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SPECIAL ARTICLES
2002 Update of the Guidelines of the Spanish Society of Cardiology for Unstable Angina/Without ST-Segment Elevation Myocardial Infarction Lorenzo López Bescós (coordinator), Fernando Arós Borau, Rosa M. Lidón Corbi, Ángel Cequier Fillat, Héctor Bueno, Joaquín J. Alonso, Isabel Coma Canella, Ángel Loma-Osorio, Julián Bayón Fernández, Rafael Masiá Martorell, José Tuñón Fernández, Antonio Fernández-Ortiz, Jaume Marrugat de la Iglesia and Miguel Palencia Pérez Sociedad Española de Cardiología.
Since the Spanish Society of Cardiology Clinical Practice Guidelines on Unstable Angina/Non-Q-Wave Myocardial Infarction were released in 1999, the conclusions of several studies that have been published make it advisable to update current clinical recommendations. The main findings are related to the developing role of Chest Pain Units in the management and early risk stratification of acute coronary syndromes in the emergency department; new information concerning the efficacy of glycoprotein IIb/IIIa inhibitors, clopidogrel and low-molecular-weight heparins in the pharmacological treatment of acute coronary syndromes without ST-segment elevation; and the role of early invasive strategy in improving the prognosis of these patients. The published evidence is reviewed and the corresponding clinical recommendations for the management of acute coronary syndromes without persistent ST-segment elevation are updated.
Key words: Acute coronary syndromes. Chest pain units. Glycoprotein IIb/IIIa inhibitors. Clopidogrel. Lowmolecular-weight heparins. Invasive strategy. Full English text available at: www.revespcardiol.org
INTRODUCTION The Clinical Practice Guidelines must be an up-todate reference document, and relevant clinical changes must be made periodically to the original document.
Correspondence: Dr. L. López Bescós. Servicio de Cardiología. Fundación Hospital de Alcorcón. Budapest, 1. 28922 Alcorcón. Madrid. Spain. E-mail:
[email protected] 105
Actualización (2002) de las Guías de Práctica Clínica de la Sociedad Española de Cardiología en angina inestable/infarto sin elevación del segmento ST Desde la elaboración de las Guías de Práctica Clínica sobre angina inestable/infarto agudo de miocardio sin onda Q de la SEC en 1999, se han publicado numerosos trabajos cuyas conclusiones hacen recomendable modificar las recomendaciones vigentes hasta la fecha. Los hallazgos más importantes están relacionados con el papel emergente de las Unidades de Dolor Torácico en el manejo y la estratificación inicial de los síndromes coronarios agudos en las unidades de urgencias, los nuevos descubrimientos sobre la eficacia de los inhibidores de la glucoproteína IIb/IIIa, el clopidogrel y las heparinas de bajo peso molecular en el tratamiento farmacológico del síndrome coronario agudo sin elevación del segmento ST y el papel de la estrategia invasiva precoz para mejorar el pronóstico de estos pacientes. En este documento se revisan las evidencias publicadas en estos campos y se actualizan las recomendaciones correspondientes en el manejo de los pacientes con síndrome coronario agudo sin elevación persistente del segmento ST.
Palabras clave: Síndrome coronario agudo. Unidades de dolor torácico. Inhibidores de la glucoproteína IIb/IIIa. Clopidogrel. Heparinas de bajo peso molecular. Estrategia invasiva.
Since the publication of the last edition of the Guide in 1999,1 various studies have been published that report new data regarding management of the acute coronary syndrome (ACS) that are being incorporated into clinical practice and therefore must not be ignored. The Ischemic Cardiopathy and Coronary Unit Section has created a document on Chest Pain Units2 that includes management of ACS in the emergency room that was not included in the original version of the Guide. There is not a new edition of the Guide, but rather an Addendum to the Guide with regard to 3 concrete Rev Esp Cardiol 2002;55(6):631-42
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López Bescós L, et al. 2002 Update of the Guidelines for Unstable Angina/Non ST-Segment Elevation Myocardial Infarction
PRE-HOSPITAL PHASE AND EMERGENCY ROOM AREA ABBREVIATIONS
Conduct in the face of non-traumatic chest pain suggestive of angina or equivalent symptomatology in the hospital emergency room [page 840]
ASA: acetylsalicylic acid. CRS: coronary revascularization surgery. AMI: acute myocardial infarction. CI: confidence interval. PCI: percutaneous coronary intervention. RR: relative risk. ACS: acute coronary syndrome. ACSWEST: acute coronary syndrome without ST elevation (encompasses the old term unstable angina/infarct without ST elevation). CPU: chest pain unit.
