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Management of Patients with Non-ST Elevation Acute Coronary Syndromes – Adult – Inpatient

Management of Patients with Non-ST Elevation Acute Coronary Syndromes – Adult – Inpatient - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Cardiovascular


1
Management of Patients with Non-ST-
Elevation Acute Coronary Syndromes –
Adult – Inpatient
Clinical Practice Guideline
Table of Contents
EXECUTIVE SUMMARY ................................................................................................ 3
SCOPE ............................................................................................................................ 4
METHODOLOGY ............................................................................................................ 4
DEFINITIONS ................................................................................................................. 5
INTRODUCTION ............................................................................................................. 5
RECOMMENDATIONS ................................................................................................... 5
ξ Initial Evaluation and Management
ξ Early Hospital Care
ξ Myocardial Revascularization
ξ Late Hospital Care, Hospital Discharge, and Posthospital Discharge Care
ξ Special Patient Groups
UW HEALTH IMPLEMENTATION.................................................................................. 6
REFERENCES ................................................................................................................ 6
CPG Contact for Content:
Name: Anne O’Connor, MD – Medicine- Cardiology
Phone Number: (608) 262-4917
Email Address: aoconnor@medicine.wisc.edu
CPG Contact for Changes:
Name: Lindsey Spencer, MS – Center for Clinical Knowledge Management (CCKM)
Phone Number: (608) 890-6403
Email Address: lspencer2@uwhealth.org
Note: Active Table of Contents -- Click to follow link
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

2
Guideline Author(s): American College of Cardiology/American Heart Association
Coordinating Team Members:
Jon Keevil, MD – Medicine- Cardiology
Amish Raval, MD – Medicine- Cardiology
Peter Mason, MD – Medicine- Cardiology
Mary Zasadil, MD – Medicine- Cardiology
Brian Sharp, MD – Emergency Medicine
Andrew Lee, MD – Emergency Medicine
Chris Francois, MD – Radiology- General
Sarah Hackenmueller, PhD, DABCC – Pathology and Laboratory Medicine
Joseph Holt, MD – Medicine- Hospitalists
Anne Rose, PharmD – Pharmacy- Inpatient Services
Katie Willenborg, PharmD – Pharmacy- Inpatient Services
Cindy Gaston, PharmD – Drug Policy Program
Stephanie Kraus, CNS – Cardiology
Kathy Wackerle, NP- Medicine- Cardiology
Rebecca Wieczorek- Heart, Vascular, Thoracic Administration
Stacey Saari- Heart, Vascular, Thoracic Administration
Brenda Larson, RN, BSN- Heart, Vascular, Thoracic Administration
Beth Gamble, NP- Heart, Vascular, Thoracic Administration
Review Individuals/Bodies:
Takushi Kohmoto, MD – Surgery- Cardiothoracic Surgery
Katherine Porter, MD – Family Medicine
Michelle Bryan, MD- Family Medicine
Mark Micek, MD- Internal Medicine
Committee Approvals/Dates:
Clinical Knowledge Management (CKM) Council (04/23/2015)
Release Date: April 2015
Next Review Date: April 2017
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

