New guidelines released for unstable angina

June 1, 2002

Pharmaceutical Representative

An update to practice guidelines on the management of unstable angina and a related form of heart attack known as non-ST-segment elevation myocardial infarction has been released by the American College of Cardiology and the American Heart Association.

An update to practice guidelines on the management of unstable angina and a related form of heart attack known as non-ST-segment elevation myocardial infarction has been released by the Bethesda, MD-based American College of Cardiology and the Dallas-based American Heart Association. The new guidelines update a previous version released a little over a year ago.

"We've learned more in a year about unstable angina and NSTEMI than we did in the preceding 20 years," said Eugene Braunwald, faculty dean for academic programs at Harvard Medical School. "The clinical landscape has changed substantially."

Abciximab out, clopidogrel in

In previous guidelines, abciximab, one of a family of medications known as glycoprotein IIb/IIIa inhibitors, played a prominent role, but in the new guidelines, its use is ruled out except in patients having an invasive procedure such as balloon angioplasty or stenting. The guidelines also downgrade - though still deliver a positive rating to - the use of two other glycoprotein IIb/IIIa inhibitors, eptifibatide and tirofiban, in high-risk patients who will be treated with medication only. The document casts doubt, however, on their value in lower-risk patients.

By comparison, clopidogrel, a member of a different family of anti-clotting medications, receives a strong vote of confidence in the new guidelines. They recommend that, in addition to aspirin and heparin, nearly all patients with unstable angina and NSTEMI receive clopidogrel, which inhibits the ability of platelets to bind blood cells into clots.

Cardiac catheterization recommended

Another important change in the guidelines is their strong recommendation that shortly after admission, high-risk patients have cardiac catheterization, a procedure in which the coronary arteries are examined by X-ray after injection of a special dye. This clinical strategy has been the subject of controversy - and conflicting studies - for many years. The latest research tipped the balance in favor of the invasive approach, which can aid in gauging patient risk and deciding whether angioplasty, stenting or bypass surgery is needed.

Statins should be used

Finally, the guidelines also recommend statins for patients with elevated blood levels of low-density-lipoprotein cholesterol, as these medications appear to reduce the risk of having another episode of unstable angina. Starting the statin early appears to be crucial to success, according to Braunwald: "If statins are started in the hospital, the chances that the patient will still be taking the medication six months or a year later are so much better." PR

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