2014 AHA-ACC Guideline For The Management of Patients With Non-ST-Elevation Acute Coronary Syndromes

AHA/ACC Guideline
2014 AHA/ACC Guideline for the Management of Patients

With NonST-Elevation Acute Coronary Syndromes
A Report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines
Developed in Collaboration With the Society for Cardiovascular Angiography
and Interventions and Society of Thoracic Surgeons
Endorsed by the American Association for Clinical Chemistry
WRITING COMMITTEE MEMBERS*
Ezra A. Amsterdam, MD, FACC, Chair; Nanette K. Wenger, MD, MACC, FAHA, Vice Chair*;
Ralph G. Brindis, MD, MPH, MACC, FSCAI; Donald E. Casey Jr, MD, MPH, MBA, FACP, FAHA;
Theodore G. Ganiats, MD; David R. Holmes Jr, MD, MACC; Allan S. Jaffe, MD, FACC, FAHA*;
Hani Jneid, MD, FACC, FAHA, FSCAI; Rosemary F. Kelly, MD;
Michael C. Kontos, MD, FACC, FAHA*; Glenn N. Levine, MD, FACC, FAHA;
Philip R. Liebson, MD, FACC, FAHA; Debabrata Mukherjee, MD, FACC;
Eric D. Peterson, MD, MPH, FACC, FAHA*#; Marc S. Sabatine, MD, MPH, FACC, FAHA*;
Richard W. Smalling, MD, PhD, FACC, FSCAI***; Susan J. Zieman, MD, PhD, FACC
The writing committee gratefully acknowledges the memory of Dr. Francis M. Fesmire (representative of the American College of Emergency Physicians),
who died during the development of this document but contributed immensely to our understanding of nonST-elevation acute coronary syndromes.
*Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other
entities may apply; see Appendix 1 for recusal information.
ACC/AHA Representative.
ACC/AHA Task Force on Practice Guidelines Liaison.
American College of Physicians Representative.
American Academy of Family Physicians Representative.
Society of Thoracic Surgeons Representative.
#ACC/AHA Task Force on Performance Measures Liaison.
**Society for Cardiovascular Angiography and Interventions Representative.
Former Task Force member; current member during the writing effort.
This document was approved by the American Heart Association Science Advisory and Coordinating Committee and the American College of Cardiology
Board of Trustees in August 2014.
The online-only Comprehensive Relationships Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/
doi:10.1161/CIR.0000000000000134/-/DC1.
The online-only Data Supplement files are available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/
CIR.0000000000000134/-/DC2.
The American Heart Association requests that this document be cited as follows: Amsterdam EA, Wenger NK, Brindis RG, Casey DE Jr, Ganiats TG,
Holmes DR Jr, Jaffe AS, Jneid H, Kelly RF, Kontos MC, Levine GN, Liebson PR, Mukherjee D, Peterson ED, Sabatine MS, Smalling RW, Zieman SJ. 2014
ACC/AHA guideline for the management of patients with nonST-elevation acute coronary syndromes: a report of the American College of Cardiology/
American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130:e344e426.
This article is copublished in the Journal of the American College of Cardiology.
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(Circulation. 2014;130:e344-e426.)
2014 by the American Heart Association, Inc., and the American College of Cardiology Foundation.
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e344
Amsterdam et al 2014 AHA/ACC NSTE-ACS Guideline e345
ACC/AHA TASK FORCE MEMBERS

Jeffrey L. Anderson, MD, FACC, FAHA, Chair;
Jonathan L. Halperin, MD, FACC, FAHA, Chair-Elect; Nancy M. Albert, PhD, RN, FAHA;
Biykem Bozkurt, MD, PhD, FACC, FAHA; Ralph G. Brindis, MD, MPH, MACC;
Lesley H. Curtis, PhD, FAHA; David DeMets, PhD; Lee A. Fleisher, MD, FACC, FAHA;
Samuel Gidding, MD, FAHA; Robert A. Guyton, MD, FACC;
Judith S. Hochman, MD, FACC, FAHA; Richard J. Kovacs, MD, FACC, FAHA;
E. Magnus Ohman, MD, FACC; Susan J. Pressler, PhD, RN, FAHA; Frank W. Sellke, MD, FACC, FAHA;
Win-Kuang Shen, MD, FACC, FAHA; William G. Stevenson, MD, FACC, FAHA;
Duminda N. Wijeysundera, MD, PhD; Clyde W. Yancy, MD, FACC, FAHA
Table of Contents
Preamble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e346
1.Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e347
1.1. Methodology and Evidence Review . . . . . . . . . e347
1.2. Organization of the GWC . . . . . . . . . . . . . . . . . e348
1.3. Document Review and Approval . . . . . . . . . . . . e349
1.4. Scope of the CPG . . . . . . . . . . . . . . . . . . . . . . . . e349
2. Overview of Acs . . . . . . . . . . . . . . . . . . . . . . . . . . . . e349
2.1. Definition of Terms . . . . . . . . . . . . . . . . . . . . . . e349
2.2. Epidemiology and Pathogenesis . . . . . . . . . . . . e349

2.2.1.Epidemiology . . . . . . . . . . . . . . . . . . . . . e349

2.2.2.Pathogenesis . . . . . . . . . . . . . . . . . . . . . . e350
3. Initial Evaluation and Management . . . . . . . . . . . . . . e350
3.1.Clinical Assessment and Initial
Evaluation: Recommendation . . . . . . . . . . . . . . e350

3.1.1.ED or Outpatient Facility
Presentation: Recommendations . . . . . . . e352
3.2. Diagnosis of NSTE-ACS . . . . . . . . . . . . . . . . . . e352

3.2.1.History . . . . . . . . . . . . . . . . . . . . . . . . . . e352

3.2.2. Physical Examination . . . . . . . . . . . . . . . e352

3.2.3.Electrocardiogram . . . . . . . . . . . . . . . . . . e353

3.2.4.Biomarkers of Myocardial
Necrosis . . . . . . . . . . . . . . . . . . . . . . . . . e353

3.2.5.Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . e353
3.3.PrognosisEarly Risk Stratification:
Recommendations . . . . . . . . . . . . . . . . . . . . . . . e353

3.3.1.Rationale for Risk Stratification
and Spectrum of Risk: High,
Intermediate, and Low . . . . . . . . . . . . . . e354

3.3.2. Estimation of Level of Risk . . . . . . . . . . e354

3.3.2.1.History: Angina Symptoms
and Angina Equivalents . . . . . . e354

3.3.2.2.Demographics and History
in Diagnosis and Risk
Stratification . . . . . . . . . . . . . . . e354

3.3.2.3.Early Estimation of Risk . . . . . e355

3.3.2.4.Electrocardiogram . . . . . . . . . . e355

3.3.2.5. Physical Examination . . . . . . . . e357
3.4.Cardiac Biomarkers and the Universal
Definition of MI: Recommendations . . . . . . . . . e357

3.4.1. Biomarkers: Diagnosis . . . . . . . . . . . . . . e357

3.4.2. Biomarkers: Prognosis . . . . . . . . . . . . . . e357

3.4.3. Cardiac Troponins . . . . . . . . . . . . . . . . . . e357

3.4.3.1.Prognosis . . . . . . . . . . . . . . . . . e358

3.4.4.CK-MB and Myoglobin Compared
With Troponin . . . . . . . . . . . . . . . . . . . . . e359
3.5. Immediate Management . . . . . . . . . . . . . . . . . . e359

3.5.1.Discharge From the ED or Chest
Pain Unit: Recommendations . . . . . . . . . e359
4. Early Hospital Care . . . . . . . . . . . . . . . . . . . . . . . . . . e359
4.1. Standard Medical Therapies . . . . . . . . . . . . . . . e360

4.1.1. Oxygen: Recommendation . . . . . . . . . . . e360

4.1.2.Anti-Ischemic and Analgesic
Medications . . . . . . . . . . . . . . . . . . . . . . . e360

4.1.2.1. Nitrates: Recommendations . . . e360

4.1.2.2.Analgesic Therapy:
Recommendations . . . . . . . . . . . e361

4.1.2.3.Beta-Adrenergic Blockers:
Recommendations . . . . . . . . . . e362

4.1.2.4.Calcium Channel Blockers:

4.1.2.5.Other Anti-Ischemic
Interventions . . . . . . . . . . . . . . . e363

4.1.2.6.Cholesterol Management . . . . . e363
4.2.Inhibitors of the Renin-Angiotensin-Aldosterone
System: Recommendations . . . . . . . . . . . . . . . . e363
4.3.Initial Antiplatelet/Anticoagulant Therapy in
Patients With Definite or Likely NSTE-ACS . . . e364

4.3.1.Initial Oral and Intravenous Antiplatelet
Therapy in Patients With Definite
or Likely NSTE-ACS Treated With
an Initial Invasive or Ischemia-Guided
Strategy: Recommendations . . . . . . . . . . e364

4.3.1.1.Aspirin . . . . . . . . . . . . . . . . . . . e365

4.3.1.2.P2Y12 Receptor Inhibitors . . . . . e365

4.3.2.Initial Parenteral Anticoagulant
Therapy in Patients With Definite
NSTE-ACS: Recommendations . . . . . . . e367

4.3.2.1.Low-Molecular-Weight
Heparin . . . . . . . . . . . . . . . . . . . e367

4.3.2.2.Bivalirudin . . . . . . . . . . . . . . . . e367

4.3.2.3.Fondaparinux . . . . . . . . . . . . . . e367

4.3.2.4. Unfractionated Heparin . . . . . . e367

4.3.2.5.Argatroban . . . . . . . . . . . . . . . . e368

4.3.3.Fibrinolytic Therapy in Patients With
Definite NSTE-ACS: Recommendation . e368
4.4.Ischemia-Guided Strategy Versus Early
Invasive Strategies . . . . . . . . . . . . . . . . . . . . . . . e368

4.4.1. General Principles . . . . . . . . . . . . . . . . . . e368

4.4.2.Rationale and Timing for Early
Invasive Strategy . . . . . . . . . . . . . . . . . . . e368

4.4.2.1.Routine Invasive Strategy
Timing . . . . . . . . . . . . . . . . . . . e368
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4.4.3.Rationale for Ischemia-Guided

Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . e368

4.4.4.Early Invasive and Ischemia-Guided
Strategies: Recommendations . . . . . . . . . e368

4.4.4.1.Comparison of Early Versus
Delayed Angiography . . . . . . . . e370

4.4.5.Subgroups: Early Invasive Strategy
Versus Ischemia-Guided Strategy . . . . . . e371

4.4.6. Care Objectives . . . . . . . . . . . . . . . . . . . . e371
4.5.Risk Stratification Before Discharge for
Patients With an Ischemia-Guided Strategy
of NSTE-ACS: Recommendations . . . . . . . . . . e371

4.5.1. Noninvasive Test Selection . . . . . . . . . . . e371

4.5.2. Selection for Coronary Angiography . . . e372
5. Myocardial Revascularization . . . . . . . . . . . . . . . . . . e372
5.1. Percutaneous Coronary Intervention . . . . . . . . . e372

5.1.1.PCIGeneral Considerations:
Recommendation . . . . . . . . . . . . . . . . . . e372

5.1.2.PCIAntiplatelet and Anticoagulant
Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . e372

5.1.2.1.Oral and Intravenous
Antiplatelet Agents:

5.1.2.2.GP IIb/IIIa Inhibitors:

5.1.2.3.Anticoagulant Therapy
in Patients Undergoing PCI:
Recommendations . . . . . . . . . . . e374
5.2.Timing of Urgent CABG in Patients
With NSTE-ACS in Relation to Use of
Antiplatelet Agents: Recommendations . . . . . . . e375
6.Late Hospital Care, Hospital Discharge,
and Posthospital Discharge Care . . . . . . . . . . . . . . . . e376
6.1.General Principles (Cardioprotective
Therapy and Symptom Management) . . . . . . . . e376
6.2.Medical Regimen and Use of Medications
at Discharge: Recommendations . . . . . . . . . . . . e376

6.2.1.Late Hospital and Posthospital
Oral Antiplatelet Therapy:
Recommendations . . . . . . . . . . . . . . . . . . e376

6.2.2.Combined Oral Anticoagulant
Therapy and Antiplatelet Therapy
in Patients With NSTE-ACS . . . . . . . . . . e378

6.2.3.Platelet Function and Genetic
Phenotype Testing . . . . . . . . . . . . . . . . . . e379
6.3.Risk Reduction Strategies for
Secondary Prevention . . . . . . . . . . . . . . . . . . . . e379

6.3.1.Cardiac Rehabilitation and Physical
Activity: Recommendation . . . . . . . . . . . e379

6.3.2.Patient Education:

6.3.3.Pneumococcal Pneumonia:
Recommendation . . . . . . . . . . . . . . . . . . e380

6.3.4. NSAIDs: Recommendations . . . . . . . . . . e380

6.3.5. Hormone Therapy: Recommendation . . . e380

6.3.6.Antioxidant Vitamins and Folic Acid:
6.4.Plan of Care for Patients With
NSTE-ACS: Recommendations . . . . . . . . . . . . . e381

6.4.1.Systems to Promote Care
Coordination . . . . . . . . . . . . . . . . . . . . . . e382
7. Special Patient Groups . . . . . . . . . . . . . . . . . . . . . . . . e382

7.1.NSTE-ACS in Older Patients:
7.2. HF: Recommendations . . . . . . . . . . . . . . . . . . . e383

7.2.1.Arrhythmias . . . . . . . . . . . . . . . . . . . . . . . e383

7.2.2. Cardiogenic Shock: Recommendation . . e386
7.3. Diabetes Mellitus: Recommendation . . . . . . . . . e386

7.3.1. Adjunctive Therapy . . . . . . . . . . . . . . . . . e387
7.4. PostCABG: Recommendation . . . . . . . . . . . . . e387
7.5.Perioperative NSTE-ACS Related to
Noncardiac Surgery: Recommendations . . . . . . e387
7.6. CKD: Recommendations . . . . . . . . . . . . . . . . . . e388

7.6.1. Antiplatelet Therapy . . . . . . . . . . . . . . . . e388
7.7. Women: Recommendations . . . . . . . . . . . . . . . . e389
7.8.Anemia, Bleeding, and Transfusion:
7.9.Thrombocytopenia . . . . . . . . . . . . . . . . . . . . . . . e390
7.10.Cocaine and Methamphetamine
Users: Recommendations . . . . . . . . . . . . . . . . . e390
7.11.Vasospastic (Prinzmetal) Angina:
7.12.ACS With Angiographically Normal
Coronary Arteries: Recommendation . . . . . . . . . e392
7.13.Stress (Takotsubo) Cardiomyopathy:
7.14.Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e393
7.15.Patients Taking Antineoplastic/
Immunosuppressive Therapy . . . . . . . . . . . . . . . e393
8.Quality of Care and Outcomes for ACSUse
of Performance Measures and Registries . . . . . . . . . . e393
8.1.Use of Performance Measures and
Registries: Recommendation . . . . . . . . . . . . . . . e393
9.Summary and Evidence Gaps . . . . . . . . . . . . . . . . . . e393
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e394
Appendix 1.Author Relationships With Industry
and Other Entities (Relevant) . . . . . . . . . . e414
Appendix 2.Reviewer Relationships With Industry
and Other Entities (Relevant) . . . . . . . . . . e417
Appendix 3. Abbreviations . . . . . . . . . . . . . . . . . . . . . . e422
Appendix 4. Additional Tables . . . . . . . . . . . . . . . . . . . . e423
Preamble
The American College of Cardiology (ACC) and the American
Heart Association (AHA) are committed to the prevention and
management of cardiovascular diseases through professional
education and research for clinicians, providers, and patients.
Since 1980, the ACC and AHA have shared a responsibility to
translate scientific evidence into clinical practice guidelines
(CPGs) with recommendations to standardize and improve
cardiovascular health. These CPGs, based on systematic
methods to evaluate and classify evidence, provide a cornerstone of quality cardiovascular care.
In response to published reports from the Institute of
Medicine1,2 and the ACC/AHAs mandate to evaluate new
knowledge and maintain relevance at the point of care, the
ACC/AHA Task Force on Practice Guidelines (Task Force)
began modifying its methodology. This modernization effort
is published in the 2012 Methodology Summit Report3 and
2014 perspective article.4 The latter recounts the history of
the collaboration, changes over time, current policies, and

planned initiatives to meet the needs of an evolving healthcare environment. Recommendations on value in proportion
to resource utilization will be incorporated as high-quality
comparative-effectiveness data become available.5 The relationships between CPGs and data standards, appropriate use
criteria, and performance measures are addressed elsewhere.4
Intended UseCPGs provide recommendations applicable
to patients with or at risk of developing cardiovascular disease.
The focus is on medical practice in the United States, but CPGs
developed in collaboration with other organizations may have
a broader target. Although CPGs may be used to inform regulatory or payer decisions, the intent is to improve the quality of
care and be aligned with the patients best interest.
Evidence ReviewGuideline writing committee (GWC)
members are charged with reviewing the literature; weighing
the strength and quality of evidence for or against particular
tests, treatments, or procedures; and estimating expected health
outcomes when data exist. In analyzing the data and developing CPGs, the GWC uses evidence-based methodologies developed by the Task Force.6 A key component of the ACC/AHA
CPG methodology is the development of recommendations on
the basis of all available evidence. Literature searches focus
on randomized controlled trials (RCTs) but also include registries, nonrandomized comparative and descriptive studies, case
series, cohort studies, systematic reviews, and expert opinion.
Only selected references are cited in the CPG. To ensure that
CPGs remain current, new data are reviewed biannually by the
GWCs and the Task Force to determine if recommendations
should be updated or modified. In general, a target cycle of 5
years is planned for full revisions.1
Guideline-Directed Medical TherapyRecognizing
advances in medical therapy across the spectrum of cardiovascular diseases, the Task Force designated the term guidelinedirected medical therapy (GDMT) to represent recommended
medical therapy as defined mainly by Class I measures, generally a combination of lifestyle modification and drug- and
device-based therapeutics. As medical science advances,
GDMT evolves, and hence GDMT is preferred to optimal
medical therapy. For GDMT and all other recommended drug
treatment regimens, the reader should confirm the dosage with
product insert material and carefully evaluate for contraindications and possible drug interactions. Recommendations are
limited to treatments, drugs, and devices approved for clinical
use in the United States.
Class of Recommendation and Level of EvidenceOnce
recommendations are written, the Class of Recommendation
(COR; ie, the strength the GWC assigns to the recommendation, which encompasses the anticipated magnitude and
judged certainty of benefit in proportion to risk) is assigned
by the GWC. Concurrently, the Level of Evidence (LOE)
rates the scientific evidence supporting the effect of the
intervention on the basis on the type, quality, quantity, and
consistency of data from clinical trials and other reports
(Table1).4 Unless otherwise stated, recommendations are
presented in order by the COR and then the LOE. Where
comparative data exist, preferred strategies take precedence.
When more than 1 drug, strategy, or therapy exists within
the same COR and LOE and there are no comparative data,
options are listed alphabetically.
Relationships With Industry and Other EntitiesThe

ACC and AHA exclusively sponsor the work of GWCs without commercial support, and members volunteer their time for
this activity. The Task Force makes every effort to avoid actual,
potential, or perceived conflicts of interest that might arise
through relationships with industry or other entities (RWI).
All GWC members and reviewers are required to fully disclose current industry relationships or personal interests from
12 months before initiation of the writing effort. Management
of RWI involves selecting a balanced GWC and requires that
both the chair and a majority of GWC members have no relevant RWI (see Appendix 1 for the definition of relevance).
GWC members are restricted with regard to writing or voting
on sections to which their RWI apply. In addition, for transparency, GWC members comprehensive disclosure information is available as an online supplement. Comprehensive
disclosure information for the Task Force is available as an
additional supplement. The Task Force strives to avoid bias
by selecting experts from a broad array of backgrounds representing different geographic regions, sexes, ethnicities, races,
intellectual perspectives/biases, and scopes of clinical practice. Selected organizations and professional societies with
related interests and expertise are invited to participate as
partners or collaborators.
Individualizing Care in Patients With Associated
Conditions and ComorbiditiesThe ACC and AHA recognize the complexity of managing patients with multiple conditions, compared with managing patients with a single disease,
and the challenge is compounded when CPGs for evaluation
or treatment of several coexisting illnesses are discordant or
interacting.7 CPGs attempt to define practices that meet the
needs of patients in most, but not all, circumstances and do not
replace clinical judgment.
Clinical ImplementationManagement in accordance with
CPG recommendations is effective only when followed; therefore, to enhance their commitment to treatment and compliance
with lifestyle adjustment, clinicians should engage the patient
to participate in selecting interventions on the basis of the
patients individual values and preferences, taking associated
conditions and comorbidities into consideration (eg, shared
decision making). Consequently, there are circumstances in
which deviations from these guidelines are appropriate.
The recommendations in this CPG are the official policy of
the ACC and AHA until they are superseded by a published
addendum, focused update, or revised full-text CPG.
Jeffrey L. Anderson, MD, FACC, FAHA
Chair, ACC/AHA Task Force on Practice Guidelines
1. Introduction
1.1. Methodology and Evidence Review
The recommendations listed in this CPG are, whenever possible, evidence based. An extensive evidence review was
conducted through October 2012, and other selected references published through April 2014 were reviewed by the
GWC. Literature included was derived from research involving human subjects, published in English, and indexed in
MEDLINE (through PubMed), EMBASE, the Cochrane
Library, Agency for Healthcare Research and Quality Reports,

Table 1. Applying Classification of Recommendations and Level of Evidence
A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the clinical practice
guidelines do not lend themselves to clinical trials. Although randomized trials are unavailable, there may be a very clear clinical consensus that a particular test or
therapy is useful or effective.
*Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as sex, age, history of diabetes mellitus, history of prior
myocardial infarction, history of heart failure, and prior aspirin use.
For comparative-effectiveness recommendations (Class I and IIa; Level of Evidence A and B only), studies that support the use of comparator verbs should involve
direct comparisons of the treatments or strategies being evaluated.
and other selected databases relevant to this CPG. The relevant data are included in evidence tables in the Online Data
Supplement. Key search words included but were not limited
to the following: acute coronary syndrome, anticoagulant
therapy, antihypertensives, anti-ischemic therapy, antiplatelet
therapy, antithrombotic therapy, beta blockers, biomarkers,
calcium channel blockers, cardiac rehabilitation, conservative management, diabetes mellitus, glycoprotein IIb/IIIa
inhibitors, heart failure, invasive strategy, lifestyle modification, myocardial infarction, nitrates, non-ST-elevation, P2Y12
receptor inhibitor, percutaneous coronary intervention, reninangiotensin-aldosterone inhibitors, secondary prevention,
smoking cessation, statins, stent, thienopyridines, troponins,
unstable angina, and weight management. Additionally, the

GWC reviewed documents related to non-ST-elevation acute
coronary syndrome (NSTE-ACS) previously published by
the ACC and AHA. References selected and published in this
document are representative and not all-inclusive.
1.2. Organization of the GWC

The GWC was composed of clinicians, cardiologists, internists, interventionists, surgeons, emergency medicine specialists, family practitioners, and geriatricians. The GWC included
representatives from the ACC and AHA, American Academy
of Family Physicians, American College of Emergency
Physicians, American College of Physicians, Society for

Cardiovascular Angiography and Interventions (SCAI), and
Society of Thoracic Surgeons (STS).
1.3. Document Review and Approval

This document was reviewed by 2 official reviewers each
nominated by the ACC and AHA; 1 reviewer each from the
American Academy of Family Physicians, American College
of Emergency Physicians, SCAI, and STS; and 37 individual content reviewers (including members of the American
Association of Clinical Chemistry, ACC Heart Failure and
Transplant Section Leadership Council, ACC Cardiovascular
Imaging Section Leadership Council, ACC Interventional
Section Leadership Council, ACC Prevention of Cardiovascular
Disease Committee, ACC Surgeons Council, Association of
International Governors, and Department of Health and Human
Services). Reviewers RWI information was distributed to the
GWC and is published in this document (Appendix 2).
This document was approved for publication by the governing bodies of the ACC and the AHA and endorsed by the
American Association for Clinical Chemistry, SCAI, and
the STS.
1.4. Scope of the CPG

The 2014 NSTE-ACS CPG is a full revision of the 2007
ACCF/AHA CPG for the management of patients with unstable angina (UA) and non-ST-elevation myocardial infarction (NSTEMI) and the 2012 focused update.8 The new title,
Non-ST-Elevation Acute Coronary Syndromes, emphasizes
the continuum between UA and NSTEMI. At presentation,
patients with UA and NSTEMI can be indistinguishable and
are therefore considered together in this CPG.
In the United States, NSTE-ACS affects >625000 patients
annually,* or almost three fourths of all patients with acute
coronary syndrome (ACS).9 In selecting the initial approach to
care, the term ischemia-guided strategy has replaced the previous descriptor, initial conservative management, to more
clearly convey the physiological rationale of this approach.
The task of the 2014 GWC was to establish a contemporary CPG for the optimal management of patients with NSTEACS. It incorporates both established and new evidence from
published clinical trials, as well as information from basic
science and comprehensive review articles. These recommendations were developed to guide the clinician in improving
outcomes for patients with NSTE-ACS. Table2 lists documents deemed pertinent to this effort and is intended for use
as a resource, thus obviating the need to repeat extant CPG
recommendations.
The GWC abbreviated the discussion sections to include an
explanation of salient information related to the recommendations. In contrast to textbook declaratory presentations, explanations were supplemented with evidence tables. The GWC
also provided a brief summary of the relevant recommendations and references related to secondary prevention rather
than detailed reiteration. Throughout, the goal was to provide
the clinician with concise, evidence-based contemporary recommendations and the supporting documentation to encourage their application.
*Estimate includes secondary discharge diagnoses.
2. Overview Of ACS
2.1. Definition of Terms
ACS has evolved as a useful operational term that refers
to a spectrum of conditions compatible with acute myocardial ischemia and/or infarction that are usually due to an
abrupt reduction in coronary blood flow (Figure1). A key
branch point is ST-segment elevation (ST-elevation) or new
left bundle-branch block on the electrocardiogram (ECG),
which is an indication for immediate coronary angiography
to determine if there is an indication for reperfusion therapy to open a likely completely occluded coronary artery.
Separate CPGs have been developed for ST-elevation myocardial infarction (STEMI).17
The absence of persistent ST-elevation is suggestive of NSTEACS (except in patients with true posterior myocardial infarction [MI], Sections 3.3.2.4, 4.3.2, and 7.2.2). NSTE-ACS can be
further subdivided on the basis of cardiac biomarkers of necrosis (eg, cardiac troponin, Sections 3.2.4 and 3.4). If cardiac biomarkers are elevated and the clinical context is appropriate, the
patient is considered to have NSTEMI34; otherwise, the patient
is deemed to have UA. ST depression, transient ST-elevation,
and/or prominent T-wave inversions may be present but are
not required for a diagnosis of NSTEMI. Abnormalities on the
ECG and elevated troponins in isolation are insufficient to make
the diagnosis of ACS but must be interpreted in the appropriate clinical context. Thus, UA and NSTEMI are closely related
conditions whose pathogenesis and clinical presentations are
similar but vary in severity. The conditions differ primarily by
whether the ischemia is severe enough to cause myocardial
damage leading to detectable quantities of myocardial injury
biomarkers. The term possible ACS is often assigned during
initial evaluation if the ECG is unrevealing and troponin data
are not yet available. UA can present without any objective data
of myocardial ischemic injury (normal ECG and normal troponin), in which case the initial diagnosis depends solely on the
patients clinical history and the clinicians interpretation and
judgment. However, with the increasing sensitivity of troponin
assays, biomarker-negative ACS (ie, UA) is becoming rarer.39
The pathogenesis of ACS is considered in the Third Universal
Definition of Myocardial Infarction.21 This statement defines
MI caused by a primary coronary artery process such as spontaneous plaque rupture as MI type 1 and one related to reduced
myocardial oxygen supply and/or increased myocardial oxygen
demand (in the absence of a direct coronary artery process) as
a MI type 2 (Appendix 4, Table A and Section 3.4 for an additional discussion on the diagnosis of MI).
2.2. Epidemiology and Pathogenesis

2.2.1. Epidemiology
In the United States, the median age at ACS presentation is 68
years (interquartile range 56 to 79), and the male-to-female
ratio is approximately 3:2.40 Some patients have a history of
stable angina, whereas in others, ACS is the initial presentation of coronary artery disease (CAD). It is estimated that in
the United States, each year, >780000 persons will experience
an ACS. Approximately 70% of these will have NSTE-ACS.9
Patients with NSTE-ACS typically have more comorbidities,
both cardiac and noncardiac, than patients with STEMI.

Table 2. Associated CPGs and Statements
Title
CPGs
Stable ischemic heart disease
Atrial fibrillation
Organization
Publication Year/
Reference
ACC/AHA/AATS/PCNA/SCAI/STS
201410* 201211
AHA/ACC/HRS
201412
Assessment of cardiovascular risk
ACC/AHA
201313
Heart failure
ACC/AHA
201314
Lifestyle management to reduce cardiovascular risk
AHA/ACC
201315
AHA/ACC/TOS
201316
ST-elevation myocardial infarction
ACC/AHA
201317
Treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults
ACC/AHA
201318
ESC
201219
ACC/AHA/HRS
201320
ESC/ACC/AHA/WHF
201221
ESC
201122
Coronary artery bypass graft surgery
ACC/AHA
201123
Hypertrophic cardiomyopathy
ACC/AHA
201124
Effectiveness-based guidelines for the prevention of cardiovascular disease in women
AHA/ACC
201125
ACC/AHA/SCAI
201126
Secondary prevention and risk reduction therapy for patients with coronary and other
atherosclerotic vascular disease
AHA/ACC
201127
Assessment of cardiovascular risk in asymptomatic adults
ACC/AHA
201028
Myocardial revascularization
ESC
201029
Unstable angina and nonST-elevation myocardial infarction
NICE
201030
Guidelines for cardiopulmonary resuscitation and emergency cardiovascular carepart 9:

postcardiac arrest care
AHA
201031
NHLBI
200332
ACC/AHA
201333
Practical clinical considerations in the interpretation of troponin elevations
ACC
201234
Testing of low-risk patients presenting to the emergency department with chest pain
AHA
201035
AHA/ADA
200736
CDC
200537
Management of overweight and obesity in adults
Acute myocardial infarction in patients presenting with ST-segment elevation

Device-based therapy
Third universal definition of myocardial infarction
Acute coronary syndromes in patients presenting without persistent ST-segment elevation
Percutaneous coronary intervention
Seventh report of the joint national committee on prevention, detection, evaluation, and treatment
of high blood pressure
Statements
Key data elements and definitions for measuring the clinical management and outcomes of patients
with acute coronary syndromes and coronary artery disease
Primary prevention of cardiovascular diseases in people with diabetes mellitus

Prevention and control of influenza
*The full-text SIHD CPG is from 2012.11 A focused update was published in 2014.10
Minor modifications were made in 2013. For a full explanation of the changes, see http://publications.nice.org.uk/unstable-angina-and-nstemi-cg94/
changes-after-publication.
AATS indicates American Association for Thoracic Surgery; ACC, American College of Cardiology; ADA, American Diabetes Association; AHA, American Heart Association;
CDC, Centers for Disease Control and Prevention; CPG, clinical practice guideline; ESC, European Society of Cardiology; HRS, Heart Rhythm Society; NHLBI, National Heart,
Lung, and Blood Institute; NICE, National Institute for Health and Clinical Excellence; PCNA, Preventive Cardiovascular Nurses Association; SCAI, Society for Cardiovascular
Angiography and Interventions; SIHD, stable ischemic heart disease; STS, Society of Thoracic Surgeons; TOS, The Obesity Society; and WHF, World Heart Federation.
2.2.2. Pathogenesis
The hallmark of ACS is the sudden imbalance between myocardial oxygen consumption (MVO2) and demand, which is
usually the result of coronary artery obstruction. The imbalance
may also be caused by other conditions, including excessive
myocardial oxygen demand in the setting of a stable flow-limiting lesion; acute coronary insufficiency due to other causes
(eg, vasospastic [Prinzmetal] angina [Section 7.11], coronary
embolism, coronary arteritis); noncoronary causes of myocardial oxygen supply-demand mismatch (eg, hypotension,
severe anemia, hypertension, tachycardia, hypertrophic cardiomyopathy, severe aortic stenosis); nonischemic myocardial
injury (eg, myocarditis, cardiac contusion, cardiotoxic drugs);

and multifactorial causes that are not mutually exclusive (eg,
stress [Takotsubo] cardiomyopathy [Section 7.13], pulmonary
embolism, severe heart failure [HF], sepsis).41
3. Initial Evaluation and Management

3.1. Clinical Assessment and Initial Evaluation:
Recommendation
Class I
1. Patients with suspected ACS should be risk stratified based on the likelihood of ACS and adverse
Figure 1. Acute Coronary Syndromes. The top half of the figure illustrates the progression of plaque formation and onset and
complications of NSTE-ACS, with management at each stage. The numbered section of an artery depicts the process of atherogenesis
from 1) normal artery to 2) extracellular lipid in the subintima to 3) fibrofatty stage to 4) procoagulant expression and weakening of the
fibrous cap. ACS develops with 5) disruption of the fibrous cap, which is the stimulus for thrombogenesis. 6) Thrombus resorption may be
followed by collagen accumulation and smooth muscle cell growth. Thrombus formation and possible coronary vasospasm reduce blood
flow in the affected coronary artery and cause ischemic chest pain. The bottom half of the figure illustrates the clinical, pathological,
electrocardiographic, and biomarker correlates in ACS and the general approach to management. Flow reduction may be related to
a completely occlusive thrombus (bottom half, right side) or subtotally occlusive thrombus (bottom half, left side). Most patients with
ST-elevation (thick white arrow in bottom panel) develop QwMI, and a few (thin white arrow) develop NQMI. Those without ST-elevation
have either UA or NSTEMI (thick red arrows), a distinction based on cardiac biomarkers. Most patients presenting with NSTEMI develop
NQMI; a few may develop QwMI. The spectrum of clinical presentations including UA, NSTEMI, and STEMI is referred to as ACS. This
NSTE-ACS CPG includes sections on initial management before NSTE-ACS, at the onset of NSTE-ACS, and during the hospital phase.
Secondary prevention and plans for long-term management begin early during the hospital phase. Patients with noncardiac etiologies
make up the largest group presenting to the ED with chest pain (dashed arrow). *Elevated cardiac biomarker (eg, troponin), Section
3.4. ACS indicates acute coronary syndrome; CPG, clinical practice guideline; Dx, diagnosis; ECG, electrocardiogram; ED, emergency
department; Ml, myocardial infarction; NQMI, non-Q-wave myocardial infarction; NSTE-ACS, non-ST-elevation acute coronary
syndromes; NSTEMI, non-ST-elevation myocardial infarction; QwMI, Q-wave myocardial infarction; STEMI, ST-elevation myocardial
infarction; and UA, unstable angina. Modified with permission from Libby et al.38

outcome(s) to decide on the need for hospitalization
and assist in the selection of treatment options.4244
(Level of Evidence: B)
Patients with suspected ACS must be evaluated rapidly to
identify those with a life-threatening emergency versus those
with a more benign condition. The goal of the initial evaluation focuses on answering 2 questions:
1. What is the likelihood that the symptoms and signs represent ACS?
2. What is the likelihood of adverse clinical outcome(s)?
Risk assessment scores and clinical prediction algorithms
using clinical history, physical examination, ECG, and cardiac troponins have been developed to help identify patients
with ACS at increased risk of adverse outcome(s). Common
risk assessment tools include the TIMI (Thrombolysis In
Myocardial Infarction) risk score,42 the PURSUIT (Platelet
Glycoprotein IIb/IIIa in Unstable Angina: Receptor
Suppression Using Integrilin Therapy) risk score,43 the
GRACE (Global Registry of Acute Coronary Events) risk
score,44 and the NCDR-ACTION (National Cardiovascular
Data Registry-Acute Coronary Treatment and Intervention
Outcomes Network) registry (https://www.ncdr.com/webncdr/
action/). These assessment tools have been applied with variable efficacy to predict outcomes in patients presenting to the
emergency department (ED) with undifferentiated chest pain
(pain encompasses not only pain, but also symptoms such as
discomfort, pressure, and squeezing).4548 The Sanchis score,49
Vancouver rule,50 Heart (History, ECG, Age, Risk Factors,
and Troponin) score,51 HEARTS3 score,52 and Hess prediction
rule53 were developed specifically for patients in the ED with
chest pain. Although no definitive study has demonstrated the
superiority of risk assessment scores or clinical prediction
rules over clinician judgment, determination of the level of
risk on initial evaluation is imperative to guide patient management, including the need for additional diagnostic testing
and treatment. See Section 3.2.2 for a discussion of risk stratification variables.
See Online Data Supplement 1 for additional information
on clinical assessment and initial evaluation.
3.1.1. ED or Outpatient Facility Presentation:
Recommendations
Class I
1. Patients with suspected ACS and high-risk features
such as continuing chest pain, severe dyspnea, syncope/presyncope, or palpitations should be referred
immediately to the ED and transported by emergency medical services when available. (Level of
Evidence: C)
Class IIb
1. Patients with less severe symptoms may be considered
for referral to the ED, a chest pain unit, or a facility
capable of performing adequate evaluation depending on clinical circumstances. (Level of Evidence: C)
Patients with suspected ACS and high-risk features should be

transported to the ED by emergency medical services when
available. Hospitals and outpatient facilities should provide
clearly visible signage directing patients transported by private vehicle to the appropriate triage area. Outpatient facilities should have the capacity for ECG and cardiac troponin
measurements with immediate ED referral for those considered to have ACS.
3.2. Diagnosis of NSTE-ACS

Differential diagnosis of NSTE-ACS includes41:
Nonischemic
cardiovascular causes of chest pain (eg,

aortic dissection, expanding aortic aneurysm, pericarditis, pulmonary embolism)
Noncardiovascular causes of chest, back, or upper
abdominal discomfort include:
Pulmonary causes (eg, pneumonia, pleuritis,
pneumothorax)
Gastrointestinal causes (eg, gastroesophageal reflux,
esophageal spasm, peptic ulcer, pancreatitis, biliary
disease)
Musculoskeletal causes (eg, costochondritis, cervical
radiculopathy)
Psychiatric disorders
Other etiologies (eg, sickle cell crisis, herpes zoster)
In addition, the clinician should differentiate NSTE-ACS
from acute coronary insufficiency due to a nonatherosclerotic
cause and noncoronary causes of myocardial oxygen supplydemand mismatch41 (Section 2.2.2).
3.2.1. History
NSTE-ACS most commonly presents as a pressure-type chest
pain that typically occurs at rest or with minimal exertion
lasting 10 minutes.41 The pain most frequently starts in the
retrosternal area and can radiate to either or both arms, the
neck, or the jaw. Pain may also occur in these areas independent of chest pain. Patients with NSTE-ACS may also present
with diaphoresis, dyspnea, nausea, abdominal pain, or syncope. Unexplained new-onset or increased exertional dyspnea
is the most common angina equivalent. Less common presentations include nausea and vomiting, diaphoresis, unexplained
fatigue, and syncope. Factors that increase the probability of
NSTE-ACS are older age, male sex, positive family history of
CAD, and the presence of peripheral arterial disease, diabetes mellitus, renal insufficiency, prior MI, and prior coronary
revascularization. Although older patients (75 years of age)
and women usually present with typical symptoms of ACS,
the frequency of atypical presentations is increased in these
groups as well as in patients with diabetes mellitus, impaired
renal function, and dementia.54,55 Atypical symptoms, including epigastric pain, indigestion, stabbing or pleuritic pain, and
increasing dyspnea in the absence of chest pain should raise
concern for NSTE-ACS.56 Psychiatric disorders (eg, somatoform disorders, panic attack, anxiety disorders) are noncardiac
causes of chest pain that can mimic ACS.57
3.2.2. Physical Examination
The physical examination in NSTE-ACS can be normal, but
signs of HF should expedite the diagnosis and treatment of

this condition. Acute myocardial ischemia may cause a S4, a
paradoxical splitting of S2, or a new murmur of mitral regurgitation due to papillary muscle dysfunction. However, these
signs may also exist without NSTE-ACS and thus are nonspecific. The coupling of pain on palpation suggesting musculoskeletal disease or inflammation with a pulsatile abdominal
mass suggesting abdominal aortic aneurysm raises concern
for nonischemic causes of NSTE-ACS. The physical examination can indicate alternative diagnoses in patients with chest
pain, several of which are life threatening. Aortic dissection
is suggested by back pain, unequal palpated pulse volume, a
difference of 15 mmHg between both arms in systolic blood
pressure (BP), or a murmur of aortic regurgitation. Acute pericarditis is suggested by a pericardial friction rub. Cardiac tamponade can be reflected by pulsus paradoxus. Pneumothorax
is suspected when acute dyspnea, pleuritic chest pain, and differential breath sounds are present. A pleural friction rub may
indicate pneumonitis or pleuritis.
3.2.3. Electrocardiogram
A 12-lead ECG should be performed and interpreted within
10 minutes of the patients arrival at an emergency facility
to assess for cardiac ischemia or injury.21 Changes on ECG
in patients with NSTE-ACS include ST depression, transient ST-elevation, or new T-wave inversion.21,58 Persistent
ST-elevation or anterior ST depression indicative of true posterior MI should be treated according to the STEMI CPG.17
The ECG can be relatively normal or initially nondiagnostic;
if this is the case, the ECG should be repeated (eg, at 15- to
30-minute intervals during the first hour), especially if symptoms recur.21 A normal ECG does not exclude ACS and occurs
in 1% to 6% of such patients.5961 A normal ECG may also be
associated with left circumflex or right coronary artery occlusions, which can be electrically silent (in which case posterior
electrocardiographic leads [V7 to V9] may be helpful). Rightsided leads (V3R to V4R) are typically performed in the case of
inferior STEMI to detect evidence of right ventricular infarction. Left ventricular (LV) hypertrophy, bundle-branch blocks
with repolarization abnormalities, and ventricular pacing may
mask signs of ischemia/injury.62
3.2.4. Biomarkers of Myocardial Necrosis
Cardiac troponins are the most sensitive and specific biomarkers for NSTE-ACS. They rise within a few hours of symptom
onset and typically remain elevated for several days (but may
remain elevated for up to 2 weeks with a large infarction).
A negative cardiac troponin obtained with more sensitive
cardiac troponin assays on admission confers a >95% negative predictive value for MI compared with high-sensitivity
assays that confer a negative predictive value 99%.6365 See
Section 3.4 for a detailed review of biomarkers for the diagnosis of MI.
3.2.5. Imaging
A chest roentgenogram is useful to identify potential pulmonary causes of chest pain and may show a widened mediastinum in patients with aortic dissection. Computed tomography
(CT) of the chest with intravenous contrast can help exclude
pulmonary embolism and aortic dissection. Transthoracic
echocardiography can identify a pericardial effusion and
tamponade physiology and may also be useful to detect

regional wall motion abnormalities. Transesophageal echocardiography can identify a proximal aortic dissection. In low-risk
patients with chest pain, coronary CT angiography can result in
a more rapid, more cost-effective diagnosis than stress myocardial perfusion imaging.66
3.3. PrognosisEarly Risk Stratification:

Recommendations
See Table 4 for a summary of recommendations from this
section.
Class I
1. In patients with chest pain or other symptoms suggestive of ACS, a 12-lead ECG should be performed
and evaluated for ischemic changes within 10 minutes of the patients arrival at an emergency facility.21
(Level of Evidence: C)
2. If the initial ECG is not diagnostic but the patient
remains symptomatic and there is a high clinical suspicion for ACS, serial ECGs (eg, 15- to 30-minute intervals during the first hour) should be performed to
detect ischemic changes. (Level of Evidence: C)
3. Serial cardiac troponin I or T levels (when a contemporary assay is used) should be obtained at presentation and 3 to 6 hours after symptom onset (see
Section 3.4, Class I, #3 recommendation if time of
symptom onset is unclear) in all patients who present with symptoms consistent with ACS to identify a
rising and/or falling pattern of values.21,64,6771 (Level
of Evidence: A)
4. Additional troponin levels should be obtained beyond
6 hours after symptom onset (see Section 3.4, Class I,
#3 recommendation if time of symptom onset is unclear) in patients with normal troponin levels on serial examination when changes on ECG and/or clinical
presentation confer an intermediate or high index of
suspicion for ACS.21,7274 (Level of Evidence: A)
5. Risk scores should be used to assess prognosis in patients with NSTE-ACS.4244,7580 (Level of Evidence: A)
Class IIa
1. Risk-stratification models can be useful in management.4244,7581 (Level of Evidence: B)
2. It is reasonable to obtain supplemental electrocardiographic leads V7 to V9 in patients whose initial ECG
is nondiagnostic and who are at intermediate/high
risk of ACS.8284 (Level of Evidence: B)
Class IIb
1. Continuous monitoring with 12-lead ECG may be a
reasonable alternative in patients whose initial ECG
is nondiagnostic and who are at intermediate/high
risk of ACS.85,86 (Level of Evidence: B)
2. Measurement of B-type natriuretic peptide or N-terminal proB-type natriuretic peptide may be considered to assess risk in patients with suspected ACS.8791

3.3.1. Rationale for Risk Stratification and Spectrum of
Risk: High, Intermediate, and Low
Assessment of prognosis guides initial clinical evaluation and
treatment and is useful for selecting the site of care (coronary care
unit, monitored step-down unit, or outpatient monitored unit),
antithrombotic therapies (eg, P2Y12 inhibitors, platelet glycoprotein [GP] IIb/IIIa inhibitors [Sections 4.3.1.2 and 5.1.2.2]), and
invasive management (Sections 4.4.2.1, 4.3.1, 4.4, 4.4.4, 4.4.5).
There is a strong relationship between indicators of ischemia
due to CAD and prognosis (Table 3 and Figure2). Patients with
a high likelihood of ischemia due to CAD are at greater risk of a
major adverse cardiac event (MACE) than patients with a lower
likelihood of ischemia due to CAD. Risk is highest at the time
of presentation but remains elevated past the acute phase. By 6
months, NSTE-ACS mortality rates may equal or exceed those
of STEMI.58 By 12months, rates of death, MI, and recurrent
instability in contemporary registries are >10%. Early events are
related to the ruptured coronary plaque and thrombosis, and later
events are more closely associated with the pathophysiology of
chronic atherosclerosis and LV systolic function.9298
3.3.2. Estimation of Level of Risk
At initial presentation, the clinical history, anginal symptoms
and equivalents, physical examination, ECG, renal function,
and cardiac troponin measurements can be integrated into an
estimation of the risk of death and nonfatal cardiac ischemic
events (Table 3 and Figure2).42,78
3.3.2.1. History: Angina Symptoms and Angina Equivalents
In patients with or without known CAD, clinicians must determine whether the presentation is consistent with acute ischemia, stable ischemic heart disease, or an alternative etiology.
Factors in the initial clinical history related to the likelihood
of acute ischemia include age, sex, symptoms, prior history of
CAD, and the number of traditional risk factors.99105
The characteristics of angina include deep, poorly localized
chest or arm pain that is reproducibly associated with exertion
or emotional stress.106 Angina is relieved promptly (ie, in <5
minutes) with rest and/or short-acting nitroglycerin. Patients
with NSTE-ACS may have typical or atypical anginal symptoms, but episodes are more severe and prolonged, may occur
at rest, or may be precipitated by less exertion than the patient
previously experienced. Some patients have no chest pain but
present solely with dyspnea or with arm, shoulder, back, jaw,
neck, epigastric, or ear discomfort.107109
Features not characteristic of myocardial ischemia include:
Pleuritic pain (sharp or knifelike pain provoked by respiration or cough);
Primary or sole location of discomfort in the middle or

lower abdomen;
Pain localized by the tip of 1 finger, particularly at the
LV apex or costochondral junction;

reproduced with movement or palpation of the
chest wall or arms;
Brief episodes of pain lasting a few seconds or less;
Pain that is of maximal intensity at onset; and
Pain that radiates into the lower extremities.
Pain
Evaluation should include the clinicians impression of

whether the pain represents a high, intermediate, or low likelihood of acute ischemia.
Table 3. TIMI Risk Score* for NSTE-ACS

TIMI Risk
Score
All-Cause Mortality, New or Recurrent MI, or Severe

Recurrent Ischemia Requiring Urgent Revascularization
Through 14 d After Randomization, %
01
4.7
8.3
13.2
19.9
26.2
67
40.9
*The TIMI risk score is determined by the sum of the presence of 7 variables at
admission; 1 point is given for each of the following variables: 65 y of age; 3 risk
factors for CAD; prior coronary stenosis 50%; ST deviation on ECG; 2 anginal
events in prior 24 h; use of aspirin in prior 7 d; and elevated cardiac biomarkers.
CAD indicates coronary artery disease; ECG, electrocardiogram; Ml, myocardial
infarction; NSTE-ACS, non-ST-elevation acute coronary syndromes; and TIMI,
Thrombolysis In Myocardial Infarction.
Modified with permission from Antman et al.42
Although typical characteristics increase the probability of

CAD, atypical features do not exclude ACS. In the Multicenter
Chest Pain Study, acute ischemia was diagnosed in 22% of
patients who presented to the ED with sharp or stabbing pain and
in 13% of those with pleuritic pain.110 Seven percent of patients
whose pain was reproduced with palpation had ACS. The ACITIPI (Acute Cardiac Ischemia Time-Insensitive Predictive
Instrument) project found that older age, male sex, chest or left
arm pain, and chest pain or pressure were the most important
findings, and each increased the likelihood of ACS.111,112
The relief of chest pain with nitroglycerin is not predictive of ACS. One study reported that sublingual nitroglycerin
relieved symptoms in 35% of patients with documented ACS
compared with 41% of patients without ACS.113 The relief of
chest pain by gastrointestinal cocktails (eg, mixtures of liquid antacids, and/or viscous lidocaine, and/or anticholinergic
agents) does not predict the absence of ACS.114
3.3.2.2. Demographics and History in Diagnosis and Risk
Stratification
A prior history of MI is associated with a high risk of obstructive and multivessel CAD.115 Women with suspected ACS are
less likely to have obstructive CAD than men. When obstructive
CAD is present in women, it tends to be less severe than it is in
men.116 It has been suggested that coronary microvascular disease and endothelial dysfunction play a role in the pathophysiology of NSTE-ACS in patients with nonobstructive CAD.116
Older adults have increased risks of underlying CAD,117,118 multivessel CAD, and a worse prognosis (Section 7.1).
A family history of premature CAD is associated with
increased coronary artery calcium scores119 and increased risk
of 30-day cardiac events in patients with ACS.120,121 Diabetes
mellitus, extracardiac (carotid, aortic, or peripheral) arterial
disease, and hypertension are major risk factors for poor outcomes in patients with ACS (Section 6.2) with both STEMI122
and NSTE-ACS.92
The current or prior use of aspirin at presentation is associated
with increased cardiovascular risk,42 likely reflecting the greater
probability that patients who have been prescribed aspirin have
an increased cardiovascular risk profile and/or prior vascular

Table 4. Summary of Recommendations for Prognosis: Early Risk Stratification
Recommendations
COR
LOE
References
Perform rapid determination of likelihood of ACS, including a 12-lead ECG within 10 min of arrival
at an emergency facility, in patients whose symptoms suggest ACS
21
Perform serial ECGs at 15- to 30-min intervals during the first hour in symptomatic patients with initial
nondiagnostic ECG
Measure cardiac troponin (cTnI or cTnT) in all patients with symptoms consistent with ACS*
N/A
21, 64, 6771
21, 7274
Measure serial cardiac troponin I or T at presentation and 36 h after symptom onset* in all patients
with symptoms consistent with ACS
Use risk scores to assess prognosis in patients with NSTE-ACS
4244, 7580
Risk-stratification models can be useful in management
IIa
4244, 7581
Obtain supplemental electrocardiographic leads V7 to V9 in patients with initial nondiagnostic

ECG at intermediate/high risk for ACS
IIa
8284
Continuous monitoring with 12-lead ECG may be a reasonable alternative with initial nondiagnostic
ECG in patients at intermediate/high risk for ACS
IIb
85, 86
BNP or NTpro-BNP may be considered to assess risk in patients with suspected ACS
IIb
8791
*See Section 3.4, Class I, #3 recommendation if time of symptom onset is unclear.