3
Executive Summary
Guideline Overview
UW Health has agreed to endorse the 2014 ACC/AHA Guideline for the Management of
Patients with Non-ST-Elevation Acute Coronary Syndromes: A Report of the American
College of Cardiology/American Heart Association Task Force on Practice Guidelines.1
Key Practice Recommendations
1. Initial Evaluation and Management
2. Early Hospital Care
3. Myocardial Revascularization
4. Late Hospital Care, Hospital Discharge, and Posthospital Discharge Care
5. Special Patient Groups
Companion Documents1,2
1. ED Chest Pain Algorithm
2. Risk Stratification of Non-ST Elevation Acute Coronary Syndrome Patients Table
3. Contraindications to Exercise Stress Testing Table
4. Stress Testing (from ED) Algorithm
5. Stress Testing Algorithm (Outpatient)
6. Non-ST Elevation Acute Coronary Syndromes Medical Therapy Algorithm
7. Non-ST Elevation Acute Coronary Syndromes Discharge Checklist
Related UW Health Clinical Practice Guidelines:
1. Unfractionated Heparin (Therapeutic Dosing) – Adult – Inpatient
2. Secondary Prevention of Atherosclerotic Cardiovascular Disease – Adult –
Inpatient/Ambulatory
3. Heart Failure- Adult- Inpatient/Ambulatory
4. Atrial Fibrillation – Adult – Inpatient/Ambulatory
Pertinent UW Health Policies & Procedures
1. UWHC Policy 1.26: Continuum of Care
2. UWHC Policy 10.24: Administration of Echocardiography Contrast Agents
Patient Resources
1. Health Information: Acute Coronary Syndrome
2. Health Information: Angina
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

4
Scope
Disease/Condition(s):
ξ Unstable angina (UA)
ξ Non-ST-elevation myocardial infarction (NSTEMI)
Clinical Specialty: Cardiology, Cardiothoracic Surgery, Hospitalists, Emergency
Medicine, Internal Medicine, Family Medicine, Pharmacy
Intended Users:
Cardiologists, Primary Care Physicians, Emergency Medicine Physicians, Pharmacists,
Registered Nurses, Cardiac Rehabilitation Therapists
CPG objective(s):
To provide recommendations for the optimal management of patients with NSTE-ACS.
Target Population:
Adult patients (18 years or older) with suspected or diagnosed NSTE-ACS.
Guideline Metrics:
CPG-derived
1. Volume of patients seen in the ED for chest pain who were discharged
2. Rate of OP stress test attendance following ED discharge
3. Amount of time between ED discharge and OP stress test
4. Volume of patients seen in the ED for chest pain who were admitted
5. Distributions of interventions performed following inpatient admission
6. 30-day and 60-day outcomes following inpatient discharge
Methodology
Methods Used to Collect/Select the Evidence:
Electronic database searches were conducted to collect evidence for review, in addition
to review of the 2014 ACC/AHA guideline.1 Expert opinion and clinical experience was
also considered during evidence review.
Methods Used to Formulate the Recommendations:
The workgroup members adopted recommendations developed by external
organizations and/or arrived at a consensus through discussion of the literature
evidence and expert experience.
Methods Used to Assess the Quality and Strength of the
Evidence/Recommendations:
Recommendations developed by external organizations (i.e., ACC/AHA) maintained the
assigned evidence grade. Recommendations internally developed during workgroup
discussions were graded using the modified grading scheme developed by AHA.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

5
Rating Scheme for the Strength of the Evidence/Recommendations:
A modified Grading of Recommendations, Assessment, Development and Evaluation
(GRADE) scheme developed by the American Heart Association and American College
of
Cardiology
(see below)
was used to
grade each
recommendation.1
Definitions
Acute Coronary Syndrome (ACS): a spectrum of conditions compatible with acute
myocardial ischemia and/or infarction due to an abrupt reduction in coronary blood
flow.1
Introduction
In the United States, NSTE-ACS affects over 625,000 patients annually, or almost three
fourths of all patients with acute coronary syndromes.1 The median age of presentation
is 68 years. Some patients have a history of stable angina, whereas in others, ACS is
the initial presentation of coronary artery disease (CAD).1
Recommendations
Recommendations related to clinical assessment and initial evaluation, diagnosis, early
hospital care, myocardial revascularization, discharge and posthospital care can be
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