Chest pain units (CPU) (new text)
aspects: 1) the concept of a Pain Unit in the management and initial categorization of ACS in the emergency room; 2) an update on the indications for IIb/IIIa glycoprotein inhibitors (GP; clopidogrel and low molecular weight heparin in ACS), and 3) changes in the indication for coronary angiography and revascularization in this context. The text of these 3 sections should be substituted for the text in the original Guide which otherwise remains in effect. The complete text of the Guide is not included here, but only those part concerning the subjects being updated. To make it clearer for the reader, the heading always includes the subsection heading where the text has been changed. The beginning page number corresponding to the original version of the Guide1 is indicated in brackets. If the heading for the subsection has been changed, the old heading will appear first in italics and will be followed by the new heading, in roman type. In the text of the modified subsection the original Guide text that is still in effect will appear in italics and the new text being added or substituted will appear in roman type. The complete text of the revised Guide can be found on the Sociedad Española de Cardiología (SEC) web page (www.secardiologia.es).
Chest pain is the most common clinical manifestation of ACS, but it is also the most frequent cause of emergency room visits (5% to 20% of patients who go to the emergency room complain of chest pain).3 It is necessary to quickly discriminate between patients presenting with ischemic myocardial pain and those who have pain stemming from other causes. In many patients with myocardial ischemia, the result of treatment is determined by how quickly the treatment is initiated. The most accepted current method for improving the diagnosis and treatment of chest pain in the emergency room is the creation of CPUs.4 The principal objective of these units is the rapid classification of patients into different risk groups. This classification should be completed within 30 minutes, and is later followed by an initial diagnostic evaluation in 6 to 9 hours. Patients with an unclear diagnosis should be kept under observation for 9 to 24 hours. The 3 phases of chest pain evaluation in the CPU are as follows: 1st phase. Rapid classification of patients with acute chest pain In this first phase, direct clinical data and an electrocardiogram (ECG), performed within 10 minutes of admission, are used and the patients are placed in 1 of 4 categories with direct implications with regard to hospital admission (Table 1). 2nd phase. Initial diagnostic evaluation Once the first phase has been completed, proceed to a better approximation of a diagnosis incorporating
TABLE 1. Rapid classification of patients with acute chest pain upon arrival at the chest pain unit Risk group
Clinical ACS
Electrocardiogram
Destination/admission
1
Yes
ST elevation or LBB
Coronary unit
2
Yes
ST decline or negative T
Coronary unit/floor
3
Yes
Normal or non-diagnostic
Chest pain unit
4
No
Normal or non-diagnostic
Discharge/other areas
LBB indicates left branch block; ACS, acute cardiac.
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López Bescós L, et al. 2002 Update of the Guidelines for Unstable Angina/Non ST-Segment Elevation Myocardial Infarction
Admission Anamnesis, physical examination, ECG 10 min
NL/NS ECG
ECG Pathological
Fig. 1. Protocol proposed by the Section of Ischemic Cardiopathy and Coronary Units of the SEC for the diagnosis of non-traumatic chest pain in the chest pain unit (modified by Bayón Fernández et al2). aConsider admission in the case of pain suggestive of myocardial ischemia with the presence of risk factors: myocardial infarct or prior coronary revascularization, cardiac insufficiency, or involvement of other vascular areas. bDiscard aortic dissection and pulmonary thromboembolism. NL/NS ECG indicates normal/nondiagnostic ECG; Tn, troponins; Rec Ang, recurrent angina.