ACS indicates acute coronary syndromes; BNP, B-type natriuretic peptide; COR, Class of Recommendation; cTnI, cardiac troponin I; cTnT, cardiac troponin T;
ECG, electrocardiogram; LOE, Level of Evidence; N/A, not available; NSTE-ACS, nonST-elevation acute coronary syndromes; and NTpro-BNP, N-terminal proB-type natriuretic peptide.
disease. Smoking is associated with a lower risk of death in

ACS,42,123,124 primarily because of the younger age of smokers
with ACS and less severe CAD. Overweight and/or obesity at
ACS presentation are associated with lower short-term risk of
death. The obesity paradox may be a function of younger age
at presentation, referral for angiography at an earlier stage of disease, and more aggressive management of ACS.123 These individuals, especially those with severe obesity (body mass index
>35), have a higher long-term total mortality risk.124129
Cocaine use can cause ACS by inducing coronary vasospasm, dissection, thrombosis, positive chronotropic and
hypertensive actions, and direct myocardial toxicity (Section
7.10).130 Methamphetamines are also associated with ACS.131
Urine toxicology screening should be considered when substance abuse is suspected as a cause of or contributor to ACS,
especially in younger patients (<50 years of age).132
3.3.2.3. Early Estimation of Risk
The TIMI risk score is composed of 7, 1-point risk indicators
rated on presentation (Table 3).42 The composite endpoints
increase as the score increases. The TIMI risk score has been
validated internally within the TIMI 11B trial and in 2 separate
cohorts of patients from the ESSENCE (Efficacy and Safety
of Subcutaneous Enoxaparin in NonQ-Wave Coronary
Event) trial.133 The TIMI risk score calculator is available at
www.timi.org. The TIMI risk index is useful in predicting
30-day and 1-year mortality in patients with NSTE-ACS.134
For patients with a TIMI risk score of 0 and normal high-sensitivity cardiac troponin 2 hours after presentation, accelerated
diagnostic protocols have been developed that predict a very
low rate of 30-day MACE (Section 3.4.3).65
The GRACE risk model predicts in-hospital and postdischarge mortality or MI.44,78,79,81 The GRACE tool was
developed from 11389 patients in GRACE and validated
in subsequent GRACE and GUSTO (Global Utilization of
Streptokinase and Tissue Plasminogen Activator for Occluded
Coronary Arteries) IIb cohorts. The sum of scores is applied to
a reference nomogram to determine all-cause mortality from

hospital discharge to 6 months. The GRACE clinical application tool is a web-based downloadable application available
at http://www.outcomes-umassmed.org/grace/ (Figure2).44,135
Among patients with a higher TIMI risk score (eg, 3),
there is a greater benefit from therapies such as low-molecularweight heparin (LMWH),133,136 platelet GP IIb/IIIa inhibitors,137
and an invasive strategy.138 Similarly, the GRACE risk model
can identify patients who would benefit from an early invasive
strategy.139 Patients with elevated cardiac troponin benefit from
more aggressive therapy, whereas those without elevated cardiac troponins may not.140 This is especially true for women in
whom some data suggest adverse effects from invasive therapies in the absence of an elevated cardiac troponin value.141
Although B-type natriuretic peptide and N-terminal proBtype natriuretic peptide are not useful for the diagnosis of ACS
per se (but rather HF, which has many etiologies), they add
prognostic value.8791
3.3.2.4. Electrocardiogram
The 12-lead ECG is pivotal in the decision pathway for the evaluation and management of patients presenting with symptoms
suggestive of ACS.58,59,85 Transient ST changes (0.5 mm [0.05
mV]) during symptoms at rest strongly suggest ischemia and
underlying severe CAD. Patients without acute ischemic changes
on ECG have a reduced risk of MI and a very low risk of inhospital life-threatening complications, even in the presence of
confounding electrocardiographic patterns such as LV hypertrophy.143145 ST depression (especially horizontal or downsloping)
is highly suggestive of NSTE-ACS.21,146,147 Marked symmetrical
precordial T-wave inversion (2 mm [0.2 mV]) suggests acute
ischemia, particularly due to a critical stenosis of the left anterior
descending coronary artery148,149; it may also be seen with acute
pulmonary embolism and right-sided ST-T changes.
Nonspecific ST-T changes (usually defined as ST deviation of <0.5 mm [0.05 mV] or T-wave inversion of <2 mm
[0.2 mV]) are less helpful diagnostically. Significant Q waves
Figure 2. Global Registry of Acute Coronary Events Risk Calculator for In-Hospital Mortality for Acute Coronary Syndrome.

are less helpful, although by suggesting prior MI, they indicate a high likelihood of significant CAD. Isolated Q waves
in lead 3 are a normal finding. A completely normal ECG in a
patient with chest pain does not exclude ACS, because 1% to
6% of such patients will have a MI, and at least 4% will have
UA.5961 Fibrinolytic therapy is contraindicated for patients
with ACS without ST-elevation, except for those with electrocardiographic evidence of true posterior MI (ie, ST-elevation
in posterior chest leads [V7 to V9]). This can be evaluated
when acute myocardial infarction (AMI) is suspected but
electrocardiographic changes are modest or not present8284;
a transthoracic echocardiogram to evaluate for posterior wall
motion abnormalities may also be helpful in this setting.
Alternative causes of ST-T changes include LV aneurysm,
pericarditis, myocarditis, bundle-branch block, LV hypertrophy, hyperkalemia, Prinzmetal angina, early repolarization,
apical LV ballooning syndrome (Takotsubo cardiomyopathy,
Section 7.13), and Wolff-Parkinson-White conduction. Central
nervous system events and therapy with tricyclic antidepressants or phenothiazines can cause deep T-wave inversion.
3.3.2.5. Physical Examination
The physical examination is helpful in assessing the hemodynamic
impact of an ischemic event. Patients with suspected ACS should
have vital signs measured (BP in both arms if dissection is suspected) and should undergo a thorough cardiovascular examination.
Patients with evidence of LV dysfunction on examination (eg, rales,
S3 gallop) or acute mitral regurgitation have a higher likelihood of
severe underlying CAD and are at high risk of a poor outcome.
In the SHOCK (Should we Emergently Revascularize Occluded
Coronaries for Cardiogenic Shock) study, NSTEMI accounted for
approximately 20% of cardiogenic shock complicating MI.150 Other
trials have reported lower percentages.92,151 The physical examination may also help identify comorbid conditions (eg, occult GI
bleeding) that could impact therapeutic risk and decision making.
on risk stratification.
3.4. Cardiac Biomarkers and the Universal

Definition of MI: Recommendations
See Table 5 for a summary of recommendations from this section and Online Data Supplement 3 for additional information
on cardiac injury markers and the universal definition of AMI.
3.4.1. Biomarkers: Diagnosis
Class I
1. Cardiac-specific troponin (troponin I or T when a
contemporary assay is used) levels should be measured at presentation and 3 to 6 hours after symptom onset in all patients who present with symptoms
consistent with ACS to identify a rising and/or falling
pattern.21,64,6771,152156 (Level of Evidence: A)
2. Additional troponin levels should be obtained beyond
6 hours after symptom onset in patients with normal
troponins on serial examination when electrocardiographic changes and/or clinical presentation confer an intermediate or high index of suspicion for
ACS.21,7274,157 (Level of Evidence: A)
3. If the time of symptom onset is ambiguous, the time of

presentation should be considered the time of onset for
assessing troponin values.67,68,72 (Level of Evidence: A)
Class III: No Benefit

1. With contemporary troponin assays, creatine kinase
myocardial isoenzyme (CK-MB) and myoglobin are not
useful for diagnosis of ACS.158164 (Level of Evidence: A)
3.4.2. Biomarkers: Prognosis
Class I
1. The presence and magnitude of troponin elevations
are useful for short- and long-term prognosis.71,73,165,166
Class IIb
1. It may be reasonable to remeasure troponin once
on day 3 or day 4 in patients with MI as an index of
infarct size and dynamics of necrosis.164,165 (Level of
Evidence: B)
2. Use of selected newer biomarkers, especially B-type
natriuretic peptide, may be reasonable to provide
additional prognostic information.87,88,167171 (Level of
Evidence: B)
Cardiac troponins are the mainstay for diagnosis of ACS and for
risk stratification in patients with ACS. The primary diagnostic
biomarkers of myocardial necrosis are cardiac troponin I and
cardiac troponin T. Features that favor troponins for detection
of ACS include high concentrations of troponins in the myocardium; virtual absence of troponins in nonmyocardial tissue;
high-release ratio into the systemic circulation (amount found
in blood relative to amount depleted from myocardium); rapid
release into the blood in proportion to the extent of myocardial
injury; and the ability to quantify values with reproducible,
inexpensive, rapid, and easily applied assays. The 2012 Third
Universal Definition of MI provides criteria that classify 5 clinical presentations of MI on the basis of pathological, clinical,
and prognostic factors.21 In the appropriate clinical context, MI
is indicated by a rising and/or falling pattern of troponin with
1 value above the 99th percentile of the upper reference level
and evidence for serial increases or decreases in the levels of
troponins.67,68,156 The potential consequences of emerging highsensitivity troponin assays include increases in the diagnosis of
NSTEMI152,172,173 influenced by the definition of an abnormal troponin.67,153,174,175 The recommendations in this section are formulated from studies predicated on both the new European Society
of Cardiology/ACC/AHA/World Health Organization criteria21
and previous criteria/ redefinitions of MI based on earlier-generation troponin assays (Appendix 4, Table A).
3.4.3. Cardiac Troponins
See Online Data Supplement 4 for additional information on
cardiac troponins.
Of the 3 troponin subunits, 2 subunits (troponin I and troponin T)
are derived from genes specifically expressed in the myocardium.
Cardiac troponin measurements provide highly sensitive results

Table 5. Summary of Recommendations for Cardiac Biomarkers and the Universal Definition of MI
Recommendations
COR
LOE
References
Measure cardiac-specific troponin (troponin I or T) at presentation and 36 h after symptom onset

in all patients with suspected ACS to identify pattern of values
21, 64, 6771, 152156
Obtain additional troponin levels beyond 6 h in patients with initial normal serial troponins with
electrocardiographic changes and/or intermediate/high risk clinical features
21, 7274, 157
Consider time of presentation the time of onset with ambiguous symptom onset for assessing
troponin values
With contemporary troponin assays, CK-MB and myoglobin are not useful for diagnosis of ACS
67, 68, 72
III: No Benefit
158164
71, 73, 165, 166
Remeasurement of troponin value once on d 3 or 4 in patients with MI may be reasonable as an

index of infarct size and dynamics of necrosis
IIb
164, 165
BNP may be reasonable for additional prognostic information
IIb
87, 88, 167171
Diagnosis
Prognosis
Troponin elevations are useful for short- and long-term prognosis
ACS indicates acute coronary syndromes; BNP, B-type natriuretic peptide; CK-MB, creatine kinase myocardial isoenzyme; COR, Class of Recommendation;
LOE, Level of Evidence; and MI, myocardial infarction.
specific for detecting cardiomyocyte necrosis.34,173 Highly sensitive

assays can identify cardiac troponin not only in the blood of patients
with acute cardiac injury, but also in the blood of most healthy people.64,68,70,166,176,177 As assay sensitivity increases, a greater proportion
of patients will have detectable long-term elevations in troponin,
thus requiring consideration of serial changes for the diagnosis of
MI. Clinicians should be aware of the sensitivity of the tests used for
troponin evaluation in their hospitals and cutpoint concentrations
for clinical decisions. Markedly elevated values are usually related
to MI, myocarditis, rare analytical factors, or chronic elevations in
patients with renal failure and in some patients with HF.
CPGs endorse the 99th percentile of the upper reference
level as the appropriate cutpoint for considering myocardial
necrosis.21,22 For the diagnosis of acute myocardial necrosis,
it is important to determine not only the peak troponin value,
but also serial changes:
1. A troponin value above the 99th percentile of the upper
reference level is required. Additionally, evidence for a
serial increase or decrease 20% is required if the initial
value is elevated.21,178
2. For any troponin values below or close to the 99th
percentile, evidence for acute myocardial necrosis is
indicated by a change of 3 standard deviations of the
variation around the initial value as determined by the
individual laboratory.21,179
3. Clinical laboratory reports should indicate whether significant changes in cardiac troponin values for the particular assay have occurred.
Absolute changes in nanograms per liter of high-sensitivity
cardiac troponin T levels appear to have a significantly higher
diagnostic accuracy for AMI than relative changes and may
distinguish AMI from other causes of high-sensitivity cardiac
troponin T elevations.71 This has also been suggested for some
contemporary assays.71 Troponins are elevated in MI as early as
2 to 4 hours after symptom onset,64,70 and many medical centers
obtain troponins at 3 hours. Depending on the assay, values may
not become abnormal for up to 12 hours. In the vast majority of
patients with symptoms suggestive of ACS, MI can be excluded
or confirmed within 6 hours, because very few patients present
immediately after symptom onset. In high-risk patients, measurements after 6 hours may be required to identify ACS.
Solitary elevations of troponin cannot be assumed to be due
to MI, because troponin elevations can be due to tachyarrhythmia, hypotension or hypertension, cardiac trauma, acute HF,
myocarditis and pericarditis, acute pulmonary thromboembolic
disease, and severe noncardiac conditions such as sepsis, burns,
respiratory failure, acute neurological diseases, and drug toxicity
(including cancer chemotherapy). Chronic elevations can result
from structural cardiac abnormalities such as LV hypertrophy or
ventricular dilatation and are also common in patients with renal
insufficiency.34 Patients with end-stage renal disease and no clinical evidence of ACS frequently have elevations of cardiac troponin.180182 With conventional assays, this is more common with
cardiac troponin T than with cardiac troponin I.180 In the diagnosis
of NSTEMI, cardiac troponin values must manifest an acute pattern consistent with the clinical events, including ischemic symptoms and electrocardiographic changes. Troponin elevations may
persist for up to 14 days or occasionally longer. There is a paucity
of guidelines for establishment of reinfarction during the acute
infarct period on the basis of troponin measurements. References
suggest that an increase of >20% of previous troponin levels or
an absolute increase of high-sensitivity cardiac troponin T values
(eg, >7 ng/L over 2 hours) may indicate reinfarction.183185
During pregnancy, troponin values are within the normal
range in the absence of cardiovascular morbidities. There is
controversy as to whether troponin levels are elevated in preeclampsia, eclampsia, or gestational hypertension.186189 When
present, cardiac troponin elevations reflect myocardial necrosis.
Point-of-care troponin values may provide initial diagnostic
information, although their sensitivity is substantially below
that of central laboratory methods.154,155,190192 In addition, the
rigorous quantitative assay standardization needed for routine
diagnosis favors central laboratory testing.
3.4.3.1. Prognosis
Troponin elevations convey prognostic assessment beyond that
of clinical information, the initial ECG, and the predischarge
stress test.71 In addition, troponin elevations may provide information to direct therapy. Patients with cardiac troponin elevations

are at high risk and benefit from intensive management and early
revascularization.193195 High risk is optimally defined by the
changing pattern as described in Section 3.4.3. Cardiac troponin
elevations correlate with estimation of infarct size and risk of
death; persistent elevation 72 to 96 hours after symptom onset
may afford relevant information in this regard.164 Elevations of
cardiac troponin can occur for multiple reasons other than MI. In
these cases, there is often substantial risk of adverse outcomes,
as troponin elevation indicates cardiomyocyte necrosis.181
3.4.4. CK-MB and Myoglobin Compared With Troponin
Previously, CK-MB was used for early evidence of myocardial injury. Because myoglobin is a relatively small molecule,
it is rapidly released from infarcted myocardium. CK-MB is
much less sensitive for detection of myocardial injury than troponin, and substantially more tissue injury is required for its
detection. With the availability of cardiac troponin, CK-MB,
myoglobin, and other diagnostic biomarkers are no longer
necessary.158,160163,196198 CK-MB may be used to estimate MI
size. Detection of MI after percutaneous coronary intervention (PCI) remains an area of controversy. Because of the
increased sensitivity of cardiac troponin, the prognostic value
associated with varying degrees of elevation remains unclear.
See Online Data Supplements 5, 6, and 7 for additional
information on cardiac injury markers.
3.5. Immediate Management

3.5.1. Discharge From the ED or Chest Pain Unit:
Recommendations
Class IIa
1. It is reasonable to observe patients with symptoms
consistent with ACS without objective evidence of
myocardial ischemia (nonischemic initial ECG and
normal cardiac troponin) in a chest pain unit or telemetry unit with serial ECGs and cardiac troponin at
3- to 6-hour intervals.196,197,199201 (Level of Evidence: B)
2. It is reasonable for patients with possible ACS who
have normal serial ECGs and cardiac troponins to
have a treadmill ECG200202 (Level of Evidence: A),
stress myocardial perfusion imaging,200 or stress
echocardiography203,204 before discharge or within 72
hours after discharge. (Level of Evidence: B)
3. In patients with possible ACS and a normal ECG,
normal cardiac troponins, and no history of CAD, it is
reasonable to initially perform (without serial ECGs
and troponins) coronary CT angiography to assess
vidence: A)
coronary artery anatomy205207 (Level of E
or rest myocardial perfusion imaging with a technetium-99m radiopharmaceutical to exclude myocardial ischemia.208,209 (Level of Evidence: B)
4. It is reasonable to give low-risk patients who are
referred for outpatient testing daily aspirin, shortacting nitroglycerin, and other medication if appropriate (eg, beta blockers), with instructions
about activity level and clinician follow-up. (Level of
Evidence: C)
The majority of patients presenting to the ED with chest pain
do not have ACS (Figure1), and most are at low risk for major
morbidity and mortality.35 Low-risk patients are usually identified by an absence of history of cardiovascular disease, normal
or near-normal initial ECG, normal initial troponin, and clinical
stability.35,202 The utility of an accelerated diagnostic protocol
for detecting patients with benign conditions versus those who
require admission for serious disease has been established.35 At
minimum, these protocols involve serial ECGs and troponin
measurements, both of which can be performed in the ED, a
separate chest pain unit, or a telemetry unit. A 30-day negative
predictive value >99% for ACS has been reported for patients
presenting to the ED with chest pain who undergo a 2-hour accelerated diagnostic protocol composed of a TIMI risk score of 0,
normal ECG, and normal high-sensitivity troponin at 0 hours and
2 hours (assuming appropriate follow-up care).65,210 Some protocols also call for a functional or anatomic test (eg, treadmill
test, rest scintigraphy, coronary CT angiography, stress imaging).
Coronary CT angiography is associated with rapid assessment,
high negative predictive value, decreased length of stay, and
reduced costs205207; however, in the latter studies, it increased the
rate of invasive coronary angiography and revascularization with
uncertain long-term benefits in low-risk patients without ECG or
troponin alterations.211 Accelerated diagnostic protocols are also
potentially applicable in intermediate-risk patients, whose presentation includes a history of cardiovascular disease, diabetes
mellitus, chronic kidney disease (CKD), and/or advanced age.202
on discharge from the ED or chest pain unit.
4. Early Hospital Care

The standard of care for patients who present with NSTE-ACS,
including those with recurrent symptoms, ischemic electrocardiographic changes, or positive cardiac troponins, is admission for
inpatient management. The goals of treatment are the immediate
relief of ischemia and the prevention of MI and death. Initially,
stabilized patients with NSTE-ACS are admitted to an intermediate (or step-down) care unit. Patients undergo continuous electrocardiographic rhythm monitoring and observation for recurrent
ischemia. Bed or chair rest is recommended for patients admitted with NSTE-ACS. Patients with NSTE-ACS should be treated
with antianginal (Section 4.1.2.5), antiplatelet, and anticoagulant
therapy (Section 4.3). Patients are managed with either an early
invasive strategy or an ischemia-guided strategy (Section 4.4).
Patients with continuing angina, hemodynamic instability,
uncontrolled arrhythmias, or a large MI should be admitted to a
coronary care unit. The nurse-to-patient ratio should be sufficient
to provide 1) continuous electrocardiographic rhythm monitoring,
2) frequent assessment of vital signs and mental status, and 3) ability to perform rapid cardioversion and defibrillation. These patients
are usually observed in the coronary care unit for at least 24 hours.
Those without recurrent ischemia, significant arrhythmias, pulmonary edema, or hemodynamic instability can be considered for
admission or transfer to an intermediate care or telemetry unit.
An assessment of LV function is recommended because
depressed LV function will likely influence pharmacological
therapies (eg, angiotensin-converting enzyme [ACE] inhibitors
for depressed left ventricular ejection fraction [LVEF]), may suggest the presence of more extensive CAD, and may influence the
choice of revascularization (PCI versus coronary artery bypass
graft surgery [CABG]). Because significant valvular disease may

also influence the type of revascularization, echocardiography
rather than ventriculography is often preferred for assessment of
LV function.
4.1. Standard Medical Therapies.

section.
4.1.1. Oxygen: Recommendation
Class I
1. Supplemental oxygen should be administered to patients with NSTE-ACS with arterial oxygen saturation less than 90%, respiratory distress, or other highrisk features of hypoxemia. (Level of Evidence: C)
with supplemental oxygen. The 2007 UA/NSTEMI CPG recommended the routine administration of supplemental oxygen to all
patients with NSTE-ACS during the first 6 hours after presentation on the premise that it is safe and may alleviate hypoxemia.212
The benefit of routine supplemental oxygen administration in
normoxic patients with NSTE-ACS has never been demonstrated.
At the time of GWC deliberations, data emerged that routine use
of supplemental oxygen in cardiac patients may have untoward
effects, including increased coronary vascular resistance, reduced
coronary blood flow, and increased risk of mortality.213215
4.1.2. Anti-Ischemic and Analgesic Medications
4.1.2.1. Nitrates: Recommendations
Class I
Patients with cyanosis, arterial oxygen saturation <90%, respiratory distress, or other high-risk features of hypoxemia are treated
1. Patients with NSTE-ACS with continuing ischemic

pain should receive sublingual nitroglycerin (0.3 mg
Table 6. Summary of Recommendations for Early Hospital Care

Recommendations
COR
LOE
References
N/A
216218
Oxygen
Administer supplemental oxygen only with oxygen saturation <90%, respiratory distress,
or other high-risk features for hypoxemia
Nitrates
Administer sublingual NTG every 5 min 3 for continuing ischemic pain and then assess need for IV NTG
Administer IV NTG for persistent ischemia, HF, or hypertension
219224
III: Harm
225227
IIb
232, 233
III: Harm
35, 234
Initiate oral beta blockers within the first 24 h in the absence of HF, low-output state, risk for cardiogenic
shock, or other contraindications to beta blockade
240242
Use of sustained-release metoprolol succinate, carvedilol, or bisoprolol is recommended for beta-blocker

therapy with concomitant NSTE-ACS, stabilized HF, and reduced systolic function
Re-evaluate to determine subsequent eligibility in patients with initial contraindications to beta blockers
N/A
Nitrates are contraindicated with recent use of a phosphodiesterase inhibitor

Analgesic therapy
IV morphine sulfate may be reasonable for continued ischemic chest pain despite maximally tolerated
anti-ischemic medications
NSAIDs (except aspirin) should not be initiated and should be discontinued during hospitalization
for NSTE-ACS because of the increased risk of MACE associated with their use
Beta-adrenergic blockers
N/A
IIa
241, 243
III: Harm
244
248250
Administer oral nondihydropyridine calcium antagonists with recurrent ischemia after use of beta
blocker and nitrates in the absence of contraindications
N/A
CCBs are recommended for ischemic symptoms when beta blockers are not successful,
are contraindicated, or cause unacceptable side effects*
Long-acting CCBs and nitrates are recommended for patients with coronary artery spasm
N/A
It is reasonable to continue beta-blocker therapy in patients with normal LV function with NSTE-ACS
IV beta blockers are potentially harmful when risk factors for shock are present
CCBs
Administer initial therapy with nondihydropyridine CCBs with recurrent ischemia and contraindications
to beta blockers in the absence of LV dysfunction, increased risk for cardiogenic shock, PR interval
>0.24 s, or second- or third-degree atrioventricular block without a cardiac pacemaker
Immediate-release nifedipine is contraindicated in the absence of a beta blocker

Cholesterol management
Initiate or continue high-intensity statin therapy in patients with no contraindications
Obtain a fasting lipid profile, preferably within 24 h
N/A
III: Harm
251, 252
269273
IIa
N/A
*Short-acting dihydropyridine calcium channel antagonists should be avoided.

CCB indicates calcium channel blocker; COR, Class of Recommendation; HF, heart failure; IV, intravenous; LOE, Level of Evidence; LV, left ventricular; MACE, major
adverse cardiac event; N/A, not available; NSAIDs, nonsteroidal anti-inflammatory drugs; NSTE-ACS, nonST-elevation acute coronary syndromes; and NTG, nitroglycerin.

to 0.4 mg) every 5 minutes for up to 3 doses, after
which an assessment should be made about the need
for intravenous nitroglycerin if not contraindicated.216218 (Level of Evidence: C)
2. Intravenous nitroglycerin is indicated for patients
with NSTE-ACS for the treatment of persistent ischemia, HF, or hypertension.219224 (Level of
Evidence: B)
Class III: Harm

1. Nitrates should not be administered to patients with
NSTE-ACS who recently received a phosphodiesterase inhibitor, especially within 24 hours of sildenafil
or vardenafil, or within 48 hours of tadalafil.225227
Nitrates are endothelium-independent vasodilators with
peripheral and coronary vascular effects. By dilating the capacitance vessels, nitrates decrease cardiac preload and reduce
ventricular wall tension. More modest effects on the arterial
circulation result in afterload reduction and further decrease in
MVO2. This may be partially offset by reflex increases in heart
rate and contractility, which counteract the reduction in MVO2
unless a beta blocker is concurrently administered. Nitrates
also dilate normal and atherosclerotic coronary arteries and
increase coronary collateral flow. Nitrates may also inhibit
platelet aggregation.228
RCTs have not shown a reduction in MACE with nitrates.
The rationale for nitrate use in NSTE-ACS is extrapolated
from pathophysiological principles and extensive (although
uncontrolled) clinical observations, experimental studies, and
clinical experience. The decision to administer nitrates should
not preclude therapy with other proven mortality-reducing
interventions such as beta blockers.
Intravenous nitroglycerin is beneficial in patients with HF,
hypertension, or symptoms that are not relieved with sublingual nitroglycerin and administration of a beta blocker.219,221224
Patients who require intravenous nitroglycerin for >24 hours
may require periodic increases in the infusion rate and use
of nontolerance-producing regimens (eg, intermittent dosing)
to maintain efficacy. In current practice, most patients who
require continued intravenous nitroglycerin for the relief of
angina undergo prompt coronary angiography and revascularization. Topical or oral nitrates are acceptable alternatives to
intravenous nitroglycerin for patients who do not have refractory or recurrent ischemia.229,230 Side effects of nitrates include
headache and hypotension. Nitrates should not be administered to patients with hypotension or to those who received a
phosphodiesterase inhibitor and are administered with caution
to patients with right ventricular infarction.231
on nitrates.
4.1.2.2. Analgesic Therapy: Recommendations
Class IIb
1. In the absence of contraindications, it may be reasonable to administer morphine sulfate intravenously to
patients with NSTE-ACS if there is continued ischemic
chest pain despite treatment with maximally tolerated

anti-ischemic medications.232,233 (Level of Evidence: B)
Class III: Harm

1. Nonsteroidal anti-inflammatory drugs (NSAIDs) (except aspirin) should not be initiated and should be
discontinued during hospitalization for NSTE-ACS
because of the increased risk of MACE associated
with their use.234,235 (Level of Evidence: B)
The role of morphine sulfate was re-evaluated for this CPG
revision, including studies that suggest the potential for
adverse events with its use.232 Morphine sulfate has potent
analgesic and anxiolytic effects, as well as hemodynamic
actions, that are potentially beneficial in NSTE-ACS. It
causes venodilation and produces modest reductions in heart
rate (through increased vagal tone) and systolic BP. In patients
with symptoms despite antianginal treatment, morphine
(1 mg to 5 mg IV) may be administered during intravenous
nitroglycerin therapy with BP monitoring. The morphine dose
may be repeated every 5 to 30 minutes to relieve symptoms
and maintain the patients comfort. Its use should not preclude
the use of other anti-ischemic therapies with proven benefits
in patients with NSTE-ACS. To our knowledge, no RCTs have
assessed the use of morphine in patients with NSTE-ACS or
defined its optimal administration schedule. Observational
studies have demonstrated increased adverse events associated with the use of morphine sulfate in patients with ACS and
acute decompensated HF.232,233,236 Although these reports were
observational, uncontrolled studies limited by selection bias,
they raised important safety concerns.
Although constipation, nausea, and/or vomiting occur in
>20% of patients, hypotension and respiratory depression
are the most serious complications of excessive use of morphine. Naloxone (0.4 mg to 2.0 mg IV) may be administered for morphine overdose with respiratory or circulatory
depression.
Traditional NSAIDs and selective cyclooxygenase
(COX)-2 inhibitors markedly block endothelial prostacyclin
production, which leads to unopposed platelet aggregation
by platelet-derived thromboxane A2. Both types of NSAIDs
prevent the beneficial actions of aspirin and interfere with the
inhibition of COX-1, thromboxane A2 production, and platelet
aggregation. Because of their inhibitory activity on the ubiquitous COXs, NSAIDs have an extensive adverse side effect
profile, particularly renal and gastrointestinal. The increased
cardiovascular hazards associated with NSAIDs have been
observed in several studies of patients without ACS.234,235,237,238
The PRECISION (Prospective Randomized Evaluation of
Celecoxib Integrated Safety Versus Ibuprofen Or Naproxen)
trial, in progress at the time of publication, is the first study of
patients with high cardiovascular risk who are receiving longterm treatment with a selective COX-2 inhibitor or traditional
NSAIDs. PRECISION will examine the relative cardiovascular safety profiles of celecoxib, ibuprofen, and naproxen in
patients without ACS.239
on analgesic therapy.

4.1.2.3. Beta-Adrenergic Blockers: Recommendations
Class I
1. Oral beta-blocker therapy should be initiated within the first 24 hours in patients who do not have
any of the following: 1) signs of HF, 2) evidence of
low-output state, 3) increased risk for cardiogenic
shock, or 4) other contraindications to beta blockade (eg, PR interval >0.24 second, second- or thirddegree heart block without a cardiac pacemaker,
active asthma, or reactive airway disease).240242
(Level of Evidence: A)
2. In patients with concomitant NSTE-ACS, stabilized
HF, and reduced systolic function, it is recommended
to continue beta-blocker therapy with 1 of the 3 drugs
proven to reduce mortality in patients with HF: sustained-release metoprolol succinate, carvedilol, or bisoprolol. (Level of Evidence: C)
3. Patients with documented contraindications to beta
blockers in the first 24 hours of NSTE-ACS should be
re-evaluated to determine their subsequent eligibility.
Class IIa
1. It is reasonable to continue beta-blocker therapy
in patients with normal LV function with NSTEACS.241,243 (Level of Evidence: C)
Class III: Harm
bronchospasm. Beta-1 selective beta blockers are preferred and

should be initiated at a low dosage.
on beta blockers, including risk factors for shock.
4.1.2.4. Calcium Channel Blockers: Recommendations
Class I
1. In patients with NSTE-ACS, continuing or frequently recurring ischemia, and a contraindication to beta
blockers, a nondihydropyridine calcium channel
blocker (CCB) (eg, verapamil or diltiazem) should
be given as initial therapy in the absence of clinically
significant LV dysfunction, increased risk for cardiogenic shock, PR interval greater than 0.24 second, or
second- or third-degree atrioventricular block without a cardiac pacemaker.248250 (Level of Evidence: B)
2. Oral nondihydropyridine calcium antagonists are
recommended in patients with NSTE-ACS who
have recurrent ischemia in the absence of contraindications, after appropriate use of beta blockers
and nitrates. (Level of Evidence: C)
3. CCBs are recommended for ischemic symptoms
when beta blockers are not successful, are contraindicated, or cause unacceptable side effects. (Level of
Evidence: C)
4. Long-acting CCBs and nitrates are recommended in
patients with coronary artery spasm. (Level of Evidence: C)
Class III: Harm
1. Administration of intravenous beta blockers is potentially harmful in patients with NSTE-ACS who have
risk factors for shock.244 (Level of Evidence: B)
Beta blockers decrease heart rate, contractility, and BP, resulting in decreased MVO2. Beta blockers without increased
sympathomimetic activity should be administered orally in
the absence of contraindications. Although early administration does not reduce short-term mortality,241,244 beta blockers
decrease myocardial ischemia, reinfarction, and the frequency
of complex ventricular dysrhythmias,240,245 and they increase
long-term survival. Early beta blockade, particularly if given
intravenously, can increase the likelihood of shock in patients
with risk factors. Risk factors for shock include patients >70
years of age, heart rate >110 beats per minute, systolic BP
<120 mmHg, and late presentation.244 In patients with LV dysfunction (LVEF <0.40) with or without pulmonary congestion,
beta blockers are strongly recommended before discharge.
Beta blockers should be used prudently with ACE inhibitors
or angiotensin-receptor blockers (ARBs) in patients with HF.
Renin-angiotensin-aldosterone system blocking agents should
be cautiously added in patients with decompensated HF.246
Beta blockers without intrinsic sympathomimetic activity
should be used, especially beta-1 blockers such as sustainedrelease metoprolol succinate, bisoprolol, or carvedilol, a beta-1
and alpha-1 blocker. This is because of their mortality benefit
in patients with HF and systolic dysfunction.246,247 In patients
with chronic obstructive lung disease or a history of asthma,
beta blockers are not contraindicated in the absence of active
1. Immediate-release nifedipine should not be administered to patients with NSTE-ACS in the absence of
beta-blocker therapy.251,252 (Level of Evidence: B)
CCBs include dihydropyridines and nondihydropyridines. The
dihydropyridines (nifedipine and amlodipine) produce the most
marked peripheral vasodilation and have little direct effect on
contractility, atrioventricular conduction, and heart rate. The
nondihydropyridines (diltiazem and verapamil) have significant
negative inotropic actions and negative chronotropic and dromotropic effects. All CCBs cause similar coronary vasodilation
and are preferred in vasospastic angina.253 They also alleviate
ischemia due to obstructive CAD by decreasing heart rate and
BP. Verapamil and diltiazem decreased reinfarction in patients
without LV dysfunction in some248,249,254 but not all studies.255,256
Verapamil may be beneficial in reducing long-term events
after AMI in hypertensive patients without LV dysfunction250
and in patients with MI and HF receiving an ACE inhibitor.257
Immediate-release nifedipine causes a dose-related increase in
mortality in patients with CAD and harm in ACS and is not
recommended for routine use in patients with ACS.251,258 Longacting preparations may be useful in older patients with systolic
hypertension.259 There are no significant trial data on efficacy of
amlodipine or felodipine in patients with NSTE-ACS.
on CCBs.
Short-acting dihydropyridine calcium channel antagonists should be
avoided.