6
found in the 2014 ACC/AHA Guideline for the Management of Patients with Non-ST-
Elevation Acute Coronary Syndromes: A Report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines1 online at
http://circ.ahajournals.org/content/130/25/e344.extract.
UW Health Implementation
Implementation Plan/Tools
1. Guideline will be housed on U-Connect in a dedicated folder for CPGs.
2. Release of the guideline will be advertised in the Clinical Knowledge Management
Corner within the Best Practice newsletter.
3. Links to this guideline will be updated and/or added in appropriate Health Link or
equivalent tools. Content will be reviewed for consistency across clinical tools,
including:
Delegation Protocols
ξ Emergency Department Immediate Orders [61]
Order Sets
ξ ED – Immediate Orders – Adult [4222]
ξ ED – Chest Pain – Adult [624]
ξ ED – Nuc Med Chest Pain Treatment – Adult [2556]
ξ ED – Coronary CT Angiography Procedure – Adult [5225]
ξ IP – Coronary CT Angiography – Adult – Procedure [2236]
ξ IP – MI/Rule Out MI – Adult – Intermediate and General Care – Admission [920]
ξ IP – MI/Rule Out MI – Adult – Intensive Care – Admission [923]
ξ IP – Cardiology – Adult – Discharge [3328]
Disclaimer
CPGs are described to assist clinicians by providing a framework for the evaluation and
treatment of patients. This Clinical Practice Guideline outlines the preferred approach for most
patients. It is not intended to replace a clinician’s judgment or to establish a protocol for all
patients. It is understood that some patients will not fit the clinical condition contemplated by a
guideline and that a guideline will rarely establish the only appropriate approach to a problem.
References
1. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC Guideline for the Management of
Patients With Non-ST-Elevation Acute Coronary Syndromes: A Report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation.
2014;130(25):e344-426.
2. Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the
diagnosis and management of patients with stable ischemic heart disease: a report of the American
College of Cardiology Foundation/American Heart Association task force on practice guidelines, and
the American College of Physicians, American Association for Thoracic Surgery, Preventive
Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and
Society of Thoracic Surgeons. Circulation. 2012;126(25):e354-471.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

Patient Presentation:
Chest Pain or Anginal Equivalent
with Concern for ACS
Definitive
NSTE-ACS or
Unstable Angina
STEMI
STEMI
Activation
Clinical
Concern for
NSTE-ACS?
Admit to CVM
for Medical
Management
Refer to UW Health
NSTE-ACS Medical
Therapy Algorithm
Coronary CTA or Stress Test
ED Provider Preference
(AHA Class Iia, LOE B)
Inclusion
Criteria met?
Perform CCTA
(AHA Class Iia, LOE B)
Use ED Order Set
Stress Lab
open?
CCTA
Result:
High risk/
Severe stenosis
Result:
Equivocal risk/
Moderate stenosis
Result:
Low risk/No or
Mild stenosis
Discharge
Follow-up
with PCP
Admit to CVM
ED Provider Preference
12-lead ECG (within 10 min of arrival) (AHA Class I, LOE C)
1
st
Troponin Lab (draw upon arrival) (AHA Class I, LOE A)
UW Health ED Chest Pain Algorithm
References
1. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes: A Report of the American College of Cardiology/
American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130(25):e344-426.
2. Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of
Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses
Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2012;126(25):e354-471.
3. Cullen L, Mueller C, Parsonage WA, et al. Validation of high-sensitivity troponin I in a 2-hour diagnostic strategy to assess 30-day outcomes in emergency department patients with possible acute coronary
syndrome. J Am Coll Cardiol. 2013;62(14):1242-1249.
4. Than M, Aldous S, Lord SJ, et al. A 2-hour diagnostic protocol for possible cardiac chest pain in the emergency department: a randomized clinical trial. JAMA Intern Med. 2014;174(1):51-58.
2
nd
Troponin
(draw 2hrs. after onset of
symptoms)*
Change in
troponin?
Stress Test
Yes
Order Stress Test**
(AHA Class IIa, LOE A,B)
ED Management
(outside guideline scope)
No
Admit to appropriate
Medical Service for
Stress Testing***
(AHA Class IIa, LOE B)
Consider for OP Stress
Testing and Discharge
- Patient Low Risk?
- Patient Agreeable?
- PCP?
Yes
No
YesNo
CCTA Inclusion Criteria:
ξ During available hours
ξ Age < 60 yrs.
ξ No history of CAD
ξ HR < threshold or no contraindications to
beta blockade
ξ ECG with NSR, no ischemia, no arrhythmia
ξ No allergy to iodinated contrast
ξ Can hold breath for 15 seconds
ξ eGFR > 60
ξ Not taking PDE-5 inhibitor drugs (i.e., 24
hrs. since sildenafil/vardenafil dose, or 48
hrs. since tadalafil dose) (AHA Class III, LOE B)
Last Revised: 04/2015
Contact CCKM for revisions.
UW Health Management of Non-ST Elevation Acute Coronary Syndromes – Adult – Inpatient/Ambulatory Clinical Practice Guideline
*UW Health uses troponin lab with higher sensitivity.
3,4
**Stress test type will be determined by the Stress Test Lab
staff using the UW Health Stress Testing (from ED) Algorithm.
***Patients may be transferred from TAC to CSC on Fri./Sat.
1
st
Troponin
positive?
Yes
No
Yes
No
NOTE: Consider
Contraindications for
Stress Testing
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

