Unstable Angina, Non-STEMI Get New Guidelines

Two new anticoagulant drugs have been introduced since the 2002 guidelines, fondaparinux (Arixtra) and bivalirudin (Angiomax), and these are deemed alternatives to the low-molecular-weight heparin enoxaparin (Lovenox) and unfractionated heparin. The guidelines also call for treatment with a glycoprotein IIb/IIIa inhibitor, such as eptifibatide (Integrilin), tirofiban (Aggrastat), or abciximab (ReoPro) for recurrent angina or prior to diagnostic angiography or coronary stenting.

Overall, the antiplatelet and anticoagulant options are numerous and complex. The guidelines “try to walk a physician through, step by step, but in some cases they can choose one option or another. To simplify things, I recommend that a physician, group, or hospital decide on a particular strategy and try to focus on using just that to make it easier for everyone,” said Dr. Anderson, who is also a professor of medicine at the University of Utah.

The guidelines also call for aggressive, ongoing medical management after the patient is discharged. At the core of the regimen is an ACE inhibitor, or an angiotensin receptor blocker for ACE inhibitor-intolerant patients. A new addition in the guidelines is use of an aldosterone receptor blocker, either spironolactone or eplerenone (Inspra) for patients with a left ventricular ejection fraction of 40% or less and either symptomatic heart failure or diabetes, as long as they don't also have significant renal dysfunction or hyperkalemia.

Other elements of the discharge regimen include following established U.S. guidelines for managing blood pressure and serum lipids, and a strong push for smoking cessation. Hormone therapy should not be started in postmenopausal women, and in general should stop in postmenopausal women who were on hormonal therapy at the time of their coronary event. Supplements with antioxidant vitamins C and E and folic acid should not be used.

Treatment with an NSAID (aside from aspirin) should be stopped when a patient is first admitted; if a drug of this type is required by the patient at discharge, it should be used at the lowest effective dose for the shortest possible time.

'A physician who chooses a conservative strategy is not a pariah. It's an acceptable strategy.' DR. WENGER