4.1.2.5. Other Anti-Ischemic Interventions
Ranolazine
Ranolazine is an antianginal medication with minimal effects
on heart rate and BP.260,261 It inhibits the late inward sodium current and reduces the deleterious effects of intracellular sodium
and calcium overload that accompany myocardial ischemia.262
Ranolazine is currently indicated for treatment of chronic
angina. The MERLIN-TIMI (Metabolic Efficiency With
Ranolazine for Less Ischemia in NonST-Elevation Acute
Coronary Syndromes-Thrombosis In Myocardial Infarction)
36 trial examined the efficacy and safety of ranolazine in 6560
patients with NSTE-ACS who presented within 48 hours of
ischemic symptoms.263 In a post hoc analysis in women, ranolazine was associated with a reduced incidence of the primary
endpoint (cardiovascular death, MI, or recurrent ischemia),
principally owing to a 29% reduction in recurrent ischemia.116
In the subgroup with prior chronic angina (n=3565), ranolazine was associated with a lower primary composite endpoint,
a significant reduction of worsening angina, and increased
exercise duration.264 Because the primary endpoint of the
original MERLIN-TIMI 36 trial was not met, all additional
analyses should be interpreted with caution. The recommended initial dose is 500 mg orally twice daily, which can
be uptitrated to a maximum of 1000 mg orally twice daily.
Ranolazine is usually well tolerated; its major adverse effects
are constipation, nausea, dizziness, and headache. Ranolazine
prolongs the QTc interval in a dose-related manner, but QTc
prolongation requiring dose reduction was comparable with
ranolazine and placebo in the MERLIN-TIMI 36 trial.263
on ranolazine.
Intra-Aortic Balloon Pump (IABP) Counterpulsation
IABP counterpulsation may be used in patients with NSTEACS to treat severe persistent or recurrent ischemia, especially
in patients awaiting invasive angiography and revascularization, despite intensive medical therapy. In experimental
studies, IABP counterpulsation increases diastolic BP and
coronary blood flow and potentially augments cardiac output
while diminishing LV end-diastolic pressure. The use of IABP
for refractory ischemia dates back several decades, and its
current application is predominantly driven by clinical experience and nonrandomized observational studies.265 When studied in rigorous RCTs, IABP counterpulsation failed to reduce
MACE in high-risk elective PCI,266 decrease infarct size after
primary PCI for acute STEMI,267 or diminish early mortality
in patients with cardiogenic shock complicating AMI.268
4.1.2.6. Cholesterol Management
Class I
1. High-intensity statin therapy should be initiated or
continued in all patients with NSTE-ACS and no contraindications to its use.269273 (Level of Evidence: A)
Class IIa
1. It is reasonable to obtain a fasting lipid profile in patients with NSTE-ACS, preferably within 24 hours of
presentation. (Level of Evidence: C)
Therapy with statins in patients with NSTE-ACS reduces

the rate of recurrent MI, coronary heart disease mortality,
need for myocardial revascularization, and stroke. High-risk
patients, such as those with NSTE-ACS, derive more benefit
in reducing these events from high-intensity statins, such as
atorvastatin which lower low-density lipoprotein cholesterol
levels by 50% as in the PROVE IT-TIMI 22 (Pravastatin or
Atorvastatin Evaluation and Infection Therapy-Thrombolysis
In Myocardial Infarction) and MIRACL (Myocardial Ischemia
Reduction With Acute Cholesterol Lowering) trials,273,274 than
from moderate- or low-intensity statins.18,272 These findings
provide the basis for high-intensity statin therapy after stabilization of patients with NSTE-ACS. In addition, early introduction of this approach can promote improved compliance
with this regimen.
4.2. Inhibitors of the Renin-AngiotensinAldosterone System: Recommendations

Class I
1. ACE inhibitors should be started and continued indefinitely in all patients with LVEF less than 0.40 and
in those with hypertension, diabetes mellitus, or stable CKD (Section 7.6), unless contraindicated.275,276
(Level of Evidence: A)
2. ARBs are recommended in patients with HF or MI
with LVEF less than 0.40 who are ACE inhibitor intolerant.277,278 (Level of Evidence: A)
3. Aldosterone blockade is recommended in patients
postMI without significant renal dysfunction (creatinine >2.5 mg/dL in men or >2.0 mg/dL in women)
or hyperkalemia (K+ >5.0 mEq/L) who are receiving
therapeutic doses of ACE inhibitor and beta blocker
and have a LVEF 0.40 or less, diabetes mellitus, or
HF.279 (Level of Evidence: A)
Class IIa
1. ARBs are reasonable in other patients with cardiac
or other vascular disease who are ACE inhibitor intolerant.280 (Level of Evidence: B)
Class IIb
1. ACE inhibitors may be reasonable in all other patients with cardiac or other vascular disease.281,282
ACE inhibitors reduce mortality in patients with recent MI,
primarily those with LV dysfunction (LVEF <0.40) with or
without pulmonary congestion.283285 In patients with normal
LV function (including patients with diabetes mellitus), total
mortality and MACE (including HF) are reduced. It has been
found that approximately 15% of patients with NSTEMI
develop HF during hospitalization, with the rate increasing to 24% of patients 1 year later.286 A metaanalysis demonstrated a small but significant (0.48%) absolute benefit of
early initiation of an ACE inhibitor on survival at 30 days,
with benefit seen as early as 24 hours after admission for
AMI.283 An ACE inhibitor should be used cautiously in the

first 24 hours of AMI, because it may result in hypotension
or renal dysfunction.283 It may be prudent to initially use a
short-acting ACE inhibitor, such as captopril or enalapril, in
patients at increased risk of these adverse events. In patients
with significant renal dysfunction, it is sensible to stabilize
renal function before initiating an ACE inhibitor or an ARB,
with re-evaluation of creatinine levels after drug initiation. An
ARB may be substituted for an ACE inhibitor with similar
benefits on survival.277,278 Combining an ACE inhibitor and an
ARB may result in an increase in adverse events.277,278 In a
study in which patients with AMI with LV dysfunction (LVEF
<0.40) with or without HF were randomized 3 to 14 days after
AMI to receive eplerenone (a selective aldosterone blocker),
eplerenone was efficacious as an adjunct to ACE inhibitors
and beta blockers in decreasing long-term mortality.279,287 In
a study of patients with HF, >50% of whom had an ischemic
etiology, spironolactone (a nonselective aldosterone inhibitor)
was beneficial279; however, RCT data on MI are not available.
on inhibitors of the renin-angiotensin-aldosterone system.
4.3. Initial Antiplatelet/Anticoagulant Therapy

in Patients With Definite or Likely NSTE-ACS
4.3.1. Initial Oral and Intravenous Antiplatelet Therapy
in Patients With Definite or Likely NSTE-ACS Treated
With an Initial Invasive or Ischemia-Guided Strategy:
Recommendations
section and Online Data Supplement 15 for additional information on initial oral and intravenous antiplatelet therapy in
patients with definite or likely NSTE-ACS treated with an
early invasive or an ischemia-guided strategy.
Class I
1. Nonenteric-coated, chewable aspirin (162 mg to
325mg) I should be given to all patients with NSTEACS without contraindications as soon as possible
after presentation, and a maintenance dose of aspirin
(81mg/d to 325 mg/d) should be continued indefinitely.288290,293,391 (Level of Evidence: A)
2. In patients with NSTE-ACS who are unable to take
aspirin because of hypersensitivity or major gastrointestinal intolerance, a loading dose of clopidogrel
followed by a daily maintenance dose should be administered.291 (Level of Evidence: B)
3. A P2Y12 inhibitor (either clopidogrel or ticagrelor) in
addition to aspirin should be administered for up to
12months to all patients with NSTE-ACS without contraindications who are treated with either an early invasive or ischemia-guided strategy. Options include:
Clopidogrel: 300-mg or 600-mg loading dose, then
75 mg daily289,292 (Level of Evidence: B)
Ticagrelor: 180-mg loading dose, then 90 mg
twice daily293,294 (Level of Evidence: B)
See Section 5.1.2.1 for recommendations at the time of PCI.
See Section 4.3.1.2 for prasugrel indications in either an early invasive
or ischemia-guided strategy.
The recommended maintenance dose of aspirin to be used with
ticagrelor is 81 mg daily.290
Class IIa
1. It is reasonable to use ticagrelor in preference to clopidogrel for P2Y12 treatment in patients with NSTEACS who undergo an early invasive or ischemiaguided strategy.293,294 (Level of Evidence: B)
Class IIb
1. In patients with NSTE-ACS treated with an early invasive strategy and dual antiplatelet therapy (DAPT) with
intermediate/high-risk features (eg, positive troponin),
a GP IIb/IIIa inhibitor may be considered as part of initial antiplatelet therapy. Preferred options are eptifibatide or tirofiban.43,94,295 (Level of Evidence: B)
Despite the large number of new antiplatelet and antithrombotic
agents, aspirin, which targets COX and subsequent thromboxane A2 inhibition, is the mainstay of antiplatelet therapy.
Multiple other pathways of platelet activation can be targeted
by agents that inhibit the platelet P2Y12 receptor, including thienopyridine prodrug agents, such as clopidogrel and prasugrel,
which require conversion into molecules that bind irreversibly
to the P2Y12 receptor. Additional pyrimidine derivatives, including ticagrelor, do not require biotransformation and bind reversibly to the P2Y12 receptor, antagonizing adenosine diphosphate
platelet activation. In addition to these oral agents, intravenous
GP IIb/IIIa receptor inhibitors, including abciximab, eptifibatide, and tirofiban, target the final common pathway of platelet
aggregation. In the EARLY ACS (Early Glycoprotein IIb/IIIa
Inhibition in Patients With NonST-Segment Elevation Acute
Coronary Syndrome) trial, patients were randomly assigned
to either early, prePCI double-bolus eptifibatide or delayed,
provisional eptifibatide. Seventy-five percent of the patients
received upstream, preprocedure clopidogrel. The risk of TIMI
major bleeding in the early eptifibatide group was 2.6% compared with 1.8% (P=0.02) in the delayed provisional group.295
In the GUSTO IV-ACS (Global Use of Strategies To Open
Occluded Coronary Arteries IV-Acute Coronary Syndromes)
trial, there was no clinical benefit of abciximab in this population; in troponin-negative patients, mortality was 8.5% compared with 5.8% in controls (P=0.002).288,289,296,297
4.3.1.1. Aspirin
Aspirin is the established first-line therapy in patients with
NSTE-ACS and reduces the incidence of recurrent MI and
death.288,289 A loading dose of nonenteric-coated aspirin 162
mg to 325 mg is the initial antiplatelet therapy. The subsequent maintenance dose is 81 mg per day to 162 mg per day;
in special circumstances, a higher maintenance dose up to
325 mg daily has been used.391 The lower dose is favored and
all patients treated with ticagrelor should receive only 81 mg
per day.290 In other countries, available low-dose aspirin formations may include 75 mg and 100 mg. High-dose (160 mg)
versus low-dose (<l60 mg) aspirin is associated with increased
bleeding risk in the absence of improved outcomes.298 Most
NSAIDs reversibly bind to COX-1, preventing inhibition by
aspirin and by COX-2 and may cause prothrombotic effects.
Enteric-coated aspirin should be avoided initially because of
its delayed and reduced absorption.299

Table 7. Summary of Recommendations for Initial Antiplatelet/Anticoagulant Therapy in Patients With Definite or Likely NSTE-ACS
and PCI
Dosing and
Special Considerations
Recommendations
COR
LOE
References
Aspirin
Nonenteric-coated aspirin to all patients promptly after
presentation
162 mg-325 mg
288290
Aspirin maintenance dose continued indefinitely
81 mg/d-325 mg/d*
288290,
293, 391
C
lopidogrel loading dose followed by daily maintenance
dose in patients unable to take aspirin
75 mg
291
P 2Y12 inhibitor, in addition to aspirin, for up to 12 mo for patients

treated initially with either an early invasive or initial ischemiaguided strategy:
Clopidogrel
Ticagrelor*
300-mg or 600-mg loading dose,

then 75 mg/d
I
289, 292
293, 294
293, 296, 302,

330, 331
P2Y12 inhibitors
180-mg loading dose, then 90 mg BID
P 2Y12 inhibitor therapy (clopidogrel, prasugrel, or ticagrelor)

continued for at least 12 mo in postPCI patients treated with
coronary stents
N/A
T icagrelor in preference to clopidogrel for patients treated

with an early invasive or ischemia-guided strategy
N/A
IIa
293, 294
Preferred options are eptifibatide

or tirofiban
IIb
43, 94, 295
1 mg/kg SC every 12 h (reduce dose

to 1 mg/kg/d SC in patients with CrCl
<30 mL/min)
Initial 30 mg IV loading dose in selected
patients
133, 136, 309
Bivalirudin until diagnostic angiography or PCI is performed in

patients with early invasive strategy only
L oading dose 0.10 mg/kg loading

dose followed by 0.25 mg/kg/h
Only provisional use of GP IIb/IIIa inhibitor
in patients also treated with DAPT
292, 293,
310, 311
SC fondaparinux for the duration of hospitalization or until PCI

is performed
2.5 mg SC daily
312314
Administer additional anticoagulant with anti-IIa activity if PCI

is performed while patient is on fondaparinux
N/A
313315
IV UFH for 48 h or until PCI is performed
Initial loading dose 60 IU/kg

(max 4000 IU) with initial infusion
12 IU/kg/h (max 1000 IU/ h)
Adjusted to therapeutic aPTT range
316322
III: Harm
93, 329
GP IIb/IIIa inhibitors
G
P IIb/IIIa inhibitor in patients treated with an early invasive
strategy and DAPT with intermediate/high-risk features
(eg, positive troponin)
Parenteral anticoagulant and fibrinolytic therapy
S C enoxaparin for duration of hospitalization or until PCI is
performed
IV fibrinolytic treatment not recommended in patients with NSTE-ACS N/A
See Section 5.1.2.1 for recommendations on antiplatelet/anticoagulant therapy at the time of PCI and Sections 6.2.1 and 6.3 for recommendations on posthospital therapy.
*The recommended maintenance dose of aspirin to be used with ticagrelor is 81 mg daily.290
aPTT indicates activated partial thromboplastin time; BID, twice daily; COR, Class of Recommendation; CrCl, creatinine clearance; DAPT, dual antiplatelet therapy; GP,
glycoprotein; IV, intravenous; LOE, Level of Evidence; max, maximum; N/A, not available; NSTE-ACS, non-ST-elevation acute coronary syndromes; PCI, percutaneous
coronary intervention; SC, subcutaneous; and UFH, unfractionated heparin.
4.3.1.2. P2Y12 Receptor Inhibitors

Three P2Y12 receptor inhibitors are approved in the United
States for treatment of ischemic myocardial disorders, including
NSTE-ACS. For discontinuation before surgery, see Section 5.
Clopidogrel
Administration of clopidogrel with aspirin was superior to
administration of aspirin alone in reducing the incidence of
cardiovascular death and nonfatal MI or stroke both acutely
and over the following 11 months.289,296 There was a slight

increase in major bleeding events with clopidogrel, including
a nonsignificant increase in life-threatening bleeding and fatal
bleeding.289 An initial loading dose of 300 mg to 600mg is recommended.289,296,300 A 600-mg loading dose results in a greater,
more rapid, and more reliable platelet inhibition compared
with a 300-mg loading dose.301 Use of clopidogrel for patients
with NSTE-ACS who are aspirin intolerant is based on a study

in patients with stable ischemic heart disease.291 When possible, discontinue clopidogrel at least 5 days before surgery.301
Prasugrel
The metabolic conversion pathways of prasugrel produce
more rapid and consistent platelet inhibition than clopidogrel.300 In patients with NSTE-ACS and defined coronary
anatomy undergoing planned PCI, a 60-mg loading dose
of prasugrel followed by 10 mg daily was compared with a
300-mg loading dose and 75 mg daily of clopidogrel. The
composite primary endpoint (cardiovascular death, nonfatal
MI, and stroke) was reduced in patients treated with prasugrel (hazard ratio [HR]: 0.81; P=0.001). This was driven by
a risk reduction for MI and stent thrombosis with no difference in mortality.302 Counterbalancing the salutary effects of
prasugrel was a significant increase in spontaneous bleeding,
life-threatening bleeding, and fatal bleeding in the patients
treated with prasugrel compared with patients treated with
clopidogrel. There was net harm in patients with a history
of cerebrovascular events and no clinical benefit in patients
>75 years of age or those with low body weight (<60 kg).302
In patients with NSTE-ACS treated with an ischemia-guided
strategy, 1 RCT comparing aspirin and either clopidogrel or
prasugrel evaluated the primary endpoint of death from cardiovascular causes, MI, or stroke for up to 30 months; there
were similar bleeding rates and no benefit of treatment with
prasugrel when compared with treatment with clopidogrel.303
The ACCOAST (A Comparison of Prasugrel at the Time of
Percutaneous Coronary Intervention or as Pretreatment at
the Time of Diagnosis in Patients With NonST-Elevation
Myocardial Infarction) RCT of high-risk patients with NSTEACS scheduled to undergo early coronary angiography found
that a strategy of administration of prasugrel at the time of
randomization before angiography did not lead to a reduction in the composite primary endpoint when compared with
a strategy of administration of prasugrel only at the time of
PCI; however, it did lead to an increase in bleeding complications.304 On the basis of TRITON (Trial to Assess Improvement
in Therapeutic Outcomes by Optimizing Platelet Inhibition
with Prasugrel) study design and the results of TRILOGY
ACS (Targeted Platelet Inhibition to Clarify the Optimal
Strategy to Medically Manage Acute Coronary Syndromes)
and ACCOAST, prasugrel is not recommended for upfront
therapy in patients with NSTE-ACS. The use of prasugrel in
patients undergoing PCI is addressed in Section 5.
Ticagrelor
Ticagrelor is an oral, reversibly binding P2Y12 inhibitor with
a relatively short plasma half-life (12 hours). Compared with
clopidogrel, ticagrelor has a more rapid and consistent onset
of action and, because it is reversible, it has a faster recovery
of platelet function. The loading dose of ticagrelor for patients
treated either invasively or with an ischemia-guided strategy
is 180 mg followed by a maintenance dose of 90 mg twice
daily.293,294 In patients with NSTE-ACS treated with ticagrelor
compared with clopidogrel, there was a reduction in the composite outcome of death from vascular causes, MI, or stroke
(reduction: 11.7% to 9.8%; HR: 0.84; P<0.001).293 The mortality rate was also lower in those patients treated with ticagrelor. Although overall major bleeding was not increased with
ticagrelor, a modest increase in major bleeding and nonprocedure-related bleeding occurred in the subgroup of patients
who did not undergo CABG (major bleeding: 4.5% versus
3.8%; P=0.02; non-procedure major bleeding: 3.1% versus
2.3%; P=0.05); however, there was no difference in blood
transfusion or fatal bleeding.305 Side effects unique to ticagrelor include dyspnea (which occurs in up to 15% of patients
within the first week of treatment but is rarely severe enough
to cause discontinuation of treatment)293 and bradycardia. The
benefit of ticagrelor over clopidogrel was limited to patients
taking 75 mg to 100 mg of aspirin.290 The short half-life
requires twice-daily administration, which could potentially
result in adverse events in non-compliant patients, particularly
after stent implantation. When possible, ticagrelor should
be discontinued at least 5 days before surgery.306 Although
ticagrelor has not been studied in the absence of aspirin, its
use in aspirin-intolerant patients is a reasonable alternative.
Intravenous GP IIb/IIIa Receptor Inhibitors
The small molecule GP IIb/IIIa receptor antagonists, tirofiban
and eptifibatide, bind reversibly to the GP IIb/IIIa receptor.
Because the drug-to-receptor ratio is high, platelet infusion is
not effective in cases of severe bleeding after use of eptifibatide or tirofiban, and they must be cleared from the circulation
to reduce bleeding. In contrast, with abciximab, the drug-toreceptor ratio is low, and platelet infusion may be effective.
Several large RCTs evaluated the impact of GP IIb/IIIa
receptor inhibitors in patients with NSTE-ACS who were
committed to an invasive strategy.295,296,306 The ACUITY (Acute
Catheterization and Urgent Intervention Triage Strategy) trial
evaluated unfractionated heparin (UFH) versus bivalirudin with
or without GP IIb/IIIa inhibitors.295,307 The rates of composite
ischemia (death, MI, unplanned revascularization) in patients
who received bivalirudin alone compared with those who
received UFH plus GP IIb/IIIa inhibitors were similar (9% versus 8%; P=0.45).307 Fewer patients experienced major bleeding
with bivalirudin alone than did with heparin plus GP IIb/IIIa
inhibitors (4% versus 7%; relative risk [RR]: 0.52; 95% confidence interval [CI]: 0.40 to 0.66; P<0.0001).307 The ACUITY
Timing trial evaluated the benefit of upstream GP IIb/IIIa
receptor antagonist compared with its deferred use, testing the
hypothesis that earlier administration of GP IIb/IIIa inhibitors
in patients destined for PCI would be superior.308 Composite
ischemia at 30 days occurred in 7.9% of patients assigned to
deferred use compared with 7.1% assigned to upstream administration (RR: 1.12; 95% CI: 0.97 to 1.29; P=0.044 for noninferiority; P=0.13 for superiority). Deferred GP IIb/IIIa inhibitors
reduced the 30-day rates of major bleeding compared with
upstream use (4.9% versus 6.1%; P<0.001).308 Similar results
were reported by the EARLY ACS investigators, who evaluated
eptifibatide given upstream versus delayed, provisional administration in >9000 patients with NSTE-ACS.295 The composite endpoint of death, MI, recurrent ischemia requiring urgent
revascularization, or thrombotic complications occurred in
9.3% of patients in the early-eptifibatide group compared with
10% in the delayed-eptifibatide group (odds ratio [OR]: 0.92;
95% CI: 0.80 to 1.06; P=0.23).308 As in the ACUITY Timing
trial, the early-eptifibatide group had significantly higher rates
of bleeding and red cell transfusions.295,308

4.3.2. Initial Parenteral Anticoagulant Therapy in Patients
With Definite NSTE-ACS: Recommendations
See Table 7 for a summary of recommendations regarding
antiplatelet/anticoagulant therapy in patients with definite or
likely NSTE-ACS and Online Data Supplement 16 for additional information on combined oral anticoagulant therapy
and antiplatelet therapy in patients with definite NSTE-ACS.
Class I
1. In patients with NSTE-ACS, anticoagulation, in addition to antiplatelet therapy, is recommended for
all patients irrespective of initial treatment strategy.
Treatment options include:
Enoxaparin: 1 mg/kg subcutaneous (SC) every
12 hours (reduce dose to 1 mg/kg SC once daily
in patients with creatinine clearance [CrCl]
<30 mL/min), continued for the duration of hospitalization or until PCI is performed. An initial
intravenous loading dose of 30 mg has been used
in selected patients.133,136,309 (Level of Evidence: A)
Bivalirudin: 0.10 mg/kg loading dose followed by
0.25 mg/kg per hour (only in patients managed
with an early invasive strategy), continued until
diagnostic angiography or PCI, with only provisional use of GP IIb/IIIa inhibitor, provided the
patient is also treated with DAPT.292,293,310,311 (Level
of Evidence: B)
Fondaparinux: 2.5 mg SC daily, continued for the
duration of hospitalization or until PCI is performed.312314 (Level of Evidence: B)
If PCI is performed while the patient is on
fondaparinux, an additional anticoagulant with
anti-IIa activity (either UFH or bivalirudin) should
be administered because of the risk of catheter
thrombosis.313315 (Level of Evidence: B)
UFH IV: initial loading dose of 60 IU/kg (maximum 4000 IU) with initial infusion of 12 IU/kg per
hour (maximum 1000 IU/h) adjusted per activated
partial thromboplastin time to maintain therapeutic anticoagulation according to the specific hospital protocol, continued for 48 hours or until PCI is
performed.316322 (Level of Evidence: B)
4.3.2.1. Low-Molecular-Weight Heparin
LMWHs have a molecular weight approximately one third that
of UFH and have balanced anti-Xa and anti-IIa activity. LMWHs
are readily absorbed after subcutaneous administration and have
less platelet activation.323 The anticoagulant activity of LMWH
does not require routine monitoring. The dose of enoxaparin is 1
mg/kg SC every 12 hours for NSTE-ACS; an initial intravenous
loading dose of 30 mg has been used in selected patients. In the
presence of impaired renal function (CrCl <30 mL per minute),
which is a common finding in older patients, the dose should
be reduced to 1 mg/kg SC once daily, and strong consideration
should be given to UFH as an alternative. Calculation of CrCl is
prudent in patients considered for enoxaparin therapy.
In the ESSENCE trial, in patients with UA or nonQ-wave MI,
the rates of recurrent ischemic events and invasive diagnostic and
See Section 5.1.2.1 for recommendations at the time of PCI.
therapeutic procedures were significantly reduced by enoxaparin

therapy in the short term, and benefit was sustained at 1 year.324
In the SYNERGY (Superior Yield of the New Strategy
of Enoxaparin, Revascularization and Glycoprotein IIb/IIIa
Inhibitors) trial of high-risk patients with NSTE-ACS treated
with an early invasive strategy, there was no significant difference
in death or MI at 30 days between those randomized to enoxaparin versus UFH. There was more TIMI major bleeding in those
treated with enoxaparin without statistically significant increase
in GUSTO severe bleeding or transfusion. Some of the increased
bleeding may have been related to patients randomized to enoxaparin who received additional UFH at the time of PCI.325,326
4.3.2.2. Bivalirudin
The direct thrombin inhibitor bivalirudin is administered intravenously. Bivalirudin was evaluated in the ACUITY trial, a
randomized open-label trial, in 13819 moderate- to high-risk
patients with NSTE-ACS with a planned invasive strategy.
Three treatment arms were tested, including UFH or LMWH
with a GP IIb/IIIa receptor inhibitor, bivalirudin with a GP
IIb/IIIa receptor inhibitor, or bivalirudin alone. The majority
of patients received clopidogrel (300 mg) before intervention, in addition to aspirin, anticoagulants, and GP IIb/IIIa
inhibitors. Bivalirudin alone was noninferior to the standard
UFH/LMWH combined with GP IIb/IIIa inhibitor (composite
ischemia endpoint 7.8% versus 7.3%; HR: 1.08; P=0.32), but
there was a significantly lower rate of major bleeding with
bivalirudin (3.0% versus 5.7%; HR: 0.53; P<0.001).310 The
anticoagulant effect of bivalirudin can be monitored in the
catheterization laboratory by the activated clotting time.
4.3.2.3. Fondaparinux
Fondaparinux is a synthetic polysaccharide molecule and the
only selective inhibitor of activated factor X available for
clinical use. Fondaparinux is well absorbed when given subcutaneously and has a half-life of 17 hours, enabling oncedaily administration. Because it is excreted by the kidneys, it
is contraindicated if CrCl is <30 mL per minute. Monitoring
of anti-Xa activity is not required, and fondaparinux does not
affect usual anticoagulant parameters such as activated partial
thromboplastin time or activated clotting time. In NSTE-ACS,
the dose of fondaparinux is 2.5 mg SC administered daily and
continued for the duration of hospitalization or until PCI is performed.312314 In the OASIS (Organization to Assess Strategies
in Ischemic Syndromes)-5 study, patients with NSTE-ACS
were randomized to receive 2.5 mg SC fondaparinux daily
or enoxaparin 1 mg/kg SC twice daily for 8 days. The incidence of the primary composite ischemic endpoint at 9 days
was similar between fondaparinux and enoxaparin, but major
bleeding was significantly less frequent with fondaparinux. To
avert catheter thrombosis when fondaparinux is used alone in
patients undergoing PCI, an anticoagulant with anti-IIa activity is also administered.313315 One regimen is 85 IU/kg of UFH
loading dose at the time of PCI (reduced to 60 IU/kg if a GP
IIb/IIIa inhibitor is used concomitantly).314
4.3.2.4. Unfractionated Heparin
Studies supporting the addition of a parenteral anticoagulant
to aspirin in patients with NSTE-ACS were performed primarily on patients with a diagnosis of unstable angina in the era
before DAPT and early catheterization and revascularization.

In general, those studies found a strong trend for reduction in
composite adverse events with the addition of parenteral UFH
to aspirin therapy.316322
Clinical trials indicate that a weight-adjusted dosing regimen of UFH can provide more predictable anticoagulation327
than a fixed initial dose (eg, 5000 IU loading dose, 1000 IU/h
initial infusion). The recommended weight-adjusted regimen
is an initial loading dose of 60 IU/kg (maximum 4000 IU)
and an initial infusion of 12 IU/kg/h (maximum 1000 IU/h),
adjusted using a standardized nomogram.
4.3.2.5. Argatroban
Argatroban, a direct thrombin inhibitor, is indicated for prophylaxis or treatment of thrombosis in patients with heparininduced thrombocytopenia, including those undergoing PCI.328
Steady state plasma concentrations are achieved in 1 to 3 hours
after intravenous administration. Because of its hepatic metabolism, argatroban can be used in patients with renal insufficiency. The usual dose is 2 mcg/kg per minute by continuous
intravenous infusion, adjusted to maintain the activated partial
thromboplastin time at 1.5 to 3 times baseline (but not >100 s).
4.3.3. Fibrinolytic Therapy in Patients With Definite
NSTE-ACS: Recommendation
Class III: Harm

1. In patients with NSTE-ACS (ie, without ST-elevation,
true posterior MI, or left bundle-branch block not
known to be old), intravenous fibrinolytic therapy
should not be used.93,329 (Level of Evidence: A)
There is no role for fibrinolytic therapy in patients with NSTEACS. Fibrinolysis with or without subsequent PCI in patients
with NSTE-ACS was evaluated by the Fibrinolytic Trialists and
TIMI investigators.93,329 There was no benefit for mortality or
MI. Intracranial hemorrhage and fatal and nonfatal MI occurred
more frequently in patients treated with fibrinolytic therapy.
See Online Data Supplement 17 for additional information on parenteral anticoagulant and fibrinolytic therapy in
patients with definite NSTE-ACS.
4.4. Ischemia-Guided Strategy Versus Early

Invasive Strategies
See Figure3 for the management algorithm for ischemiaguided versus early invasive strategy.
4.4.1. General Principles
Two treatment pathways have emerged for all patients with
NSTE-ACS. The invasive strategy triages patients to an invasive diagnostic evaluation (ie, coronary angiography). In
contrast, the initial ischemia-guided strategy calls for an invasive evaluation for those patients who 1) fail medical therapy
(refractory angina or angina at rest or with minimal activity
despite vigorous medical therapy), 2) have objective evidence
of ischemia (dynamic electrocardiographic changes, myocardial perfusion defect) as identified on a noninvasive stress
test, or 3) have clinical indicators of very high prognostic risk
(eg, high TIMI or GRACE scores). In both strategies, patients
should receive optimal anti-ischemic and antithrombotic
medical therapy as outlined in Section 4.1. A subgroup of
patients with refractory ischemic symptoms or hemodynamic
or rhythm instability are candidates for urgent coronary angiography and revascularization.
4.4.2. Rationale and Timing for Early Invasive Strategy
This strategy seeks to rapidly risk stratify patients by assessing their coronary anatomy. The major advantages of invasive
therapy when appropriate are 1) the rapid and definitive nature
of the evaluation, 2) the potential for earlier revascularization
in appropriate patients that might prevent occurrence of further complications of ACS that could ensue during medical
therapy, and 3) facilitation of earlier discharge from a facility.
4.4.2.1. Routine Invasive Strategy Timing
The optimal timing of angiography has not been conclusively
defined. In general, 2 options have emerged: early invasive
(ie, within 24 hours) or delayed invasive (ie, within 25 to 72
hours). In most studies using the invasive strategy, angiography was deferred for 12 to 72 hours while antithrombotic and
anti-ischemic therapies were intensified.138,332337 The concept
of deferred angiography espouses that revascularization may
be safer once plaque is stabilized with optimal antithrombotic
and/or anti-ischemic therapies. Conversely, early angiography
facilitates earlier risk stratification and consequently speeds
revascularization and discharge but can place greater logistic
demands on a healthcare system.
4.4.3. Rationale for Ischemia-Guided Strategy
The ischemia-guided strategy seeks to avoid the routine
early use of invasive procedures unless patients experience
refractory or recurrent ischemic symptoms or develop hemodynamic instability. When the ischemia-guided strategy is
chosen, a plan for noninvasive evaluation is required to detect
severe ischemia that occurs at a low threshold of stress and to
promptly refer these patients for coronary angiography and
revascularization as indicated. The major advantage offered
by the ischemia-guided strategy is that some patients conditions stabilize during medical therapy and will not require
coronary angiography and revascularization. Consequently,
the ischemia-guided strategy may potentially avoid costly and
possibly unnecessary invasive procedures.
4.4.4. Early Invasive and Ischemia-Guided Strategies:
Recommendations
Class I
1. An urgent/immediate invasive strategy (diagnostic
angiography with intent to perform revascularization
if appropriate based on coronary anatomy) is indicated in patients (men and women) with NSTE-ACS
who have refractory angina or hemodynamic or electrical instability (without serious comorbidities or
contraindications to such procedures).42,44,138,338 (Level
of Evidence: A)
2. An early invasive strategy (diagnostic angiography
with intent to perform revascularization if appropriate based on coronary anatomy) is indicated in initially stabilized patients with NSTE-ACS (without
serious comorbidities or contraindications to such
procedures) who have an elevated risk for clinical
events (Table 8).42,44,138,333,334,338,339 (Level of Evidence: B)
See Section 7.7 for additional information on women.
Figure 3. Algorithm for Management of Patients With Definite or Likely NSTE-ACS.* *See corresponding full-sentence recommendations
and their explanatory footnotes. In patients who have been treated with fondaparinux (as upfront therapy) who are undergoing PCI, an
additional anticoagulant with anti-IIa activity should be administered at the time of PCI because of the risk of catheter thrombosis. ASA
indicates aspirin; CABG, coronary artery bypass graft; cath, catheter; COR, Class of Recommendation; DAPT, dual antiplatelet therapy;
GPI, glycoprotein IIb/IIIa inhibitor; LOE, Level of Evidence; NSTE-ACS, nonST-elevation acute coronary syndrome; PCI, percutaneous
coronary intervention; pts, patients; and UFH, unfractionated heparin.
Class IIa
1. It is reasonable to choose an early invasive strategy
(within 24 hours of admission) over a delayed invasive strategy (within 25 to 72 hours) for initially stabilized high-risk patients with NSTE-ACS. For those
not at high/intermediate risk, a delayed invasive approach is reasonable.139 (Level of Evidence: B)
Class IIb
1. In initially stabilized patients, an ischemia-guided strategy may be considered for patients with

Table 8. Factors Associated With Appropriate Selection
of Early Invasive Strategy or Ischemia-Guided Strategy in
Patients With NSTE-ACS
Immediate invasive
(within 2 h)
Refractory angina
Signs or symptoms of HF or new or worsening
mitral regurgitation
Hemodynamic instability
Recurrent angina or ischemia at rest or with
low-level activities despite intensive medical
therapy
Sustained VT or VF
Ischemia-guided strategy
Low-risk score (eg, TIMI [0 or 1],

GRACE [<109])
Low-risk Tn-negative female patients
Patient or clinician preference in the absence
of high-risk features
Early invasive (within 24 h)
None of the above, but GRACE risk score >140

Temporal change in Tn (Section 3.4)
New or presumably new ST depression
Delayed invasive (within

2572 h)
None of the above but diabetes mellitus Renal

insufficiency (GFR <60 mL/min/1.73 m2)
Reduced LV systolic function (EF <0.40)
Early postinfarction angina
PCI within 6 mo
Prior CABG
GRACE risk score 109140; TIMI score 2
CABG indicates coronary artery bypass graft; EF, ejection fraction; GFR, glo
merular filtration rate; GRACE, Global Registry of Acute Coronary Events; HF, heart
failure; LV, left ventricular; NSTE-ACS, nonST-elevation acute coronary syndrome;
PCI, percutaneous coronary intervention; TIMI, Thrombolysis In Myocardial Infarc
tion; Tn, troponin; VF, ventricular fibrillation; and VT, ventricular tachycardia.
STE-ACS (without serious comorbidities or contraN

indications to this approach) who have an elevated
risk for clinical events.333,334,338 (Level of Evidence: B)
2. The decision to implement an ischemia-guided strategy in initially stabilized patients (without serious
comorbidities or contraindications to this approach)
may be reasonable after considering clinician and
patient preference. (Level of Evidence: C)

1. An early invasive strategy (ie, diagnostic angiography with intent to perform revascularization) is not
recommended in patients with:
a. Extensive comorbidities (eg, hepatic, renal, pulmonary failure; cancer), in whom the risks of revascularization and comorbid conditions are likely to outweigh
the benefits of revascularization. (Level of Evidence: C)
b. Acute chest pain and a low likelihood of ACS who
are troponin-negative (Level of Evidence: C), especially women.141 (Level of Evidence: B)
Several studies93,138,334337 and meta-analyses141, 340 have concluded that a strategy of routine invasive therapy is generally
superior to an ischemia-guided strategy or selectively invasive
approach. One study reported that the routine invasive strategy
resulted in an 18% relative reduction in death or MI, including
a significant reduction in MI alone.341 The routine invasive arm
was associated with higher in-hospital mortality (1.8% versus

1.1%), but this disadvantage was more than compensated for by
a significant reduction in mortality between discharge and the
end of follow-up (3.8% versus 4.9%). The invasive strategy was
also associated with less angina and fewer rehospitalizations.
Patients undergoing routine invasive treatment also had improved
quality of life. In an analysis of individual patient data340 that
reported 5-year outcomes from the FRISC (Framingham and
Fast Revascularization During Instability in Coronary Artery
Disease)-II trial,339 ICTUS (Invasive Versus Conservative
Treatment in Unstable Coronary Syndromes) trial,338 and RITA
(Randomized Trial of a Conservative Treatment Strategy Versus
an Interventional Treatment Strategy in Patients with Unstable
Angina)-3 trial,334 14.7% of patients (389 of 2721) randomized
to a routine invasive strategy experienced cardiovascular death
or nonfatal MI versus 17.9% of patients (475 of 2746) in the
selective invasive strategy (HR: 0.81; 95% CI: 0.71 to 0.93;
P=0.002). The most marked treatment effect was on MI (10.0%
routine invasive strategy versus 12.9% selective invasive strategy), and there were consistent trends for fewer cardiovascular
deaths (HR: 0.83; 95% CI: 0.68 to 1.01; P=0.068) and all-cause
mortality (HR: 0.90; 95% CI: 0.77 to 1.05). There were absolute reductions of 2.0% to 3.8% in cardiovascular death or MI
in the low- and intermediate-risk groups and an 11.1% absolute
risk reduction in the highest-risk patients. The invasive strategy
demonstrated its greatest advantage in the highest-risk stratum
of patients with no significant benefit on mortality over the
noninvasive approach in moderate- and low-risk patients.342 An
ischemia-guided strategy has been used with favorable results in
initially stabilized patients with NSTE-ACS at elevated risk for
clinical events, including those with positive troponin levels.338
One limitation of these studies is the absence of adherence to
optimal medical therapy in non-invasively treated patients during long-term management. In addition, in FRISC-II, invasive
management was delayed and patients with markedly positive
stress tests (up to 2.9-mm exercise-induced ST depression) were
randomized to noninvasive or invasive therapy.338
on comparison of early invasive strategy and ischemia-guided
strategy.
4.4.4.1. Comparison of Early Versus Delayed Angiography
In some studies, early angiography and coronary intervention
have been more effective in reducing ischemic complications than
delayed interventions, particularly in patients at high risk (defined
by a GRACE score >140).139,336 A more delayed strategy is also
reasonable in low- to intermediate-risk patients. The advantage of
early intervention was achieved in the context of intensive background antithrombotic and anti-ischemic therapy. However, this
question was also assessed by a meta-analysis of 11 trials (7 RCTs
and 4 observational studies).343 Meta-analysis of the RCTs was
inconclusive for a survival benefit of the early invasive strategy
(OR: 0.83 [95% CI: 0.64 to 1.09]; P=0.180), and there were no significant differences in MI or major bleeding; a similar result was
found with the observational studies. These data are limited by the
small sample size of the individual trials, low event rates, inconsistency in timing of intervention, and heterogeneous patient profiles.
on comparison of early versus delayed angiography.

4.4.5. Subgroups: Early Invasive Strategy Versus IschemiaGuided Strategy
The TACTICS-TIMI (Treat Angina With Tirofiban and
Determine Cost of Therapy With an Invasive or Conservative
Strategy-Thrombolysis In Myocardial Infarction) 18 trial
demonstrated a reduction in the 6-month endpoint of death or
MI in older adults with ACS.138 Controversy exists over revascularization treatment differences between men and women
with ACS. The FRISC-II trial showed a benefit of revascularization in men for death or MI that was not observed for
women.344 In contrast, death, MI, or rehospitalization rates
were reduced for both men and women in TACTICS-TIMI
18.138 RITA-3 showed that the routine strategy of invasive
evaluation resulted in a beneficial effect in high-risk men that
was not seen in women.342 A meta-analysis suggests that in
NSTE-ACS, an invasive strategy has a comparable benefit in
men and high-risk women for reducing the composite endpoint of death, MI, or rehospitalization.141,345,346 In contrast, an
ischemia-guided strategy is preferred in low-risk women.141
Another collaborative meta-analysis of randomized trials
reported that an early invasive strategy yielded similar RR
reductions in overall cardiovascular events in patients with
and without diabetes mellitus.347 However, an invasive strategy appeared to reduce recurrent nonfatal MI to a greater
extent in patients with diabetes mellitus.
4.4.6. Care Objectives
Coronary angiography is designed to provide detailed information about the size and distribution of coronary vessels,
the location and extent of atherosclerotic obstruction, and the
suitability for revascularization. The LV angiogram, usually
performed with coronary angiography, provides an assessment of the extent of focal and global LV dysfunction and of
the presence and severity of coexisting disorders (eg, valvular
or other associated lesions). Patients with NSTE-ACS can be
divided into risk groups on the basis of their initial clinical
presentation. The TIMI, PURSUIT, and GRACE scores are
useful tools for assigning risk to patients with NSTE-ACS.
Risk stratification identifies patients who are most likely to
benefit from subsequent revascularization. Patients with left
main disease or multivessel CAD with reduced LV function
are at high risk for adverse outcomes and are likely to benefit
from CABG. Clinical evaluation and noninvasive testing aid
in the identification of most patients at high risk because they
often have 1 of the following high-risk features: advanced
age (>70 years of age), prior MI, revascularization, ST deviation, HF, depressed resting LV function (ie, LVEF 0.40) on
noninvasive study, or noninvasive stress test findings, including magnetic resonance imaging.348 Any of these risk factors
or diabetes mellitus may aid in the identification of high-risk
patients who could benefit from an invasive strategy.
Some patients with NSTE-ACS are not in the very highrisk group and do not have findings that portend a high risk
for adverse outcomes. They are not likely to receive the same
degree of benefit from routine revascularization afforded to
high-risk patients, and an invasive study is optional for those at
lower risk and can be safely deferred pending further clinical
evidence. Decisions about coronary angiography in patients
who are not at high risk according to findings on clinical
examination and noninvasive testing can be individualized on

the basis of patient preferences and/or symptoms.
4.5. Risk Stratification Before Discharge for Patients

With an Ischemia-Guided Strategy of NSTE-ACS:
Recommendations
Class I
1. Noninvasive stress testing is recommended in lowand intermediate-risk patients who have been free of
ischemia at rest or with low-level activity for a minimum of 12 to 24 hours.349353 (Level of Evidence: B)
2. Treadmill exercise testing is useful in patients able
to exercise in whom the ECG is free of resting ST
changes that may interfere with interpretation.349352
3. Stress testing with an imaging modality should be
used in patients who are able to exercise but have ST
changes on resting ECG that may interfere with interpretation. In patients undergoing a low-level exercise test, an imaging modality can add prognostic
information.349352 (Level of Evidence: B)
4. Pharmacological stress testing with imaging is recommended when physical limitations preclude adequate exercise stress. (Level of Evidence: C)
5. A noninvasive imaging test is recommended to evaluate LV function in patients with definite ACS.349352
The management of patients with NSTE-ACS requires continuous risk stratification. Important prognostic information is
derived from initial assessment, the patients course during the
early days of management, and the response to anti-ischemic
and antithrombotic therapy. The choice of stress test is based
on the patients resting ECG and ability to exercise, local
expertise, and available technologies. The exercise intensity
of the treadmill test (low level or symptom-limited) is used
at the discretion of the attending clinician based on individual patient assessment. For invasively managed patients with
residual nonculprit lesions, additional evaluation may be indicated to ascertain the significance of such lesions. Refer to the
PCI CPG for additional details.26
4.5.1. Noninvasive Test Selection
The goals of noninvasive testing in patients with a low or
intermediate likelihood of CAD and high-risk patients who
did not have an early invasive strategy are to detect ischemia
and estimate prognosis. This information guides further diagnostic steps and therapeutic measures.
Because of its simplicity, lower cost, and widespread familiarity with its performance and interpretation, the standard lowlevel exercise electrocardiographic stress test remains the most
reasonable test in patients who are able to exercise and who
have a resting ECG that is interpretable for ST shifts. There
is evidence that imaging studies are superior to exercise electrocardiographic evaluation in women for diagnosis of CAD.350
However, for prognostic assessment in women, treadmill exercise testing has provided comparable results to stress imaging.354 Patients with an electrocardiographic pattern that would
interfere with interpretation of the ST segment (baseline ST

abnormalities, bundle-branch block, LV hypertrophy with ST-T
changes, intraventricular conduction defect, paced rhythm,
pre-excitation, and digoxin) should have an exercise test with
imaging. Patients who are unable to exercise should have a
pharmacological stress test with imaging. Low- and intermediate-risk patients with NSTE-ACS may undergo symptom-limited stress testing, provided they have been asymptomatic and
clinically stable at 12 to 24 hours for those with UA and 2 to 5
days for patients at similar risk with NSTEMI.349 The optimal
testing strategy in women is less well defined than in men.
4.5.2. Selection for Coronary Angiography
In contrast to noninvasive tests, coronary angiography provides
detailed structural information for assessment of prognosis
and appropriate management. When combined with LV angiography, it also provides an assessment of global and regional
LV function. Coronary angiography is usually indicated in
patients with NSTE-ACS who have recurrent symptoms or
ischemia despite adequate medical therapy or who are at high
risk as categorized by clinical findings (HF, serious ventricular
arrhythmias), noninvasive test findings (significant LV dysfunction with EF <0.40, large anterior or multiple perfusion defects
or wall motion abnormalities on echocardiography, high-risk
Duke treadmill score 11), high-risk TIMI or GRACE scores,
or markedly elevated troponin levels. Patients with NSTE-ACS
who have had previous PCI or CABG should also be considered
for early coronary angiography, unless prior coronary angiography data indicate that no further revascularization is feasible.
The general indications for coronary angiography and
revascularization should be tempered by individual patient
characteristics and preferences (a patient-centered approach).
Patient and clinician judgments about risks and benefits are
important for patients who might not be candidates for coronary revascularization, such as very frail older adults and
those with serious comorbid conditions (eg, severe hepatic,
pulmonary, or renal failure; active or inoperable cancer).
on risk stratification.
5. Myocardial Revascularization
Recommendations about coronary artery revascularization
indications, benefits, and choice of revascularization procedure (PCI or CABG) for all anatomic subsets have been published in the 2011 PCI CPG,26 the 2011 CABG CPG,23 and the
2012 stable ischemic heart disease CPG and its 2014 focused
update.10,11 The main difference between management of
patients with stable ischemic heart disease and NSTE-ACS is
a stronger impetus for revascularization in those with NSTEACS. Myocardial ischemia in ACS may progress to MI and
is potentially life threatening. In addition, in patients with
ACS, angina (including recurrent angina) is more likely to be
reduced by revascularization than by medical therapy.26
A heart team approach to revascularization decisions, involving an interventional cardiologist and cardiothoracic surgeon, is used in patients with unprotected left
main or complex CAD. Calculation of SYNTAX (Synergy
Between Percutaneous Coronary Intervention With TAXUS
and Cardiac Surgery) and STS scores is reasonable in these
patients to guide the choice of revascularization.23,26,355
Factors that influence the choice of revascularization procedure include the extent and complexity of CAD; short-term
risk and long-term durability of PCI; operative mortality
(which can be estimated by the STS score); diabetes mellitus;
CKD; completeness of revascularization; LV systolic dysfunction; previous CABG; and the ability of the patient to tolerate and comply with DAPT. In general, the greater the extent
and complexity of the multivessel disease, the more compelling the choice of CABG over multivessel PCI.23,26,356358
In patients with NSTE-ACS, PCI of a culprit unprotected left
main coronary artery lesion is an option if the patient is not a
candidate for CABG.23,26
See Online Data Supplements 21 and 22 for additional
information on myocardial revascularization.
5.1. Percutaneous Coronary Intervention

5.1.1. PCIGeneral Considerations: Recommendation
Class IIb
1. A strategy of multivessel PCI, in contrast to culprit lesiononly PCI, may be reasonable in patients undergoing coronary revascularization as
part of treatment for NSTE-ACS.330,359364 (Level of
Evidence: B)
Approximately half of all PCI procedures are performed in
patients with UA or NSTEMI, and approximately 32% to
40% of patients with NSTE-ACS will undergo PCI.365 As
discussed previously, in patients with NSTE-ACS, a strategy
of early angiography and revascularization (primarily with
PCI) results in lower rates of recurrent UA, recurrent rehospitalization, MI, and death.366,367 Although PCI of a nonculprit lesion is not advocated in patients with STEMI,26 there is
less agreement on whether nonculprit lesions should undergo
intervention at the time of culprit-lesion PCI for NSTE-ACS.
Most reports,359364 but not all,330 comparing culprit lesion
only PCI with multivessel PCI (eg, PCI of multiple vessels
performed at the same time) in patients with NSTE-ACS did
not find an increased risk of MACE with multivessel PCI and
found a reduction in the need for repeat revascularization.
However, the data consist predominantly of post hoc analysis
of nonrandomized data with variable duration of follow-up.
This question has not been resolved and is an area of current
investigation.
5.1.2. PCIAntiplatelet and Anticoagulant Therapy
5.1.2.1. Oral and Intravenous Antiplatelet Agents:
Recommendations
Class I
1. Patients already taking daily aspirin before PCI
should take 81 mg to 325 mg nonenteric-coated aspirin before PCI.26,368370 (Level of Evidence: B)
2. Patients not on aspirin therapy should be given non
enteric- coated aspirin 325 mg as soon as possible before PCI.26,368370 (Level of Evidence: B)
3. After PCI, aspirin should be continued indefinitely
at a dose of 81 mg to 325 mg daily.27,288,371 (Level of
Evidence: B)

4. A loading dose of a P2Y12 receptor inhibitor should
be given before the procedure in patients undergoing
PCI with stenting.26,293,302,331,372375 (Level of Evidence: A)
Options include:
a. Clopidogrel: 600 mg331,372374,376378 (Level of Evidence:
B) or
b. Prasugrel#: 60 mg302 (Level of Evidence: B) or
c. Ticagrelor: 180 mg293 (Level of Evidence: B)
5. In patients with NSTE-ACS and high-risk features
(eg, elevated troponin) not adequately pretreated
with clopidogrel or ticagrelor, it is useful to administer a GP IIb/IIIa inhibitor (abciximab, double-bolus
eptifibatide, or high-dose bolus tirofiban) at the time
of PCI.379382 (Level of Evidence: A)
6. In patients receiving a stent (bare-metal stent or
drug-eluting stent [DES]) during PCI for NSTEACS, P2Y12 inhibitor therapy should be given for at
least 12 months.330 Options include:
a. Clopidogrel: 75 mg daily296,331 (Level of Evidence:
B) or
b. Prasugrel#: 10 mg daily302 (Level of Evidence: B) or
c. Ticagrelor: 90 mg twice daily293 (Level of
Evidence: B)
Class IIa
1. It is reasonable to choose ticagrelor over clopidogrel for P2Y12 inhibition treatment in patients with
NSTE-ACS treated with an early invasive strategy
and/or coronary stenting.293,294 (Level of Evidence: B)
2. It is reasonable to choose prasugrel over clopidogrel
for P2Y12 treatment in patients with NSTE-ACS who
undergo PCI who are not at high risk of bleeding
complications.302,303 (Level of Evidence: B)
(eg, elevated troponin) treated with UFH and adequately pretreated with clopidogrel, it is reasonable
to administer a GP IIb/IIIa inhibitor (abciximab,
double-bolus eptifibatide, or high-bolus dose tirofiban) at the time of PCI.195,383,384 (Level of Evidence: B)
4. After PCI, it is reasonable to use 81 mg per day of
aspirin in preference to higher maintenance doses.331,368,385388 (Level of Evidence: B)
5. If the risk of morbidity from bleeding outweighs the
anticipated benefit of a recommended duration of
P2Y12 inhibitor therapy after stent implantation, earlier discontinuation (eg, <12 months) of P2Y12 inhibitor therapy is reasonable.330 (Level of Evidence: C)
Class IIb
1. Continuation of DAPT beyond 12 months may be
considered in patients undergoing stent implantation. (Level of Evidence: C)
#Patients should receive a loading dose of prasugrel, provided that they
were not pretreated with another P2Y12 receptor inhibitor.
Class III: Harm