Risk Stratification for NSTE-ACS Patients in the Emergency Department
HIGH RISK INTERMEDIATE RISK LOW RISK
At least 1 of the following: No high - risk features, but 1 of the following:
No high - or intermediate - risk features, but any
of the following:
History
Accelerating tempo of
ischemic symptoms in
preceding 48 hrs.
ξPrior MI, peripheral or cerebrovascular disease, or
CABG
ξPrior aspirin use
N/A
Characteristics of Pain Prolonged ongoing
(>20 min.) rest pain
ξProlonged (>20 min.) rest angina, now resolved, with
moderate to high likelihood of CAD
ξRest angina (>20 min.) or relieved with rest or
sublingual NTG
ξNocturnal angina
ξNew-onset or progressive CCS Class III or IV angina
in previous 2 wks. without prolonged (>20 min) rest
pain but with intermediate or high likelihood of CAD
ξIncreased angina frequency,
severity, or duration
ξAngina provoked at a lower
threshold
ξNew-onset angina with onset 2 wks.
to 2 months before presentation
Clinical Findings
ξPulmonary edema, most
likely due to ischemia
ξNew or worsening mitral
regurgitation murmur S3
or new/worsening rales
ξHypotension,
bradycardia, or
tachycardia
ξAge > 75 yrs.
Age > 70 yrs. N/A
ECG
ξAngina at rest with
transient ST-segment
changes > 0.5mm
ξBundle-branch block, new
or presumed new
ξSustained ventricular
tachycardia
ξT-wave changes
ξPathological Q waves or resting ST -depression <
1mm in multiple lead groups (anterior, inferior,
lateral)
Normal or unchanged ECG
Cardiac Markers
(UW Health Lab) TnI > 0.50 ng/mL TnI = 0.06 -0.49 ng/mL TnI = 0.00 -0.05 ng/mL
Last revised/reviewed: 04/2015 | Contact CCKM for revisions. | UW Health Non-ST-Elevation Acute Coronary Syndromes – Adult – Inpatient/Ambulatory CPG
Reference: Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the
American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive
Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2012;126(25):e354-471.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

