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Introduction
Acute coronary syndromes are due to rupture or erosion of an atherosclerotic coronary artery plaque with superimposed platelet aggregation and coronary thrombosis. Complete thrombotic occlusion of a coronary artery generally causes acute ST-elevation myocardial infarction (STEMI), whereas incomplete occlusion will usually cause some myocardial necrosis (as shown by a rise in a cardiac-specific serum biomarker such as troponin) and is termed ‘non-ST elevation myocardial infarction’ (NSTEMI). When myocardial ischaemia is present without evidence of myocardial necrosis the clinical syndrome is described as unstable angina (UA). Hospital Episodes Statistics data for England suggest that there may be as many as 100 000–150 000 admissions with UA or NSTEMI per year (Green S, Personal communication, 2010). Although very early mortality (first few days) is lower for NSTEMI than for STEMI, over a longer period (6 months) their risk of death is comparable.1
The recently published NICE clinical guideline on the early management of UA and NSTEMI (CG94) examines selected aspects of in-hospital management, including risk assessment and its impact on patient management, antiplatelet and antithrombin therapy, the role of coronary angiography, revascularisation and intra-aortic balloon counterpulsation, testing for myocardial ischaemia and left ventricular function, specialist versus non-specialist care, rehabilitation and discharge planning. Detailed discussion of the evidence for the guideline can be found in the full version (http://guidance.nice.org.uk/CG94/Guidance/pdf/English, accessed August 2010), and this article summarises the most important conclusions. CG94 assumes that a firm diagnosis of UA or NSTEMI has already been established, and the differentiation of cardiac from non-cardiac chest pain is dealt with in separate NICE guidance (http://guidance.nice.org.uk/CG95/Guidance/pdf/English, accessed August 2010).
Risk assessment
An appreciation of an individual's risk of an adverse outcome following UA or NSTEMI is important when assessing which treatment strategies are most appropriate. For instance, antithrombotic agents may reduce further ischaemic events, but increase bleeding complications, and this …
Footnotes
Full membership of the Guideline Development Group
Professor John Camm (Chair)
BHF Professor of Clinical Cardiology, St. George's Hospital, University of London
Prof Huon Gray
Clinical Advisor, National Clinical Guideline Centre (NCGC), London; Consultant Cardiologist, Southampton University Hospital
Mr Sotiris Antoniou Principal Cardiac Pharmacist, Barts and the London NHS Trust and Lead Pharmacist for North East London Cardiac and Stroke Network
Ms Lina Bakhshi
Senior Information Scientist, NCGC
Ms Jenny Cadman
Cardiac Rehabilitation Service Manager, Senior Nurse in Cardiology,
Luton and Dunstable
Dr Emily Crowe
Senior Research Fellow, NCGC (from May 2008)
Dr Mark de Belder
Consultant Cardiologist, James Cook University Hospital, Middlesbrough
Dr Jose Diaz
Research Fellow, NCGC (until May 2008)
Mr David H Geldard
Patient/Carer representative; Immediate Past President, Heart Care Partnership (UK)
Dr Robert Henderson
Consultant Cardiologist, Nottingham University Hospitals
Professor Marjan Jahangiri
Professor of Cardiac Surgery, St George's Hospital, University of London
Ms Taryn Krause
Senior Project Manager, NCGC (from November 2008)
Miss Kate Lovibond
Health Economist, NCGC
Mr Gavin Maxwell
Patient/Carer representative, Patient and Carer Network,
Royal College of Physicians of London
Dr Francis Morris
Accident and Emergency Physician, Sheffield University Hospitals
Mr Alun Roebuck
Cardiology Nurse Consultant, Sunderland
Ms Nicola Sloan
Research Fellow, NCBC (July 2008-March 2009)
Ms Claire Turner
Senior Project Manager, NCBC (until November 2008)
Professor S Richard Underwood
Professor of Cardiac Imaging, Royal Brompton Hospital, London
Mr Mark Whitbread
Clinical Practice Manager/Senior Paramedic/Cardiac Lead Medical Directorate, London Ambulance Service NHS Trust.
Funding This work was undertaken by National Clinical Guideline Centre for Acute and Chronic Conditions which received funding from the National Institute for Health and Clinical Excellence. The views expressed in this publication are those of the authors and not necessarily those of the Institute.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
↵i See full guideline for details of the modification, which used surrogates of heart failure and renal impairment recorded in MINAP, for Killip class and creatinine recorded in GRACE. Adjustment resulted in risk stratification by mini-GRACE being very similar to that of the full GRACE score.