1. Prasugrel should not be administered to patients
with a prior history of stroke or transient ischemic
attack.302 (Level of Evidence: B)
Comprehensive recommendations on the use of antiplatelet
and anticoagulant therapy in patients with NSTE-ACS undergoing PCI are given in the 2011 PCI CPG.26 Aspirin reduces the
frequency of ischemic complications after PCI and is ideally
administered at least 2 hours, and preferably 24 hours, before
PCI.26,368,369 DAPT, consisting of aspirin and a P2Y12 inhibitor,
in patients treated with coronary stents reduces the risk of stent
thrombosis and composite ischemic events.296,331,372375,389,390
Compared with a loading dose of 300 mg of clopidogrel, a loading dose of 600 mg of clopidogrel in patients undergoing PCI
achieves greater platelet inhibition with fewer low responders
and decreases the incidence of MACE.376378 In patients with
ACS who have undergone coronary stenting, treatment with
prasugrel or ticagrelor, compared with treatment with clopidogrel, results in a greater reduction in composite ischemic
events and the incidence of stent thrombosis, although at a
risk of increased nonCABG bleeding.293,302 The optimal duration of DAPT therapy in patients treated with DES is not well
established.26 However, aspirin is continued indefinitely in all
patients managed with a bare-metal stent or DES, and DAPT is
an option for >12months in patients who have received a DES.
This determination should balance the risks of stent thrombosis and ischemic complications versus bleeding and should be
jointly made by the clinician and the patient.
Loading and short-term maintenance doses of clopidogrel were studied in CURRENTOASIS (Clopidogrel
Optimal Loading Dose Usage to Reduce Recurrent Events
Organization to Assess Strategies in Ischemic Syndromes)
7, which demonstrated a potential benefit of higher-dose
clopidogrel (600-mg loading dose, 150 mg daily for 6 days,
75 mg daily thereafter) in patients with NSTE-ACS undergoing an invasive management strategy.292,391 Although the
overall trial292 failed to demonstrate a significant difference
in the primary endpoint between the clopidogrel and aspirin
groups (4.2% versus 4.4%), the PCI subset (n=17263) showed
significant differences in the clopidogrel arm.391 Notably, the
higher-dose clopidogrel therapy increased major bleeding in
the entire group (2.5% versus 2.0%; P=0.012) and the PCI
subgroup (1.1% versus 0.7%; P=0.008). In addition, during
the period of several hours required for conversion of clopidogrel to its active metabolite, there is reduced effectiveness.
However, efficacy is restored following conversion.
Patients undergoing PCI who have previously received a
loading dose of 300 mg of clopidogrel and are on a 75-mg
daily maintenance dose should receive another 300-mg
loading dose.315 There are no data appropriate for prasugrel
because this drug is administered before PCI. For ticagrelor,
there are no data on additional loading.
5.1.2.2. GP IIb/IIIa Inhibitors: Recommendations
Class I
1. In patients with NSTE-ACS and high-risk features (eg,
elevated troponin) who are not adequately pretreated

with clopidogrel or ticagrelor, it is useful to administer
a GP IIb/IIIa inhibitor (abciximab, double-bolus eptifibatide, or high-dose bolus tirofiban) at the time of
PCI.379382 (Level of Evidence: A)
Class IIa
(eg, elevated troponin) treated with UFH and adequately pretreated with clopidogrel, it is reasonable
to administer a GP IIb/IIIa inhibitor (abciximab,
double-bolus eptifibatide, or high-dose bolus tirofiban) at the time of PCI.195,383 (Level of Evidence: B)
GP IIb/IIIa receptor antagonist therapy in patients with
NSTE-ACS undergoing PCI reduced the incidence of composite ischemic events, primarily through a decrease in
documented MI, although in some trials this is counterbalanced by an increased rate of bleeding.193,195,310,379382,392
Most, but not all, randomized trials of the use of GP IIb/IIIa
inhibitor were conducted in the era before clopidogrel
therapy.193,195,310,379383,392 Abciximab, double-bolus eptifibatide, and high-bolus dose tirofiban result in a high degree of
platelet inhibition, reduce ischemic complications in patients
undergoing PCI, and appear to afford comparable angiographic and clinical outcomes.26 As trials of the GP IIb/IIIa
inhibitors generally excluded patients at high risk of bleeding, recommendations for the use of GP IIb/IIIa inhibitors
are best understood as applying to patients not at high risk of
bleeding complications. Although GP IIb/IIIa inhibitors were
used in 27% and 55% of patients, respectively, in the PLATO
(Platelet Inhibition and Patient Outcomes) and TRITON
studies of ticagrelor and prasugrel, there are insufficient
data293,302,393 (and no RCT data) from which to make specific
recommendations about GP IIb/IIIa inhibitor use in patients
treated with either of these P2Y12 inhibitors.
on GP IIb/IIIa inhibitors.
5.1.2.3. Anticoagulant Therapy in Patients Undergoing PCI:
Recommendations
Class I
1. An anticoagulant should be administered to patients
with NSTE-ACS undergoing PCI to reduce the risk
of intracoronary and catheter thrombus formation.
2. Intravenous UFH is useful in patients with NSTEACS undergoing PCI. (Level of Evidence: C)
3. Bivalirudin is useful as an anticoagulant with or
without prior treatment with UFH in patients with
NSTE-ACS undergoing PCI.310,394398 (Level of Evidence: B)
4. An additional dose of 0.3 mg/kg IV enoxaparin
should be administered at the time of PCI to patients with NSTE-ACS who have received fewer
than 2 therapeutic subcutaneous doses (eg, 1 mg/kg
SC) or received the last subcutaneous enoxaparin
dose 8 to 12 hours before PCI.309,399403 (Level of Evidence: B)
5. If PCI is performed while the patient is on

fondaparinux, an additional 85 IU/kg of UFH should
be given intravenously immediately before PCI because of the risk of catheter thrombosis (60 IU/kg
IV if a GP IIb/IIIa inhibitor used with UFH dosing
based on the target-activated clotting time).26,313315,404
6. In patients with NSTE-ACS, anticoagulant therapy
should be discontinued after PCI unless there is a
compelling reason to continue such therapy. (Level of
Evidence: C)
Class IIa
1. In patients with NSTE-ACS undergoing PCI who are
at high risk of bleeding, it is reasonable to use bivalirudin monotherapy in preference to the combination
of UFH and a GP IIb/IIIa receptor antagonist.310,396
Class IIb
1. Performance of PCI with enoxaparin may be reasonable in patients treated with upstream subcutaneous
enoxaparin for NSTE-ACS.26,309,399402,405,406 (Level of
Evidence: B)
Class III: Harm

1. Fondaparinux should not be used as the sole anticoagulant to support PCI in patients with NSTEACS due to an increased risk of catheter thrombosis.26,313315 (Level of Evidence: B)
Anticoagulant therapy prevents thrombus formation at the
site of arterial injury, on the coronary guide wire, and in the
catheters used for PCI.26,407 With rare exceptions, all PCI
studies have used some form of anticoagulant at the time
of PCI.26 Intravenous UFH and bivalirudin both have Class
I recommendations in patients undergoing PCI in the 2011
PCI CPG.26 Patients who have received multiple doses of
subcutaneously-administered enoxaparin who undergo PCI
within 8 hours of the last subcutaneous dose generally have
received adequate anticoagulation to undergo PCI, but the
degree of anticoagulation may diminish 8 to 12 hours after
the last subcutaneous dose. In such patients, as well as in
patients who have received fewer than 2 subcutaneous doses
of enoxaparin, the addition of enoxaparin (0.3 mg/kg IV) at
the time of PCI provides additional anticoagulation and has
become standard practice.26,309,399403 Patients who undergo
PCI >12 hours after the last subcutaneous dose of enoxaparin are usually treated with full-dose de novo anticoagulation with an established regimen (eg, full-dose UFH or
bivalirudin). Fondaparinux as the sole anticoagulant during
PCI has been associated with catheter thrombosis, and use
of an anticoagulant with anti-IIa activity is recommended
when patients treated with fondaparinux undergo PCI.313315
One suggested regimen is UFH 85 IU/kg IV if no GP IIb/IIIa
inhibitor is used and 60 IU/kg IV if a GP IIb/IIIa inhibitor is
used with UFH dosing based on the target-activated clotting
time314,404 (Table 9).26,313315

Table 9. Dosing of Parenteral Anticoagulants During PCI
Drug*
Enoxaparin
In Patients Who Have Received

Prior Anticoagulant Therapy
In Patients Who Have Not Received

Prior Anticoagulant Therapy
For prior treatment with enoxaparin, if last SC dose was administered

812 h earlier or if <2 therapeutic SC doses of enoxaparin have been
administered, an IV dose of enoxaparin 0.3 mg/kg should be given
0 .5 mg/kg-0.75 mg/kg IV loading dose
If the last SC dose was administered within prior 8 h, no additional

enoxaparin should be given
Bivalirudin
For patients who have received UFH, wait 30 min, then give 0.75 mg/kg
IV loading dose, then 1.75 mg/kg/h IV infusion
0 .75 mg/kg loading dose, 1.75 mg/kg/h IV infusion
For patients already receiving bivalirudin infusion, give additional

loading dose 0.5 mg/kg and increase infusion to 1.75 mg/kg/h
during PCI
Fondaparinux
For prior treatment with fondaparinux, administer additional IV

treatment with anticoagulant possessing anti-IIa activity, considering
whether GPI receptor antagonists have been administered
N/A
UFH
IV GPI planned: additional UFH as needed (eg, 20005000 U) to

achieve ACT of 200250 s
IV GPI planned: 5070 U/kg loading dose to achieve ACT of

200250 s
No IV GPI planned: additional UFH as needed (eg, 20005000 U) to

achieve ACT of 250300 s for HemoTec, 300350 s for Hemochron
No IV GPI planned: 70100 U/kg loading dose to achieve target

ACT of 250300 s for HemoTec, 300350 s for Hemochron
*Drugs presented in order of the COR and then the LOE as noted in the Preamble. When more than 1 drug exists within the same LOE, and there are no comparative
data, then the drugs are listed alphabetically.
ACT indicates activated clotting time; COR, Class of Recommendation; GPI, glycoprotein IIb/IIIa inhibitor; IV, intravenous; LOE, Level of Evidence; N/A, not applicable;
PCI, percutaneous coronary intervention; SC, subcutaneous; and UFH, unfractionated heparin.
Modified from Levine et al.26
5.2. Timing of Urgent CABG in Patients With

NSTE-ACS in Relation to Use of Antiplatelet
Agents: Recommendations
Class I
1. Nonenteric-coated aspirin (81 mg to 325 mg daily)
should be administered preoperatively to patients
undergoing CABG.408410 (Level of Evidence: B)
2. In patients referred for elective CABG, clopidogrel
and ticagrelor should be discontinued for at least
5days before surgery23,411413 (Level of Evidence: B)
and prasugrel for at least 7 days before surgery.8,414
3. In patients referred for urgent CABG, clopidogrel
and ticagrelor should be discontinued for at least
24hours to reduce major bleeding.8,412,415417 (Level of
Evidence: B)
4. In patients referred for CABG, short-acting intravenous GP IIb/IIIa inhibitors (eptifibatide or tirofiban)
should be discontinued for at least 2 to 4 hours before
surgery418,419 and abciximab for at least 12 hours before to limit blood loss and transfusion.389 (Level of
Evidence: B)
Class IIb
1. In patients referred for urgent CABG, it may be
reasonable to perform surgery less than 5 days after
clopidogrel or ticagrelor has been discontinued and
less than 7 days after prasugrel has been discontinued. (Level of Evidence: C)
In-hospital CABG is performed in 7% to 13% of patients
hospitalized with NSTE-ACS.420422 Approximately one third
of patients with NSTEMI undergo CABG within 48 hours of

hospital admission.421 In these patients, CABG was performed
at a median time of 73 hours after admission (interquartile
range: 42 to 122 hours).421 In-hospital mortality in patients
with NSTEMI undergoing CABG is approximately 3.7%.421
Recommendations for management of patients treated
with oral and intravenous antiplatelet agents who undergo
CABG are given in the 2011 CABG CPG.23 Preoperative
aspirin reduces operative morbidity and mortality, and CABG
can be performed safely in patients on aspirin therapy with
only a modest increase in bleeding risk.23,408410 The use of
P2Y12 inhibitors in patients with NSTE-ACS is associated
with an increase in postCABG bleeding and the need for
transfusion.293,302,411,413,423425 Although it is recommended that
clopidogrel and ticagrelor be discontinued at least 5 days
before surgery and prasugrel at least 7 days before surgery
in patients referred for elective CABG,23,411413 the timing
of CABG in patients with NSTE-ACS treated with a P2Y12
inhibitor330 should reflect a balance of the potential increase
in bleeding against the potential benefits of not delaying surgery 5 to 7 days. The risk of major bleeding complications
is increased when CABG is performed <24 hours after discontinuation of clopidogrel.23,416,417 In patients who undergo
CABG 1 to 4 days after discontinuation of clopidogrel, it
appears that the incidence of life-threatening bleeding is not
significantly increased, but an increase in blood transfusions is
likely.23,415,416,425,426 In the TRITON-TIMI 38 trial,302 the incidence of CABG-related major bleeding was higher in patients
treated with prasugrel than in patients treated with clopidogrel.23,386 In the PLATO trial, the rates of major bleeding and
transfusion requirements were similar between patients treated
with ticagrelor and patients treated with clopidogrel.294 The
more rapid recovery of platelet function in pharmacokinetic

studies of ticagrelor did not translate to a lower risk of bleeding or lessen the need for transfusion compared with clopidogrel when CABG was performed early (ie, <5 days) after drug
discontinuation.23,293,412
See Online Data Supplements 21 and 22 for more information on myocardial revascularization.
6. Late Hospital Care, Hospital Discharge,

And Posthospital Discharge Care
6.1. General Principles (Cardioprotective Therapy
and Symptom Management)
The goals of therapy after NSTE-ACS are to restore the patient
to normal activities to the extent possible and to use the acute
event to re-evaluate the plan of care, particularly lifestyle and
risk factor modification. Aggressive risk factor modifications
that can prolong survival should be the main goal of long-term
management of patients with stable CAD. Patients presenting
with NSTE-ACS represent a high-risk cohort in whom secondary cardiovascular disease prevention is likely to be particularly effective (Table 10). Clinicians have an opportunity
to provide evidence-based care to this high-risk cohort and
to aggressively treat the underlying atherosclerotic process
through lifestyle modification and effective pharmacological
therapies.427 In most cases, the inpatient anti-ischemic medical regimen should be continued after discharge, and the antiplatelet/anticoagulant medications should be changed to an
outpatient regimen. The goals for continued medical therapy
after discharge relate to potential prognostic benefits (primarily shown for antiplatelet agents, beta blockers, statins, and
inhibitors of the renin-angiotensin aldosterone system, especially for LVEF <0.40). Added benefits are control of ischemic
symptoms (nitrates, beta blockers, CCBs, and ranolazine) and
treatment of major risk factors such as smoking, hypertension,
dyslipidemia, physical inactivity, obesity, and diabetes mellitus.427 Selection of a medical regimen should be individualized to each patient on the basis of in-hospital findings, risk
factors for CAD, drug tolerability, and recent procedural interventions. The mnemonic ABCDE (Aspirin, Antianginals,
and ACE Inhibitors; Beta Blockers and BP; Cholesterol
and Cigarettes; Diet and Diabetes Mellitus; Education and
Exercise) is useful in guiding treatment.428
6.2. Medical Regimen and Use of Medications at

Discharge: Recommendations
Class I
1. Medications required in the hospital to control ischemia should be continued after hospital discharge in
patients with NSTE-ACS who do not undergo coronary revascularization, patients with incomplete or
unsuccessful revascularization, and patients with recurrent symptoms after revascularization. Titration of
the doses may be required.427,428 (Level of Evidence: C)
2. All patients who are postNSTE-ACS should be given sublingual or spray nitroglycerin with verbal and
written instructions for its use.429 (Level of Evidence: C)
3. Before hospital discharge, patients with NSTE-ACS
should be informed about symptoms of worsening
myocardial ischemia and MI and should be given

verbal and written instructions about how and when
to seek emergency care for such symptoms.429 (Level
of Evidence: C)
4. Before hospital discharge, patients who are post
NSTE-ACS and/or designated responsible caregivers should be provided with easily understood and
culturally sensitive verbal and written instructions
about medication type, purpose, dose, frequency, side
effects, and duration of use.429 (Level of Evidence: C)
5. For patients who are postNSTE-ACS and have initial angina lasting more than 1 minute, nitroglycerin
(1 dose sublingual or spray) is recommended if angina does not subside within 3 to 5 minutes; call 9-1-1
immediately to access emergency medical services.429
6. If the pattern or severity of angina changes, suggesting worsening myocardial ischemia (eg, pain is more
frequent or severe or is precipitated by less effort or
occurs at rest), patients should contact their clinician
without delay to assess the need for additional treatment or testing.429 (Level of Evidence: C)
7. Before discharge, patients should be educated about
modification of cardiovascular risk factors.428 (Level
of Evidence: C)
6.2.1. Late Hospital and Posthospital Oral Antiplatelet
Therapy: Recommendations
Class I
1. Aspirin should be continued indefinitely. The maintenance dose should be 81 mg daily in patients treated
with ticagrelor and 81 mg to 325 mg daily in all other
patients.288290 (Level of Evidence: A)
2. In addition to aspirin, a P2Y12 inhibitor (either clopidogrel or ticagrelor) should be continued for up to
12 months in all patients with NSTE-ACS without
contraindications who are treated with an ischemiaguided strategy. Options include:
Clopidogrel: 75 mg daily289,296 (Level of Evidence:
B) or
Ticagrelor: 90 mg twice daily293,294 (Level of
Evidence: B)
3. In patients receiving a stent (bare-metal stent or
DES) during PCI for NSTE-ACS, P2Y12 inhibitor
therapy should be given for at least 12 months.330
Options include:
Clopidogrel: 75 mg daily296,331 (Level of Evidence:
B) or
Prasugrel#: 10 mg daily302 (Level of Evidence: B) or
Ticagrelor: 90 mg twice daily293 (Level of Evi
dence: B)
Class IIa
1. It is reasonable to use an aspirin maintenance dose of
81 mg per day in preference to higher maintenance
#Patients should receive a loading dose of prasugrel, provided they
were not pretreated with another P2Y12 receptor inhibitor.

Table 10. Plan of Care for Patients With NSTE-ACS
Plan of Care
Resources/References
Medications
Antithrombotic therapies
Sections 6.2.1 and 6.2.2
Beta blockers
Section 4.1.2.3
ACE inhibitors/ARBs/aldosterone antagonists
Section 4.2
CCBs
Section 4.1.2.4
Statins
2013 Blood cholesterol CPG18
Discontinuation of antithrombotic therapies for elective surgical

and medical procedures with increased risk of bleeding
2014 SIHD focused update10

2012 SIHD CPG11
2012 Management of AMI in patients with persistent STEMI CPG19
2011 Secondary prevention CPG27
2007 Science Advisory on the prevention of premature discontinuation of DAPT
in patients with coronary artery stents504
Inappropriate use of analgesics (NSAIDs)
2010 Expert consensus document on PPIs and thienopyridines430
Use of PPIs
2011 PCI CPG26
Risk factor modification/lifestyle interventions and physical activity/cardiac rehabilitation

Smoking cessation
Tobacco cessation toolkit505
Diet nutrition
2013 Lifestyle CPG15
Physical activity

Cardiorespiratory fitness (MET capacity)

2010 Performance measures on cardiac rehabilitation454
2012 Scientific statement on sexual activity and cardiovascular disease231
Management of comorbidities
Overweight/obesity
2013 Obesity CPG16

Statins

2013 Blood cholesterol CPG18
Hypertension
2014 Report on high BP501

2013 Science advisory on high BP control506
Diabetes mellitus
2013 Position statement on standards of medical care in diabetes507
HF
2013 HF CPG14
Arrhythmia/Arrhythmia risk
2012 Focused update incorporated into the 2008 DBT CPG20

2014 AF CPG12
Psychosocial factors
Sexual activity
2012 Scientific statement on sexual activity and cardiovascular disease231

2013 Consensus document on sexual counseling for individuals with
cardiovascular disease and their partners508
Gender-Specific issues
2007 Cardiovascular disease prevention in women CPG475
Depression, stress, and anxiety
2008 Science advisory on depression and coronary heart disease509
Alcohol use
Culturally sensitive issues
2009 Consensus report on a comprehensive framework and preferred

practices for measuring and reporting cultural competency510
Return to work schedule

Clinician follow-up
Cardiologist

2013 Hospital to Home Quality Initiative511
Primary care clinician

Advanced practice nurse/physician assistant
Pharmacists
2013 Discharge counseling for patients with HF or MI512
Other relevant medical specialists

Electronic personal health records
Influenza vaccination
2005 Recommendations for prevention and control of influenza37
(Continued)

Table 10. Continued
Plan of Care
Resources/References
Patient/family education
Plan of care for AMI
2010 CPG for cardiopulmonary resuscitation and emergency cardiovascular

carepart 9: postcardiac arrest care31
2013 STEMI CPG17
Recognizing symptoms of MI
Activating EMS, signs and symptoms for urgent vs. emergency evaluations
CPR training for family members
Risk assessment and prognosis
Advanced directives
Social networks/social isolation
Socioeconomic factors
Access to health insurance coverage
Access to clinicians
Effective communication and care coordination513
Disability
Cardiovascular disability: updating Social Security listings514
Social services
Community services
ACE indicates angiotensin-converting enzyme; AF, atrial fibrillation; AMI, acute myocardial infarction; ARB, angiotensin receptor blocker; BP, blood pressure; CCB,
calcium channel blocker; CPG, clinical practice guideline; CPR, cardiopulmonary resuscitation; DAPT, dual antiplatelet therapy; DBT, device-based therapy; ECC, emergency
cardiovascular care; EMS, emergency medical services; HF, heart failure; MET, metabolic equivalent; MI, myocardial infarction; NSAID, nonsteroidal anti-inflammatory
drug; NSTE-ACS, nonT-elevation acute coronary syndromes; PCI, percutaneous coronary intervention; PPI, protein pump inhibitor; SIHD, stable ischemic heart disease;
and STEMI, ST-elevation myocardial infarction.
doses in patients with NSTE-ACS treated either invasively or with coronary stent implantation.26,331,368,385388
2. It is reasonable to use ticagrelor in preference to clopidogrel for maintenance P2Y12 treatment in patients
with NSTE-ACS who undergo an early invasive or
ischemia-guided strategy.293,294 (Level of Evidence: B)
3. It is reasonable to choose prasugrel over clopidogrel
for maintenance P2Y12 treatment in patients with
NSTE-ACS who undergo PCI who are not at high risk
for bleeding complications.302,303 (Level of Evidence: B)
4. If the risk of morbidity from bleeding outweighs the
anticipated benefit of a recommended duration of
P2Y12 inhibitor therapy after stent implantation, earlier discontinuation (eg, <12 months) of P2Y12 inhibitor therapy is reasonable.330 (Level of Evidence: C)
Class IIb
1. Continuation of DAPT beyond 12 months may be
considered in patients undergoing stent implantation. (Level of Evidence: C)
6.2.2. Combined Oral Anticoagulant Therapy and
Antiplatelet Therapy in Patients With NSTE-ACS
Class I
1. The duration of triple antithrombotic therapy with
a vitamin K antagonist, aspirin, and a P2Y12 receptor inhibitor in patients with NSTE-ACS should be
minimized to the extent possible to limit the risk of
bleeding. (Level of Evidence: C)
2. Proton pump inhibitors should be prescribed in patients with NSTE-ACS with a history of gastroin-
testinal bleeding who require triple antithrombotic

therapy with a vitamin K antagonist, aspirin, and a
P2Y12 receptor inhibitor.26,430,431 (Level of Evidence: C)
Class IIa
1. Proton pump inhibitor use is reasonable in patients
with NSTE-ACS without a known history of gastrointestinal bleeding who require triple antithrombotic
therapy with a vitamin K antagonist, aspirin, and a
P2Y12 receptor inhibitor.26,430,431 (Level of Evidence: C)
Class IIb
1. Targeting oral anticoagulant therapy to a lower international normalized ratio (INR) (eg, 2.0 to 2.5)
may be reasonable in patients with NSTE-ACS managed with aspirin and a P2Y12 inhibitor. (Level of
Evidence: C)
The combination of oral antiplatelet therapy and oral anticoagulant therapy significantly increases the risk of bleeding. This risk varies widely, but on average, the addition of a
single antiplatelet agent increased the risk of bleeding from a
range of 2% to 3% to a range of 4% to 6%, whereas the addition of DAPT to oral anticoagulant therapy (triple therapy)
increased the risk of bleeding from a range of 4% to 6% to a
range of 10% to 14%.432435 This risk was also related to the
duration of triple therapy.
In patients with NSTE-ACS in whom there are indications for triple therapy, the benefit of such therapy in terms
of prevention of stent thrombosis, thromboembolic events,
and recurrent MI must be weighed against the risk of bleeding
complications. Similarly, DAPT, in addition to anticoagulant

therapy, requires consideration of the increased risk of bleeding. It is essential that therapeutic decision making in this critical area include discussion with the patient about the options,
advantages, and limitations of available approaches.
Recommendations about the management of patients treated
with triple therapy have been published in ACC/AHA CPGs
and by other organizations.17,26,430,433,436 Although some organizations have recommended a target INR of 2.0 to 2.5 in patients
with atrial fibrillation (AF) who require triple therapy,437 others
continue to recommend a target INR of 2.0 to 3.0.12,436 The HASBLED (Hypertension, Abnormal Renal/Liver Function, Stroke,
Bleeding History or Predisposition, Labile INR, Elderly, Drugs/
Alcohol Concomitantly) score has relevance in these deliberations.439 No prospective study to date has demonstrated that a
target INR of 2.0 to 2.5 reduces bleeding complications.
Whenever possible, shorter durations of triple therapy are
favored in preference to longer durations of triple therapy. In
patients with NSTE-ACS who require oral anticoagulation for
AF, mechanical heart valve, deep venous thrombosis, or other
conditions, a bare-metal stent may offer the advantages of lower
bleeding risk over a DES because of the potentially shorter duration of triple antithrombotic therapy. The WOEST (What is the
Optimal Antiplatelet and Anticoagulant Therapy in Patients
With Oral Anticoagulation and Coronary Stenting) trial is the
first published study to address the question of optimal antiplatelet therapy in patients taking oral anticoagulant medication.440
WOEST was a randomized, open-label trial of 563 patients
(approximately 25% of whom had NSTE-ACS) receiving oral
anticoagulant therapy and undergoing coronary stenting. Patients
randomized to single antiplatelet treatment with clopidogrel had
significantly fewer bleeding complications and no increase in
thrombotic events compared with those randomized to DAPT
with aspirin and clopidogrel. Larger clinical trials are needed to
compare double versus triple therapy in the setting of coronary
stenting and NSTE-ACS. One such study that has been initiated
is PIONEER AF-PCI (an Open-Label, Randomized, Controlled,
Multicenter Study Exploring two Treatment Strategies of
Rivaroxaban and a Dose-Adjusted Oral Vitamin K Antagonist
Treatment Strategy in Subjects With Atrial Fibrillation who
Undergo Percutaneous Coronary Intervention).
Although there are some data on therapy with aspirin, clopidogrel, and warfarin, there is sparse information on the use of
newer P2Y12 inhibitors (prasugrel, ticagrelor), direct thrombin
inhibitor (dabigatran), or factor-Xa inhibitors (rivaroxaban,
apixaban) in patients receiving triple therapy. Prasugrel302
and ticagrelor412 produce a greater degree of platelet inhibition than clopidogrel and are associated with greater rates of
bleeding.300,302,412,441 These are important potential disadvantages in patients requiring triple therapy, a group in which the
inherent risks of bleeding are significantly increased. (Overall
bleeding risk was not increased with ticagrelor, although there
was increased bleeding in certain subgroups on this drug).412
Because there are no well-established therapies to reverse the
anticoagulant effects of the newer oral antiplatelet agents,
caution is required when considering the use of these agents
in patients who require triple therapy and are at significantly
increased risk of bleeding. This admonition is especially
important in elderly patients, a group in which bleeding risk is
inherently increased (Section 7.1).
Proton pump inhibitors decrease the risk of gastrointestinal bleeding in patients treated with DAPT431 and are used in
patients treated with DAPT who have a history of gastrointestinal bleeding and those at increased risk of bleeding, which
is associated with oral anticoagulation therapy even if there
is no history of gastrointestinal bleeding.430 On the basis of
these results, proton pump inhibitors are also used in patients
receiving triple antithrombotic therapy who have a history
of gastrointestinal bleeding. Although the clinical evidence
that omeprazole and esomeprazole diminish the antiplatelet efficacy of clopidogrel is weak,430 the US Food and Drug
Administration has issued a warning to avoid concomitant use
of these 2 proton pump inhibitors with clopidogrel.442
6.2.3. Platelet Function and Genetic Phenotype Testing
Although higher platelet reactivity has been associated with
a greater incidence of adverse events in patients undergoing
stent implantation, a strategy of adjusting antiplatelet therapy
based on routine platelet function testing has not been beneficial in reducing ischemic complications.26,443445 Similarly,
a strategy of routine genetic phenotype testing has also not
been beneficial and thus is not recommended.26,446448 A more
detailed discussion of these issues and current recommendations about platelet function testing and genetic testing are in
the 2011 PCI CPG.26
6.3. Risk Reduction Strategies for Secondary

Prevention
Secondary prevention is a critical aspect of the management of
care for the survivor of NSTE-ACS. It has been clearly established that in this high-risk cohort, subsequent cardiovascular
morbidity and mortality can be reduced by a comprehensive
approach to favorably modifying patients risk profiles.27
Secondary prevention comprises lifestyle changes, risk factor education, medical therapy, and, where appropriate, revascularization. These elements are discussed in Section 6.4.
Despite the proven utility of secondary prevention, its implementation remains suboptimal, and enhanced application is a
major goal in this patient population.
on risk reduction strategies.
6.3.1. Cardiac Rehabilitation and Physical Activity:
Recommendation
Class I
1. All eligible patients with NSTE-ACS should be referred to a comprehensive cardiovascular rehabilitation program either before hospital discharge or during the first outpatient visit.449452 (Level of Evidence: B)
The US Public Health Service emphasizes comprehensive cardiac rehabilitation programs,449 and the 2011 secondary prevention CPG underscores referral to cardiac rehabilitation for
survivors of ACS.27 Since 2007, referral to these programs has
been designated a quality performance measure.453455 Barriers
to referral can be obviated by discussion with the patient and
referral by the patients primary care clinician and/or cardiovascular caregiver. These comprehensive programs provide
patient education, enhance regular exercise, monitor risk

factors, and address lifestyle modification.456 Aerobic exercise
training can generally begin 1 to 2 weeks after discharge in
patients treated with PCI or CABG.457 Mild-to-moderate resistance training can be considered and started 2 to 4 weeks after
aerobic training.458 Unsupervised exercise may target a heart
rate range of 60% to 75% of maximum age-predicted heart rate
based on the patients exercise stress test. Supervised training
may target a higher heart rate (70% to 85% of age-predicted
maximum).457 Additional restrictions apply when residual ischemia is present. Daily walking can be encouraged soon after
discharge for most patients. Resource publications on exercise prescription in cardiovascular patients are available.456,457
Regular physical activity reduces symptoms in patients with
cardiovascular disease, enhances functional capacity, improves
other risk factors such as insulin resistance and glucose control, and is important in weight control.456 Questionnaires and
nomograms for cardiac patients have been developed to guide
exercise prescription if an exercise test is unavailable.459462 See
Section 6.4 and Table10 for more information.
6.3.2. Patient Education: Recommendations
Class I
1. Patients should be educated about appropriate cholesterol management, BP, smoking cessation, and lifestyle management.15,16,18 (Level of Evidence: C)
2. Patients who have undergone PCI or CABG derive
benefit from risk factor modification and should
receive counseling that revascularization does not
obviate the need for lifestyle changes.463 (Level of
Evidence: C)
Results of testing should be discussed with the patient, the
patients family, and/or the patients advocate in an understandable manner. Test results should be used to help determine the advisability of coronary angiography, the need for
adjustments in the medical regimen, and the specifics for secondary prevention measures. See Section 6.4 and Table 10 for
more information on plan of care.
6.3.3. Pneumococcal Pneumonia: Recommendation
Class I
1. The pneumococcal vaccine is recommended for
patients 65 years of age and older and in high-risk
patients with cardiovascular disease.464466 (Level of
Evidence: B)
Vaccination with the 23-valent pneumococcal polysaccharide vaccine is recommended for all adults 65 years of age.
Adults of any age who are at increased risk, including smokers and those with asthma, should also be given the vaccine.
Immunocompromised adults should receive the 13-valent
conjugate vaccine in addition to the 23-valent vaccine.464466
The influenza vaccine is discussed in Section 6.4.
6.3.4. NSAIDs: Recommendations
Class I
1. Before hospital discharge, the patients need for treatment of chronic musculoskeletal discomfort should
be assessed, and a stepped-care approach should be

used for selection of treatments. Pain treatment before consideration of NSAIDs should begin with acetaminophen, nonacetylated salicylates, tramadol, or
small doses of narcotics if these medications are not
adequate.17,237 (Level of Evidence: C)
Class IIa
1. It is reasonable to use nonselective NSAIDs, such
as naproxen, if initial therapy with acetaminophen,
nonacetylated salicylates, tramadol, or small doses of
narcotics is insufficient.237 (Level of Evidence: C)
Class IIb
1. NSAIDs with increasing degrees of relative COX2 selectivity may be considered for pain relief only
for situations in which intolerable discomfort persists despite attempts at stepped-care therapy with
acetaminophen, nonacetylated salicylates, tramadol,
small doses of narcotics, or nonselective NSAIDs.
In all cases, use of the lowest effective doses for the
shortest possible time is encouraged.234,235,237,467 (Level
of Evidence: C)
Class III: Harm

1. NSAIDs with increasing degrees of relative COX2 selectivity should not be administered to patients
with NSTE-ACS and chronic musculoskeletal discomfort when therapy with acetaminophen, nonacetylated salicylates, tramadol, small doses of narcotics, or nonselective NSAIDs provide acceptable pain
relief.234,235,237,467 (Level of Evidence: B)
Selective COX-2 inhibitors and other nonselective NSAIDs
have been associated with increased cardiovascular risk, and
the risk appears to be amplified in patients with established.
cardiovascular disease.17,234,235,467,469 In a large Danish observational study of patients with first MI (n=58432), the HR and
95% CI for death were 2.80 (2.41 to 3.25) for rofecoxib, 2.57
(2.15 to 3.08) for celecoxib, 1.50 (1.36 to 1.67) for ibuprofen,
2.40 (2.09 to 2.80) for diclofenac, and 1.29 (1.16 to 1.43) for
other NSAIDs.234 There were dose-related increases in risk
of death and nondose-dependent trends for rehospitalization for MI for all drugs.234,467 An AHA scientific statement on
the use of NSAIDs concluded that the risk of cardiovascular
events is proportional to COX-2 selectivity and the underlying risk in the patient.237 Non-pharmacological approaches
were recommended as the first line of treatment, followed
by the stepped-care approach to pharmacological therapy, as
shown in Figure4.
6.3.5. Hormone Therapy: Recommendation
Class III: Harm

1. Hormone therapy with estrogen plus progestin, or
estrogen alone, should not be given as new drugs for
secondary prevention of coronary events to postmenopausal women after NSTE-ACS and should
Figure 4. Stepped-Care Approach to Pharmacological Therapy for Musculoskeletal Symptoms in Patients With Known Cardiovascular
Disease or Risk Factors for Ischemic Heart Disease. ASA indicates aspirin; COX-2, cyclooxygenase; GI, gastrointestinal; NSAIDs,
nonsteroidal anti-inflammatory drugs; and PPI, proton-pump inhibitor. Modified from Jneid et al.8
not be continued in previous users unless the benefits outweigh the estimated risks.17,470472 (Level of
Evidence: A)
Although prior observational data suggested a protective effect
of hormone therapy for coronary events, a randomized trial
of hormone therapy for secondary prevention of death and
MI (the HERS [Heart and Estrogen/Progestin Replacement]
study) failed to demonstrate a beneficial effect.473 There was
an excess risk for death and MI early after initiation of hormone therapy. The Womens Health Initiative included randomized primary prevention trials of estrogen plus progestin and
estrogen alone.472 Both trials were stopped early owing to an
increased risk related to hormone therapy that was believed to
outweigh the potential benefits of further study.470472 It is recommended that post-menopausal women receiving hormone
therapy at the time of a cardiovascular event discontinue its
use and that hormone therapy should not be initiated for the
primary or secondary prevention of coronary events. However,
there may be other permissible indications for hormone therapy
in postmenopausal women (eg, treatment of perimenopausal
symptoms such as flushing or prevention of osteoporosis) if the
benefits are believed to outweigh the increased cardiovascular
risk. Postmenopausal women who are >1 to 2 years past the initiation of hormone therapy who wish to continue such therapy
for another compelling indication should weigh the risks and
benefits, recognizing the greater risk of cardiovascular events
and breast cancer (combination therapy) or stroke (estrogen).473
6.3.6. Antioxidant Vitamins and Folic Acid:
Recommendations

1. Antioxidant vitamin supplements (eg, vitamins E, C,
or beta carotene) should not be used for secondary
prevention in patients with NSTE-ACS.474,475 (Level of
Evidence: A)
2. Folic acid, with or without vitamins B6 and B12,
should not be used for secondary prevention in patients with NSTE-ACS.476,477 (Level of Evidence: A)
Although there is an association of elevated homocysteine
blood levels and CAD, a reduction in homocysteine levels with
routine folate supplementation did not reduce the risk of CAD
events in 2 trials (the NORVIT [Norwegian Vitamin Trial] and
the HOPE [Heart Outcomes Prevention Evaluation] study)

that included postMI or high-risk stable patients476478 and
produced poorer outcomes in another study.479 Additionally, in
the NORVIT trial, there was a trend toward increased cardiovascular events (95% CI: 1.00 to 1.50; P=0.05) in the cohort
receiving the combination of folic acid, vitamin B6, and vitamin B12; the authors cautioned against using the treatment for
secondary prevention.476 Similarly, experience in large clinical
trials with antioxidant vitamins has failed to demonstrate benefit for primary or secondary prevention.474,475,480
on antioxidant vitamins and folic acid.
6.4. Plan of Care for Patients With NSTE-ACS:

Recommendations
Class I
1. Posthospital systems of care designed to prevent
hospital readmissions should be used to facilitate
the transition to effective, coordinated outpatient
care for all patients with NSTE-ACS.481485 (Level of
Evidence: B)
2. An evidence-based plan of care (eg, GDMT) that promotes medication adherence, timely follow-up with
the healthcare team, appropriate dietary and physical activities, and compliance with interventions for
secondary prevention should be provided to patients
with NSTE-ACS. (Level of Evidence: C)
3. In addition to detailed instructions for daily exercise, patients should be given specific instruction on
activities (eg, lifting, climbing stairs, yard work, and
household activities) that are permissible and those
to avoid. Specific mention should be made of resumption of driving, return to work, and sexual activity.452,486,487 (Level of Evidence: B)
4. An annual influenza vaccination is recommended for
patients with cardiovascular disease.27,488 (Level of
Evidence: C)
Education of patients with NSTEMI and their families is critical and often challenging, especially during transitions of care.
Failure to understand and comply with a plan of care may
account for the high rate of AMI rehospitalization rates in
the United States.489,490 An important intervention to promote

coordination is to provide patients and caregivers with a comprehensive plan of care and educational materials during the
hospital stay that support compliance with evidence-based therapies.491493 The posthospitalization plan of care for patients with
NSTE-ACS (Table 10) should address in detail several complex
issues, including medication adherence and titration, timely
follow-up, dietary interventions, physical and sexual activities,
cardiac rehabilitation, compliance with interventions for secondary prevention, and reassessment of arrhythmic and HF risks.
In addition, clinicians should pay close attention to psychosocial and socioeconomic issues, including access to care, risk of
depression, social isolation, and healthcare disparities.494496
6.4.1. Systems to Promote Care Coordination
There has been improved understanding of the system changes
necessary to achieve safer care.497 This includes adoption
by all US hospitals of a standardized set of Safe Practices
endorsed by the National Quality Forum,498 which overlap with the National Patient Safety Goals espoused by The
Joint Commission.499 Examples of patient safety standards
for all patients after AMI include improved communication
among clinicians, nurses, and pharmacists; medication reconciliation; careful transitions between care settings; and consistent documentation. The National Quality Forum has also
endorsed a set of patient-centered Preferred Practices for
Care Coordination,500 which detail comprehensive specifications that are necessary to achieve successful care coordination for patients and their families. Systems of care designed
to support patients with NSTE-ACS, STEMI, and other cardiac diseases can result in significant improvement in patient
outcomes. Table 10 provides reference documents for multiple
risk-reduction strategies for secondary prevention in the posthospital phase of NSTE-ACS. These include the 2013 ACC/
AHA CPGs on management of blood cholesterol,18 obesity,16
and lifestyle15 and the 2014 recommendations for management
of hypertension,501 which were published during the development of this CPG. To provide the interventions and services
listed in Table 10, appropriate resources must be used so that
patients with MI have full access to evidence-based therapies
and follow-up care. There is a growing emphasis on penalizing
hospitals for avoidable hospital readmissions. It is imperative
for health systems to work with clinicians, nurses, pharmacists,
communities, payers, and public agencies to support the interventions that achieve comprehensive care. Several patient characteristics have been predictors of readmission after AMI.502,503
7. Special Patient Groups

See Table 11 for summary of recommendations for this
section.
7.1. NSTE-ACS in Older Patients:

Recommendations
Class I
1. Older patients** with NSTE-ACS should be treated
with GDMT, an early invasive strategy, and revascularization as appropriate.515519 (Level of Evidence: A)
**Those 75 years of age (see text).
2. Pharmacotherapy in older patients** with NSTEACS should be individualized and dose adjusted by
weight and/or CrCl to reduce adverse events caused
by age-related changes in pharmacokinetics/dynamics, volume of distribution, comorbidities, drug interactions, and increased drug sensitivity.515,520522 (Level
of Evidence: A)
3. Management decisions for older patients** with
NSTE-ACS should be patient centered, and consider
patient preferences/goals, comorbidities, functional
and cognitive status, and life expectancy.515,523525 (Level
of Evidence: B)
Class IIa
1. Bivalirudin, rather than a GP IIb/IIIa inhibitor plus
UFH, is reasonable in older patients** with NSTEACS, both initially and at PCI, given similar efficacy
but less bleeding risk.396,526528 (Level of Evidence: B)
2. It is reasonable to choose CABG over PCI in older
patients** with NSTE-ACS who are appropriate candidates, particularly those with diabetes mellitus or
complex 3-vessel CAD (eg, SYNTAX score >22), with
or without involvement of the proximal LAD artery, to
reduce cardiovascular disease events and readmission
and to improve survival.529534 (Level of Evidence: B)
In this CPG, older adults refers to patients 75 years of age.515
Older adults have the highest incidence, prevalence, and adverse
outcomes of NSTE-ACS.9,515517,535,536 Older age is accompanied
by comorbidities, polypharmacy, and age- and disease-related
physiological changes that adversely impact NSTE-ACS presentation, management, and outcome. As older patients are underrepresented in clinical trials, the recommendations in this CPG
are largely supported by registry data and meta-analyses.516,537
Older patients with NSTE-ACS primarily present with chest
pain but frequently have atypical symptoms. ECGs may be
less diagnostic than in younger patients.517,538 Older patients
with NSTE-ACS derive the same or greater benefit from pharmacological therapies, interventional therapies, and cardiac
rehabilitation as younger patients, but older patients receive
significantly less GDMT than younger patients, even when
adjusted for comorbidities.515517,535,538,539 In the ACSIS (Acute
Coronary Syndrome Israeli Survey) registry, patients >80 years
of age referred for early coronary angiography, compared with
no angiography, had lower 30-day and 1-year mortality rates.540
Age-related pharmacokinetics and pharmacodynamic
changes can alter drug dosing, efficacy, and safety of
many NSTE-ACS therapies, as can drugdrug interactions
(Appendix 4, Table B).515,520,521,541,542 CrCl or glomerular filtration rate (GFR) should be estimated initially and throughout
care for all older patients with NSTE-ACS, and pharmaceutical agents should be renally and weight dose-adjusted to limit
drug toxicity (especially bleeding risk), given the unreliability of serum creatinine to assess age-related renal dysfunction515,522,526,543545 (Appendix 4, Table C). Bleeding in older
patients with NSTE-ACS is multifactorial, resulting in narrower therapeutic windows.541,542,544,546,547
In the CRUSADE (Can Rapid Risk Stratification of
Unstable Angina Patients Suppress Adverse Outcomes With