Contraindications for Exercise Stress Testing1
Absolute
‡ $cute m\ocardial inIarction �ZitKin � days)
‡High-risk unstable angina
‡ 8ncontrolled cardiac arrK\tKmias causing symptoms or hemodynamic
compromise
‡ 6\mptomatic seYere aortic stenosis
‡ 8ncontrolled s\mptomatic Keart Iailure
‡ $cute pulmonar\ embolus or pulmonar\ inIarction
‡ $cute m\ocarditis or pericarditis
‡ $cute aortic dissection
Relative*
‡ /eIt main coronar\ stenosis
‡ Moderate stenotic YalYular Keart disease
‡ (lectrol\te abnormalities
‡Severe arterial hypertension**
‡ 7acK\arrK\tKmias or brad\arrK\tKmias
‡ +\pertropKic cardiom\opatK\ and otKer Iorms oI outIloZ tract obstruction
‡ Mental or pK\sical impairment leading to inability to exercise adequately
‡ +igK-degree atrioventricular block
*Re lative contraindications can be superseded if the benefits of exercise outweigh the risks.
**In the absence of definitive evidence, the AHA/ACC suggests systoli c blood pressure of > 200 mmHg and/or
diastolic blood pressure of > 110 mmHg. Modified from Fletcher et al. 2
Last revised/reviewed: 04/2015 | Contact CCKM for revisions.
UW Health Non-ST-Elevation Acute Coronary Syndromes – Adult – Inpatient/Ambulatory CPG
References:
1. Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHA 2002 guideline update for exercise testing: summary article. A
report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines
(Committee to Update the 1997 Exercise Testing Guidelines). J Am Coll Cardiol. 2002;40(8):1531-1540.
2. Fletcher GF, Balady G, Froelicher VF, Hartley LH, Haskell WL, Pollock ML. Exercise standards. A statement for
healthcare professionals from the American Heart Association. Writing Group. Circulation. 1995;91(2):580-615.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

Discharge &
Follow-up with
PCP
Stress Test Ordered
(per Cardiology)
Consider coronary
revascularization.
Admit to CVM
Contraindications
to stress testing?
Patient able
to exercise ?
No
Known CAD?
Yes
Perform Pharm Stress MPI
(AHA Class I, LOE B)
No
Resting ECG
interpretable?
No
Perform MPI with Exercise
(AHA Class I, LOE B)
Yes
Perform MPI with
Exercise
(AHA Class I, LOE B)
No
Review Test Result
Result:
High/Moderate risk
Result:
Low risk
References
1. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes: A Report of the American College of Cardiology/
American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130(25):e344-426.
2. Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College
of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses
Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2012;126(25):e354-471.
UW Health Stress Testing (from ED) Algorithm
Last Revised: 04/2015
Contact CCKM for revisions.
UW Health Management of Non-ST Elevation Acute
Coronary Syndromes – Adult – Inpatient/Ambulatory
Clinical Practice Guideline
Consider CCTA
(AHA Class Iia, LOE C)
OR
Initiate Medical Therapy
Refer to UW Health Non-STE
ACS Medical Therapy
Algorithm
Yes
Use CAD Consortium 1 Risk Calculator
Low Pretest Probability (<20 %):
Perform Standard Exercise ECG ( AHA Class IIa, LOE C)
Intermediate/ High Likelihood IHD (>20 %):
Perform MPI with Exercise ( AHA Class Iia, LOE B)
Yes
Note: Consider
Contraindications
for Stress Testing
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

Follow-up with
PCP
Stress Test Ordered
by ED
Expedited
Cardiology Evaluation
(i.e., TAC consult,
Cardiology Clinic, Stress
reader)
Admit to CVM vs.
OP cath
Contraindications
to stress testing?
Patient able
to exercise ?
No
Known CAD?
Yes
Perform Pharm Stress MPI (AHA Class I, LOE B)
OR Pharm Stress with Echo (AHA Class I, LOE B)
No
Resting ECG
interpretable?
No
Perform MPI with Exercise
(AHA Class IIa, LOE B)
OR Exercise Echo (AHA Class I, LOE B)
Yes
Perform MPI with
Exercise
(AHA Class I, LOE B)
OR
Exercise Echo
(AHA Class I, LOE B)
No
Chest Pain APP places order
Result:
High risk
Result:
Low risk
References
1. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes: A Report of the American College of Cardiology/
American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130(25):e344-426.
2. Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of
Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses
Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2012;126(25):e354-471.
UW Health Stress Testing Algorithm
For Patients Discharged from the ED for Testing
UW Health Management of Non-ST
Elevation Acute Coronary Syndromes
– Adult – Inpatient/Ambulatory
Clinical Practice Guideline
Expedited Follow-up with
the PCP or Cardiology
Clinic
Yes
Use CAD Consortium 1 Risk Calculator
Low Pretest Probability ( < 25 %):
Perform Standard Exercise ECG ( AHA Class IIa, LOE C)
Intermediate/ High Likelihood IHD (> 25 %):
Perform MPI with Exercise ( AHA Class IIa, LOE B)
OR Exercise Stress with Echo (AHA Class IIa, LOE B)
Yes
Order reviewed by
Chest Pain APP
EF < 40% or
unknown?
No
Perform MPI with Exercise
(AHA Class I, LOE B)
Yes
Result:
Moderate risk
Review Test Result
Guideline-directed
Medical Therapy for
Stable Ischemic Heart
Disease
Follow-up with PCP
(with Cardiology
referral as needed)
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

