QwMI. The spectrum of clinical presentations ranging from UA through NSTEMI and STEMI is referred to as the acute coronary syndromes. This UA/NSTEMI guideline, as diagrammed in the upper panel, includes sections on initial management before UA/NSTEMI, at the onset of UA/NSTEMI, and during the hospital phase. Secondary prevention and plans for long-term management begin early during the hospital phase of treatment. *Positive serum cardiac marker. Modified with permission from Libby P. Current concepts of the pathogenesis of the acute coronary syndromes. Circulation 2001;104:365;⁷ © 2001 Lippincott, Williams & Wilkins; The Lancet, 358, Hamm CW, Bertrand M, Braunwald E. Acute coronary syndrome without ST elevation: implementation of new guidelines, 1553–8. Copyright 2001, with permission from Elsevier;⁸ and Davies MJ. The pathophysiology of acute coronary syndromes. Heart 2000;83:361–6.⁹ © 2000 Lippincott, Williams & Wilkins. CK-MB = MB fraction of creatine kinase; Dx = diagnosis; ECG = electrocardiogram.
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2012 ACCF/AHA Focused Update Incorporated Into the ACCF/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction
Circulation June 2013, 127 (23) e663-e828; DOI: https://doi.org/10.1161/CIR.0b013e31828478ac

Figure 2.
Algorithm for Evaluation and Management of Patients Suspected of Having ACS. To facilitate interpretation of this algorithm and a more detailed discus...Show More

Algorithm for Evaluation and Management of Patients Suspected of Having ACS. To facilitate interpretation of this algorithm and a more detailed discussion in the text, each box is assigned a letter code that reflects its level in the algorithm and a number that is allocated from left to right across the diagram on a given level. ACC/AHA = American College of Cardiology/American Heart Association; ACS = acute coronary syndrome; ECG = electrocardiogram; LV = left ventricular.Show Less
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2012 ACCF/AHA Focused Update Incorporated Into the ACCF/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction
Circulation June 2013, 127 (23) e663-e828; DOI: https://doi.org/10.1161/CIR.0b013e31828478ac

Figure 3.
Patient (Advance) Instructions for NTG Use and EMS Contact in the Setting of Non–Trauma-Related Chest Discomfort/Pain. If patients experience chest di...Show More

Patient (Advance) Instructions for NTG Use and EMS Contact in the Setting of Non–Trauma-Related Chest Discomfort/Pain. If patients experience chest discomfort/pain and have been previously prescribed NTG and have it available (right side of algorithm), it is recommended that they be instructed (in advance) to take 1 dose of NTG immediately in response to symptoms. If chest discomfort/pain is unimproved or worsening 5 min after taking 1 NTG sublingually, it is recommended that the patient call 9-1-1 immediately to access EMS. In patients with chronic stable angina, if the symptoms are significantly improved after taking 1 NTG, it is appropriate to instruct the patient or family member/friend/caregiver to repeat NTG every 5 min for a maximum of 3 doses and call 9-1-1 if symptoms have not totally resolved. If patients are not previously prescribed NTG (left side of algorithm), it is recommended that they call 9-1-1 if chest discomfort/pain is unimproved or worsening 5 min after it starts. If the symptoms subside within 5 min of when they began, patients should notify their physician of the episode. (For those patients with newonset chest discomfort who have not been prescribed NTG, it is appropriate to discourage them from seeking someone else’s NTG [eg, from a neighbor, friend, or relative].) *Although some trials have used enteric-coated aspirin for initial dosing, more rapid buccal absorption occurs with non–enteric-coated formulations. EMS = emergency medical services; NTG = nitroglycerin.Show Less