Early Implementation of the American College of Cardiology/
American Heart Association Guidelines) study, excessive
doses of UFH, LMWH, and GP IIb/IIIa inhibitors accounted
for 15% of major bleeding, longer lengths of stay, and increased
mortality.522,548 Aspirin should be maintained at 81 mg per day
(after initial stent implantation). Owing to excess bleeding
without clinical benefit, the US Food and Drug Administration
lists a Black Box warning that does not recommend administration of prasugrel to patients with NSTE-ACS who are 75
years of age or weigh <60 kg except in those at very high
risk. A metaanalysis of 6 RCTs about the use of GP IIb/IIIa
inhibitors in patients with NSTE-ACS reported no significant
age-treatment interaction, although older women had significantly more adverse events.549 Bivalirudin appears safer for
older patients with NSTE-ACS PCI than GP IIb/IIIa inhibitors plus UFH, with less bleeding and similar efficacy.526,550
AF is more common in older patients with NSTE-ACS, and
triple therapy (DAPT and warfarin) entails a marked bleeding
risk.551 In the WOEST (What is the Optimal Antiplatelet and
Anticoagulant Therapy in Patients With Oral Anticoagulation
and Coronary Stenting) study, it was found that in patients
taking oral coagulants who required PCI, use of clopidogrel
without aspirin was associated with a significant reduction
in bleeding complications and no increase in thrombotic
events.440 Nonetheless, practice should not be changed on the
basis of this limited study alone.
Older patients with NSTE-ACS benefit as much or more
than younger patients from an early invasive strategy compared with an ischemia-guided strategy.340,341,515,518,519 In a
5-year follow-up meta-analysis of FRISC-II and RITA-3, an
early invasive strategy versus an ischemia-guided strategy
was associated with a significant reduction in death/MI and
MI in patients 75 years of age but not in patients <65 years
of age.518 Although the highest risk reduction in death/MI with
an early invasive strategy occurred in those 75 years of age,
this strategy was associated with a 3-fold bleeding risk.552
However, despite the overall favorable evidence for an early
invasive strategy in older patients, age is the strongest risk factor for this group not undergoing an early invasive strategy.553
PCI has increased in older patients, including the very
elderly (90 years of age), with success rates similar to
younger patients and declining complication rates, including
major bleeding.515,517,526528,554 Several large registries report a
greater RR reduction in mortality of older patients treated with
revascularization versus medical therapy compared with those
65 years of age, despite increased comorbidities.517,540,554556
Operative mortality rates for CABG in patients 80 years
of age with NSTE-ACS range from 5% to 8% (11% for urgent
cases) and increase to approximately 13% at 90 years of age.
Complications occur more frequently in older patients with
CABG.557,558 Length of stay averages 6 days longer in older
patients than in patients <50 years of age, and discharge (to
home [52%]) is less frequent than in younger patients.557 In
a metaanalysis, off-pump CABG appeared to offer a potentially safer and more effective revascularization technique
compared with on-pump CABG in older patients with NSTEACS.559 Older patients with NSTE-ACS with diabetes mellitus
had a greater survival advantage with CABG.529 Evaluation
tools can help identify older patients with NSTE-ACS whose
risk and comorbidity profile predict mortality within 6 to 12

months and possibly guide a palliative approach.524
on older patients.
7.2. HF: Recommendations

Class I
1. Patients with a history of HF and NSTE-ACS should
be treated according to the same risk stratification
guidelines and recommendations for patients without
HF.14,4244,7581 (Level of Evidence: B)
2. Selection of a specific revascularization strategy
should be based on the degree, severity, and extent
of CAD; associated cardiac lesions; the extent of
LV dysfunction; and the history of prior revascularization procedures.14,138,141,333,334,337,341,560,561 (Level of
Evidence: B)
In patients with HF and NSTE-ACS, the plan of care should
be implemented as in patients without HF using medical
therapy and an early invasive approach, because patients with
abnormal LV function are at increased risk of mortality and
morbidity.562 HF itself may be associated with elevated serum
troponin in the presence or absence of obstructive CAD. After
angiography, risk stratification can be used to select revascularization strategies. The effect of surgical revascularization
on improving survival has been most clearly demonstrated
in patients with both extensive CAD and LV dysfunction.356,357,563567 Such patients should undergo testing to identify the severity and extent of ischemia and should in general
be referred for coronary angiography. In selected patients with
appropriate anatomy, PCI has been used.23,568 In patients who
have already undergone CABG or in whom the anatomy is
not favorable for CABG, PCI has been performed using CPGbased PCI performance strategies if specific targeted areas
that are amenable to PCI can be identified.26 If there is a large
amount of ischemic territory and very poor LV function, percutaneous ventricular assist devices or, in less severe cases, an
IABP can be used for support during the procedure.266,569573
on HF.
7.2.1. Arrhythmias
Ventricular arrhythmias are common early after onset of
NSTE-ACS, and not all require intervention. The mechanisms
for these arrhythmias include continuing ischemia, hemodynamic and electrolyte abnormalities, reentry, and enhanced
automaticity. Approximately 5% to 10% of hospitalized
patients may develop ventricular tachycardia (VT)/ventricular
fibrillation (VF), usually within 48 hours of presentation.574
The incidence of VF in otherwise uncomplicated AMI appears
to have decreased within the past few years from >4% to <2%,
of which 59% of patients had nonQ-wave MI.574 A study
of 277 consecutive patients with NSTE-ACS who underwent cardiac catheterization within 48 hours found VT/VF
occurring in 7.6% of patients, 60% of which developed
within 48 hours after admission.575 Risk factors for VT/VF
include HF, hypotension, tachycardia, shock, and low TIMI
flow grade. Treatment consists of immediate defibrillation or

Table 11. Summary of Recommendations for Special Patient Groups
Recommendations
COR
LOE
References
515519
515, 520522
515, 523525
Bivalirudin rather than GP IIb/IIIa inhibitor plus UFH is reasonable for older patients (75 y of
age), given similar efficacy but less bleeding risk
IIa
396, 526528
It is reasonable to choose CABG over PCI in older patients, particularly those with DM or
multivessel disease, because of the potential for improved survival and reduced CVD events
IIa
529534
Treat patients with a history of HF according to the same risk stratification guidelines and
recommendations for patients without HF
14, 4244, 7581
Select a revascularization strategy based on the extent of CAD, associated cardiac lesions,
LV dysfunction, and prior revascularization
14, 138, 141, 333, 334,

337, 341, 560, 561
560, 588, 589
138, 339, 601
67, 68, 141, 340342
Perioperative NSTE-ACS
Administer GDMT to perioperative patients with limitations imposed by noncardiac surgery
626, 627
Direct management at underlying cause of perioperative NSTE-ACS
21, 626634
CKD
Estimate CrCl and adjust doses of renally cleared medications according to pharmacokinetic
data
649, 650
NSTE-ACS in older patients

Treat older patients (75 y of age) with GDMT, early invasive strategy, and revascularization
as appropriate
Individualize pharmacotherapy in older patients, with dose adjusted by weight and/or CrCl
to reduce adverse events caused by age-related changes in pharmacokinetics/dynamics,
volume of distribution, comorbidity, drug interactions, and increased drug sensitivity
Undertake patient-centered management for older patients, considering patient
preferences/goals, comorbidities, functional and cognitive status, and life expectancy
HF
Cardiogenic shock
Recommend early revascularization for cardiogenic shock due to cardiac pump failure
DM
Recommend medical treatment and decisions for testing and revascularization similar to
those for patients without DM
PostCABG
Recommend GDMT antiplatelet and anticoagulant therapy and early invasive strategy
because of increased risk with prior CABG
Administer adequate hydration to patients undergoing coronary and LV angiography

Invasive strategy is reasonable in patients with mild (stage 2) and moderate (stage 3) CKD
N/A
IIa
649652
669673
141, 345, 346, 561
IIa
674
III: No Benefit
141, 345, 346
N/A
522, 697, 698
III: No Benefit
699703
N/A
Women
Manage women with the same pharmacological therapy as that for men for acute care and
secondary prevention, with attention to weight and/or renally calculated doses of antiplatelet
and anticoagulant agents to reduce bleeding risk
Early invasive strategy is recommended in women with NSTE-ACS and high-risk features
(troponin positive)
Myocardial revascularization is reasonable for pregnant women if ischemia-guided strategy
is ineffective for management of life-threatening complications
Women with low-risk features (Section 3.3.1) should not undergo early
invasive treatment because of lack of benefit and the possibility of harm
Anemia, bleeding, and transfusion
Evaluate all patients for risk of bleeding
Recommend that anticoagulant and antiplatelet therapy be weight-based where appropriate
and adjusted for CKD to decrease the risk of bleeding
There is no benefit of routine blood transfusion in hemodynamically stable patients with
hemoglobin levels >8 g/dL
Cocaine and methamphetamine users
Manage patients with recent cocaine or methamphetamine use similarly to those without
cocaine- or methamphetamine-related NSTE-ACS. The exception is in patients with signs
of acute intoxication (eg, euphoria, tachycardia, and hypertension) and beta-blocker use
unless patients are receiving coronary vasodilator therapy
(Continued)

Table 11. Continued
Recommendations
COR
LOE
References
IIa
741744
III: Harm
N/A
753758
Recommend HMG-CoA reductase inhibitor, cessation of tobacco use, and atherosclerosis

risk factor modification
759763
Recommend coronary angiography (invasive or noninvasive) for episodic chest pain

with transient ST-elevation to detect severe CAD
N/A
IIb
764767
IIb
629, 773776
Stress (Takotsubo) cardiomyopathy

Consider stress-induced cardiomyopathy in patients with apparent ACS and nonobstructive CAD
N/A
Perform ventriculography, echocardiography, or MRI to confirm or exclude diagnosis
795798
Treat with conventional agents (ACE inhibitors, beta blockers, aspirin, and diuretics)
if hemodynamically stable
Administer anticoagulant therapy for LV thrombi
N/A
N/A
IIa
N/A
Cocaine and methamphetamine users (cont'd)

It is reasonable to use benzodiazepines alone or in combination with NTG
to manage hypertension and tachycardia and signs of acute cocaine
or methamphetamine intoxication
Do not administer beta blockers to patients with recent cocaine or methamphetamine
use who have signs of acute intoxication due to risk of potentiating coronary spasm
Vasospastic (Prinzmetal) angina
Recommend CCBs alone or in combination with nitrates
Provocative testing during invasive coronary angiography* may be considered for

suspected vasospastic angina when clinical criteria and noninvasive assessment
fail to determine diagnosis
ACS with angiographically normal coronary arteries
Invasive physiological assessment (coronary flow reserve measurement) may be
considered with normal coronary arteries if endothelial dysfunction is suspected
It is reasonable to administer catecholamines for symptomatic hypotension in the

absence of LV outflow tract obstruction
It is reasonable to use IABP for refractory shock
IIa
N/A
It is reasonable to use beta blockers and alpha-adrenergic agents for LV outflow tract obstruction
IIa
N/A
Prophylactic anticoagulation may be considered to prevent LV thrombi
IIb
N/A
*Provocative testing during invasive coronary angiography (eg, using ergonovine, acetylcholine, methylergonovine) is relatively safe, especially when performed
in a controlled manner by experienced operators. However, sustained spasm, serious arrhythmias, and even death can also occur but very infrequently. Therefore,
provocative tests should be avoided in patients with significant left main disease, advanced 3-vessel disease, presence of high-grade obstructive lesions, significant
valvular stenosis, significant LV systolic dysfunction, and advanced HF.
ACE indicates angiotensin-converting enzyme; ACS, acute coronary syndrome; CABG, coronary artery bypass graft; CAD, coronary artery disease; CCB, calcium
channel blocker; CKD, chronic kidney disease; COR, Class of Recommendation; CrCl, creatinine clearance; CVD, cardiovascular disease; DM, diabetes mellitus;
GDMT, guideline-directed medical therapy; GP, glycoprotein; HF, heart failure; IABP, intra-aortic balloon pump; LOE, Level of Evidence; LV, left ventricular;
MRI, magnetic resonance imaging; N/A, not available; NSTE-ACS, nonST-elevation acute coronary syndrome; NTG, nitroglycerin; PCI, percutaneous coronary
intervention; and UFH, unfractionated heparin.
cardioversion for VF or pulseless sustained VT. Early administration of beta blockers has been associated with reduction in
incidence of VF.576 The prophylactic use of lidocaine is not recommended. Although VT/VF is associated with higher 90-day
mortality risk, premature ventricular contractions not associated with hemodynamic compromise and accelerated ventricular rhythms do not confer higher mortality risks and do not
require specific therapy other than maintaining electrolyte balance. NSTE-ACS non-sustained VT occurring >48hours after
admission indicates an increased risk of cardiac and sudden
death, especially when associated with accompanying myocardial ischemia.577 Life-threatening ventricular arrhythmias
that occur >48 hours after NSTE-ACS are usually associated
with LV dysfunction and signify poor prognosis. RCTs in
patients with ACS have shown consistent benefit of implantable cardioverter-defibrillator therapy for survivors of VT or
VF arrest.578582 For other at-risk patients, especially those with

significantly reduced LVEF, candidacy for primary prevention
of sudden cardiac death with an implantable cardioverter-defibrillator should be readdressed 40 days after discharge.583
Alife vest may be considered in the interim.
AF, atrial flutter, and other supraventricular arrhythmias
may be triggered by excessive sympathetic stimulation, atrial
stress due to volume overload, atrial infarction, pericarditis,
electrolyte abnormalities, hypoxia, or pulmonary disease. AF
is the most common of these arrhythmias and may develop in
>20% of patients. AF is associated with shock, HF, stroke, and
increased 90-day mortality.584 Management of AF requires rate
control and adequate anticoagulation according to the 2014
AF CPG.12 For hemodynamically unstable patients and those
with continuing ischemia, treatment should be implemented
according to the 2010 advanced cardiac life support CPGs.585

Sinus bradycardia is especially common with inferior
NSTEMI. Symptomatic or hemodynamically significant sinus
bradycardia should be treated with atropine and, if not responsive, temporary pacing. The incidence of complete heart block
is 1.0% to 3.7% in NSTEMI, based on anterior or posterior/
inferior location, respectively.586 Atrioventricular block and bundle-branch block develop in approximately 5% of patients.587
High-degree atrioventricular block or bundle-branch block in
anterior NSTEMI is more ominous because of a greater extent of
myocardial injury and involvement of the conduction system.587
First-degree atrioventricular block does not require treatment. High-grade atrioventricular block after inferior
NSTEMI usually is transient, with a narrow QRS complex
and a junctional escape rhythm that can be managed with an
ischemia-guided strategy. Prophylactic placement of a temporary pacemaker is recommended for high-grade atrioventricular block, new bundle-branch block, or bifascicular block
with anterior infarction. Indications for permanent pacing are
reviewed in the 2012 device-based therapy CPG.20
7.2.2. Cardiogenic Shock: Recommendation
Class I
1. Early revascularization is recommended in suitable
patients with cardiogenic shock due to cardiac pump
failure after NSTE-ACS.560,588,589 (Level of Evidence: B)
AMI is the leading cause of cardiogenic shock. Early revascularization is a mainstay in the treatment of cardiogenic shock.560,589
Compared with medical therapy, early revascularization is associated with improved 6-month mortality560 and 13% absolute
mortality reduction at 6 years.588 Urgent revascularization with
CABG may be indicated for failed PCI, coronary anatomy not
amenable to PCI, and at the time of surgical repair of a mechanical defect (eg, septal, papillary muscle, free-wall rupture). Age
alone is not a contraindication to urgent revascularization for
cardiogenic shock.589,590 Mortality after cardiogenic shock has
steadily improved,591 including in older adults,589,590 with 30-day
mortality ranging from approximately 40% with milder forms of
shock268 to >45% with refractory shock.592 Approximately 30%
of patients in the IABP-SHOCK (Intra-Aortic Balloon Pump in
Cardiogenic Shock) II trial presented with NSTEMI,268 and 22%
of patients in the TRIUMPH (Tilarginine Acetate Injection in a
Randomized International Study in Unstable Acute Myocardial
Infarction Patients With Cardiogenic Shock) trial had ST depression on presentation.592 Of the 23% of patients with ACS who
had NSTEMI in the GRACE registry, 4.6% of patients experienced cardiogenic shock.593 Of the 2992 patients in shock, 57%
underwent cardiac catheterization, and in-hospital revascularization was performed in 47% of this group.
In-hospital mortality of all patients with shock was 59%.594
Patients with NSTEMI developed cardiogenic shock later than
patients with STEMI, and had higher-risk clinical characteristics, more extensive CAD, and more recurrent ischemia and
infarction before developing shock compared with patients with
STEMI, and shock developed later in patients with NSTEMI.151
Patients with NSTEMI constituted >17% of those in the SHOCK
trial registry.595 They were also older and had more comorbidities but had comparable mortality to patients with STEMI. The
left circumflex coronary artery was the culprit vessel in 30% of
patients with NSTEMI, suggesting the presence of true posterior MI.595 Dopamine in patients with cardiogenic shock may
be associated with increased mortality compared with norepinephrine.596 The use of percutaneous ventricular assist devices
has been hampered by the need for interventional expertise,
cost, and lack of supportive evidence.597 IABP has been used for
decades,265,598 and it may facilitate intervention in patients who
are hemodynamically unstable, but it did not reduce mortality or
secondary endpoints in 1 RCT of 598 patients with cardiogenic
shock complicating AMI.268 Newer devices with higher levels of
support have provided better hemodynamic support but without
improved clinical outcomes compared with IABP.599,600
on cardiogenic shock.
7.3. Diabetes Mellitus: Recommendation

Class I
1. Medical treatment in the acute phase of NSTE-ACS and
decisions to perform stress testing, angiography, and revascularization should be similar in patients with and
without diabetes mellitus.138,339,601 (Level of Evidence: A)
CAD accounts for 75% of deaths in patients with diabetes mellitus; >30% of patients with NSTE-ACS have diabetes mellitus;
and patients with NSTE-ACS and diabetes mellitus have more
adverse outcomes (eg, death, MI, readmission with ACS, or HF)
during follow up.593,602,603 The latter may be related to increased
plaque instability and comorbidities, including hypertension,
LV hypertrophy, cardiomyopathy, HF, and autonomic dysfunction.603605 Patients with diabetes mellitus and ACS have longer
delays from symptom onset to presentation,593,606,607 which may
be attributable to their atypical symptoms.
There is a U-shaped relationship between glucose levels and
mortality in patients with diabetes mellitus and ACS.543 Both
hyperglycemia and hypoglycemia have similar adverse effects on
in-hospital and 6-month mortality. The urgency to aggressively
control blood glucose has been moderated by the results of the
NICE-SUGAR (Normoglycemia in Intensive Care Evaluation
and Survival Using Glucose Algorithm Regimen) trial.608 In this
study of patients admitted to medical and surgical intensive care
units, intensive glucose control (target 81 mg/dL to 108 mg/dL)
resulted in increased all-cause mortality and hypoglycemia compared with moderate glucose control (target <l80 mg/dL). Blood
glucose should be maintained at <l80 mg/dL while avoiding
hypoglycemia. There is no established role for the administration
of glucose-insulin-potassium infusions in NSTE-ACS.609611
Although patients with diabetes mellitus and NSTE-ACS
are at higher risk for in-hospital and longer-term events, they
undergo less frequent revascularization procedures. In a multinational study of 6385 patients with ACS, 25% of whom
had diabetes mellitus, those with diabetes mellitus had more
adverse risk profiles, more atypical presentations, longer treatment delays, more HF, and renal insufficiency but underwent
less angiography and revascularization.607 In the GRACE
Registry593 and other studies,606 patients with diabetes mellitus and NSTE-ACS in the United Kingdom603 and Finland612
had higher baseline risk profiles but received effective medical
cardiac therapies and revascularization less frequently.

Although there are no RCTs of patients specifically diagnosed
with diabetes mellitus and ACS, there are ample data on patients
with diabetes mellitus treated with PCI or CABG.564,565,613615
The largest RCT, the FREEDOM (Future Revascularization
Evaluation in Patients With Diabetes Mellitus: Optimal
Management of Multivessel Disease) trial,616 evaluated 1900
patients (approximately 30% with recent [interval unspecified]
ACS) with 2- or 3-vessel CAD randomized to a DES or CABG.
At 5 years, there was a significant decrease in all-cause mortality
(P=0.049; MI: P<0.001) associated with CABG. There was no
specific analysis of outcomes in patients with recent (interval
unspecified) ACS. CABG was also superior to PCI in reducing
MACE in other trials564,613615 (Appendix 4, Table D).
The importance of the severity and complexity of CAD was
underscored in the SYNTAX trial, in which those with less severe
and complex CAD had similar outcomes with PCI and CABG
compared with those with more severe and complex disease, in
which CABG improved outcomes, including survival.355,565
7.3.1. Adjunctive Therapy
A meta-analysis (6 trials: 23072 patients without diabetes mellitus, 6458 patients with diabetes mellitus) of the effect of GP
IIb/IIIa platelet receptor inhibitors (abciximab, eptifibatide,
and tirofiban) on mortality in NSTEMI revealed that for the
entire patient group, a GP IIb/IIIa inhibitor was associated with
reduced 30-day mortality (6.2% to 4.6%; P=0.007).392 This
benefit was particularly large in the 1279 patients with diabetes mellitus who underwent PCI (4.0% to 1.2%; P=0.002).
The ACUITY trial in ACS (13819 patients, 3852 with diabetes mellitus) reported that 30-day adverse clinical outcomes
(death, MI, or unplanned revascularization) or major bleeding
were increased in patients with diabetes mellitus (12.9% versus 10.6%; P<0.001).617 Bivalirudin plus a GP IIb/IIIa inhibitor
resulted in increased similar rates of the composite ischemia
compared with heparin plus a GP IIb/IIIa inhibitor. Bivalirudin
alone was associated with a similar increased rate of composite
ischemia but less major bleeding (3.7% versus 7.1%; P<0.001).
Several studies evaluated the benefit of oral antiplatelet therapy during ACS in patients with diabetes mellitus. In TRITONTIMI 38, patients with diabetes mellitus had a greater reduction
in ischemic events without an observed increase in TIMI major
bleeding with prasugrel compared with clopidogrel.618 In
PLATO, ticagrelor compared with clopidogrel reduced ischemic events irrespective of diabetic status and glycemic control, without an increase in major bleeding.619
on diabetes mellitus.
7.4. PostCABG: Recommendation

Class I
1. Patients with prior CABG and NSTE-ACS should
receive antiplatelet and anticoagulant therapy according to GDMT and should be strongly considered
for early invasive strategy because of their increased
risk.67,68,141,340342 (Level of Evidence: B)
Although CABG reduces morbidity and mortality in selected
patients with complex CAD, they remain at risk for development of disease progression of ungrafted native vessels or
significant atherothrombotic disease in saphenous vein grafts

and subsequent ACS. These patients constitute a higher-risk
group because they have already undergone CABG, typically for
more extensive CAD, and they have more comorbidities.620624
In the PURSUIT trial, 12%1,134 of the patients had prior
CABG and more adverse follow-up outcomes, including
increased mortality, but had a benefit with eptifibatide similar
to those without prior CABG.622 Patients with prior CABG are
less likely to undergo early catheterization after NSTEMI. In
the Get With The Guidelines study of patients with NSTEMI,
18.5% had prior CABG and a lower likelihood of early invasive evaluation but had higher rates of guideline-recommended
clopidogrel and bivalirudin therapy and lower rates of GP IIb/
IIIa and anticoagulant therapy.625 In patients with prior CABG
who develop NSTE-ACS that is related to an ungrafted native
coronary vessel, treatment should follow GDMT.26
Because patients with prior CABG presenting with ACS
are a high-risk group with increased comorbid characteristics and high-risk anatomy, a strategy of early angiography
should be implemented (unless clinically contraindicated),
and these patients should receive optimal antiplatelet and
anticoagulant therapy.
on post-CABG.
7.5. Perioperative NSTE-ACS Related to

Noncardiac Surgery: Recommendations
Class I
1. Patients who develop NSTE-ACS following noncardiac surgery should receive GDMT as recommended
for patients in the general population but with the
modifications imposed by the specific noncardiac
surgical procedure and the severity of the NSTEACS.626,627 (Level of Evidence: C)
2. In patients who develop NSTE-ACS after noncardiac
surgery, management should be directed at the underlying cause.21,626634 (Level of Evidence: C)
Patients with NSTE-ACS following noncardiac surgery should
be managed according to the guidelines for patients in the general population, with risk stratification and guideline-based pharmacological and invasive management directed at the etiology
(eg, hypertension, tachycardia, HF, hypotension, sepsis, and anemia) with modifications based on the severity of NSTE-ACS and
the limitations imposed by the noncardiac surgical procedure.
The definition of ACS has a substantial effect on reported
incidence.178,184,635644 Some patients may not be able to give a
history of ischemic symptoms because of the noncardiac surgery. The criteria in the 2012 Third Universal Definition of MI
should be applied.21 In patients at risk of ACS following noncardiac surgery, routine monitoring of troponins and ECGs may
be performed. As the sensitivity of troponin assays improves,
the frequency of identifying perioperative MI will increase. In
the POISE (Perioperative Ischemic Study Evaluation) trial,645
of 8351 patients randomized to extended-release metoprolol
versus placebo, 5.7% of patients in the control group had a
perioperative MI typically occurring within 48 hours and often
not associated with ischemic symptoms.

ACS in the setting of noncardiac surgery is associated with
increased mortality. Several risk scores have been developed
to determine the probability of mortality.646648 A meta-analysis
of the prognostic value of troponin and CK-MB after noncardiac surgery that included 14 studies enrolling 3318 patients
demonstrated that elevated troponin after surgery was an
independent predictor of mortality both in the hospital and at
1-year follow-up.639 Markedly elevated troponins are associated with increased mortality compared with minimal troponin
elevation, even though the latter still indicates a postoperative
MI.184,639,641,642 In patients with UA in whom the risks of bleeding with antiplatelet therapy outweigh the benefits, GDMT
with beta blockers, nitrates, and ACE inhibitors should be
optimized to achieve symptom control. In patients with a relative or absolute contraindication to antiplatelet or anticoagulant therapy, coronary angiography may be helpful to identify
anatomy requiring revascularization after recovery from the
noncardiac surgery.
7.6. CKD: Recommendations

Class I
1. CrCl should be estimated in patients with NSTEACS, and doses of renally cleared medications should
be adjusted according to the pharmacokinetic data
for specific medications.649,650 (Level of Evidence: B)
2. Patients undergoing coronary and LV angiography should receive adequate hydration. (Level of
Evidence: C)
Class IIa
1. An invasive strategy is reasonable in patients with
mild (stage 2) and moderate (stage 3) CKD.649652
CKD is a major risk factor for poor outcomes in patients with
NSTEMI.652657 Patients with impaired renal function have
additional adverse baseline characteristics, including older
age, a history of prior HF, and peripheral arterial disease. It
is prudent to omit LV angiography in patients with CKD and
assess LV function with echocardiography.
In an analysis from 3 ACS trial databases of 19304 patients
with NSTEMI, 42% (8152 patients) had abnormal renal function on the basis of serum creatinine and calculated CrCl; total
mortality and mortality/MI were increased at 30 days and
180 days. CrCl was independently associated with mortality
(HR: 0.81) and the risk of mortality/MI (HR: 0.93).656 The
VALIANT (Valsartan in Acute Myocardial Infarction) trial
included 14527 high-risk patients with AMI with LV dysfunction or HF and a serum creatinine level 1.5 mg/dL.658,659 The
Modification of Diet in Renal Disease equation was used, and
patients were analyzed based on their estimated GFR. There
was an increasing adjusted HR for both death and the composite endpoint of cardiovascular death, reinfarction, HF, stroke,
or resuscitation after cardiac arrest with decreasing estimated
GFR. For death, with a GFR <45.0 mL per minute/1.73 m2,
the adjusted HR was 1.70 compared with patients with a GFR
of 60.0 mL per minute/1.73 m2 to 74.9 mL per minute/1.73 m2
in whom the adjusted HR was 1.14. There are insufficient data

on the benefit-to-risk ratio of an invasive strategy in patients
with NSTE-ACS and advanced CKD (stages 4 and 5).652 There
is also less evidence-based medical therapy and revascularization data in patients with CKD because of the risk for contrast-induced nephropathy, increased need for dialysis, and
increased mortality. Multiple studies have evaluated radiographic agents, including ionic versus nonionic media and
isosmolar or low-osmolar agents.
The strength and consistency of relationships between specific isosmolar or low-osmolar agents and contrast-induced
nephropathy or renal failure are insufficient for selection of
low-osmolar and isosmolar media. Limitation of the risk of
contrast-induced nephropathy is based on reduced contrast
volume660 and adequate hydration.661
A recent meta-analysis of 5 RCTs evaluated 1453 patients
with NSTE-ACS and CKD, all with GFR <60 mL per minute/1.73 m2.651 Patients were analyzed according to baseline
renal function: stage 3a, 3b, and 4 to 5. An invasive strategy
was associated with a nonsignificant reduction in all-cause
mortality and the composite of death or nonfatal MI. An early
invasive strategy in patients with CKD and ACS reduced
rehospitalization and resulted in a trend toward lower mortality and nonfatal reinfarction. The increased risk of mortality
associated with mild, moderate, and severe CKD is evident
across studies, and risks are increased as the gradient of renal
dysfunction worsens.649651,662
on CKD.
7.6.1. Antiplatelet Therapy
Patients with CKD with ACS are at increased risk for ischemic complications, including stent thrombosis and post
PCI ischemic events.663 They are also predisposed to higher
bleeding complications, which, in addition to the lack of
clinical trial data, result in their undertreatment with antiplatelet therapy. Patients with advanced CKD exhibit high
residual platelet reactivity despite treatment with clopidogrel independent of the presence of diabetes mellitus.664
Hyporesponsiveness to thienopyridines is associated with
increased adverse cardiovascular outcomes, including cardiovascular mortality,665 and higher dosing regimens of
clopidogrel do not appear to further suppress adenosine
diphosphate-induced platelet aggregation.664,666
Although prasugrel may be more efficient than doubling
the dose of clopidogrel in achieving adequate platelet inhibition,667 no clinical studies have demonstrated its efficacy
in patients with CKD with ACS. Ticagrelor, however, was
studied in a prespecified analysis from the PLATO trial.668 In
patients with an estimated GFR <60 mL per minute (nearly
21% of patients in PLATO with available central laboratory
serum creatinine levels), ticagrelor significantly reduced
the primary cardiovascular endpoint (17.3% versus 22.0%;
HR: 0.77; 95% CI: 0.65 to 0.90) compared with clopidogrel.667 Notably, this was associated with a 4% absolute risk
reduction in all-cause mortality favoring ticagrelor and with
no differences in major bleeding, fatal bleeding, and non
CABG-related major bleeding events, demonstrating its utility in patients with renal insufficiency.
7.7. Women: Recommendations

Class I
1. Women with NSTE-ACS should be managed with the
same pharmacological therapy as that for men for
acute care and for secondary prevention, with attention to weight and/or renally calculated doses of antiplatelet and anticoagulant agents to reduce bleeding
risk.669673 (Level of Evidence: B)
2. Women with NSTE-ACS and high-risk features (eg,
troponin positive) should undergo an early invasive
strategy.141,345,346,561 (Level of Evidence: A)
Class IIa
1. Myocardial revascularization is reasonable in pregnant women with NSTE-ACS if an ischemia-guided
strategy is ineffective for management of lifethreatening complications.674 (Level of Evidence: C)

1. Women with NSTE-ACS and low-risk features (see
Section 3.3.1) should not undergo early invasive
treatment because of the lack of benefit141,345,346 and
the possibility of harm.141 (Level of Evidence: B)
Women of all ages have higher rates of in-hospital and longterm complications of NSTE-ACS than men, including bleeding, HF, cardiogenic shock, acute renal failure, recurrent MI,
stroke, and readmissions.670,675,676
Women present later after symptom onset of NSTE-ACS
and have higher rates of inappropriate discharges from the
ED.671,677,678 Women more commonly report atypical symptoms than men.675,679 Women presenting with chest pain are
more likely than men to have either a noncardiac cause or
cardiac causes other than obstructive epicardial coronary disease.108,677,680,681 Women with NSTE-ACS with no apparent
obstructive epicardial disease have a 2% risk of death or MI
within 30 days and require secondary prevention and symptom management.682
Women derive the same treatment benefit as men from aspirin, clopidogrel, anticoagulants, beta blockers, ACE inhibitors, and statins.385,670672,675,676,683,684 Despite worse outcomes,
women with NSTE-ACS are underprescribed guidelinedirected pharmacological therapy, both during the acute illness and at discharge.538,685,686 The basis for pharmacotherapy
for women with NSTE-ACS with abnormal biomarkers and/
or functional tests, but without significant obstructive epicardial disease, remains unclear (Section 7.13). In addition to
risk factor modification, some studies support the benefit of
imipramine, ranolazine, beta blockers, and/or ACE inhibitors
to reduce adverse outcomes.687 Women with NSTE-ACS incur
a higher rate of bleeding complications672,673 (Section 7.8) and
renal failure. A risk score has been developed to attempt to
reduce the bleeding risk in women with NSTE-ACS.688
The decision for an early invasive versus an ischemia-guided
strategy in women with NSTE-ACS is based on a meta-analysis366
and post hoc gender analyses of clinical trials, including FRISC
II, RITA-3, and TACTICS-TIMI 18.344,346,689 The Agency for
Healthcare Research and Quality analysis of an early invasive

versus ischemia-guided strategy345 provides further evidence
that an early invasive strategy should be reserved for women
with positive troponins, as shown in TACTICS-TIMI 18.346
Such women had a significant reduction of death and MI at
1 year with an early invasive versus ischemia-guided strategy.
Women with NSTE-ACS and no elevation in troponin who
underwent an early invasive strategy had a nonsignificant
increase in events, as did women with a low-risk TIMI score
(OR: 1.59 for early invasive versus ischemia-guided strategy),
prompting the Class III recommendation in this CPG.
The NCDR-ACTION registry reported increased complication rates of myocardial revascularization in women
(https://www.ncdr.com/webncdr/action/). Women also have
higher rates of contrast-induced nephropathy and vascular
complications.673,690,691 Despite having fewer high-risk angiographic lesions, a higher percentage of normal LV function,
and up to 25% angiographically normal coronary arteries,
women with NSTE-ACS have a paradoxically higher rate
of persistent angina, reinfarction, functional decline, and
depression after PCI.141,675,677,680,682 Clinical trials,692,693 and a
meta-analysis694 of DES for NSTE-ACS reported no gender
differences in short- and long-term (up to 5 years) outcome,
including target vessel revascularization, MACE, cardiac
death, or MI. However, women were older and had more
comorbidities than men at enrollment.
Women with NSTE-ACS referred for CABG are older with
more comorbidities, which is reflected by higher periprocedural mortality, HF, bleeding, MI, and renal failure.686,695,696
Women required more periprocedural IABP, vasopressors,
mechanical ventilation, dialysis, and blood products and had
longer stays in the intensive care unit and hospital, higher rates
of wound infection, depression, and longer recovery.549,677
An Agency for Healthcare Research and Quality metaanalysis of 10 RCTs through December 2011 reported no efficacy
or safety difference between PCI and CABG for NSTE-ACS in
men or women in 30-day or 1-year MACE (death/MI/stroke).
At 2 years, the procedural success remained equal in women
but favored CABG in men (P=0.002).345,564 The Agency for
Healthcare Research and Quality reported similar outcomes
in women with diabetes mellitus with PCI and CABG for
NSTE-ACS at 7 years, but men with diabetes mellitus had
fewer events with CABG. A prespecified gender analysis of
the FREEDOM trial favored CABG over PCI for women with
diabetes mellitus, although the difference was not as significant as it was for men.616
Consistent with the European Society of Cardiology recommendations, myocardial revascularization should be reserved
for pregnant women with NSTE-ACS and very serious complications unresponsive to medical therapy.674
See Online Data Supplement 30 for more information on
women.
7.8. Anemia, Bleeding, and Transfusion:

Recommendations
Class I
1. All patients with NSTE-ACS should be evaluated for
the risk of bleeding. (Level of Evidence: C)

2. Anticoagulant and antiplatelet therapy should be
weight-based where appropriate and should be adjusted when necessary for CKD to decrease the risk
of bleeding in patients with NSTE-ACS.522,697,698 (Level
of Evidence: B)

1. A strategy of routine blood transfusion in hemodynamically stable patients with NSTE-ACS and hemoglobin levels greater than 8 g/dL is not recommended.699703 (Level of Evidence: B)
Anemia in patients with ACS is associated with an increased risk
for Holter monitordetected recurrent ischemia and for MACE,
with greater anemia correlating with greater risk.704708 In 1 large
analysis of multiple studies, the risk of adverse outcome was higher
in patients with NSTE-ACS with hemoglobin levels <11 g/dL.704
The potentially detrimental effects of severe anemia include
decreased myocardial oxygen delivery and increased MVO2
related to maintenance of a higher cardiac output.704,709,710 Patients
with anemia are less likely to be treated with aspirin, and patients
with ACS and anemia are likely to have more bleeding complications with PCI.711 This has been correlated with increased shortterm risk of MACE outcomes, including mortality; long-term risk
remains controversial.712717 The ACUITY study suggests that the
risk of mortality associated with bleeding is at least as great as that
associated with procedure-related or spontaneous MI.718
Major bleeding is a coprimary endpoint in many trials
and is a consideration when assessing the net clinical benefit of a new drug. A universal definition of bleeding has
been proposed to assist clinicians.547,719721 The incidence of
major bleeding in patients with ACS varies widely (0.4% to
10%)715,722 owing to differing definitions of major bleeding,
patient populations, anticoagulation regimens, and PCI or
CABG. Factors in patients with ACS related to an increased
bleeding risk include older age, female sex, lower body
weight, history of prior bleeding and/or invasive procedures,
anemia, use of GP IIb/IIIa inhibitors or thrombolytics, and
CKD.522,711,713715,722,723 Nonweight-based dosing of anticoagulants and dosing of antithrombin and antiplatelet medications
that are not adjusted for CKD are associated with an increased
risk of bleeding.522,697,698 Bleeding is related to adverse outcomes because it may be a marker of underlying disease, such
as occult malignancy; leads to cessation of antithrombin and
antiplatelet therapy; may prompt transfusion, which itself may
have adverse effects; can cause hypotension; and, if intracranial, can be fatal.724 Proton pump inhibitors decrease the risk
of upper GI bleeding, including in patients treated with DAPT.
Proton pump inhibitors are used in patients with a history of
prior GI bleeding who require DAPT and are an option in
patients at increased risk of GI bleeding.26,430
Evaluation of the risk of bleeding includes a focused history of bleeding symptoms, identification of predisposing
comorbidities, evaluation of laboratory data, and calculation
of a bleeding risk score.688,716,725 Approximately 15% of all
patients with NSTE-ACS and 3% to 12% of those not undergoing CABG receive blood transfusion.702 Rates vary widely
and are closer to the lower figure but increase in association
with factors such as coronary intervention, anticoagulant/
antithrombotic therapy, older age, female sex, anemia, renal

insufficiency, and frailty. Tissue oxygenation does not change
or may actually decrease with transfusion.722 Blood transfusion in patients with ACS is associated with an increased risk
of adverse outcome, including death.702704 A restrictive transfusion strategy leads to an outcome that is at least as good, if
not better, than a liberal transfusion strategy.699,700 An analysis
of a large ACS registry found no benefit from blood transfusion in patients with a nadir hematocrit >24%.702 In a metaanalysis of 10 studies of patients with AMI, transfusion versus
no transfusion was associated with an increase in all-cause
mortality (18.2% versus 10.2%; P<0.001) and subsequent
MI rate (RR: 2.0; 95% CI: 1.06 to 3.93; P=0.03).726 A restrictive approach to transfusion generally consists of no routine
transfusion for a hemoglobin level >7 g/dL to 8 g/dL.699,700,727
Arestrictive approach to blood transfusion is advocated by
the American Association of Blood Banks700 and the European
Society of Cardiology.727 On the basis of data available at the
time of publication, a strategy of routine liberal blood transfusion in hemodynamically stable patients with NSTE-ACS and
mild to moderate anemia is not recommended.
See Online Data Supplement 31 for more information on
anemia, bleeding, and transfusion.
7.9. Thrombocytopenia
The incidence of thrombocytopenia in patients with ACS varies from 1% to 13%. In 1 large prospective registry, one third
of patients treated with prolonged heparin therapy developed
some degree of thrombocytopenia.728 Independent risk factors for the development of thrombocytopenia include lower
baseline platelet count, older age, ACS, cardiac or vascular
surgery, intravenous UFH or both UFH and LMWH, duration
of heparin therapy, and low body mass index.728730 The risk of
thrombocytopenia is increased in patients treated with abciximab and, to a lesser degree, with eptifibatide or tirofiban.731734
Thrombocytopenia on presentation or related to antithrombotic therapy is associated with significantly increased risk of
thrombotic events, MI, major bleeding, and in-hospital mortality in patients with and without ACS.728731,735739 The OR for
development of these endpoints with thrombocytopenia (compared to without thrombocytopenia) is 2 to 8. Data from the
CATCH (Complications After Thrombocytopenia Caused by
Heparin) registry identified a platelet count nadir of 125 109/L
as a threshold, below which there is a linear augmentation in
probability of bleeding.740 Results from CATCH highlighted
that thrombocytopenia and heparin-induced thrombocytopenia are often not diagnosed.728 Thrombocytopenia is generally a contraindication for GP IIb/IIIa inhibitor therapy; direct
thrombin inhibitors are often considered in preference to UFH
or LMWH in patients with thrombocytopenia.
See Online Data Supplements 31 and 32 for additional
information on anemia, bleeding, and transfusion.
7.10. Cocaine and Methamphetamine Users:

Recommendations
Class I
1. Patients with NSTE-ACS and a recent history of
cocaine or methamphetamine use should be treated

in the same manner as patients without cocaine- or
methamphetamine-related NSTE-ACS. The only exception is in patients with signs of acute intoxication
(eg, euphoria, tachycardia, and/or hypertension) and
beta-blocker use, unless patients are receiving coronary vasodilator therapy. (Level of Evidence: C)
Class IIa
1. Benzodiazepines alone or in combination with nitroglycerin are reasonable for management of hypertension and tachycardia in patients with NSTE-ACS and
signs of acute cocaine or methamphetamine intoxication.741744 (Level of Evidence: C)
Class III: Harm

1. Beta blockers should not be administered to patients
with ACS with a recent history of cocaine or methamphetamine use who demonstrate signs of acute intoxication due to the risk of potentiating coronary spasm.
Cocaine exerts multiple effects on the cardiovascular system,
which may precipitate ACS.48,744,745 Acute cocaine exposure
results in increased BP, heart rate, endothelial dysfunction,
and platelet aggregation, all of which may precipitate ACS.
Cocaines direct vasoconstrictor effect can produce coronary
vasospasm. Long-term use of cocaine results in progressive
myocyte damage and accelerated atherosclerosis.48,744,745
ACS in patients with a history of cocaine use should be
treated in the same manner as patients without cocaine use.744
The exception is in patients with ACS in the presence of acute
cocaine intoxication. Because cocaine stimulates both alphaand beta-adrenergic receptors, administration of intravenous
beta blockers may result in unopposed alpha stimulation with
worsening coronary spasm.48,132,744746 Evidence suggests it is
safe to administer intravenous beta blockers in patients with
chest pain and recent cocaine ingestion, although information
is lacking about the effects of beta-blocker administration during the acute stages of cocaine intoxication.747,748 Intravenous
beta blockers should be avoided in patients with NSTE-ACS
with signs of acute cocaine intoxication (euphoria, tachycardia, and/or hypertension). In these patients, benzodiazepines
alone or in combination with nitroglycerin have been useful
for management of hypertension and tachycardia owing to
their effects on the central and peripheral manifestations of
acute cocaine intoxication.741744
Methamphetamine abuse is becoming increasingly common in the United States owing to the ease of manufacturing and the lower cost of methamphetamines compared with
cocaine.131,749,750 Methamphetamines may be ingested orally,
inhaled, or used intravenously. Methamphetamine affects the
central nervous system by simultaneously stimulating the
release and blocking the reuptake of dopamine and norepinephrine.751 Like cocaine, methamphetamine exerts multiple
effects on the cardiovascular system, all of which may precipitate ACS.131,750752 The acute effects of methamphetamine
are euphoria, tachycardia, hypertension, and arrhythmias.
MI may result from coronary spasm or plaque rupture in the
presence of enhanced platelet aggregation. Long-term use

of methamphetamine has been associated with myocarditis, necrotizing vasculitis, pulmonary hypertension, and cardiomyopathy.750752 Because methamphetamine and cocaine
have similar pathophysiological effects, treatment of patients
with ACS associated with methamphetamine and cocaine use
should theoretically be similar.
about cocaine and methamphetamine users.
7.11. Vasospastic (Prinzmetal) Angina:

Recommendations
Class I
1. CCBs alone753757 or in combination with longacting nitrates755,758 are useful to treat and reduce
the frequency of vasospastic angina. (Level of
Evidence: B)
2. Treatment with HMG-CoA reductase inhibitor,759,760 cessation of tobacco use,761,762 and additional atherosclerosis risk factor modification762,763 are
useful in patients with vasospastic angina. (Level of
Evidence: B)
3. Coronary angiography (invasive or noninvasive) is
recommended in patients with episodic chest pain accompanied by transient ST-elevation to rule out severe obstructive CAD. (Level of Evidence: C)
Class IIb
1. Provocative testing during invasive coronary angiography may be considered in patients with suspected vasospastic angina when clinical criteria and noninvasive testing fail to establish the diagnosis.764767
Vasospastic (Prinzmetal) angina chest pain typically occurs
without provocation, is associated with ST-elevation, and usually resolves spontaneously or with rapid-acting nitroglycerin.
Vasospastic angina may also be precipitated by emotional
stress, hyperventilation, exercise, or the cold. It results from
coronary vasomotor dysfunction leading to focal spasm,768
which may occasionally be multifocal within a single vessel
and rarely involves >1 vessel. Vasospastic angina occurs with
normal coronary arteries, nonobstructive CAD, and obstructive CAD, but prognosis is least favorable with the latter.
ST-elevation indicates transmural ischemia and corresponds
to the distribution of the involved artery.769 A circadian variation is often present; most attacks occur in the early morning.770,771 The most prominent coronary risk factor is smoking.
Most episodes resolve without complications, but arrhythmias, syncope, MI, and sudden death can occur.772
Provocative testing during invasive coronary angiography (eg, using
ergonovine, acetylcholine, methylergonovine) is relatively safe, especially
when performed in a controlled manner by experienced operators.
However, sustained spasm, serious arrhythmias, and even death can also
occur very infrequently. Therefore, provocative testing should be avoided
in patients with significant left main disease, advanced 3-vessel disease,
presence of high-grade obstructive lesions, significant valvular stenosis,
significant LV systolic dysfunction, and advanced HF.