Non-STE ACS Medical Therapy Algorithm
Patient with Definite or Likely Non-ST Elevation ACS
Postadmission Medical Therapy ( Floor- CVM)
1. Continue pharmacotherapy initiated in ED
ξ Anticoagulation (enoxaparin or IV heparin ) should be continued for
duration of hospitalization or until PCI is performed
ξ Anticoagulation does not need to be held on the morning of
planned coronary angiogram
2. Administer additional pharmacotherapy:
ξ Beta Blocker (AHA Class I, LOE A)
ξ ACE-I (or ARB if into lerant) if EF < 40%, hypertension , diabetes , or
stable CKD (AHA Class I, LOE A)
ξ Aldosterone blockade (i.e., spirlactone or eplereone) if EF < 40% ,
diabetes, or heart failure and no significant renal dysfunction (Cr >
2.5 mg/dL in men or > 2.0 mg/dL in women) or hyperkalemia (K >
5.0 mEq/L) (AHA Class I, LOE A)
ξ Atorvastain (80 mg daily) (AHA Class I, LOE A)
3. Administer supplemental oxygen if saturations < 90% or in
respiratory distress (AHA Class I, LOE C)
4. Maintain nutrition status of NPO (expect medications)
5. Repeat ECG with any new symptoms
6. Complete laboratory tests (if not completed in ED):
ξ Troponin (every 6 hours until peak or 3 negative results)(AHA Class I,
LOE A)
ξ Lipid Profile (AHA Class Iia, LOE C)
ξ CBC without diffe rential
ξ BMP (Na, K, Cl, total CO2, glucose, BUN, Cr, Ca)
ξ ALT
ξ A1c
ξ PT/INR (if patient on coumadin)
7. Obtain transthoracic echocardiogram (TTE) for EF assessment to aid
risk stratification (AHA Class I, LOE C)
8. Consult Cardiac Rehabilitation
Risk Stratification to determine initial therapy strategy using TIMI
risk score and/or Grace risk model
Last Revised: 06/2015
Contact CCKM for revisions.
UW Health Management of Non-ST Elevation Acute Coronary Syndromes – Adult – Inpatient/Ambulatory Guideline
NOTE: Invasive strategy is not recommended in patients with extensive co-
morbidities (hepatic, renal (CKD stage > 4), pulmonary failure, or cancer) in whom
the risks likely outweigh the benefits of revascularization.
Confirm clopidogrel
loading dose (600 mg)
Perform PCI
Anticoagulation during
procedure to be determined by
Interventional Cardiology, with
preference for unfractionated
heparin (AHA Class I, LOE B) if low
bleed risk and bivalirudin(AHA
Class I, LOE B) if high bleed risk.
Perform CABG
1. Initiate or continue aspirin
therapy (AHA Class I, LOE B)
2. Hold ACE-I or ARB on day of
surgery
3. Refer to guideline for timing of
other antiplatelet therapy
cessation before surgery
(AHA Class I, LOE B)
Initial Medical Therapy ( ED Initiation)
1. Administer initial pharmacotherapy:
ξAspirin(325 mg STAT; 81 mg daily) (AHA Class I, LOE A)
Avoid all other NSAIDs (AHA Class III, LOE B)
ξClopidogrel (600 mg loading; 75 mg daily) (AHA Class I, LOE B)
ξEnoxaparin (1 mg/kg subcutaneous Q12 hrs) (AHA Class I, LOE A)
If CKD, administer heparin instead (60 IU/kg initial dose; 12 IU/
kg/hr infusion) (AHA Class I, LOE B)
ξNitroglycerin (0.4 mg Q5 min up to 3 doses) (AHA Class I, LOE C)
If HTN, heart failure or pain persists, consider IV. (AHA Class I, LOE
B) Do not administer if recent use of PDE-5 inhibitors (i.e., 24
hrs. since sildenafil/vardenafil dose, or 48 hrs. since tadalfil
dose) (AHA Class III, LOE B)
ξMorphine (if ischemic pain persists despite max . tolerated
nitrates) (AHA Class Iib , LOE B)
2. Administer supplemental oxygen if saturation < 90 % or
patient is in respiratory distress. (AHA Class I, LOE C)
Ischemia-guided
Strategy
Risk stratification using
noninvasive imaging
Perform diagnostic cardiac cath
Results
normal or mildly
abnormal?
Discharge
Refer to NSTE-ACS Discharge Checklist
Medical Management
Continue medications required to
control ischemia after discharge in
patients who do not undergo
coronary revascularization , patients
with incomplete/unsuccessful
revascularization, or those with
recurrent symptoms after
revascularization (AHA Class I, LOE C)
Yes No
Yes No
Invasive
strategy
warranted?
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org