↑ vST
↓ vST, neg T waves CK-MB and Tn
admission UC
admission Observation
Pain Typical/atypicala CK-MB and Tn 30 min
Repeat of ECG, CK-MB, Tn
Pre-discharge evaluation
Discharge from CPU Evaluate other diagnostics
CK-MB and Tn (-) and NL/NS ECG
Admission
1. Anamnesis and physical examination. The existence of any of the following increases the likelihood myocardial ischemia: a) characteristic pain or the presence of vegetative signs; b) equivalent symptoms in diabetics, the elderly, or patients with prior cardiac insufficiency; c) accompanying symptoms such as left ventricular insufficiency, arrhythmias, or syncope, and d) factors such as age, cardiovascular risk factors, a history of ischemic cardiopathy, or the involvement of other vascular areas. 2. The ECG. This has greater diagnostic value if performed during an episode of pain. The patient in this unit receives serial ECGs and, if possible, is under continuous control. It must be underlined that: a) a normal or non-specific ECG indicates low risk, but does not exclude the diagnosis of myocardial ischemia;6,7 b) a transitory or sustained elevation or decline in ST suggests a greater probability of myocardial ischemia and greater risk,8,9 and c) T-waves have less significance.10 3. Indicators of cardiac damage. The appearance in peripheral blood of intracellular markers is diagnostic for myocardial damage. The 3 most useful markers are: a) myoglobin, which is the earliest marker. It is very sensitive and not very specific. A negative value during the first 4 to 8 hours precludes myocardial ne-
Pain Non-coronaryb
Repeat ECG at 20 min (+) (–)
CK-MB and Tn (+) or pathologic ECG or Rec. Ang.
biological markers, clinical signs, and the ECG.5 This is based on data obtained from:
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Chest pain unit
6-9 hours Stress test (–)
(+) Admission
9-24 hours
Discharge
crosis;11 b) troponin (T or I) that begins to increase at 4 to 6 hours. This is very specific for myocardial damage, although it is not pathognomonic of ACS and has prognostic value.12 If it is initially negative, it should be repeated at 8 to12 hours from the start of symptoms, and c) the CK-MB mass, which, according to the National Academy of Clinical Biochemistry,13 begins increasing at 4 to 5 hours and is less sensitive than troponin, but specific with regard to myocardial necrosis. With this initial data the patients are classified into 3 diagnostic groups that form the basis for the initial ACS treatment algorithms (Figure 1): 1. Patients with ASC (with or without ST elevation). In this first group, patients with ST elevation must be treated immediately with coronary reperfusion.14 Patients with ASC without ST elevation (ACSWEST) and risk markers must be admitted and treated according to the recommendations of this Guide. 2. Patients with non-coronary chest pain. These patients are managed according to their etiology. 3. Patients with chest pain of uncertain etiology. Once the patients with an admitting diagnosis of ACS and those with chest pain of another etiology have been identified, approximately one-third of patients will be left who do not have a clear diagnosis; for the majority of protocols, this is the population that should Rev Esp Cardiol 2002;55(6):631-42
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López Bescós L, et al. 2002 Update of the Guidelines for Unstable Angina/Non ST-Segment Elevation Myocardial Infarction
be followed in the Chest Pain Unit. If the ECG continues to be normal, the patients should remain under observation and the ECG and tests for markers of necrosis should be repeated at 6 to 8 hours. On the other hand, if there are ischemic changes on ECG, the markers become positive, or there is a new episode of angina, the patient should be admitted. The recommended observation period varies from 6 to 24 hours. 3rd phase. Final evaluation in the CPU Approximately 70% of patients admitted into the CPU and are observed for 6 to 24 hours have negative markers for necrosis, do not show changes on serial ECG, and do not show signs of hemodynamic instability.15 Nevertheless, up to 3% of these patients could have an ACS and should not be discharged. For this reason, most protocols include an ischemia provocation test in the evaluation of patients in the CPU. Patients with a positive ischemia provocation test should be admitted and treated according to this Guide (Figure 1). Patients with a negative ischemia provocation test are in a low-risk group and can be treated in as outpatients. PRE-HOSPITALIZATION PHASE AND THE HOSPITAL EMERGENCY ROOM Proposed classification for risk categorization [page 841]
troponin I there are several methods with different values that can be used, but the 10 times normal value level is also valid as a criterion).16,17 – Post-infarct angina. – Serious ventricular arrhythmias. – FEVI