Nonpharmacological provocative tests, such as cold pressor
and hyperventilation, have been used diagnostically; potent
vasoconstrictors (eg, acetylcholine) may be useful when noninvasive assessment is uninformative.764767 Smoking, which
exacerbates coronary vasospasm, should be proscribed, and
CCBs are first-line therapies642; long-acting nitrates are also
effective when combined with CCBs.755,758 Statins improve
endothelium-dependent vasodilation and can be useful in vasospastic angina.759,760 Magnesium supplementation and alphareceptor blockers may be effective and can be added.755,758
7.12. ACS With Angiographically Normal Coronary

Arteries: Recommendation
Class IIb
1. If coronary angiography reveals normal coronary
arteries and endothelial dysfunction is suspected,
invasive physiological assessment such as coronary
flow reserve measurement may be considered.629,773776
ACS associated with angiographically normal or nonobstructive (<50% stenosis) coronary arteries (also referred
to as syndrome X) may be related to coronary endothelial
dysfunction777; plaque rupture that may be evident only with
intracoronary ultrasound778; coronary vasospasm779; and coronary artery dissection.780 Myocarditis may present with electrocardiographic and biomarker findings similar to ACS and
can be distinguished by magnetic resonance imaging.781783
Intracoronary ultrasound and/or optical coherence tomography to assess the extent of atherosclerosis and exclude
obstructive lesions may be considered in patients with possible ACS and angiographically normal coronary arteries.778 If
ECGs during chest pain are not available and coronary spasm
cannot be ruled out, coronary angiography and provocative
testing with acetylcholine, adenosine, or methacholine and
24-hour ambulatory ECG may be undertaken after a period
of stabilization. Endothelial dysfunction is more common
in women than in men,679,777,784786 and chest pain is typical
or atypical.785,786 In the absence of a culprit coronary lesion,
prognosis of coronary endothelial dysfunction and/or occult
plaque rupture is favorable.765,787
Risk factor reduction and medical therapy with nitrates,
beta blockers, and CCBs alone or in combination are considered for endothelial dysfunction.788790 High doses of arginine
have also been given.791 Imipramine or aminophylline have
been used in patients with endothelial dysfunction for continued pain despite optimal medical therapy. In postmenopausal
women, estrogen reverses acetylcholine-induced coronary
arterial vasoconstriction, presumably by improving endothelium-dependent coronary vasomotion, and reduces frequency
of chest pain.792 However, estrogen is not recommended
because of its demonstrated increase in cardiovascular and
other risks.793
Spontaneous coronary artery dissection affects a young,
predominantly female population. Treatment of spontaneous
coronary artery dissection with CABG or stenting is described
to improve outcome,794 but high rates of stenting complications are reported.780
7.13. Stress (Takotsubo) Cardiomyopathy:

Recommendations
Class I
1. Stress (Takotsubo) cardiomyopathy should be considered in patients who present with apparent ACS
and nonobstructive CAD at angiography. (Level of
Evidence: C)
2. Imaging with ventriculography, echocardiography, or
magnetic resonance imaging should be performed to
confirm or exclude the diagnosis of stress (Takotsubo)
cardiomyopathy.795798 (Level of Evidence: B)
3. Patients should be treated with conventional agents
(ACE inhibitors, beta blockers, aspirin, and diuretics) as otherwise indicated if hemodynamically stable. (Level of Evidence: C)
4. Anticoagulation should be administered in patients
who develop LV thrombi. (Level of Evidence: C)
Class IIa
1. It is reasonable to use catecholamines for patients
with symptomatic hypotension if outflow tract obstruction is not present. (Level of Evidence: C)
2. The use of IABP is reasonable for patients with refractory shock. (Level of Evidence: C)
3. It is reasonable to use beta blockers and alphaadrenergic agents in patients with outflow tract
obstruction. (Level of Evidence: C)
Class IIb
1. Prophylactic anticoagulation may be considered
to inhibit the development of LV thrombi. (Level of
Evidence: C)
Stress (Takotsubo) cardiomyopathy (also referred to as transient LV apical ballooning or Takotsubo cardiomyopathy)
mimics NSTE or STEMI.799803 There is no obstructive CAD,
and the distribution of electrocardiographic changes and LV
wall motion abnormalities usually includes >1 coronary artery
territory.801 Cardiac troponin elevations are usually modest.798
The majority of cases occur in postmenopausal women, and
presentation is typically precipitated by emotional or physical stress. Imaging by echocardiography, ventriculography,696
or magnetic resonance imaging699 demonstrates characteristic
hypokinesis or dyskinesis of the LV apex with basilar increased
contractility. Variants include hypokinesis of the mid or base of
the left ventricle,795 and right ventricular involvement is common.804 In the vast majority of patients, electrocardiographic
and LV wall motion abnormalities normalize within 1 to 4
weeks, and recurrences are uncommon.805 The pathogenesis
has been attributed to excess catecholamine release,803 coronary spasm, or small coronary vessel hypoperfusion.806
Care is predominantly supportive and includes beta blockers, vasodilators, and catecholamines. The latter 2 interventions must be used cautiously, because they may induce
outflow tract obstruction.800 If shock is present, IABP can be
used. Prophylactic anticoagulation should be considered to
prevent or treat LV thrombus.798
7.14. Obesity
Obesity is associated with conditions such as dyslipidemia,
diabetes mellitus, hypertension, arrhythmias, and HF that
adversely affect ACS outcomes. In the MADIT (Multicenter
Automatic Defibrillator Implantation)-II trial, there was an
inverse relation between body mass index and both all-cause
mortality and sudden cardiac death in patients with LV dysfunction after MI.807 In the SYNERGY trial of 9837 patients
with NSTEMI, mortality was lower in morbidly obese
patients, consistent with the obesity paradox.808 The obesity paradox has not been clarified and is under continuing
investigation. Standard approaches to weight reduction in
obese patients are usually unsuccessful in producing large
decreases in weight. A weight reduction study of obese and
morbidly obese patients following AMI resulted in weight
loss of only 0.5% in obese patients and 3.5% in morbidly
obese patients after 1 year.809 Two drugs, controlled-release
phentermine/topiramate810 and lorcaserin,811 are available for
weight reduction but have not been studied in patients following NSTE-ACS. Bariatric surgery has been successful in
reducing cardiovascular risk factors, including diabetes mellitus, hypertension, and dyslipidemia but has not been evaluated in postACS patients.812 The 2013 obesity CPG provides
comprehensive strategies for weight reduction.16
7.15. Patients Taking Antineoplastic/

Immunosuppressive Therapy
Antineoplastic or immunosuppressive therapy may contribute to the development of NSTE-ACS. For example, antineoplastic agents such as gemcitabine, sorafenib sunitinib,
and 5-fluorouracil have been associated with coronary artery
spasm or stenosis.813,814 Trastuzumab and possibly other anticancer drugs may alter biomarker levels.815 Antineoplastic
agents can induce changes in the arterial wall,813 and modulators of inflammation may promote atherogenesis.816 In patients
receiving these agents, it is prudent to communicate with the
prescribing clinician about the necessity of their continuation
during NSTE-ACS and future resumption.
8. Quality of Care and Outcomes for ACSUse

of Performance Measures and Registries
8.1. Use of Performance Measures and Registries:
Recommendation
Class IIa
1. Participation in a standardized quality-of-care data
registry designed to track and measure outcomes,
complications, and performance measures can be
beneficial in improving the quality of NSTE-ACS
care.817825 (Level of Evidence: B)
The development of national systems for ACS is crucial and
includes the participation of key stakeholders to evaluate care
using standardized performance and quality-improvement
measures for ACS.819,821 Standardized quality-of-care data registries include the NCDR RegistryGet With the Guidelines,
the Get With the Guidelines quality-improvement program,
the Acute Myocardial Infarction Core Measure Set, and
performance measures required by The Joint Commission

and the Centers for Medicare and Medicaid Services.817,823825
The AHA has promoted its Mission: Lifeline initiative to
encourage cooperation among prehospital emergency medical services personnel and cardiac care professionals.817 The
evaluation of ACS care delivery across traditional boundaries can identify problems with systems and enable application
of modern quality-improvement methods.818,820,822 On a local
level, registries as part of the Chronic Care Model were associated with improved outcomes in chronic diseases, including
cardiovascular disease.826,827
9. Summary and Evidence Gaps

Despite landmark advances in the care of patients with NSTEACS since the publication of the 2007 UA/NSTEMI CPG,212
many emerging diagnostic and therapeutic strategies have
posed new challenges. There is general acceptance of an early
invasive strategy for patients with NSTE-ACS in whom significant coronary vascular obstruction has been precisely
quantified. Low-risk patients with NSTE-ACS are documented
to benefit substantially from GDMT, but this is often suboptimally used. Advances in noninvasive testing have the potential
to identify patients with NSTE-ACS who are at intermediate
risk and are candidates for invasive versus medical therapy.
Newer, more potent antiplatelet agents in addition to anticoagulant therapy are indicated irrespective of initial treatment
strategy. Evidence-based decisions will require comparative-effectiveness studies of available and novel agents. The
paradox of newer and more potent antithrombotic and anticoagulant drugs that reduce major adverse cardiac outcomes
but increase bleeding risk occurs with greater frequency in
patients with AF. Patients with AF who develop NSTE-ACS
and receive a coronary stent are the population at risk from
triple anticoagulant/antiplatelet therapy. This regimen has
been reported to be safely modified by elimination of aspirin,
a finding that requires confirmation.
Among the most rapidly evolving areas in NSTE-ACS
diagnosis is the use of cardiac troponin, the preferred biomarker of myocardial necrosis. Although a truly high-sensitivity cardiac troponin is not available in the United States at
the time this CPG was prepared, the sensitivity of contemporary assays continues to increase. This change is accompanied by higher rates of elevated cardiac troponin unrelated to
coronary plaque rupture. The diagnostic quandary posed by
these findings necessitates investigation to elucidate the optimal utility of this advanced biomarker. A promising approach
to improve the diagnostic accuracy for detecting myocardial
necrosis is measurement of absolute cardiac troponin change,
which may be more accurate than the traditional analysis of
relative alterations.
Special populations are addressed in this CPG, the most
numerous of which are older persons and women. More than
half of the mortality in NSTE-ACS occurs in older patients, and
this high-risk cohort will increase as our population ages. An
unmet need is to more clearly distinguish which older patients
are candidates for an ischemia-guided strategy compared with
an early invasive management strategy. An appreciable number
of patients with NSTE-ACS have angiographically normal or
nonobstructive CAD, a group in which women predominate.

Their prognosis is not benign, and the multiple mechanisms of
ACS postulated for these patients remain largely speculative.
Clinical advances are predicated on clarification of the pathophysiology of this challenging syndrome.
A fundamental aspect of all CPGs is that these carefully
developed, evidence-based documents cannot encompass all
clinical circumstances, nor can they replace the judgment of
individual physicians in management of each patient. The science of medicine is rooted in evidence, and the art of medicine
is based on the application of this evidence to the individual
patient. This CPG has adhered to these principles for optimal
management of patients with NSTE-ACS.
Presidents and Staff

American College of Cardiology
Patrick OGara, MD, FACC, President
Shalom Jacobovitz, Chief Executive Officer
William J. Oetgen, MD, MBA, FACC, Executive Vice
President, Science, Education, and Quality
Amelia Scholtz, PhD, Publications Manager, Clinical Policy
and Pathways
American College of Cardiology/American Heart

Association
Lisa Bradfield, CAE, Director, Science and Clinical Policy
Emily Cottrell, MA, Quality Assurance Specialist, Science
and Clinical Policy
Alexa Papaila, Specialist, Science and Clinical Policy
American Heart Association

Elliot Antman, MD, FAHA, President
Nancy Brown, Chief Executive Officer
Rose Marie Robertson, MD, FAHA, Chief Science Officer
Gayle R. Whitman, PhD, RN, FAHA, FAAN, Senior Vice
President, Office of Science Operations
Marco Di Buono, PhD, Vice President, Science, Research,
and Professional Education, Office of Science Operations
Jody Hundley, Production Manager, Scientific Publications,
Office of Science Operations
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KEY WORDS:AHA Scientific Statements acute coronary syndrome
angina, unstable antiplatelet agents coronary artery bypass graft
electrocardiography ischemia myocardial infarction percutaneous
coronary intervention troponin

Appendix 1. Author Relationships With Industry and Other Entities (Relevant)2014 AHA/ACC Guideline for the Management
of Patients With Non-St-Elevation Acute Coronary Syndromes
Committee
Member
Employment
Consultant
Speakers
Bureau
Ownership/
Partnership/
Principal
Personal
Research
Institutional,
Organizational,
or Other Financial Benefit
Expert
Witness
Voting Recusals
by Section*
Ezra A.
Amsterdam
(Chair)
University of
California (Davis)
Medical Center,
Division of
CardiologyProfessor
None
None
None
None
None
None
None
Nanette K.
Wenger
(Vice Chair)
Emory University,
School of Medicine
Professor of Medicine
(Cardiology)
Abbott
Amgen
AstraZeneca
Gilead
Sciences
Janssen
Pharmaceuticals
Medtronic
Merck
Pfizer
None
None
Abbott
Eli Lilly
G
ilead
Sciences
Merck
Pfizer
None
None
All sections
except 3.1.1, 3.4,
5.2, 6.3.1, 6.3.2,
6.3.6, 7.5, 7.6, 7.8,
and 8.
Ralph G.
Brindis
University of
California, San
Francisco Department
of Medicine and the
Phillip R. Lee Institute
for Health Policy
StudiesClinical
Professor
of Medicine
None
Volcano
None
None
None
None
None
Donald E.
Casey, Jr
Atlantic HealthVice
President of Health
and Chief Medical
Officer
None
None
None
None
None
None
None
Theodore G.
Ganiats
University of
California, San Diego
School of Medicine
Executive Director
of Health Services
Research Center
None
None
None
None
None
None
None
David R.
Holmes, Jr
Mayo Clinic
Consultant,
Cardiovascular
Diseases
None
None
None
None
None
None
None
Allan S.
Jaffe
Mayo Clinic,
Cardiovascular
DivisionProfessor of
Medicine
Abbott
Alere
Amgen
B
eckmanCoulter
C
ritical
Diagnostics
ET Healthcare
O
rtho Clinical
Diagnostic
Radiometer
Roche
Thermo-Fishert
Trinity
None
None
None
None
None
All sections
except 3.1,
3.1.1,3.3, 4.1.2.14.1.2.3, 4.2, 4.3.1,
4.3.2, 4.5, 5.1, 5.2,
6.2.1, 6.3.1, 6.3.3,
6.3.6, 7.2.2, 7.5,
7.6, and 8.
Hani Jneid
Baylor College
of MedicineThe
Michael E. DeBakey
VA Medical Center
Assistant Professor of
Medicine
None
None
None
None
None
None
None
(Continued)

Appendix 1. Continued
Committee
Member
Ownership/
Partnership/
Principal
Personal
Research
Institutional,
Organizational,
Expert
Witness
Voting Recusals
by Section*
None
None
None
None
None
None
None
None
All sections
Employment
Consultant
Speakers
Bureau
Rosemary F.
Kelly
University of
MinnesotaProfessor
of Surgery; VA
Medical Center
Chief, Cardiothoracic
Surgery
None
None
Michael C.
Kontos
Virginia
Commonwealth
University, Pauley
Heart Center
Medical Director,
Coronary Intensive
Care Unit, and
Associate Professor,
Internal Medicine
Glenn N.
Levine
Baylor College of
MedicineProfessor
of Medicine; Director,
Cardiac Care Unit
None
None
None
None
None
None
None
Philip R.
Liebson
Rush University
Medical Center
McMullan-Eybel
Chair of Excellence
in Clinical Cardiology
and Professor
of Medicine and
Preventive Medicine
None
None
None
None
None
None
None
Debabrata
Mukherjee
Texas Tech University

Health Sciences
CenterChief,
Cardiovascular
Medicine
None
None
None
None
None
None
None
Eric D.
Peterson
Duke University
Medical Center
Fred Cobb, MD,
Distinguished
Professor of
Medicine; Duke
Clinical Research
InstituteDirector
None
None
Eli Lilly
Johnson &
Johnson
Janssen
Pharmaceuticals
DCRI has numerous

grants and contracts
sponsored by industry
that are relevant to the
content of this CPG. Dr.
Peterson participated in
discussions but recused
himself from writing or
voting, in accordance
with ACC/AHA policy.
See comprehensive RWI
table for a complete list
of companies pertaining
to this organization.
None
All sections
Astellas
Astellas
General Electric AstraZeneca
Ikaria
Prevencio
Sanofi-aventis
Wellpoint/Anthem
Boehringer
Ingelheim
Genentech
Janssen
Pharmaceuticals
Johnson &
Johnson
Merck
Astellas
Eli Lilly
Merck
Novartis
(Continued)

Committee
Member
Employment
Consultant
Amgen
AstraZeneca
Bristol-Myers
Squibb
Merck
Pfizer
Sanofi-aventis
Speakers
Bureau
Ownership/
Partnership/
Principal
None
None
A bbott
Laboratories
Amgen
AstraZeneca
B
ristol-Myers
Squibb
C
ritical
Diagnostics
Daiichi-Sankyo
Genzyme
GlaxoSmithKline
Nanosphere
R
oche
Diagnostics
Sanofi-aventis
Takeda
Cordis
E -valve Abbott
Vascular
E dwards
Lifesciences
Gilead
aquet
M
Datascope
Marc S.
Sabatine
Brigham and
Womens Hospital,
ChairmanTIMI
Study Group,
Division of
Cardiovascular
Medicine;
Harvard Medical
SchoolProfessor
of Medicine
Richard W.
Smalling
University of
Gilead
Texas, Health
Maquet
Science Center at
HoustonProfessor
and Director of
Interventional
Cardiovascular
Medicine;
James D. Woods
Distinguished Chair
in Cardiovascular
Medicine
None
None
Susan J.
Zieman
National Institute
on Aging/NIH,
Geriatrics Branch,
Division of Geriatrics
and Clinical
Gerontology
Medical Officer
None
None
None
Personal
Research
None
Institutional,
Organizational,
Expert
Witness
Voting Recusals
by Section*
AstraZeneca
Daiichi-Sankyo
Gilead
J ohnson &
Johnson
BRAHMS
Proventys
Siemens
Singulex
None
All sections except

3.1.1, 5.2, 6.3.1,
6.3.2, 7.5, 7.8,
and 8.
Cordis
E-valve
None
All sections except

3.1, 3.1.1, 3.3,
3.4, 3.5.1, 4.1.2.14.1.2.3, 4.2, 4.3.1,
4.3.2, 5.2, 6.2.1,
6.3.1, 6.3.2, 6.3.3,
6.3.6, 7.2.2, 7.5,
7.8, and 8.
None
None
None
This table represents the relationships of committee members with industry and other entities that were determined to be relevant to this document. These
relationships were reviewed and updated in conjunction with all meetings and/or conference calls of the GWC during the document development process. The table
does not necessarily reflect relationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the interest represents
ownership of 5% of the voting stock or share of the business entity, or ownership of $10000 of the fair market value of the business entity; or if funds received by
the person from the business entity exceed 5% of the persons gross income for the previous year. Relationships that exist with no financial benefit are also included for
the purpose of transparency. Relationships in this table are modest unless otherwise noted.
According to the ACC/AHA, a person has a relevant relationship IF: a) the relationship or interest relates to the same or similar subject matter, intellectual property
or asset, topic, or issue addressed in the document; or b) the company/entity (with whom the relationship exists) makes a drug, drug class, or device addressed in the
document, or makes a competing drug or device addressed in the document; ore) the person or a member of the persons household, has a reasonable potential for
financial, professional or other personal gain or loss as a result of the issues/content addressed in the document.
*Writing members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply. Section
numbers pertain to those in the full-text CPG.
Significant relationship.
No financial benefit.
ACC indicates American College of Cardiology, AHA, American Heart Association, BMS, Bristol-Myers Squibb; CPG, clinical practice guideline; DCRI, Duke Clinical
Research Institute; NIH, National Institutes of Health; NYU, New York University; RWI, relationships with industry and other entities; TIMI, Thrombolysis In Myocardial
Infarction; and VA, Veterans Affairs.

Appendix 2. Reviewer Relationships With Industry and Other Entities (Relevant)2014 AHA/ACC Guideline for the
Management of Patients With Non-ST-Elevation Acute Coronary Syndromes
Reviewer
Representation
Employment
Consultant
BMS/Pfizer
DCRI (BMS/
Pfizer)
DCRI (Eli Lilly)
Eli Lilly
Deepak L.
Bhatt
Official
ReviewerAHA
VA Boston
Healthcare
SystemProfessor
of Medicine,
Harvard Medical
School; Chief of
Cardiology
John E.
Brush, Jr
Official
ReviewerACC
Board of
Trustees
Eastern Virginia
Medical School
Professor of Medicine,
Chief of Cardiology
E. Magnus
Ohman
Official
ReviewerACC/
AHA Task Force
on Practice
Guidelines
Duke Medicine
Professor of
Medicine
John F.
Robb
Official
ReviewerACC
Board of
Governors
Dartmouth-Hitchcock
Medical Center
Director, Interventional
Cardiology
and Cardiac
Catheterization
Laboratories
Sarah A.
Spinier
Official
ReviewerAHA
Gorav
Ailawadi
None
Institutional,
Organizational,
or Other
Financial Benefit
Speakers
Bureau
Ownership/
Partnership/
Principal
None
None
AstraZeneca*
Bristol-Myers
Squibb*
Ethicon*
The Medicines
Company
Medtronic*
Sanofi-aventis*
Takeda
Medscape
Cardiology
(Advisory
Board)
WebMD
(Steering
Committee)
None
None
None
None
None
None
None
Daiichi-Sankyo*
Eli Lilly*
Gilead*
None
None
AstraZeneca
Gilead*
Bristol-Myers
Janssen
Squibb
Pharmaceuticals
Gilead*
Janssen
Pharmaceuticals*
The Medicines
Company
Merck
Pozen
Roche
Sanofi-aventis
Personal
Research
Expert
Witness
None
None
None
None
None
Defendant,
adverse
drug
reaction,
2012
Philadelphia College
of Pharmacy,
University of
the Sciences in
Philadelphia
Professor of Clinical
Pharmacy
Bristol-Myers
Squibb
Daiichi-Sankyo
Janssen
Pharmaceuticals
Merck
None
None
None
None
P laintiff,
clopidogrel,
2013
Organizational
ReviewerSTS
University of
Virginia Health
SystemThoracic
and Cardiovascular
Surgery
Abbott
Atricure
None
None
None
None
None
Srihari S.
Naidu
Organizational
ReviewerSCAI
Winthrop University
HospitalDirector,
Cardiac Catheterization
Laboratory
None
None
None
None
None
None
Robert L.
Rich, Jr
Organizational
ReviewerAAFP
Bladen Medical
AssociatesFamily
Physician
None
None
None
None
None
None
Mouaz H.
Al-Mallah
Content
ReviewerACC
Prevention of
Cardiovascular
Disease
Committee
King Abdul-Aziz
Cardiac Center
Associate Professor
of Medicine
None
None
None
None
None
None
(Continued)

Personal
Research
Institutional,
Organizational,
or Other
Financial Benefit
Expert
Witness
Employment
Consultant
Speakers
Bureau
Ownership/
Partnership/
Principal
Content
Reviewer
University of California
San Francisco Fresno
Department of
MedicineProfessor
of Medicine; Chief of
Cardiology; Program
Director, Cardiology
Fellowship
None
None
None
None
None
None
Giuseppe
Ambrosio
Content
Reviewer-ACC
Prevention of
Cardiovascular
Disease
Committee
Hospital of University
of Perugia School
of MedicineMedical
Director, Division
of Cardiology
None
None
None
None
H. Vernon
Anderson
Content
Reviewer
University of Texas
Professor of Medicine,
Cardiology Division
None
None
None
Jeffrey L.
Anderson
Content
ReviewerACC/
AHA Task Force
on Practice
Guidelines
Intermountain Medical Sanofi-aventis

CenterAssociate
Chief of Cardiology
None
None
GlaxoSmithKline
Harvard
(DSMB)-TIMI
-48, -51, and
-54 Studies
Fred S.
Apple
Content
Reviewer
University of
Minnesota School of
Medicine, Hennepin
County Medical
CenterProfessor,
Laboratory Medicine
and Pathology
Abbott
Diagnostics
Alere
Beckman Coulter
T2 Biosystems
None
None
Abbott*
Abbott
Alere/Biosite*
Diagnostics-PI
Biomerieux*
Alere-PI
Ortho-Clinical
Diagnostics-PI
Ortho-Clinical
Diagnostics*
Radiometer*
Roche
Laboratories*
Siemens*
Emmanouil S. Content
Brilakis
ReviewerACC
Interventional
Section
Leadership
Council
UT Southwestern
Medical School
Director, Cardiac
Catheterization
Laboratory, VA North
Texas Healthcare
System
Bridgepoint
Medical/Boston
Scientific*
Janssen
Pharmaceuticals
Sanofi-aventis
None
None
Matthew J.
Budoff
Content
ReviewerACC
Cardiovascular
Imaging
Section
Leadership
Council
Los Angeles
Biomedical Research
InstituteProgram
Director, Division
of Cardiology and
None
James A.
Burke
Content
ReviewerACC
Interventional
Section
Leadership
Council
Lehigh Valley
Health Network
Interventional
Cardiologist
None
Reviewer
Representation
John A.
Ambrose
Merck
Bayer*
Schering-Plough
The Medicines
Company
Pfizer
Merck
Schering-Plough
Sanofi-aventis
None
AstraZeneca
None
None
None
None
General
Electric*
None
Eli Lilly
None
None
None
None
Abbott
Vascular
AstraZeneca
Cordis*
Daiichi-Sankyo*
The Medicines
Company
Medtronic*
None
None
Plaintiff,
cardiac
treatment,
2013
None
None
(Continued)

Reviewer
Representation
Employment
Consultant
Speakers
Bureau
Ownership/
Partnership/
Principal
Robert H.
Christenson
Content
ReviewerAACC
University of Maryland BG Medicine

School of Medicine
C
ritical
Professor of Pathology;
Diagnostics
Professor of Medical and Siemens Medical
Research Technology;
Diagnostics
Director, Rapid
Response Laboratory
None
None
Joaquin E.
Cigarroa
Content
ReviewerACC
Interventional
Section
Leadership
Council
Oregon Health and

Science University
Associate Professor
of Medicine
None
None
None
Marco A.
Costa
Content
ReviewerACC
Cardiovascular
Imaging Section
Leadership
Council
University Hospital for

ClevelandCardiologist
Abbott
Vascular*
Boston
Scientific
Medtronic
None
None
Prakash C.
Deedwania
Content
ReviewerACC
Prevention of
Cardiovascular
Disease
Committee
San FranciscoChief
of Cardiology
Amgen
Pfizer
Pfizer
Takeda
Pharmaceuticals
None
James A. de
Lemos
Content
Reviewer
AstraZeneca
UT Southwestern
Diadexus
Medical School
Janssen
Pharmaceuticals
Associate Professor
Coronary Care Unit and
Cardiology Fellowship
None
Burl R. Don
Content
Reviewer
DavisProfessor of
Medicine; Director of
Clinical Nephrology
None
None
None
Lee A.
Fleisher
Content
Reviewer
University of Pennsylvania
Department of
AnesthesiologyProfessor
of Anesthesiology
None
None
Mary G.
George
Content
ReviewerHHS
Centers for Disease

Control and Prevention
Senior Medical Officer,
Division for Heart Disease
and Stroke Prevention
None
Linda D.
Gillam
Content
ReviewerACC
Cardiovascular
Imaging Section
Leadership
Council
Morristown Medical
CenterProfessor of
Cardiology; Vice Chair,
Cardiovascular Medicine
None
Personal
Research
Institutional,
Organizational,
or Other
Financial Benefit
The Medicines AACC

Company
(President)
Roche
Diagnostics
(University
of Maryland
School of
Medicine)*
None
C
atheterization
and
Cardiovascular
Intervention
(Editorial
Board)
Abbott
Abbott
Cordis
Vascular*
Medtronic
Boston
Scientific*
Cordis*
IDEV
Technology
The Medicines
Company
Medtronic*
Micell*
OrbusNeicht
None
Expert
Witness
None
None
None
None
None
Daiichi-Sankyo
None
None
None
None
None
None
None
None
None
None
None
None
None
None
None
None
None
None
A bbott
Diagnostics
(Continued)

Consultant
Speakers
Bureau
Ownership/
Partnership/
Principal
Personal
Research
Institutional,
Organizational,
or Other
Financial Benefit
Expert
Witness
Reviewer
Representation
Employment
Robert A.
Guyton
Content
ReviewerACC/
AH A Task Force
on Practice
Guidelines
Emory ClinicProfessor
and Chief, Division
of Cardiothoracic
Surgery
Medtronic
None
None
None
None
None
Joerg
Herrmann
Content
ReviewerACC
Interventional
Section
Leadership
Council
Mayo Medical SchoolInternal Medicine and

Cardiovascular Disease
None
None
None
None
None
None
Judith S.
Hochman
Content
ReviewerACC/
AHA Task Force
on Practice
Guidelines
New York University

School of Medicine,
Division of
CardiologyClinical
Chief of Cardiology
GlaxoSmithKline
Janssen
Pharmaceuticals
None
None
None
None
None
Yuling
Hong
Content
ReviewerHHS
Centers for Disease

Control and Prevention
Associate Director
None
None
None
None
None
None
Lloyd W.
Klein
Content
ReviewerACC
Interventional
Section
Leadership
Council
Rush Medical
College-Professor
of Medicine
None
None
None
None
None
None
Frederick G.
Kushner
Content
Reviewer
Tulane University School

of MedicineClinical
Professor of Medicine;
Heart Clinic of Louisiana
Medical Director
None
None
None
None
None
None
Ehtisham
Mahmud
Content
ReviewerACC
Interventional
Section
Leadership
Council
University of California,
San DiegoProfessor
of Medicine/Cardiology,
Chief of Cardiovascular
Medicine; Director,
Interventional Cardiology
and Cardiovascular
Catheterization
Laboratory
Eli Lilly*
Medtronic
None
Abbott Vascular*
Accumetrics*
M
erck
Schering-Plough
B
oston
Scientific*
Gilead*
T he Medicines
Company
Sanofi-aventis*
None
None
Carlos
MartnezSnchez
Content
ReviewerAIG
Cardiology Society of
MexicoPresident
None
None
AstraZenecat
Eli Lilly
Sanofi-aventis
None
None
L. Kristen
Newby
Content
Reviewer
Duke University Medical Johnson &

CenterAssociate
Johnson
Professor of Clinical
Daiichi-Sankyo
Medicine
None
None
Amylin
AstraZeneca
Bristol-Myers
Squibb*
Eli Lilly
GlaxoSmithKline
Merck*
None
None
Patrick T.
OGara
Content
Reviewer
Brigham and Womens

HospitalProfessor
of Medicine, Harvard
Medical School; Director,
Clinical Cardiology
None
None
None
None
None
Abiomed
Cordist
Eli Lilly*
Gilead
Johnson &
Johnson
Medtronic
None
None
(Continued)

Reviewer
Representation
Employment
Consultant
Speakers
Bureau
Ownership/
Partnership/
Principal
Personal
Research
Institutional,
Organizational,
or Other
Financial Benefit
Expert
Witness
Narith Ou
Content
Reviewer
Mayo Clinic
Pharmacotherapy
Coordinator,
Pharmacy Services
None
None
None
None
None
None
Gurusher S.
Panjrath
Content
ReviewerACC
Heart Failure and
Transplant Section
Leadership
Council
George Washington
Medical Faculty
AssociatesAssistant
Director of Heart
Failure and Mechanical
Support Program
None
None
None
None
None
None
Rajan
Patel
Content
ReviewerACC
Cardiovascular
Imaging Section
Leadership
Council
Ochsner Clinic
Foundation
Interventional
Cardiologist
None
None
None
None
None
None
Carl J.
Pepine
Content
Reviewer
Shands Hospital
at University of
FloridaProfessor
and Chief, Division
of Cardiovascular
Medicine
Lilly/Cleveland
Clinic (DSMB)
None
Sunil V.
Rao
Content
ReviewerACC
Interventional
Section
Leadership
Council
Duke University
Medical CenterAssociate Professor
of Medicine
AstraZeneca
Daiichi-Sankyo
Eli Lilly
Terumo Medical
The Medicines
Company
None
None
Pasala S.
Content Reviewer Oregon Health and
Ravichandran ACC Surgeons
Science University
Scientific Council Associate Professor
None
None
None
None
None
None
Michael W.
Rich
Content
Reviewer
Washington University
School of Medicine
None
None
None
None
None
None
Frank W.
Sellke
Content ReviewerACC/AHA Task

Force on Practice
Guidelines
Brown Medical School,

Rhode Island Hospital
Professor; Chief of
Cardiothoracic Surgery
None
None
None
None
None
None
Alan Wu
Content
ReviewerAACC
San Francisco General

Hospital and Trauma
CenterChief, Clinical
Chemistry Laboratory
Abbott
Singulex
None
None
None
None
None
None
AstraZeneca* None
Gilead
Sciences*
Park-Davis*
Pfizer*
Sanofi-aventis*
None
Sanofi-aventis Abbott
Vascular
None
This table represents the relationships of reviewers with industry and other entities that were disclosed at the time of peer review and determined to be relevant to
this document. It does not necessarily reflect relationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the
interest represents ownership of 5% of the voting stock or share of the business entity, or ownership of $10000 of the fair market value of the business entity; or if
funds received by the person from the business entity exceed 5% of the persons gross income for the previous year. A relationship is considered to be modest if it is
less than significant under the preceding definition. Relationships that exist with no financial benefit are also included for the purpose of transparency. Relationships in
this table are modest unless otherwise noted. Names are listed in alphabetical order within each category of review.
According to the ACC/AHA, a person has a relevant relationship IF: a) the relationship or interest relates to the same or similar subject matter, intellectual property
or asset, topic, or issue addressed in the document; or b) the company/entity (with whom the relationship exists) makes a drug, drug class, or device addressed in the
document, or makes a competing drug or device addressed in the document; or c) the person or a member of the persons household, has a reasonable potential for
financial, professional or other personal gain or loss as a result of the issues/content addressed in the document.
*Significant relationship.
AAAHC indicates Accreditation Association for Ambulatory Health Care; AACC, American Association for Clinical Chemistry; AAFP, American Academy of Family
Physicians; AHA, American Heart Association; AIG, Association of International Governors; BMS, Bristol-Myers Squibb; DCRI, Duke Clinical Research Institute; DSMB,
data safety monitoring board; HHS, Health and Human Services; NHLBI, National Heart, Lung, and Blood Institute; NIH, National Institutes of Health; SCAI, Society for
Cardiovascular Angiography and Interventions; STS, Society of Thoracic Surgeons; TIMI, Thrombolysis In Myocardial Infarction; and VA, Veterans Affairs.

Appendix 3. Abbreviations
ACE = angiotensin-converting enzyme
HF = heart failure
ACS = acute coronary syndrome
IABP = intra-aortic balloon pump
AF = atrial fibrillation
IV = intravenous
AMI = acute myocardial infarction
LMWH = low-molecular-weight heparin
BP = blood pressure
LV = left ventricular
CABG = coronary artery bypass graft
LVEF = left ventricular ejection fraction
CAD = coronary artery disease
MACE = major adverse cardiac event
CKD = chronic kidney disease
MI = myocardial infarction
CK-MB = creatine kinase myocardial isoenzyme
MVO2 = myocardial oxygen consumption
COX = cyclooxygenase
NSAID = nonsteroidal anti-inflammatory drug
CPG = clinical practice guideline
NSTE-ACS = non-ST-elevation acute coronary syndromes
CrCl = creatinine clearance
NSTEMI = non-ST-elevation myocardial infarction
CT = computed tomography
PCI = percutaneous coronary intervention
DAPT = dual antiplatelet therapy
RCT = randomized controlled trial
DES = drug-eluting stent
SC = subcutaneous
ECG = electrocardiogram
STEMI = ST-elevation myocardial infarction
ED = emergency department
GDMT = guideline-directed medical therapy
GP = glycoprotein
GFR = glomerular filtration rate
GWC = guideline writing committee
UA = unstable angina
UFH = unfractionated heparin
VF = ventricular fibrillation
VT = ventricular tachycardia

Appendix 4. Additional Tables
Table A. Universal Classification of MI
Type 1: Spontaneous MI
Spontaneous MI related to atherosclerotic plaque rupture, ulceration, fissuring, erosion, or dissection with resulting intraluminal thrombus in 1 of the coronary
arteries leading to decreased myocardial blood flow or distal platelet emboli with ensuing myocyte necrosis. The patient may have underlying severe CAD, but on
occasion nonobstructive or no CAD.
Type 2: MI secondary to ischemic imbalance
In instances of myocardial injury with necrosis where a condition other than CAD contributes to an imbalance between MVO2, eg, coronary endothelial dysfunction,
coronary artery spasm, coronary embolism, tachy-/bradyarrhythmias, anemia, respiratory failure, hypotension, and hypertension with or without LVH.
Type 3: MI resulting in death when biomarker values are unavailable
Cardiac death with symptoms suggestive of myocardial ischemia and presumed new ischemic electrocardiographic changes or new LBBB, but death occurred before
blood samples could be obtained, before cardiac biomarker could rise, or in rare cases where blood was not collected for cardiac biomarker testing.
Type 4a: MI related to PCI
MI associated with PCI is arbitrarily defined by elevation of cTn values >5 99th percentile URL in patients with normal baseline values (<99th percentile URL) or a
rise of cTn values >20% if baseline values are elevated and are stable or falling. In addition, either (i) symptoms suggestive of myocardial ischemia, (ii) new ischemic
electrocardiographic changes or new LBBB, (iii) angiographic loss of patency of a major coronary artery or a side branch or persistent slow or no flow or embolization,
or (iv) imaging demonstration of new loss of viable myocardium or new regional wall motion abnormality is required.
Type 4b: MI related to stent thrombosis
MI associated with stent thrombosis is detected by coronary angiography or autopsy in the setting of myocardial ischemia and with a rise and/or fall of cardiac
biomarker values with 1 value above the 99th percentile URL.
Type 5: MI related to CABG
MI associated with CABG is arbitrarily defined by elevation of cardiac biomarker values >10 99th percentile URL in patients with normal baseline cTn values (<99th
percentile URL). In addition, either (i) new pathological Q waves or new LBBB, or (ii) angiographically documented new graft or new native coronary artery occlusion,
or (iii) imaging evidence of new loss of viable myocardium or new regional wall motion abnormality.
CABG indicates coronary artery bypass graft; CAD, coronary artery disease; cTn, cardiac troponin; LBBB, left bundle-branch block; LVH, left ventricular hypertrophy;
MI, myocardial infarction; MVO2, myocardial oxygen consumption; PCI, percutaneous coronary intervention; and URL, upper reference limit.
Modified from Thygesen et al.21
Table B. Pharmacological Therapy in Older Patients With NSTE-ACS

Age-Related
Pharmacological Change
Clinical
Effect
Dose-Adjustment
Recommendations
Additional
Precautions
General principles
In renal function (CrCl*):

drug clearance, water/
electrolyte balance
S Cr unreliable measure of
renal function in older adults
Change in body composition
Fat, lean body mass/total
water
GI absorption
Levels renally cleared drug

Risk high/low electrolyte levels
Levels hydrophilic agents
Levels lipophilic agents
Longer time to reach steadystate lipophilic agents
alculate CrCl in all ptsrenalC

dose accordingly
S tart at lowest recommended
dose, titrate up slowly
Avoid interacting drugs
onsider doses in women,
C
malnourished, hypovolemic
C
aution fall risk with BP agents
and diuretics
M
onitor for ADR, especially
delirium
F requent monitoring of renal
function/electrolytes
inimize polypharmacywatch
M
for drug-drug interactions
ASA
Hydrophilic; levels with

total body water; age-related
plasma concentration for
similar dose
Bleeding risk with age,

dehydration, frailty, diuretics
Maintenance=81 mg/d
(lowest possible dose)
Bleeding with NSAIDs, other AP,

AC, AT; risk peptic ulcer with
NSAIDs
Nitrates
Sensitivity
Hypotensive response with

baroreceptor response
Lowest dose possible,

especially if hypovolemic
Risk OH, syncope, falls
ACE inhibitors
First-pass metabolism (some)

with effect; enalapril effect
May have effect
May need dose
Risk AKI and K+ and effect with

NSAIDs; avoid K-sparing diuretics
ARBs
No significant age-related
changes
No age-related clinical changes
None
Risk AKI and K+ and effect with

NSAIDs; avoid K-sparing diuretics
Alpha blockers
Sensitivity; BP with
baroreceptor response
BP; OH
Avoid when possible
Risk OH, falls, syncope, especially

with loop diuretics
Beta blockers
Myocardial sensitivity
(postreceptor signaling),
conduction system sensitivity
Bradycardia/heart block; BP
effect vs. younger pts
May need dose with age
Caution conduction system blocks
(Continued)

Table B. Continued
Age-Related
Clinical
Effect
Dose-Adjustment
Recommendations
Additional
Precautions
DHPs
(amlodipine;
nifedipine)
Lipophilic; hepatic and

overall clearance; fat storage;
sinus node sensitivity;
baroreceptor response to BP
BP more than nonDHP and

with age; edema hypotension,
bradycardia
Initiate low dose, titrate

cautiously
Inhibits clopidogrel; risk OH,

falls, syncope; most potent BP
first 3 mo, then less
Non-DHP
(verapamil;
diltiazem)
Hepatic and overall

clearance; less PR
prolongation than DHP and
with age; negative inotropy;
SA node sensitivity and HR
than DHP and with age;
AV conduction with age;
baroreceptor response to BP
BP more with tage;

edema; heart block;
hypotension; bradycardia and
bradyarrhythmias with age
Initiate low dose, titrate

cautiously
Risk OH, falls, syncope;

consider rhythm monitoring
Diuretics
Diuretic/natriuretic
response, EC space, drug
concentration if GFR;
baroreceptor response to
volume shifts
Sensitivity; hypotension; risk

hypokalemia/hypomagnesemia/
hyponatremia; diuretic
effect with GFR; risk
hypovolemia- thirst
May need doses if GFR;

may need dose if cotreating
with NSAIDs
M
onitor Na+, K+, Mg2+ levels;
risk OH/falls;
W
ith NSAIDs: natriuretic and
diuretic effect, K+, Mg2+
UFH
Hydrophilic; concentration,
especially if lean body mass
or plasma proteins; levels
with age
Bleeding risk with age; more

potent anticoagulation per dose
with age; weight-based dosing
but with precautions for shift in
body composition
Weight-based 60 U/kg
loading dose + 12 U/kg/h INF.
Suggested max loading dose:
400 U and 900 U/h INF or
5000 U loading dose/1000 U/h
if pt weight >100 kg
Bleeding with ASA; bleeding

risk with other AP, AT, and GP
IIb/IIIa; vigilantly monitor aPTT
LMWH
Cleared renally; more

predictable dose response
than UFH; not dependent on
plasma protein levels; levels
with lean body mass; effect
with age
Bleeding risk with age and

weight and renally dosed
Enoxaparin: Weight-based
1mg/kg SC q 12 h; CrCl*
<30mL/minavoid or
1 mg/kg SC q 24 h; CrCl
3060 mL/min: 75%;
Dalteparin: Use caution in
older pts with low body weight
or renal insufficiency
Bleed with ASA

M
onitor anti-Xa; bleeding
with GP IIb/IIIa with age
CCBs
Heparins
Direct Thrombin Inhibitors

Bivalirudin
Cleared renally; more

predictable dose response;
not dependent on plasma
protein levels
Significantly less bleeding

in older pts, even with renal
dysfunction vs. UFH + GP IIb/IIIa
with similar efficacy
CrCl <30 mL/min: 1 mg/kg/h;

CrCl: 30 to 60 mL/minless
bleeding than UFH
Less bleeding than GP IIb/IIIa

inhibitor + heparin
Fondaparinux
Cleared renally
Renal/weight adjust; less

bleeding but similar efficacy
vs. enoxaparin in older pts with
NSTE-ACS, even with mild to
moderate renal dysfunction
Renal adjustment: CrCl

<30contraindicated;
CrCl 30 to 60preferred
over enoxaparin
Bleeding vs. enoxaparin;

good safety profile vs.
UFH/LMWH
Clopidogrel
Lipophilic; HPR;
metabolism; fat distribution;
to steady state (fat
distribution/T)
Antiplatelet effect in some

older pts
Maintenance: 75 mg
(no response to higher dose)
Effect with proton pump

inhibitors; if HPRmay respond
to prasugrel or ticagrelor
Prasugrel
l9% Active metabolite >75y

of age
Bleeding risk
Avoid in pts 75 y of age or if

weight 60 kg; 10 mg in very
high-risk pts
N/A
Ticagrelor
None known
N/A
None
Reversible
N/A
Bleeding with age
Not recommended
N/A
P2Y12 Inhibitors
GP IIb/IIIa Inhibitors
Abciximab
Bleeding risk without

clinical benefit
(Continued)

Table B. Continued
Age-Related
Clinical
Effect
Dose-Adjustment
Recommendations
Additional
Precautions
GP IIb/IIIa Inhibitors (continued)

Eptifibatide
Weight/renally dosed
Bleeding risk
Weight-based: 180 mcg/kg

loading dose + 2 mcg/kg/min
INF; CrCl 50 mL/min:
1.0 mcg/kg/min INF
Tirofiban
Weight/renally dosed
Bleeding risk
Weight-based: 12 mcg/kg
In older pts with high bleeding
loading dose + 0.14 mcg/kg/min risk, low-dose INF effective
INF; CrCl <30 mL/min:
with bleeding
6 mcg/kg loading dose +
0.05 mcg/kg/min INF
Warfarin
Sensitivity; 20%40%
Bleeding risk at lower INR;
clearance; protein binding;
higher INR/dose with age risk
inhibition vitamin K-dependent GI bleeding
clotting factors at same plasma
levels with age
Loading: 4 mg/d 4 d
Maintain mean dose
0.4 mg/w/y of age
Multiple drug interactions,

frequency of monitoring;
ASApotentiates effect
New Oral AC
N/A
N/A
Contraindicated if CrCl
<15 mL/min
If pt taking when admitted, stop

consider delaying angiogram/
PCI until effect wanes, switch
to UFH/dalteparin/bivalirudin/
fondaparinux; AP and DAPT
bleeding 2 post-ACSconsider
BMS and radial access. Avoid
GP IIb/IIIa inhibitor if possible;
thrombotic risk following
discontinuation.
Rivaroxaban
35% cleared renally; 65%

hepatic (CYP3A4); levels
in hepatic and/or renal
dysfunction and age
Bleeding risk; not reversible
CrCl 1549 mL/min: 15 mg QD;

consider avoiding if CrCl
1530 mL/min if bleeding risk;
CrCl >50 mL/min: 20 mg QD
Some drug interactions
Dabigatran
80% cleared renally; plasma

level with age, especially
75 y
CrCl 1530 mL/min: 75 mg

BID with caution; CrCl
3049 mL/min: 75 mg BID;
CrCl >50 mL/min: 150 mg BID
Monitor pt and renal function

frequently; longest for effect
to wane with CrCl; risk
dyspepsia, GI bleeding
Apixaban
Hepatically cleared (minor

CYP3A4); dose adjust if weight
60 kg; highly protein bound
CrCl 1529 mL/min: 2.5 mg

Risk abnormal liver
BID or with 2 of the following:
function tests
age 80 y/weight 60 kg/SCr
1.5 mg/ dL: SCr <1.5: 5 mg BID
Less benefit/more bleeding

with age
*CrCl should be calculated for all older pts because SCr level does not accurately reflect renal dysfunction: CrCl decreases with age 0.7 mL/min/y.
These agents are not approved for NSTE-ACS but are included for management of pts with nonvalvular chronic atrial fibrillation.
AC indicates anticoagulants; ACE, angiotensin-converting-enzyme; ACS, acute coronary syndromes; ADR, adverse drug reactions; AKI, acute kidney injury; AP,
antiplatelets; aPTT, activated partial thromboplastin time; ARB, angiotensin receptor blocker; ASA, aspirin; AT, antithrombins; AV, atrioventricular; BID, twice daily;
BMS, bare-metal stent; BP, blood pressure; CCBs, calcium channel blockers; CrCl, creatinine clearance; DAPT, dual antiplatelet therapy; DHP, dihydropyridine;
EC, extracellular; GFR, glomerular filtration rate; GI, gastrointestinal; GP, glycoprotein; HPR, high platelet reactivity; HR, heart rate; INF, infusion; INR, international
normalized ratio; K+, potassium; LMWH, low-molecular-weight heparin; max, maximum; Mg, magnesium; N/A, not available; NSAIDs, nonsteroidal anti-inflammatory
drugs; NSTE-ACS, non-ST-elevation acute coronary syndromes; OH, orthostatic hypotension; PCI, percutaneous coronary intervention; pts, patients; QD; once daily;
SA, sinoatrial; SC, subcutaneous; SCr, serum creatinine; T, half-life; and UFH, unfractionated heparin.