Non-ST Elevation Acute Coronary Syndromes
Discharge Check List
Note: This checklist does not replace individual clinical judgement and/ or consideration for patient tolerance of
specific medications or therapies.
 Aspirin 81 mg daily. ( A HA Class I, LO E A)
 Clopidogrel 75 mg daily for 12 months post NSTE-ACS (with no interruption if drug covered stent
was placed). ( AHA Class I, LOE B)
 Sublingual nitroglycerin PRN. ( AHA Class I, LO E C)
 Proton pump inhibitor if history of GI bleeding and/or requires triple therapy with vitamin K
antagonists, aspirin, and p2Y 12 receptor inhibitor. ( AHA Class I, LOE C)
 Beta blockers ( AHA Class I, LOE A)
 ACE inhibitors (or ARBs if ACE-I intolerant): EF < 40%, HTN, DM, stable CKD. ( AHA Class I, LOE A)
 Aldosterone blockage (spirlactone 25 mg daily of eplereone 50 mg daily) if EF < 40%, DM, or HF
(provided creatinine < 2.5 mg/dL for men and < 2.0 mg/dL for women and potassium is less than 5
mEq/L. ( AHA Class I, LO E A)
 High Dose Statin – atorvastatin 80 mg daily. (AHA Class I, LOE A)
 Cardiac Rehab Consult ( AHA Class I, LO E B)
 Pneumococcal Vaccine ( AHA Class I, LOE B)
 Annual influenza Vaccine ( AHA Class I, LOE C)
 Avoid NSAIDs ( AHA Class I II, LOE B)
 Follow-up with patient (AHA Class I, LOE B)
ξ UW Health recommends in 1-2 weeks with PCP and 4-6 weeks with Cardiology
 Patient Education ( AHA Class I, LOE C) to include:
ξ Warning symptoms
ξ When to seek emergency care.
ξ Medication education.
ξ CV risk Factor modification.
ξ Smoking Cessation
Last revised/reviewed: 04/2015 | Contact CCKM for revisions.
UW Health Non-ST-Elevation Acute Coronary Syndromes – Adult – Inpatient/Ambulatory CPG
Reference: Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC Guideline for the Management of Patients With
Non-ST-Elevation Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines. Circulation. 2014;130(25):e344-426.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 02/2017CCKM@uwhealth.org