Table C. Age-Related Physiological Changes: Clinical Impact in Older Patients With NSTE-ACS
Age-Related Change
Clinical Alteration
Clinical Impact in NSTE-ACS
Central arterial stiffness
SBP/DBP; LVH; diastolic function; coronary

perfusion pressure; ischemia/infarct threshold for
tachycardia/hypertension with and without coronary
obstructive disease; PA pressure
Risk end-organ damage (cerebrovascular accident, AKI);

BP lability; reinfarction/ischemia; orthostatic hypotension;
HF; pulmonary edema
LV diastolic function
LA size; early passive LV filling; late LV filling and

LV EDP; PA pressure
Risk AF; (pulmonary edema/CO), DOE; pulmonary

edema with HR/BP
Response to beta-adrenergic
stimulation
HR/inotropic responsiveness to stress; resting systolic

LV function unchanged with age
Hypotension, HF, HR response
Conduction system changes
Sinus node cells; AV conduction; LBBB; and RBBB
Difficult to interpret electrocardiographic MI/ischemia; heart

block; SSS; SVT, sensitivity to conduction system drugs
Volume regulating hormones
Na, K, and water regulationBP lability
Altered electrolytes, sensitivity to fluid therapy/diuretics
Renal changes
GFR (0.8 mL/min/y), Na/K clearance, normal serum

creatinine despite moderate to severe CKD, altered drug
clearance; urine concentrating ability
CrCl or eGFR must be calculated for drug dosing, sensitivity

to contrast nephropathy, risk AKI
Fat-muscle redistribution
Third spacing of fluid, may alter drug storage; Vo2max
May alter fluid/drug dosing, decreased CO; DOE; early

fatigability
Baroreceptor sensitivity
BP lability
Orthostatic hypotension, fall risk
Clotting factor/platelet
function/hemostasis
Bleeding and clotting risk, sensitivity to

anticoagulants/antithrombins
Risk cerebrovascular accident/reinfarction/recurrent

ischemia, bleeding, thrombosis, PE, DVT; may alter drug
dosing/sensitivity; stent thrombosis
AF indicates atrial fibrillation; AKI, acute kidney injury; AV, atrioventricular; BP, blood pressure; CKD, chronic kidney disease; CO, cardiac output; CrCl, creatinine
clearance; DBP, diastolic blood pressure; DOE, dyspnea on exertion; DVT, deep vein thrombosis; EDP, end-diastolic pressure; eGFR, estimated glomerular filtration
rate; GFR, glomerular filtration rate; HF, heart failure; HR, heart rate; K, potassium; LA, left atrium; LBBB, left bundle-branch block; LV, left ventricular; LVH, left
ventricular hypertrophy; MI, myocardial infarction; NA, sodium; Na/K sodium and potassium clearance; NTSE-ACS, nonST-elevation acute coronary syndrome;
PA, pulmonary artery; PE, pulmonary embolism; RBBB, right bundle-branch block, SBP, systolic blood pressure; SSS, sick sinus syndrome; SVT, supraventricular
tachycardia; and Vo2max, maximum oxygen consumption.
Table D. FREEDOM Trial: Key Outcomes at 2 Years and 5 Years After Randomization
2y
5y
PCI
CABG
PCI
CABG
121 (13.0)
108(11.9)
200 (26.6)
146 (18.7)
Death from any cause

MI
62 (6.7)
57 (6.3)
114(16.3)
83 (10.9)
62 (6.7)
42 (4.7)
98 (13.9)
48 (6.0)
Stroke
14(1.5)
24 (2.7)
20 (2.4)
37 (5.2)
0.03
Cardiovascular death
9 (0.9)
12(1.3)
73(10.9)
52 (6.8)
0.12
Number (%)
Outcome
Primary composite
P Value*
0.005*
0.049
<0.001
*P values were calculated with the log-rank test on the basis of all available follow-up data (ie, >5 y).
The primary composite outcome was rate of death from any cause, MI, or stroke.
P=0.006 in the as-treated (non-intention-to-treat) analysis.
P=0.16 by the WaLd test of the Cox regression estimate for study-group assignment in 1712 patients after adjustment for average glucose Level after procedure.
CABG indicates coronary artery bypass graft; FREEDOM, Future Revascularization Evaluation in Patients With Diabetes Mellitus: Optimal Management of Multivessel
Disease; MI, myocardial infarction; and PCI, percutaneous coronary intervention.
Modified with permission from Farkouh et al.616
2014 AHA/ACC Guideline for the Management of Patients With NonST-Elevation Acute
Coronary Syndromes: A Report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines
Ezra A. Amsterdam, Nanette K. Wenger, Ralph G. Brindis, Donald E. Casey, Jr, Theodore G.
Ganiats, David R. Holmes, Jr, Allan S. Jaffe, Hani Jneid, Rosemary F. Kelly, Michael C.
Kontos, Glenn N. Levine, Philip R. Liebson, Debabrata Mukherjee, Eric D. Peterson, Marc S.
Sabatine, Richard W. Smalling and Susan J. Zieman
Circulation. 2014;130:e344-e426; originally published online September 23, 2014;
doi: 10.1161/CIR.0000000000000134
Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright 2014 American Heart Association, Inc. All rights reserved.
Print ISSN: 0009-7322. Online ISSN: 1524-4539
The online version of this article, along with updated information and services, is located on the
World Wide Web at:
http://circ.ahajournals.org/content/130/25/e344
An erratum has been published regarding this article. Please see the attached page for:
http://circ.ahajournals.org/content/130/25/e433.full.pdf
Data Supplement (unedited) at:

http://circ.ahajournals.org/content/suppl/2014/09/23/CIR.0000000000000134.DC1.html
http://circ.ahajournals.org/content/suppl/2014/09/23/CIR.0000000000000134.DC2.html
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Correction
In the article by Amsterdam et al 2014 ACC/AHA Guideline for the Management of Patients With
NonST-Elevation Acute Coronary Syndromes: A Report of the American College of Cardiology/
American Heart Association Task Force on Practice Guidelines, which published online September
23, 2014, and appeared in the December 23/30, 2014, issue of the journal (Circulation. 2014;130:
e344e426), several corrections were needed.
1. On the title page, the Society for Cardiovascular Angiography and Interventions has been
added to the collaborating organizations line. It now reads, Developed in Collaboration With
the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic
Surgeons.
2. On page e356, in Figure 2A, the GRACE Risk Model Nomogram, the footnote read, To convert serum creatine level to micromoles per liter, multiply by 88.4. It now reads, To convert
serum creatinine level to micromoles per liter, multiply by 88.4.
3. On page e363, in the second column, the Class I, Recommendation 3 paragraph read, hyperkalemia (K >5.0mEq/L). It now reads or hyperkalemia (K+ >5.0 mEq/L).
4. On page e364, in the first column, in the Class I, Recommendation 1 paragraph, the maintenance dose for aspirin has been changed. Additionally, the references shown below,
numbered 293 and 391, have been added to the text. The recommendation read, and a
maintenance dose of aspirin (81 mg/d to 162 mg/d) should be continued indefinitely.288290 It
now reads, and a maintenance dose of aspirin (81 mg/d to 325 mg/d) should be continued
indefinitely.288-290,293,391

293. Wallentin L, Becker RC, Budaj A, et al. Ticagrelor versus clopidogrel in patients with acute
coronary syndromes. N Engl J Med. 2009;361:104557
391. Mehta SR, Tanguay JF, Eikelboom JW, et al. Double-dose versus standard-dose clopidogrel
and high-dose versus low-dose aspirin in individuals undergoing percutaneous coronary
intervention for acute coronary syndromes (CURRENT-OASIS 7): a randomized factorial
trial. Lancet. 2010;376:123343.
5. On page e364, in the second column, the fourth paragraph, the third sentence, the maintenance
dose for aspirin has been changed and the reference shown below, numbered 391, has been
added to the text. The third sentence read, The subsequent maintenance dose is 81 mg per day
to 162 mg per day; patients treated with ticagrelor should receive only 81 mg per day.290 It
now reads, The subsequent maintenance dose is 81 mg per day to 162 mg per day; in special
circumstances, a higher maintenance dose up to 325 mg daily has been used.391 The lower dose
is favored and all patients treated with ticagrelor should receive only 81 mg per day.290 In other
countries, available low dose aspirin formulations may include 75 mg and 100 mg.
trial. Lancet. 2010;376:123343.
6. On page e365, in Table 7, the fourth row Aspirin maintenance dose, the second column
Dosing, the text regarding aspirin maintenance dosing has been modified. The table entry
now reads, 81 mg/d-325 mg/d.* The asterisk inserted after 325 mg/d, refers to text added to
the Table 7 footnote. The additional text in the footnote reads, *The recommended maintenance
dose of aspirin to be used with ticagrelor is 81 mg daily. The references shown below, numbered
293 and 391, were added to the fifth column, References.
293. Wallentin L, Becker RC, Budaj A, et al. Ticagrelor versus clopidogrel in patients with acute
coronary syndromes. N Engl J Med. 2009;361:104557
trial. Lancet. 2010;376:123343.
(Circulation. 2014;130:e433-e434.)
2014 American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.org
DOI: 10.1161/CIR.0000000000000151
e433

The fourth row originally read,
Dosing and Special

Considerations
COR
LOE
References
81 mg/d to 162 mg/d
(280282)
Dosing and Special

Considerations
COR
LOE
References
81 mg/d to 325 mg/d*
(288290,293,391)
Recommendations
Aspirin
Aspirin maintenance dose
continued indefinitely
The corrected row now reads,
Recommendations
Aspirin
Aspirin maintenance dose
continued indefinitely
7. On page e365, in Table 7, in the thirteenth row SC enoxaparin for duration, in the second
column Dosing., the second bullet read, Initial IV loading dose 30 mg. It now reads,
Initial 30 mg IV loading dose in selected patients.
8. On page e367, in the first column, the Class I, Recommendation 1 paragraph, the first sentence in the
first bullet read, Enoxaparin: 1 mg/kg subcutaneous (SC) every 12 hours (reduce dose to 1 mg/kg
SC once daily in patients with creatinine clearance [CrCl] <30 mL/min), continued for the duration
of hospitalization or until PCI is performed. An initial intravenous loading dose is 30 mg.133,136,309
It now reads, Enoxaparin: 1 mg/kg subcutaneous (SC) every 12 hours (reduce dose to 1 mg/kg
SC once daily in patients with creatinine clearance [CrCl] <30 mL/min), continued for the duration of hospitalization or until PCI is performed. An initial intravenous loading dose of 30 mg
has been used in selected patients.133,136,309
9. On page e367, in the first column, the penultimate paragraph, the fourth sentence read, The
dose of enoxaparin is 1 mg/kg SC every 12 hours for NSTE-ACS; an initial intravenous loading
dose is 30 mg. It now reads, The dose of enoxaparin is 1 mg/kg SC every 12 hours for NSTEACS; an initial intravenous loading dose of 30 mg has been used in selected patients.
10. On page e378, in the first column, the second paragraph, in the Class IIa, Recommendation
2, the first sentence read, It is reasonable to choose ticagrelor over clopidogrel for maintenance P2Y12 treatment in patients with NSTE-ACS treated with an early invasive strategy and/
or PCI.293, 294 It now reads, It is reasonable to use ticagrelor in preference to clopidogrel for
maintenance P2Y12 treatment in patients with NSTE-ACS who undergo an early invasive or
ischemia-guided strategy.293, 294
These corrections have been made to the print version and to the current online version of the
article, which is available at http://circ.ahajournals.org/content/130/25/e344.
Amsterdam EA, et al.

2014 AHA/ACC NSTE-ACS Guideline
Author Relationships With Industry and Other Entities (Comprehensive)2014 AHA/ACC Guideline for the Management of Patients With NonST-Elevation Acute Coronary Syndromes (July 2013)
Committee
Member
Employment
Consultant
Speakers
Bureau
Ownership/
Partnership/
Principal
Ezra A.
Amsterdam (Chair)
University of
California (Davis)
Medical Center,
Division of
CardiologyProfessor
None
None
Nanette K. Wenger
(Vice Chair)
Emory University,
School of Medicine
(Cardiology)
None
None
Abbott*
Eli Lilly*
Gilead Sciences*
Merck
NHLBI*
Pfizer*
Ralph G. Brindis
University of
California, San
Francisco
Department of
Medicine and the
Phillip R. Lee Institute
for Health Policy
StudiesClinical
Abbott
Amgen
AstraZeneca
Gilead Sciences*
Janssen
Pharmaceuticals
Medtronic
Merck
Pfizer
Ivivi Health
Sciences
Volcano Corp.
None
None
None
Personal Research
California CABG
Project
Institutional,
Organizational or
Other Financial
Benefit
American Journal of
Cardiology
Clinical Cardiology
2010 School of
Medicine Research
Award*
ACC-NCDR
ACTION Registry
Subcommittee Research and
Publications
ACC Extended
Learning
CCCOA
Clinical Cardiology
Review Editor
Society for
Womens Health
Research
ACC-NCDR(Senior
Medical Officer,
External Affairs)
DAPT trial
(Advisory Board)
California State
Elective PCI Project
(Advisory Board)
C-PORT Elective
RCT (DSMB)
FDA Cardiovascular
Device Panel
State of California
Expert Witness
None
None
None

Donald E. Casey,
Jr
Theodore G.
Ganiats
David R. Holmes,
Jr
Allan S. Jaffe
Hani Jneid
Rosemary F. Kelly
Atlantic HealthVice
President of Health and
Chief Medical Officer
University of
California, San Diego
School of Medicine
Executive Director of
Health Services
Research Center
Mayo Clinic
Consultant,
Cardiovascular
Diseases
Mayo Clinic,
Cardiovascular
DivisionProfessor of
Medicine
Baylor College of
MedicineThe
Michael E. DeBakey
VA Medical Center
Assistant Professor of
Medicine
University of
MinnesotaDivision
Health Dept:
STEMI/PCI Work
Group (DSMB)
State of California
OSHPD (DSMB)
None
None
None
None
None
None
None
None
None
AHRQ
NIH (DSMB)
None
Plaintiff, deep
vein
thrombosis,
2011
None
None
None
None
Atritech
None
Abbott
Alere
Amgen
Beckman-Coulter
Critical
Diagnostics
ET Healthcare
Ortho Clinical
Diagnostic
Radiometer*
Roche
Trinity
Thermo Fisher
None
None
None
None
None
None
None
None
None
None
None
None
None
None
None
None
None

Michael C. Kontos
Glenn N. Levine
Philip R. Liebson
Debabrata
Mukherjee
Eric D. Peterson
Marc S. Sabatine
of Cardiothoracic
Surgery, Professor of
Surgery
Virginia
Commonwealth
University, Pauley
Heart CenterMedical
Director, Coronary
Intensive Care Unit;
Associate Professor,
Internal Medicine
Baylor College of
MedicineProfessor
Cardiac Care Unit
Rush University
Medical Center
McMullan-Eybel Chair
of Excellence in
Clinical Cardiology
and Professor of
Medicine and
Preventive Medicine
Texas Tech University
Health Sciences
CenterChief,
Cardiovascular
Medicine
Duke University
Medical CenterFred
Cobb, MD,
Distinguished
Duke Clinical
Research Institute
Director
Brigham and Women's
Hospital, Chairman
TIMI Study Group,
Astellas
General Electric
Ikaria
Prevencio
Quest Diagnostics
Sanofi-aventis
Wellpoint/Anthem
Astellas
AstraZeneca
None
Mission Lifeline
Scientific Committee
Society of Chest Pain
Centers
AHA
Astellas
Eli Lilly
Merck
NIH
Novartis
Plaintiff,
malpractice
case with
failure to treat
properly, 2012
None
None
None
None
None
None
None
None
None
None
None
None
None
None
None
None
None
None
Boehringer
Ingelheim
Genentech
Janssen
Pharmaceuticals
None
None
Eli Lilly*
Johnson & Johnson*
Janssen
Pharmaceuticals*
DCRI
None
Aegerion
Amgen
AstraZeneca*
None
None
Abbott*
Amgen*
AstraZeneca*
AstraZeneca*
Athera
Biotechnologies*
None

Division of
Cardiovascular
Medicine; Harvard
Medical School
Bristol-Myers
Squibb
Canadian
Cardiovascular
Society
Creative
Educational
Concepts
Diasorin
GlaxoSmithKline
Health Sciences
Media
Merck
Pfizer
Sanofi-aventis
Vertex
Vox Media
WebMD
Gilead
St Jude Medical
Maquet
Toshiba
Bristol-Myers Squibb*
BRAHMS*
Critical Diagnostics*
Daiichi-Sankyo*
Eisai*
Genzyme*
GlaxoSmithKline*
Intarcia*
Nanosphere*
NIH*
Roche Diagnostics*
Sanofi-aventis*
Takeda*
Daiichi-Sankyo*
Gilead*
GlaxoSmithKline*
Johnson & Johnson*
Merck*
Muljibhai Patel
Society for Research
in Nepro-Urology*
Proventys*
Siemens*
Singulex*
University of Texas,
None
None
None
Amarin
Cordis*
Health Science Center
Cordis
E-Valve*
at HoustonProfessor
E-valve/Abbott
St. Jude
and Director of
Vascular
Interventional
Gilead
Cardiovascular
St. Jude Medical
Medicine; James D.
Maquet-Datascope
Woods Distinguished
Edwards Lifesciences
Chair in
Cardiovascular
Medicine
Susan J. Zieman
National Institute on
None
None
None
None
None
American Geriatrics
Aging/NIH, Geriatrics
Society
Branch, Division of
AHA
Geriatrics and Clinical
NIH*
GerontologyMedical
Officer
This table represents all healthcare relationships of committee members with industry and other entities that were reported by authors, including those not
deemed to be relevant to this document, at the time this document was under development. The table does not necessarily reflect relationships with industry at the
time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of 5% of the voting stock or share of the
business entity, or ownership of $10,000 of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of
Richard W.
Smalling

the persons gross income for the previous year. Relationships that exist with no financial benefit are also included for the purpose of transparency.
Relationships in this table are modest unless otherwise noted. Please refer to http://www.cardiosource.org/Science-And-Quality/Practice-Guidelines-and-QualityStandards/Relationships-With-Industry-Policy.aspx for definitions of disclosure categories or additional information about the ACC Disclosure Policy for
Writing Committees.
*Significant relationship.
DCRI has numerous grants and contracts sponsored by industry. These include the following: Aastrom Biosciences; Abbott; Abiomed; Acom Cardiovascular; Adolor Corp;
Advanced Cardiovascular Systems; Advanced Stent Technologies; Adynnx; Aijnomoto; Allergan; Amgen; Alnylam Pharma; Alpharma; Amylin Pharmaceuticals; Anadys;
Anesiva; Angel Medical Systems; ANGES MG; Angiomedtrix; APT Nidus Center; ASCA Biopharma; Astellas Pharma; Asklepios; AstraZeneca; Atritech; Attention
Therapeutics; Aventis; Baxter; Bayer; Berlex; BG Medicine; Biogen; Biolex Therapeutics; Biomarker Factory; Biosite; Boehringer Ingelheim Biogen; Boston Scientific; BristolMyers Squibb; BMS Pfizer; Carbomed; CardioDx; CardioKinetix; Cardiovascular Systems; Cardiovax; Celsion Corp; Centocor; Cerexa; Chase Medical; Conatus Pharmaceuticals;
Conor Medsystems; Cortex; Corgentech; CSL Behring; CV Therapeutics; Daiichi Pharmaceuticals; Daiichi-Sankyo; Daiichi-Sankyo/Lilly; Dainippon; Datascope; Dendreon; Dr.
Reddys Laboratories; Eclipse Surgical Technologies; Edwards Lifesciences; Eisai; Endicor; EnteroMedics; Enzon Pharmaceuticals; Eli Lilly; Ethicon; Ev3; Evalve; F2G; Flow
Cardia; Fox Hollow Pharmaceuticals; Fujisawa; Genetech; General Electric; General Electric Co.; General Electric Healthcare; General Electric Medical Systems; Genzyme Corp.;
Genome Canada; Gilead Sciences; GlaxoSmithKline; Guidant Corp.; Heartscape Technologies; Hoffman-LaRoche; Hospira; Idera Pharmaceuticals; Ikaria; Imcor
Pharmaceuticals; Immunex; INFORMD; Inimex; Inspire Pharmaceuticals; Ischemix; Janssen; Johnson and Johnson; Jomed; Juventus Therapeutics; KAI Pharmaceuticals; King
Pharmaceuticals; Kyowa Pharma; Luitpold; Mardil; MedImmune; Medscape; Medtronic Diabetes; Medtronic; Medtronic Vascular; Merck Group; MicroMed Technology;
Millennium Pharmaceuticals; Mitsubishi Tanabe; Momenta; Nabriva; Neuron Pharmaceuticals; NitroMed; NovaCardia Inc; Novartis AG Group; Novartis Pharmaceuticals;
Oncura; Orexigen; Ortho-McNeil-Janssen; OSI Eyetech; OSI Pharmaceuticals; Pfizer; Pharmacyclics; Pharmasset; Pharmos; Phyxius Pharmaceuticals; Pharsight; Pluristen
Therapeutics; Portola Pharmaceuticals; Proventys; Radiant; Regado Biosciences; Rengeneron Pharmaceuticals; Roche Molecular Systems; Roche Group; Roche Diagnostic; Salix
Pharmaceuticals; Sanofi-Pasteur; Sanofi-aventis; Santaris Pharmaceuticals; Schering-Plough; Scios; Siemens; Southwest Oncology Group; Spectranetics; Summit; Sunovion
Pharmaceuticals; TAP Pharmaceutical Products; Tengion; The Medicines Company; Theravance; TherOx; Tethys Bioscience; Theregen; Three Rivers Pharmaceuticals; The
EMMES Corporation; UCB; Valentis; Valleylab; Vertex; Viacor; and Wyeth.
ACC indicates American College of Cardiology; AHA, American Heart Association; AHRQ, Agency for Healthcare Research and Quality; CABG, coronary
artery bypass graft; CCCOA, Council on Cardiovascular Care for Older Adults; C-PORT, Cardiovascular Patient Outcomes Research Team; DAPT, dual
antiplatelet therapy; DCRI, Duke Clinical Research Institute; DSMB, data safety monitoring board; FDA, Food and Drug Administration; MI, myocardial
infarction; NCDR, National Cardiovascular Data Registry; NIH, National Institutes of Health; NHLBI, National Heart, Lung, and Blood Institute; OSHPD;
Office of Statewide Health Planning and Development; PCI, percutaneous coronary intervention; RCT, randomized controlled trial; STEMI, ST-elevation
myocardial infarction; TIMI, Thrombolysis In Myocardial Infarction; and VA, Veterans Affairs.
2014 NSTE-ACS Guideline Data Supplements

(Section numbers correspond to the full-text guideline.)
Data Supplement 1. Clinical Assessment and Initial Evaluation (Section 3.1) ............................................................................................................................................................................................................... 3
Data Supplement 2. Risk Stratification (Section 3.3) ...................................................................................................................................................................................................................................................... 7
Data Supplement 3. Cardiac Injury Markers and the Universal Definition of AMI (Section 3.4) .................................................................................................................................................................................. 8
Data Supplement 4. Cardiac Troponins (Section 3.4.3)................................................................................................................................................................................................................................................. 10
Data Supplement 5. CK-MB, MB Isoforms and Myoglobin, Compared With Troponins (Section 3.4.4) ................................................................................................................................................................... 12
Data Supplement 6. Bedside Testing for Cardiac Biomarkers (Section 3.4.4) .............................................................................................................................................................................................................. 14
Data Supplement 7. Summary Comparison of Injury Markers (Section 3.4.4) ............................................................................................................................................................................................................. 17
Data Supplement 8. Discharge from ED or Chest Pain Unit (Section 3.5.1)................................................................................................................................................................................................................. 20
Data Supplement 9. Nitrates (Section 4.1.2.1) ............................................................................................................................................................................................................................................................... 22
Data Supplement 10. Analgesic Therapy (Section 4.1.2.2) ........................................................................................................................................................................................................................................... 25
Data Supplement 11. Beta-Adrenergic Blockers (Section 4.1.2.3)................................................................................................................................................................................................................................ 26
Data Supplement 12. Calcium Channel Blockers (Section 4.1.2.4) .............................................................................................................................................................................................................................. 29
Data Supplement 13. Other Anti-Ischemic Inverventions (Ranolazine) (Section 4.1.2.5) ............................................................................................................................................................................................ 32
Data Supplement 14. Inhibitors of the Renin-Angiotensin-Aldosterone System (Section 4.2) ..................................................................................................................................................................................... 34
Data Supplement 15. Oral and Intravenous Antiplatelet Therapy in Patients With Likely or Definite NSTE-ACS Treated With Initial Invasive or Conservative Strategy (Section 4.3.1) .................................... 37
Data Supplement 16. Combined Oral Anticoagulant Therapy and Antiplatelet Therapy in Patients With Definite NSTE-ACS (Section 4.3.2) ........................................................................................................ 52
Data Supplement 17. Parenteral Anticoagulant and Fibrinolytic Therapy (Section 4.3.3) ............................................................................................................................................................................................ 57
Data Supplement 18. Comparison of Early Invasive and Initial Conservative Strategy (Section 4.4.4) ....................................................................................................................................................................... 74
Data Supplement 19. Comparison of Early Versus Delayed Angiography (Section 4.4.4.1)........................................................................................................................................................................................ 80
Data Supplement 20. Risk Stratification Before Discharge for Patients With Conservatively Treated NSTE-ACS (Section 4.5)............................................................................................................................... 81
Data Supplement 21. RCTs and Relevant Meta-Analyses of GP IIb/IIIa Inhibitors in Trials of Patients With NSTE-ACS Undergoing PCI (Section 5) .......................................................................................... 83
Data Supplement 22. Studies of Culprit Lesion Versus Multivessel (Culprit and Nonculprit) PCI in Patients with NSTE-ACS (Section 5) ............................................................................................................. 83
Data Supplement 23. Risk Reduction Strategies for Secondary Prevention (Sections 6.3.) .......................................................................................................................................................................................... 84
Data Supplement 24. Older Patients (Section 7.1)......................................................................................................................................................................................................................................................... 86
Data Supplement 25. Heart Failure (Section 7.2) .......................................................................................................................................................................................................................................................... 95
Data Supplement 26. Cardiogenic Shock (Section 7.2.2) ............................................................................................................................................................................................................................................ 101
Data Supplement 27. Diabetes Mellitus (Section 7.3) ................................................................................................................................................................................................................................................. 103
Data Supplement 28. Post-CABG (Section 7.4) .......................................................................................................................................................................................................................................................... 106
Data Supplement 29. Chronic Kidney Disease (Section 7.6) ...................................................................................................................................................................................................................................... 110
Data Supplement 30. Women (Section 7.7) ................................................................................................................................................................................................................................................................. 113
Data Supplement 31. Anemia, Bleeding, and Transfusion-Relationship Between Transfusion and Mortality (Section 7.8) ..................................................................................................................................... 120
Data Supplement 32. Anemia, Bleeding, and Transfusion Studies for Weight-Based and Renally-Adjusted Dosing of Anticoagulants (Section 7.8)............................................................................................. 121
Data Supplement 33. Cocaine and Methamphetamine Users (Section 7.10)............................................................................................................................................................................................................... 122
Additional Data Supplement Tables ............................................................................................................................................................................................................................................................................ 125
Data Supplement A. Other (Newer) Biomarkers ..................................................................................................................................................................................................................................................... 125
American Heart Association, Inc and American College of Cardiology Foundation
Data Supplement B. Other Anticoagulants .............................................................................................................................................................................................................................................................. 127

Data Supplement C. Lipid Management .................................................................................................................................................................................................................................................................. 129
Data Supplement D. Blood Pressure Control........................................................................................................................................................................................................................................................... 132
Data Supplement E. Diabetes Mellitus .................................................................................................................................................................................................................................................................... 133
Data Supplement F. Smoking Cessation .................................................................................................................................................................................................................................................................. 135
Data Supplement G. Weight Management .............................................................................................................................................................................................................................................................. 138
Data Supplement H. Cardiac Rehabilitation ............................................................................................................................................................................................................................................................ 140
References .................................................................................................................................................................................................................................................................................................................... 141
Data Supplement 1. Clinical Assessment and Initial Evaluation (Section 3.1)

Title, Author,
Study Aim
Study Type/Size (N)
Patient Population
Year
Inclusion
Exclusion Criteria
Criteria
Antman EM et al. Develop a simple Retrospective,
Inclusion in
Not included in
2000
scoring system to observational study;
TIMI 11B trial or these trials
10938172 (1)
predict the risk of TIMI 11B pts not
ESSENCE trial
death and
receiving UFH group
ischemic events
test cohort (N=1,957);
for pts with
TIMI 11B pts receiving
UA/NSTEMI
enoxaprin (N=1,953)
and ESSENCE trial pts
(N=3,171) validation
cohort
Boersma E et al.
2000
10840005 (2)
Develop a model
for predicting 30d death and
myocardial
(re)infarction in
pts without STEACS
Retrospective analysis
of pts with NSTE-ACS
enrolled in PURSUIT
trial (N=9,461; 3.6% with
1 outcome)
Pts enrolled in
PURSUIT trial
Pts not enrolled in

PURSUIT trial; pts
with STE on initial
ECG
Granger CB et al.
2003
14581255 (3)
Develop a
regression model
in pts with
diagnosed ACS
(including pts with
Retrospective
observational study
utilizing pts from
GRACE (N=11,389; 509
deaths); validation set
Inclusion in
GRACE or
GUSTO-IIb trial
Not included in
these trials
Endpoints
Primary Endpoint & Results
Adverse events defined as new or
recurrent MI, severe recurrent
ischemia requiring urgent revasc,
and death within 14 d of pt
presentation; regression model
selected the following 7 significant
risk factors: 65 y, 3 coronary
risk factors, documented prior
stenosis 50%; ST-segment
deviation on initial ECG, 2
anginal events in prior 24 h, use
of ASA within 7 d of presentation,
and elevated serum markers;
presence of factor was given 1
point and absence of risk factor
given 0 points; rates of adverse
events for TIMI score as follows:
0/1: 4.7%; 2: 8.3%; 3:13.2%; 4:
19.9%; 5:26.2%; 6/7: 40.9%
1 outcome: 30-d death; 2
outcome: composite of 30-d death
and myocardial (re)infarction;
More than 20 variables were
found to be predictive of 1 and 2
outcomes
Adverse event defined as inhospital mortality; Regression

model identified following 8
independent risk factors:
accounted age, Killip class, SBP,
P Values,
OR: HR: RR: & 95 CI:
Safety Endpoint &
Results
N/A
Adverse Events
Study Limitations
Event rates <significantly as

TIMI risk score <in test cohort
in TIMI 11B
(p=001 by 2 for trend).
Pattern of <event rates with
<TIMI risk score confirmed in
all 3 validation groups
(p=001). Slope of <in event
rates with <numbers of risk
factors significantly lower in
enoxaparin groups in both
TIMI 11B (p=0.01) and
ESSENCE (p=0.03) and there
was significant interaction
between TIMI risk score and
treatment (p=0.02)
N/A
Regression model developed

in pts with diagnosed ACS
and was not designed to be
applied indiscriminately to
undifferentiated chest pain pts
N/A
7 factors most predictive of

death: age (adjusted []2=95),
heart rate ([]2=32), SBP
([]2=20), ST-segment
depression ([]2=20), signs of
HF ([]2=18), and cardiac
markers ([]2=15); C-index for
the mortality model was 0.814
N/A
N/A
The discrimination ability of

the simplified model was
excellent with C-statistics of
0.83 in the derived database,
0.84 in the confirmation
N/A

and not designed to be
undifferentiated chest pain
pts; difficult to calculate;
original model requires
preexisting programmed
calculator; simplified version
requires print-out of scoring
system for each variable with
corresponding figure to
interpret data
(including STEMI pts) and
was not designed to be
STEMI) for inhospital mortality
included a subsequent
cohort of 3,972 pts
enrolled in GRACES
and 12,142 pts enrolled
in GUSTO-IIb trial
Chase M et al.
2006
16934646(4)
Validate TIMI
score in ED chest
pain pts
Prospective (N=1,354;
136 with 1 outcome)
Pts with chest

pain who had
an ECG
obtained
Pts <30; cocaine

use within 7 d
1 outcome composite of death,

MI, PCI, CABG within 30 d of
initial presentation
Increasing TIMI score

associated with
increased rates of
adverse outcome
Lyon R et al.
2007
17360096(5)
Compare GRACE
and TIMI score in
risk stratification
of undifferentiated
chest pain pts
Prospectively
validate a
modified TIMI risk
of prospective database
(N=760; 123 with 1
endpoint)
Pts with
undifferentiated
chest pain
Pts<20 y
Recurrent MI, PCI, or death within

30 d of pt presentation (note: pts
with MI on initial presentation
excluded from outcome)
Prospective; 117 pts

with 1 endpoint
(N=1,017)
Pts presenting
to ED with chest
pain in whom a
Pts with STE-AMI,

hemodynamic
instability, cocaine
1 outcome defined as MI, PCI,

CABG, or cardiac death within 30
d of initial presentation
GRACE score and

TIMI score equivalent
in risk stratification of
undifferentiated ED
chest pain pts
Increasing sens of
modified TIMI score
seen with increasing
Hess EP et al.
2010
20370775(6)
ST-segment deviation, cardiac

arrest during presentation, serum
creatinine level, positive initial
cardiac enzyme findings, and
heart rate
GRACE data set, and 0.79 in

the GUSTO-IIb database; OR
for the 8 independent risk
factors were: age (OR: 1.7 per
10 y), Killip class (OR: 2.0 per
class), SBP (OR: 1.4 per 20
mmHg decrease), STsegment deviation (OR: 2.4),
cardiac arrest during
presentation (OR: 4.3), serum
creatinine level (OR: 1.2 per 1
mg/dL [88.4 mol/L]
increase), positive initial
cardiac enzyme findings (OR:
1.6), and heart rate (OR: 1.3
per 30 beat/min increase)
N/A
N/A
N/A
undifferentiated chest pain

pts; difficult to calculate;
original model requires preexisting programmed
calculator; simplified version
requires print-out of scoring
system for each variable with
corresponding nomogram
The incidence of 30-d

death, AMI, and
revasc according to
TIMI score is as
follows: TIMI 0, 1.7%
(95% CI: 0.422.95);
TIMI 1, 8.2% (95% CI:
5.2711.04); TIMI 2,
8.6% (95% CI: 5.02
12.08); TIMI 3, 16.8%
(95% CI: 10.91
22.62); TIMI 4, 24.6%
(95% CI: 16.38
32.77); TIMI 5, 37.5%
(95% CI: 21.25
53.75); and TIMI 6,
33.3% (95% CI: 0
100)
GRACE AUC-ROC
0.80 (95% CI: 0.75
0.85). TIMI AUC-ROC
0.79 (95% CI: 0.74
0.85)
The modified TIMI risk
score outperformed
the original with regard
15% of pts did not have

cardiac marker
measurements; pts with
STEMI included
Retrospective; 240 pts from

initial database of 1,000
excluded; Did not count MI on
presentation as adverse event
Only 72% of eligible pts
enrolled; 4.6% of pts without
30-d follow-up
score to risk
stratify ED chest
pain pts; The
modification of
TIMI score was
assigning 5 points
if pt had either
elevated Tn or
ischemic ECG
findings
Lee B et al. 2011
21988945(7)
Compared
GRACE,
PURSUIT, and
TIMI scores in
risk stratification
of chest pain pts
Prospective data
collection for TIMI score;
retrospective
determination of
PURSUIT and GRACE
score (N=4,743; 319 pts
with 1 outcome)
Sanchis J et al.
2005
16053956(8)
Develop a risk
score for ED pts
with chest pain
Retrospective (N=646;
6.7% with 1 endpoint)
Tn value was
obtained
use, terminal illness,

or pregnancy
Chest pain
pts>30 y who
had ECG
obtained and
were enrolled in
previous study
utilizing TIMI
score in risk
stratification of
chest pain pts
Chest pain pts
presenting to
ED undergoing
evaluation for
ACS who
subsequently
were admitted
to chest pain
unit
Pts in which scores

were unable to be
calculated due to
incomplete data
(e.g., no creatinine
obtained)
1 outcome composite of death,

MI, PCI, or CABG within 30 d of
presentation
Significant STE or
depression on initial
ECG; abnormal Tn;
not admitted to
chest pain unit
N/A
score; sens and spec

at potential decision
thresholds were:
>0=sens 96.6%, spec
23.7%; >1=sens
91.5%, spec 54.2%;
and >2=sens 80.3%,
spec 73.4%; sens for
30-d ACS for a score
of 0, 1, 2 was 1.8%,
2.1%, and 11.2%
The TIMI and
GRACE score
outperformed the
PURSUIT score in
risk stratification of
ED chest pain pts
1 endpoint: 1-y
mortality or MI;
point); 4 factors were
found to be predictive
of 1 endpoint and
were assigned
following score: chest
pain score 10
points: 1 point, 2
pain episodes in last
24 h: 1 point; age67
y: 1 point; IDDM: 2
points, and prior PCI:
1 point; Pts were
classified in 5
categories of risk (0,
1, 2, 3, 4, >4) with
direct correlation of
increasing rates of 1
outcome with risk
score
5
to overall diagnostic
accuracy (area under
the ROC curve=0.83
vs. 0.79; p=0.030;
absolute difference
0.037; 95% CI: 0.0040.071)
N/A
The AUC for TIMI was

0.757 (95% CI: 0.7280.785); GRACE, 0.728
(95% CI: 0.701-0.755);
and PURSUIT, 0.691
(95% CI: 0.662-0.720)
Retrospective nature of
comparison of TIMI score to
GRACE and PURSUIT
N/A
Accuracy of score was

greater than that of the
TIMI risk score for the
1 (C-index of 0.78 vs.
0.66; p=0.0002) and 2
(C-index of 0.70 vs.
0.66; p=0.1) endpoints
Small study size; selection

bias towards more healthy pts
as study population limited to
pts admitted to chest pain
unit; chest pain component of
score is not easily calculated
Christenson J et
al. 2006
16387209(9)
Develop a scoring
system for
discharge of pts
from the ED that
would miss <2%
of ACS
Prospective cohort with

retrospective creation of
decision rule (N=769;
165 with 1 outcome)
Pts presenting
to ED with chest
pain between 7
am-10 pm h
<25, traumatic or
radiologically
evident cause of
CP, enrolled in
study in previous 30
d, or had terminal
noncardiac illness
1 outcome MI or definite UA
Backus BE et al.
2010
20802272(10)
Validation of the
HEART Score
which utilizes
elements of
patient History,
ECG, Age, Risk
factors, and
Troponin to risk
stratify ED chest
pain pts
Improve upon the
HEART score in
risk stratification
of chest pain pts
by incorporating
sex, serial ECG,
and serial Tn;
weighting of
elements of
scoring
determined by
likelihood ratio
analysis
(N=880; 158 with 1
outcome)
Pts admitted to
cardiology ED
STE on initial ECG
1 outcome was a composite of

AMI, PCI, CABG, and death
within 6 wk of initial presentation
(N=2,148; 315 with 1
outcome)
Pts presenting
to ED with chest
pain undergoing
evaluation for
ACS
Develop a
prediction rule for
pts at low risk of
30-d adverse
cardiac events
(N=2,718 pts; 336 with
adverse events)
Pts presenting
to ED with chest
pain in whom
Tn value was
obtained
STE on initial ECG;

chest pain in the
presence of TAAR,
pts with pulmonary
edema, pts with
chest pain deemed
not to require any
cardiac workup
(obvious
nonischemic chest
pain and absence of
risk factors or preexisting disease that
would prompt
screening workup)
Pts with STE-AMI,
hemodynamic
instability, cocaine
use, terminal illness,
or pregnancy
Fesmire et al.
2012
22626816(11)
Hess EP et al.
2012
21885156(12)
Prediction rule: if pt
had normal initial
ECG, no Hx CAD,
age<40 y, and
normal baseline CKMB<3.0 ng/mL, or no
increase in CK-MB or
Tn at 2 h; 30-d ACS;
prediction rule 98.8%
sens and 32.5% spec
Rates of 1 outcome
seen with increasing
score: 03: 0.1%; 4
6: 11.6%; 710:
65.2%
CI for prediction rule not

supplied
N/A
Prediction rule developed

retrospectively; not supplied,
but exceed the threshold of
allowed 2% miss rate; 2%
miss rate not standard of care
in United States
N/A
Retrospective; weighting of
the elements of HEART Score
arbitrarily assigned and not
based on likelihood ratio
analysis or regression
analysis
1 outcome was 30-d ACS

defined as MI, PCI, CABG, lifethreatening cardiac complications,
or death within 30 d of initial
presentation
Increasing HEARTS3
score was associated
with increasing risk of
30-d ACS; likelihood
ratio analysis
revealed significant
discrepancies in
weight of the 5
individual elements
shared by the
HEART and
HEARTS3 score
N/A
Hx, ECG, and Tn were

independent predictors
of the combined
endpoint (p<0.0001).
Avg HEART score in
the no endpoint group
was 3.81.9; pts with
at least 1 endpoint 7.2
1.7 (p0.0001). C
stat 0.897
HEARTS3 score
outperformed the
HEART score as
determined by
comparison of areas
under the receiver
operating
characteristic curve for
30-d ACS (0.901 vs.
0.813; 95% CI
difference in areas,
0.0640.110)
1 outcome defined as MI, PCI,

CABG, or cardiac death within 30
d of initial presentation
Prediction rule
consisted of the
absence of 5
predictors: ischemic
ECG changes, Hx of
CAD, pain typical for
ACS, initial or 6-h Tn
N/A
Rule was 100% sens

(95% CI: 97.2%
100.0%) and 20.9%
spec (95% CI: 16.9%
24.9%) for a cardiac
event within 30 d
Rule developed
retrospectively; only 82% of
eligible pts enrolled
Retrospective; utilized oldergeneration Tn
level > 99th

percentile, and age
<50 y. Pts aged 40
y required only a
single Tn evaluation
1 indicates primary; ACS; acute coronary syndrome; AMI, acute myocardial infarction; ASA, aspirin; AUC, area under the curve; BP, blood pressure; CABG, coronary artery bypass graft; CAD, coronary artery disease; CK-MB, creatine kinase-MB; CP, chest pain;
ECG, electrocardiograph; ED, emergency department; ESSENCE, Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q wave Coronary Events; GRACE, Global Registry of Acute Coronary Events; GUSTO, Global Utilization of Streptokinase and Tissue
Plasminogen Activator for Occluded Coronary Arteries trial; HEART, Healing and Early Afterload Reducing Therapy Trial; HF, heart failure; Hx, history; MI, myocardial infarction; N/A, not applicable; NSTE, non-ST-elevation; NSTE-ACS, non-ST-elevation acute
coronary syndrome; NSTEMI, nonST-elevation myocardial infarction; Pts, patients; PCI, percutaneous coronary intervention; revasc, revascularization; PURSUIT, Platelet Glycoprotein IIb/IIIa in Unstable Angina:Receptor Suppression Using Integrilin Therapy; ROC,
receiver operator curve; SBP, systolic blood pressure; Sens, sensitivity/sensitivities; Spec, specificity/specificities; STE, ST-elevation; STE-AMI, ST-elevation acute myocardial infarction; STEMI, ST-elevation myocardial infarction; TAAR, tachyarrhythmia; TIMI,
Thrombolysis In Myocardial Infarction; Tn, troponin; UA, unstable angina; and UFH, unfractionated heparin.
Data Supplement 2. Risk Stratification (Section 3.3)
Study Name,
Study Aim
Study Type/Size (N)
Author, Year
Intervention vs.
Comparator (n)
Patient Population
Study
Intervention
Endpoints
Primary Endpoint &

Results
P Values
Inclusion Criteria
Exclusion
Criteria
Secondary
Endpoint &
Results
N/A
Planned revasc,
bleeding risks,
and correctable
cause for angina
New STE
N/A
All-cause mortality, new or

recurrent MI, severe
ischemia leading to revasc
N/A
Death/MI/revasc over 30 d
In-hospital and
14-d events
Antman 2000
10938172(1)
Development of original
score to risk stratify pts
presenting with ACS
Multisite RCTs, TIMI11 B and ESSENCE
N/A
Clinical ACS, ECG

changes, and
elevated biomarkers
Pollack 2006
16365321(13)
Validation in ED
population with chest
pain
Attempt to add
creatinine to TIMI risk
score
Convenience sample
N=3,326 without new
STE
Single center N=798
N/A
Chest Sx and ECG

obtained
N/A
Ischemic Sx within
48 h
STEMI
N/A
CV death, MI, urgent

revasc or Sx, and elevated
biomarkers
N/A
Huynh 2008
19960136(15)
Across all ACS

spectrum
Multicenter RCT with

N=1,491 from
angiographic arm
N/A
NSTE-ACS and
STEMI
N/A
N/A
6-mo death and MI
N/A
Boersma 2000
10840005(2)
N/A
Multicenter
RCT-Pursuit
N/A
NSTE-ACS
STE
N/A
Death and MI
N/A
Eagle 2004
15187054(16)
Original GRACE
validation
Registry N=17,141
N/A
All ACS
N/A
N/A
6-mo all-cause mortality
N/A
Go 2011
21691204(14)
Study Limitations
p<2 selected for

multivariate modeling,
then variables scored
Biomarkers all
elevated; 65 y pg age
cutoff
Graded relationship
between score and
events
Renal dysfunction
increased risk, but not
enough to add variable to
system
2 mm ST deviation
increased risk and risk
was less regardless of
score with less
Similar risk prediction to
TIMI over groups with
many similar variables
p<0.25 into multivariate
model
Used parts of score to

define management
Small and only 9%
with eGFR, 30
All high-risk pts
No biomarkers
Registry data, 200 pts
without 6-mo follow-up
Granger 2003
14581255(3)
Eggers 2010
20598977(17)
Validation in NSTE-ACS
as training set and then
test set in registry with
validation in RCT
11,389 from registry

and then testing in
3,872 from GRACE
and 12,142 from
GUSTO IIb
Single center trial of
453 chest pain pts
N/A
NSTE-ACS
N/A
N/A
All-cause mortality during

hospitalization
N/A
p<0.25 into multivariate

model
Only high-risk pts
Incremental prognostic
NT-proBNP,
Possible ACS
N/A
Biomarkers at
All-cause mortality at 6 mo NT-pro BNP not
ROC analysis
Small, but 92 deaths
value of multiple
cystatin
presentation
additive, cystatin
biomarkers in NSTEGDF-15
minimally and
ACS
GDF-15 helpful
Abu-Assi 2010
Does GRACE score still MASCARA national
N/A
Confirmed ACS
N/A
LVEF included In-hospital and 6-mo
LVEF did not add N/A
Registry data, but
21095268(18)
work with modern
registry N=5,985
mortality
to GRACE score
contemporary
management
management
Meune 2011
Question as to whether
370 pts from APACE
Hs-cTnT and NTNon-STE-ACS
N/A
N/A
Hospital and 1-y mortality
No additive
N/A
All pts likely had
21444339(19)
hs-cTn or NT-proBNP
trial with 192 MIs
pro added to
benefit
elevated hs-cTnT
influence prediction
GRACE score
ACS indicates acute coronary syndrome; APACE, Advantageous Predictors of Acute Coronary Syndromes Evaluation trial; BNP, B-type natriuretic peptide; CV, cardiocvascular; ECG, electrocardiograph; ED, emergency department; ESSENCE, Efficacy and Safety of
Subcutaneous Enoxaparin in Non-Q wave Coronary Events; eGFR, estimated glomerular filtration rate; GDF,growth and differentiation factors; GRACE, Global Registry of Acute Coronary Events; GUSTO, Global Utilization of Streptokinase and Tissue Plasminogen
Activator for Occluded Coronary Arteries trial; hs-cTn, high sensitivity cardiac troponin; hs-cTnT, high sensitivity cardiac troponin T; LVEF, left ventricular ejection fraction; MASCARA, Manejo del Sndrome Coronario Agudo. Registro Actualizado national registry; MI,
myocardial infarction; N/A, not applicable; NSTE, non-ST-elevation; NSTE-ACS, non-ST-elevation acute coronary syndrome; Pts, patients; NT-pro, N-terminal pro; NT-proBNP, N-terminal pro-brain natriuretic peptide revasc, revascularization; RCT, randomized
controlled trial; ROC, receiver operating characteristic; STE, ST-elevation; STEMI, ST-elevation myocardial infarction; Sx, symptom; and TIMI, Thrombolysis In Myocardial Infarction.
Data Supplement 3. Cardiac Injury Markers and the Universal Definition of AMI (Section 3.4)
Study Name,
Study Aim
Study Type/Size
Intervention vs.
Patient Population
Author, Year
(N)
Comparator (n)
Inclusion
Exclusion Criteria
Criteria
Thygesen 2012
Definition of MI
Guideline
N/A
N/A
N/A
22958960(20)
Roger 2006
Prospective
Prospective
Identification of MI County residents
Lower TrT values
16908764(21)
Evaluation of new
community based
using TrT vs. CKwith TrT 0.03
criteria for Dx of MI
epidemiologic
MB and CK
ng/mL identifying
study
compared with
MI
WHO and ARIC
criteria
Hamm 2000
Classification of UA Reclassification
N/A
Angina at rest
N/A
10880424(22)
based on Tr levels
within 48-h Class
IIIB into Tr+ and
Tr-
Study
Intervention
Endpoints
P Values,
Study Limitations
Primary Endpoint &

Results
N/A
Secondary Endpoint &

Results
N/A
N/A
N/A
N/A
Identification of MI 538
MI with TrT; 327 with
CK; 427 with CK-MB
Clinician Dx mentioned MI
in only 42% of TrT-based
criteria (diagnosing UA in
many) vs. 74% using
previous criteria p<0.001
74% increase
TrT vs. CK (95% CI:
69%79%) 41% inc TrT
vs. CK-MB
(95% CI: 37%46%)
Participation rate of MIs

was only 80% but similar
to median of similar
participation studies
N/A
30-d risk of death

20% in IIIB Tr+, <2% in
IIIB Tr +
N/A
N/A
N/A
N/A
Kavsak 2006
16824840(23)
Impact of new
classification of MI
Retrospective
analysis using CKMB vs. TnI
analysis for MI
defined by 258 pts
with ACS
Retrospective
evaluation of
stable community
sample (995) and
post-AMI pts
(1380) with
TrI99th percentile
Multicenter
observational
prospective
Registry (GRACE)
26,267 pts with
ACS
Eggers 2009
19231317(24)
Effects of new
UDMI on
misdiagnosis with
single evaluation of
Tr
Goodman 2006
16504627(25)
Diagnostic and
prognostic impact of
new UDMI
Eggers 2011
20869357(26)
Clinical implications
of relative change in
cTnI levels with
chest pain
Retrospective
study of 454 pts
with ACS within 24
h of admission with
5.8-y follow-up
Mills 2012
22422871(27)
Evaluation of ACS
pts by using cTnI
diagnostic threshold
and 99th percentile
on Dx and risk for
future events
Retrospective
cohort study with
1-y follow-up of
2,092 consecutive
pts with suspected
ACS
TRITON-TIMI 38
Bonaca 2012
22199016(28)
Association
between new and
recurrent MI using
new UDMI
classification
system and risk of
death
Prospective cohort
analysis of 13,608
pts with ACS
undergoing PCI
TRITON-TIMI 38
study
TrI vs. CK-MB Dx

based on MONICA
or AHA definition
of MI
2 SPSS CK-MB,
TrI 20% change
using 99% TrT
cutoff
N/A
2 specimens
CK-MB, TrI
drawn at least
6 h apart
AMI prevalence
MONICA CK-MB 19.4%
AHA 19.8%.
TnI to 35.7%
TrI-vs. CK-MB
p<0.001 for increase MI
definition using TnI
cTnI
35.7% (30.141.7)
Relative increase 84%
Exclusion of
nonischemic diseases
causing Tr elevation
Evaluation of
single Tr in stable
population
Stable community
population.
Stable 3-mo postMI pts
Evidence of clinical
instability
1 cTnI
Community
Sample; 0.6%
MI by UDMI
Stable post-MI; 6.7% MI
by UDMI
N/A
N/A
N/A
Use of CK and Tn
neg 16,797 vs.
CK-MB and Tn
10,719 for hospital.
fatality, 14,063 vs.
8,785 for 6-mo
mortality
UDMI with
prespecified cTnI
changes from
20%, 50%, 100%
>18 y with
possible ACS
with ECG
abnormal or CAD
history. CK, CKMB. Tn.
NS comorbity,
trauma, surgery,
lack of 1 biomarker
CK
CK-MB
Tn
Follow up for 6
mo
Tn+ levels demonstrate

higher in-hospital and 6mo mortality rates than
higher CK levels
In entire population, Tn+

status vs. CK status 6-mo.
mortality:1.6 (1.41.9)
Hospital fatality rates

higher with Tn+ vs. CK+:
2.2 (95% CI: 1.62.9)
with Tn+/CK-MB-: 2.1
(95% CI: 1.4-3.2)
34% in GRACE registry

excluded because of
use of 1 biomarker only
N/A
cTnI <99th
percentile
cTnI levels
Peak cTnl level 99th

percentile positive
change 20% in 160
pts. 25 pts had no AMI
by ESC/ACC criteria
N/A
Study groups:
cTnI <0.012,
0.0120.049, and
0.50 (99th
percentile) with C
of V 20% vs.
previous
diagnostic criteria
Follow-up of
recurrent MI vs. no
follow-up MI and
risk of death at 6
mo
cTnI
ACS
Noncardiac chest
pain,
tachyarrhythmia,
anemia. Severe
Valve HD, HOCM,
pericarditis,
cocaine use
cTnI values
Compared with 0.050, Tr

0.0120.049 had a higher
risk profile, but less likely to
be investing for AMI
Analysis of assay could

not be validated by hs-Tr
assay.
No review of pts records
for type I or 2 AMI
No long-term risk
assessment
Not a prospective study.
Tn levels of 0.012-0.049
were considered
normal and not
repeated. Possible
myocardial ischemia due
to noncardiac illness.
Types 1, 2, 3, 4, 5
MI
Cardiogenic shock
or any condition
that was
associated with
decreased survival
over 15 mo
Tn used
preferentially
for recurrent
MI and CK-MB
for peri-PCI MI
1-y outcomes based on

cTnI subgroups:
0.0120.049 had higher
mortality and re-MI than
<0.012 (13% vs. 3%)
Increase in Dx of MI
based on new criteria by
47%
Risk of death at 6 mo
after follow-up MI: MI at
follow-up 6.5% vs. 1.3%
and by subtypes
All 160 pts had

significant raised
mortality
HR 2.5 (95% CI: 1.7
3.8) Higher TnI deltas
were not associated with
higher mortalities
p<0.001 for 1-y outcome
of 0,0120.049 vs.
<0.012
p<0.001 for death after

recurrent MI vs. no
recurrent MI
p<0.001 for difference
with each of 5 subtypes
Association of MI with
death not necessarily
related to causality.
Confounders could
explain relationship.
Standard Cox
regression may bias
N/A
results
ACC indicates American College of Cardiology; ACS, acute coronary syndrome; AHA, American Heart Association; AMI, acute myocardial infarction; ARIC, Atherosclerosis Risk in Communities; CAD, coronary artery disease; C of V, coefficient of variation; CK,
Creatine Kinase; CK-MB, Creatine kinase-MB; cTnl, Cardiac troponin I; Dx, diagnosis; ECG, electrocardiograph; Elev, elevation; ESC, European Society of Cardiology; GRACE, Global Registry of Acute Coronary Events; HD, heart disease; Hs-Tn, high-sensitivity
Troponin; HOCM, Hypertrophic Obstructive Cardiomyopathy; MB, myocardial band; MI, myocardial infarction; MONICA, Multinational MONItoring of trends and determinants in CArdiovascular disease; N/A, not applicable; NSTEMI, non-ST segment elevation
myocardial infarction; pt, patient; PCI, percutaneous coronary intervention; SPSS; STEMI, ST elevation MI; TIMI, thrombolysis in myocardial infarction; Tn, Troponin; Tn+, positive troponin, Tn-, negtative troponin; Tr, Troponin; TRITON, Trial to Assess Improvement in
Therapeutic Outcomes by Optimizing Platelet Inhibition With Prasugrel; TrT, Troponin T; TrI, Troponin I; UA, Unstable angina; UDMI, Universal Definition of MI; and WHO, World Health Organization.
Data Supplement 4. Cardiac Troponins (Section 3.4.3)
Study Name,
Study Aim
Study Type/Size
Author, Year
(N)
Apple 2009
19299542(29)
Bonaca 2010
20447535(30)
Kontos 2010
21095267(31)
Intervention vs.
Comparator (n)
Patient Population
Inclusion Criteria
Exclusion Criteria
Study Intervention
Dx, accuracy of
cTnI for early
detection of AMI
and risk prediction
for adverse events
Prospective cohort
study 381 with
possible ACS
VITROS Tnl-ES
assay 2 vs. clinical
Dx of AMI
Sx suggestive of
ACS in ED
No 2nd Tn level
Tn assay at
admission and 6 h
later for delta
change
Px implication.of
low-level inclusion
in Hs-cTnI in
possible ACS
Prospective multi
study
4,513 with NSTACS
+ or hs-cTnI
99th percentile for
death/MI in 30 d
NST-ACS
Shock ,STelevation, revasc

before random
Baseline cTnI with

cutpoint at 99th
percentile
NSTEMI with +Tn

but -CK-MB in
treatment and
outcomes
Post hoc data

base analysis
16,064 with
NSTEMI
Tr+ MB- vs. Tr+ MB+
Present within 24 h
of Sx with NSTEMI
No STEMI
Biomarkers on
admission, Tr and
CK-MB
10
Endpoints
Primary Endpoint &
Results
Sens and spec for MI
from admission and
delta change (see p
values)
Sens increased from
admission to 6-h cTnI
and ROC from 0.82
0.96 (p<0.001)

Results
Risk stratification
improved by 30^
Delta to initial cTnI >99th
percentile.
Risk of death/follow-up
MI within 60 d
+cTnI higher risk of

death/MI at 30 d than cTnI
6.1% vs. 2.0%
p<0.001
Treatment and inhospital outcomes.
In-hospital mortality
lower in MB pts
Pts with low-level

increases
0.04-1.0 at <risk than
cutpoint of 0.04 (5.0%
vs. 2.0%); p=0.001
MB- were older and had
more comorbidities.
p<0.01 and fewer
intervals
P Values,
Study Limitations
Sens admission
cTnI for AMI
69% (95% CI: 55%
81%)
Spec 78% (95% CI:
73%82%)
6-h cTnI
Sens 94% (95% CI: 84
99)
Spec 81% (95% CI:
77%85%)
Deltas >30%
Sens 75% (95% CI:
6%86%)
Spec 91% (95% CI:
87%94%)
Delta cTnI added to
initial or follow-up cTnI
improved risk
stratification p<0.001
Risk of death 12 mo vs.
<0.04 ug/L
6.4% vs. 2.4%; p=0.005
Difficulty in
ascertaining time of
initial Sx.
Problems with
getting 2nd sample at
6h
Question of false
+cTnI
Initial rather than
discharge sampling
may have biased
evaluation of risk at
60 d
In-hospital mortality:
MB+ 4.9 vs. 3.8 MB
p<0.02
No central core lab in

multi-institutional
study
Does not address all

pts with nontraumatic
chest pain
Lindahl 2010
20691825(32)
Giannitsis 2010
20167697(33)
Hs-cTnT
comparison with
std cTnT for risk
assessment
Dx, performance of
Hs-cTnT for
detection of
NSTEMI in ACS
Tr+ and MBCK Prospective cohort

1,452
Effect of + by both
assays vs. only 1
assay
Pts with ACS
No coronary
angiography within
12 h
Both cTnT collected

48 h after
randomization
+Hs-TnT same 1-y

mortality. Whether + or with St-TnT
Retrospective
cohort analysis
57 with UA and
evolving NSTEMI
Baseline
concentrations and
serial concentrations
at 3 h and 6 h
UA or NSTEMI with
initial cTnT
Immediate PCI or
kidney dysfunction
Hs-cTnT baseline,
3, 6 h
delta change
>20%,or ROC
optimized value
>117% 3 h, or
246% 6 h
TnT at admission
and daily to 96 h.
Hs-cTnt Dx 61% at
baseline to 100% at 6 h.
Dx increase by 34%
above std cTnT
Giannitsis 2008
18206741(34)
Serial TnT
measurements vs.
MRI infarct mass
Retrospective
cohort analysis
31 STEMI and 30
NSTEMI
AMI with TnT and

MRI
STEMI and
NSTEMI with MRI
before discharge
Lack of biomarkers
at any of 5 up to
96 h from
admission
Keller 2011
22203537(35)
Diagnostic
performance of hscTnI with
continued. cTnI for
serial changes
Hs-TnI and St-TnI
Suspected ACS
Major surgery or
trauma within 4 wk,
pregnancy, drug
abuse
Hs-TnI and St-TnI

at baseline and 3 h
serial changes
Both Hs-Tnl and St-TnI

at 99th percentile at
admission and 3 h had
similar sens and spec
Younger 2007
17540686(36)
72-h TnI estimate

with MRI for infarct
size
Prospective
multicenter
analysis
1,818 with
suspected ACS,
413 with AMI
Prospective cohort
analysis
93 MI
19 NSTEMI
TnI correlation with

MRI
STEMI, NSTEMI,
LBBB
1st MI
TnI
CK
MRI
Prior AMI
contraindication to
MRI previous
revasc, PCI before
MRI
Admission and 12-h

TnI and CK
MRI average 3.7 d
from admission
72h Tn similar to CK for

infarct size estimate
and superior to 12-h TnI
Apple 2012
22465126(37)
Diagnostic
accuracy and risk
stratification of
cTnI-ultra assay
Prospective cohort
study
371
cTnI at admission and

up to 24 h for
optimum deltas using
ROC analysis
Possible ACS with

follow-up for 60 d
N/A
cTnI at 0-, 6-, 24-h

for optimum %
change, absolute %
change, change,
absolute value of
change
Cardiac events and

death in 60 d. Optimal
value of change was
absolute value of
change delta
11
Except for admission

values, all TnT at
various times correlated
with infarct size
For death or AMI at 30

d
+ only for Hs-TnT had
interim risk
Doubling of hs-TnT with
initial 99% + positive
predicted value 100%
predicted value 88%
+Hs-TnT 1-y mortality

9,2% vs. 1.6%; p=0.001
For by both
assays
Delta changes and
ROC optimized values
spec 100% with sens
69% and 76%
Pts with higher

pretest risk than
typical chest pain pts
in ED
Admission to chest
pain unit more
selective than typical
ED admissions
Estimation of infarct
mass on d 4 was lower
for NSTEMI than
STEMI
r=0.75 STEMI
r=0.36 NSTEMI
3 h after admission.
Sens 98.2% and
predicted value 99.4%
for both assays.
cTnT at d 4 showed
highest correlation and
performed as well as
peak cTnT and AUC
r=0.66 vs. r=0.65 vs.
r=0.69
Hs-TnI at admission
sens 82.3%,pred
value 94.7%
St Tnl sens 79.4%
Correlation of 12-h TnI

with microvascular
obstruction was NS
p=0.16
Compared with peak
CK r=0.44
72-h TnI r=0.46
p=0.0002
Sens and Specs:
Absolute value:
89.8-93.7
Change:
67.5-99.0
Absolute value of %
change:
75.5-85.7
% change:
71.4-89.7
72 h TnI vs. MRI

R=0.62 p<0.0001
12-h TNI
R=0.56 p=0.0003
Peak CK
R=0.75 p<0.0001
Possible poor timing

of sampling with
NSTEMI and
visualization
problems with MRI in
NSTEMI vs. STEMI
Final Dx of AMI by in
house Tn, biasing
biomarker assays
toward Tn
High proportion of MI
vs. other studies
12 and 72-h TnI
available only on 37
pts and 64 pts.
Only 19 NSTEMI.
Data larger than on
previous studies of
Tn MRI correlations.
AUC Diagnostic
accuracy of absolute
value of change 0.96
(0.94, 0.98).
Change 0.76
Absolute value of %
change 0.88
% change 0.77
Long period needed

to evaluate deltas.
Further studies need
to determine whether
23-h changes can
provide adequate Dx
and prognostic
information
Reichlin 2011
21709058(38)
Diagnostic
accuracy of
absolute value
relative changes in
cTn
Prospective
multicenter
836 with ACS
Absolute value
relative changes in
cTn
Sx suggesting AMI
STEMI, terminal
kidney failure
Hs-TnT and cTnI

ultra at admission
and 1 h and 2 h
ROC at 2-h higher for

absolute than relative
changes
ROC absolute cutoff 2 h

0.007 ug/L hs and
0.020 ug/L for ultra
Aldous 2012
22291171(39)
Early means of hsTnT vs.

conventional cTnT
in NSTE-ACS
Prospective cohort
909, and 205 with
AMI
NSTE-ACS with
conventional and hsTnT assays
NSTE-ACS
STEMI
<18 y, unable to
follow-up
Hs-TnT and
conservative TnT at
admission, 2 h and
6-12 h
Dx of MI on admission
at 2 h
Hs-sens 92.2% and
spec of 79.7%
Mueller 2012
22134520(40)
Kinetic changes on
hs-cTnT in ACS
and non-ACS
Prospective cohort
784
NSTEMI 165
Pts with ACS with hs

TnT vs. non-ACS with
hs-TnT above 99th
percentile
ACS with 2nd blood

draw within 6-h
Non-ACS with 2
blood draws
STEMI or LBBB
Hs-TnT-ACS and
non-ACS with
elevated hs-TnT2
blood draw within 6
h
Mortality at 1 y
Hs superior to
conventional
Death 5.4 (95% CI: 2.7
10.7) and HF 27.8 (95%
CI: 6.6116.4)
+Predicted value of
absolute change 82.8%
-predicted 93.0%
ROC absolute change

Hs-TnT
0.95 (95% CI: 0.92
0.98) vs. relative
change 0.76 (95% CI:
0.700.83) p<0.001
Hs TnT 95% CL for MI
Dx at 2 h
Sens (95% CI: 88.1%
95.0%) spec (95% CI:
78.680.5)
Observation cannot
quantify clinical
benefit of results
Blood samples not

taken beyond 2 h.
Used cTnI as gold
standard for Dx of MI
Absolute delta vs.

ROC for absolute
Relative changes
relative delta
change added value for confined to 6 h, not
ROC-optimized value
entire ACS cohort vs.
24 h.
6.9 ng/L was sup to rel
relative change.
Not all pts received
change
p<0.0001
angiography
20%
ACS indicates acute coronary syndrome; AMI, acute myocardial infarction; ASA, aspirin; AUC, area under the curve; CK, Creatine Kinase; CKD, chronic kidney disease; CK-MB, creatine kinase-MB; cTnT, cardiac troponin T; cTn, cardiac troponin; cTnl, cardiac troponin
l; Dx, diagnosis; ED, emergency department; Hs, high sensitivity; hs-cTnI, high-sensitivity cardiac troponin I; hs-cTnT, high-sensitivity cardiac troponin T; hs-TnT, high-sensitivity troponin T; LBBB, left bundle-branch block; MBCK, MB Isoenzyme of Creatine Kinase; MI,
myocardial infarction; MRI, magnetic resonance imaging; N/A, not applicable; NST-ACS, non-ST acute coronary syndrome; NSTE, Non-ST-elevation; NSTEMI, Non-ST elevation myocardial infarction; PCI, percutaneous coronary intervention; Pts, patients; Px,
prognosis; ROC, Receiver Operating Curves; Sens, sensitivity/sensitivities; Spec, specificity/specificities; Std TnI, standard troponin I; Std cTnT, standard cardiac troponin T; STEMI, ST-elevation myocardial infarction; Sx, symptom; Tn, troponin; TnT, troponin T; TnI,
troponin I; and UA, unstable angina.
Data Supplement 5. CK-MB, MB Isoforms and Myoglobin, Compared With Troponins (Section 3.4.4)
Study Name,
Study Aim
Study Type/Size
Intervention vs.
Patient Population
Author, Year
(N)
Comparator (n)
Inclusion
Exclusion
Criteria
Criteria
Apple 1999
Use of triage panel of Multicenter
Comparison of
Pts in ED with
N/A
9931041(41)
TrT, CK-MB, and
prospective study
myoglobin, TnI and
ACS
myoglobin for AMI
192
CK-MB for sens and
detection
spec
TACTICS-TIMI 18
Kleiman 2002
12354426(42)
CK-MB vs. TnT to

predicted cardiac risk
and benefit in AMI
invasive strategy
Multicenter
prospective study
2,220
CK-MB elevated in
826. With CK-MB-,
TnT elevated in 361
1st 24 h of chest
pain
N/A
Study Intervention
Triage panel
biomarkers to
evaluate ROC for
AMI pred
Invasive or
conservative strategy
with CK-MB and TrT
for 30-d and 180-d
risk.
12
Endpoints
Primary Endpoint &
Results
Concordance
for detection or rule-out
of MI
TnI >89%
CK-MB >81%
Myoglobin >69%
CV events 30 d/180 d
Event rates 2 as high
with CK-MB+ value .
benefit in invasive with
Tr+, but CK-

Results
Sens/Spec
TnI: 98/100
CK-MB: 95/91
Myoglobin: 81/92
No evidence of
interaction between CKMB elevation and
strategy on 30-d and
180-d endpoints
P Values,
Study Limitations
ROC values
TnI: 0.97
CK-MB: 0.905
Myoglobin: 0.818
diff p<0.05
Does not address

reinfarction or AMI
presenting after 72 h
OR benefit of invasive
strategy
CK-Tr+
30 d: 0.13 (95% CI:
0.040.39)
180 d: 0.29 (95% CI:
0.160.52)
Small group
analysishypothesis
generating
Aviles 2002
12372578(43)
Long term Px
in UA with elevated
TnI and normal CKMB and CK
Sens
of myoglobin with
normal TnI in AMI
Retrospective
cohort
724
All CK-MB- and TnI+
Clinical UA
including Class
IIIa
N/A
Using TrI with normal

CK and CK-MB for 2y risk evaluation
2-y all-cause mortality

20% with Tn>0.5 ug/L,
8% with <0.5 ug/L
N/A
Prospective
multicenter
817
Myoglobin and TnI
Possible AMI with

normal TrI (27)
Incomplete
biomarker panel
or noncardiac
Myoglobin Dx of MI
with normal TnI
Increase myoglobin of 20
ng/mL from 0-90 min
max diagnostic utility with
myoglobin and-TnI at
admission
Combination sens
change myoglobin+ TnI
at 90 min
97.3%
Eggers 2004
15459585(44)
Value of adding
myoglobin to TnI to
exclude AMI
Prospective cohort
197
TnI and CK-MB
Chest pain >15

min in past 24 h
STE
TnI and Myoglobin

for exclusion of MI
TnI highest sens of all

markers at all-time pts.
TnI 0.07 ug/L cutoff

sens:
30 min=93%, 2 h=98%,
3 h=100%
Storrow 2006
17112930(45)
Associated among
discordant Tn, CK,
and CK-MB chest
pain evaluation
Multicenter
prospective
registry
1,614
Discordant CK-MB/Tn
113
includes MB with
normal CK 239
Possible ACS
Transfer
or ECG for
routine purposes
CK-MB and Tr with

evaluation of
significance. of
discordant values
OR for AMI vs. Tr-/CKMB-both positive: 26.6

Tn+ 4.8
CK-MB+ 2.2
CK-MB+/CK5.7 (95% CI: 4.47.4)

CKMN+/CK+
4.36 (95% CI: 3.65.2)
Ref: vs. CK-MB-
CRUSADE
Newby 2006
16412853(46)
Frequency and
implications of
discordant CK-MB
and Tn in ACS
Multicenter
prospective
29,357
22,687 Tn+
20,506 CK-MB+
3,502 both
2,988 only CK+
5,349 only Tn +
High-risk NSTEACS
N/A
CK-MB and Tr during

1st 36 h of ACS to
evaluate discordance
Adjusted OR for hospital

mortality
CK-MB+/Tn +: 1.53
CK-MB-/Tn+: 1.15
CK-MB+/Tn- 1.02
both: 2.7%
both+: 5.9%
Only CK-MB+: 3.0%
Only Tn: 4.5%
Kavsak 2007
17306781(47)
Effect of Tn on
myoglobin and CKMB isoforms in ACS
Retrospective
cohort
228
CK-MB isoforms,
myoglobin and Accu
TnI
Possible ACS
N/A
CK-MB , myoglobin
and TrI to compare
utility in R/O MI <6 h
assays
N/A
Jaffery 2008
19061710(9)
Myoglobin and TnI

pred of long-term
mortality in ACS
Retrospective
cohort
951
TnI, myoglobin, and

CK-MB
Possible ACS
N/A
TnI, Myoglobin, and

CK-MB at
presentation with
ACS
Clinical sens for AMI:

For both myoglobin and
CK-MB Dec. in
ESC/ACC
MI def
+TnI and +Myoglobin,
but not +CK-MB
Pred. 5-y all-cause
mortality
Di Chiara 2010
Pred value of TnI vs.
Prospective
55 STEMI and 5
AMI + reperfusion
No pacemakers,
TnI and CK-MB at
Tn at 72 h most accurate
N/A
Sallach 2004
15464666(4)
13
N/A
2-y mortality Tr >0.5

vs. <0.5
HR 2.59 (95% CI:
1.664.05); p<0.001
Change Myoglobin
>20
90 min
Sens: 83.3%, 88.6%
spec: 99.5%
Predicted value for
AMI
TnI sens 93% spec
81% at 2-h
CK-MB 79%
Myoglobin 67%
CK-MB/Tn+:
26.6 (95% CI: 18.0
39.3) Tn+/CK-MB-:
4.8 (95% CI: 3.46.8)
Tn-/CK-MB+:
2.2 (95% CI: 1.72.8)
CK-MB+/Tn+:
1.53 (95% CI: 1.18
1.98)
CK-MB-tn+:
1.15 (95% CI: 0.86
1.54) NS
CK-MB+/Tn-:
1.02 (95% CI: 0.75
1.38) NS
WHO MI def:
sen >90%
ESC/ACC def:
Both sen<70%
Using TnI assay
+TnI:
1.7 (95% CI: 1.32.3)
+Myoglobin:
1.6 (95% CI: 1.22.1)
+MB: NS
TnI:
Study did not

evaluate serial ECGs
for dynamic changes
Relatively small
number of AMIs.
Predetermined
values of myoglobin
not evaluated
Relatively small
group.
Relatively long delay
time from pain to
admission
N/A
Used individual labs

for ULN.
No account for timing
of positive markers
Insufficient time
elapse before
remeasuring TnI
Single center. TnI
assay no longer in
use.
No peak levels of
markers recorded
Blood samples every
20588136(10)
CK-MB for infarct

size with CMR
cohort
60
NSTEMI
TnI, CK-MB
with CMR within 7

d
clips, peak
markers on
admission
admission and
serially up to 96 h
from Sx onset
estimate of predischarge
infarct volume
ACTION-GWTG
Registry
Chin 2012
22434769(48)
Prognostic value of
CK-MB vs. Tn in AMI
Retrospective
registry
26,854
Peak CK-MB and TnI
AMI in data
registry with
biomarkers
Peak values
below lab ULN
Peak CK-MB and TnI

for in-hospital
mortality
Both peak CK-MB and

TnI are independently
associated with hospital
mortality CK-MB >TnI
N/A
Ilva 2005
15667582(12)
Novel TnI in early risk

stratification in ACS
Prospective cohort
531
Standard TnI novel TnI

myoglobin
Biomarkers at 0
h, 1-12 h and 24
h after admission
Absence of 1 or
more biomarkers
Comparison of 3
biomarkers at times
indicated
Positivity of novel TnI

assay for AMI in higher
percent than other
biomarkers
MI within 3 h of
presentation: 50% by
novel TnI and only
11.5% by reference TnI
assay, (p<0.001)
44% by myoglobin
(p=NS)
Volz 20012
21129891(13)
Can Tn alone be
used for initial AMI
screening with
elimination of CK-MB
Retrospective
cohort
11,092
TrT and CK-MB
All pts with TrT in

ED with
correspond CKMB
Initial
nonnegative Tn
CK-MB+ with TnT- to

determine value on
AMI screening
None with Tn- but CKMB+

Judged to have AMI
N/A
Lim 2011
21292125(49)
CK-MB vs. Tn in Dx
of AMI after PCI
Prospective cohort
32
TnI and CK-MB
PCI and CMR

imaging baseline
and 7 d
N/A
CK-MB and TnI after

PCI to determine Dx
of AMI
Only small min of +Tn

had CMR abnormal CKMB+ closely approximate
CMR injury
Percent changes in
inflamed markers
corresponded with CKMB, but not TnI levels
for CRP and SAA
0.84 (95% CI: 0.75

0.91)
CK-MB:
0.42 (0.190.62)
p<0.02
Peak CK-MB
C-statistic 0.831
Peak TnI
C-statistic 0.824
p=0.001
Novel TnI+ in 27.5%,
standard TnI in 17.5%,
(p<0.010) and
myoglobin+ in 24.1%
(p=0.067)
ROC: novel TnI 0.937,
ref TnI 0.775,
myoglobin 0.762
(p<0.001)
Rate of true +CK MB
with Tn- :
0% (95% CI: 00.04%)
6 h could be too
sparse.
Could miss
biomarker peak
Registry only collects
in-hospital outcomes.
Participation in
registry voluntary
Use a 1st generation
TnI assay with low
analytic limits
No evaluation of CKMB in pts with

intermed or Tn+.
No follow-up with CK-MB or Tn.
Small sample size.
No evaluation of
inflammed markers
after 24 for TNF
alpha
ROC for detection of

new MI
CK-MB: 0.97
TnI: 0.985
NS, but poor
TnI specific
22% TnI
93% CK-MB
ACC indicates American College of Cardiology; ACS, acute coronary syndrome; AMI, acute myocardial infarction; CK, creatine kinase; CK-MB, creatine kinase MB; CK-Tr+, creatine kinase troponin positive; CMR, cardiovascular magnetic resonance; CRP, C-reactive
protein; CV, cardiovascular; Dx, diagnosis; ECG, electrocardiograph; ED, emergency department; ESC, European Society of Cardiology; MI, myocardial infarction; Myo, myoglobin; N/A, not applicable; NSTE-ACS, Non-ST elevation acute coronary syndrome; NS, not
significant; NSTEMI, non-ST segment myocardial infarction; OR, odds ratio; PCI, percutaneous coronary intervention; Pred, predicted; pts, patients; Px, prognosis; ROC, receiver operator curve; SAA, serum amyloid A protein; Sens, sensitivity/sensitivities; Spec,
specificity/specificities; STEMI, ST segment elevation MI; Tn, troponin; Tn+, positive troponin, Tn-, negtative troponin; TNF, tumor necrosis factor; TnI, troponin I; TnT, troponin T; TrT, troponin T; UA, unstable angina; ULN, upper limit normal; and WHO, World Health
Organization.
Data Supplement 6. Bedside Testing for Cardiac Biomarkers (Section 3.4.4)
Study Name, Author,
Study Aim
Study Type/
Intervention vs.
Year
Size (N)
Comparator (n)
Patient Population
Study Intervention
14
Endpoints
P Values,
OR: HR: RR: & 95
CI:
Study Limitations
Inclusion
Criteria
Exclusion
Criteria
Primary
Endpoint &
Results
AMI
TrI sens: 100%
TrT sens: 94%
Safety
Endpoint &
Results
N/A
Secondary
Endpoint &
Results
Event rates for
tests:
1.1% TnT
0.3% TnI
Hamm 1997
9385123(50)
Bedside evaluation
of TnT and TnI in
acute chest pain
Prospective
cohort
773
TnT vs. TnI for Dx

of MI and 30-d
events
+TnT 123
+TnI 171
Acute chest
pain <12 h
without STE
STE or AMI
within 2 wk
Bedside tests of TrT

and TrI 2, arrival and
>4 h
Van Domburg
2000
10980212(51)
Long-term
prognostic
significance of
bedside TnT
Prospective
cohort
163
TnT, CK-MB,
myoglobin
98 TnT + <12 h
48 + baseline
50 positive 3-12 h
2 positive 12-96 h
Suspected
ACS
MI within
previous wk
29%+ on
admission
60%+ in 12 h
N/A
Early myoglobin
predict 3-y
mortality
3.7 (95% CI:
1.012.0)
+TROPT risk for 3-y

mortality:
4.3 (95% CI: 1.3
14.0)
Quantitative assay
2.9 (95% CI: 1.08.6)
Amodio
2007
17429291(52)
POC TnI at 99th

percentile cutoff for
diagnostic accuracy
of MI
Retrospective
cohort
516
Higher vs. lower

TnI cutoffs and Dx
of AMI
70 TnI+
Suspected
angina or AMI
STE-ACS or
LBBB
Blood specimen at 0 h,
3 h, 6 h, 12 h, 24 h, 48
h, 72 h, 96 h
Bedside assay TROPT
and quantitative assay
sample up to 12-h
effect on mortality
prediction
Bedside TrI
Stratus CS for AMI Dx
using different cutoffs
0.030.07 ug/L
Best clinical
cutoff at 99th
percentile 0.03
N/A
Sens of
myoglobin at 2
cutoffs
36.4% and 49%
Tn Sens at 99th
percentile 77.3%
(68.384.7)
0.03>0.07
p<0.005
DISPO-ACS
Ryan 2009
18691791(53)
POC length of stay

in ED
Multi-institute
prospective study
2,000
Bedside Tn testing
+ central lab
Central lab only
1,000 in each arm
Suspected
ACS with
biomarkers
Tachyarrhythmia
or ECG AMI
POC markers vs. lab

markers
N/A
Transfer to inpt
POC 5.4 h
Lab 5.5 h
Turnaround at
baseline
POC 0.30 h
Lab 1.07 h
CRUSADE
Takakuwa
2009
19743496(54)
Use patterns of POC

testing for Tn in
NSTE-ACS
Retrospective
multi-institutional
12,604
POC with Tn+ vs.

Tn6,185 +POC result
6,419 negative
POC result
POC Tn in
NSTE-ACS
Death within 24 h
Hospital with 30
pts.
Infrequent
percentage use
of bedside Tn
N/A
POC vs. core lab

testing for time
saving and
cost/benefit
Prospective
cohort
151
POC and core lab

testing of TnT
TnT+ in 12 pts
Suspected
ACS with 2
TnT 6 h apart
STE, ECG, or
lack of serial
biomarkers
6.5 h saved
using POC and
relative sens of
100%.
p<.00001
N/A
ED length of
stay (h)
No POC 4.2
(2.96.5)
High POC
3.9 (2.66.0)
p<0.0001
POC pathway
had 32% false
positives
POC sens
100%, spec 65%
Accuracy 68%
+POC results
associated with
expedited and higher
use of anti-ischemic
therapy.
p<0.0001
Birkhahn 2011
20825823(55)
Hospital and pt
characteristics
In-hospital events and
care variables
Hospital using POC
testing >50% vs. <50%
testing
POC (TnT) CK-MB,
myoglobin vs. central
lab testing (TnI)
baseline +2h
vs. baseline +6 h
POC discharge
Home 4.5 h
Lab discharge
Home
4.6 h
Higher POC had
shorter ED stay,
less likely to use
drug IV
15
30-d event
TrT 26 (1049)
TrI 61 (15512)
POC benefited 60%

(95% CI: 5268) of
pts with cost of $7.40
(95% CI: $6.40
$8.70) per direct pt
care h saved.
All pts with +TnT

admitted so event
rate may be lower
than that with
conventional decision
making
Detection limit of TnT
higher than 2nd
generation Tn
No info on outcomes
Long median delay
time from pain onset
to admission
No consideration of
muscle trauma or
renal insufficiency
Possible Hawthorne
effect bias in testing
areas.
Different interinstitute
sampling times.
Sample size relatively
limited.
No record of type of
bedside marker test.
No std. for + or test
Time of 2nd blood test
varied widely
Scharnhorst 2011
21350097(56)
Sens and spec of

bedside Tn
compared with CKMB and myoglobin
Prospective
cohort
137
POC evaluation
Tn, CK-MB,
myoglobin, for
rapid detection of
+test
37+ ACS:
7 UA
26 NSTEMI
4 STEMI
POC evaluation
Tn, CK-MB,
Myoglobin
3260 ADP+
270 ADP
3,582 30-d followup
2 POC vs. 2
central laboratory
assays
cTnI
Suspected
NSTEMI
STE on AD
ambulance to
hospital
POC Tn values
T0T12 h and
sens/spec
for MI at 99%
cutoff
At T2 Sens: 87%
Spec: 100%
+PV: 100%
PV: 96%
N/A
Use of 30%
Diff T2-T0
without absolute
included above
99th percentile
Sens: 100%
Spec: 87%
2-h sens and spec of

myoglobin and CKMB lower than Tn
Myoglobin: 50/92
CK-MB: 48/96
Low number of pts.

No subgroup
analysis. Broad 95%
CI.
ASPECT
Than 2011
21435709(57)
Validate safety of
predefine 2 h
protocol (ADP) for
ACS
Multicenter
prospective
observation study
3,582
Suspected
ACS
STE ACS,
Noncoronary
chest pain
ADP use of POC Tn,

CK-MB, and myoglobin
with 30-d follow-up
Major CV events
at 30 d
ADP
Sens 99.3%
ADP class.
9.8% low risk.
Major adverse
event in only
0.9%
For 30-d events

TIMI + ECG
Sens: 98.1%
Spec: 14.6%
-PV: 98.3%
For 30-d events

ADP Sens: 99.3%
(95% CI: 07.999.8)
Spec: 11% (1012.2)
PV: 99.1% (97.3
99.8)
Low specificity.
Atypical Sx not
included
GUSTO-IV
Venge 2010
21095269 (58)
Comparison of POC
vs. laboratory
assays of Tn
Prospective
cohort
1,069
All pts in ED
with Tn assays
N/A
Tn assays with 99th

percentile URL cutoffs
N/A
No attempts to relate
results to Dx of MI,
only outcome
predictions
POC vs. central

lab assays at 6
hospitals
Suspected, but
not proven
AMI at 6
hospitals.
Proven MI by
ECG, high-risk
ACS, known
CAD, serious
noncoronary
pathology,
recurrent chest
pain
POC or std care with

CK-MB, myoglobin,
and Tn biomarkers
OR varied from 0.12

(95% CI: 0.011.03)
to 11.07 (05% CI:
6.2319.66) with
significant
heterogeneity
between hospitals
1 outcome based
upon 1 effectiveness
outcome rather than
economic measures.
Response rate was
only 70% so possible
responder bias
Multicenter
prospective
analysis
2,243
Std care 1,118

POC 1,125
Suspected, but
not proven
AMI at 6
hospitals
Proven MI by
ECG, high-risk
ACS, known
CAD, serious
noncoronary
pathology,
recurrent chest
pain
POC or std care with

CK-MB, myoglobin,
and Tn biomarkers
POC associated
with higher ED
costs, coronary
care costs, and
cardiac
intervention
costs, but lower
general pts costs
N/A
Central lab
identified more
who died of CV
disease up to 3
mo:
88% vs. 50%
1: 81% vs. 54%
2
The cost per pt
varied from
214.49 <control
group to
646.57 more
expensive with
weak evidence
of heterogeneity
among centers
p=0.08
Probability of std
care being
dominant 0.888
POC dominant
0.004
99th percentile
POC 1 vs. central lab
1: 20% vs. 39%
POC 2 vs. central
lab:
2:27% vs. 74%
p<0.001 for each
Multicenter
prospective
analysis
2,243
99th percentile
cutoffs:
central lab
cutoffs identified
more pts with
high cTnI and
predicted higher
% deaths
Difference in
proportion of pts
successfully
discharged. POC
led to higher
proportion in 4,
lower in 1 and
equivocal in 1.
[RATPAC]
Bradburn 2012
21617159(10)
Variation in
outcomes and costs
in different hospitals
using POC
[RATPAC]
Fitzgerald 2011
21569168(59)
Cost effectiveness of
POC biomaker
assay
Mean costs per pt

$1,987.14 with POC
vs. $1,568.64 with
std care p=0.056
1 outcome based on
1 effectiveness
outcome rather than
economic measures.
Response rate 70%
so possible responder
bias.
16
N/A
1 indicates primary; ACS, acute coronary syndrome; ADP, adenosine diphosphate; AMI, acute myocardial infarction; CAD, coronary artery disease; CK-MB, creatine kinase MB; cTnI, cardiac troponin I; CV, cardiovascular; Dx, diagnosis; ECG, electrocardiograph; ED,
emergency department; IV, intravenous; Lab, laboratory; LBBB, left bundle-branch block; MI, myocardial infarction; Myo, myoglobin; NSTE ACS, non-ST elevation acute coronary syndrome; NSTEMI, Non-ST-elevation MI; POC, point of care; pts, patients; +PV, positive
predictive value; -PV, negative predictive value; Sens, sensitivities; Spec, specificities; Std, standard; STE, ST-elevation; STE ACS, ST-elevation acute coronary syndrome; STEMI, ST-elevation MI; Sx, symptom; TIMI, thrombolysis in MI; TnI, Troponin I; TnT, troponin
T; TrI, troponin I; TROPT, Troponin T rapid test; TrT, troponin T; and UA, unstable angina.
Data Supplement 7. Summary Comparison of Injury Markers (Section 3.4.4)
Study Name,
Study Aim
Study Type /
Intervention vs.
Author, Year
Size (N)
Comparator (n)
Patient Population
Inclusion
Criteria
UA or possible
MI within 72 h
Exclusion
Criteria
Increased risk
of bleeding
(dalteparin
trial)
Study
Intervention
Primary Endpoint &

Results
Cardiac death at 37 mo
Multivariate analysis
TnT and CRP
independently predicted
of mortality

Results
Highest tertile of CRP
significant for mortality.
Lowest 2 tertiles NS
difference
p=0.001 3rd vs. 2nd tertile
30-d mortality
RR
0 Biomarker+: 1
1 Biomarker+: 1.8
2 Biomarker+: 3.5
3 Biomarker+: 6
p=0.014
Only inclusion of BNP
provided info above that
from traditional risk
factors
FRISC
Lindahl 2000
11036119(60)
Multiple biomarkers
as long-term risk
predictors for CV
death
Multi-institution
prospective 917
TnT
CRP
Fibrinogen
TACTICS-TIMI18
Sabatine 2002
11956114(61)
Use of multiple
biomarkers to predict
MACE in NSTE-ACS
TnI, CRP, BNP in

combination vs. each
alone
Possible ACS
within 72 h
Age <18 y
pregnancy,
significant
comorbidities,
bleeding
tendency
3 biomarkers at
enrollment
Death/MI/HF at 6 mo
Number of elevated
biomarkers include
prediction of outcome
HOPE
Blankenberg
2006
16831981(62)
9 Biomarkers to
evaluate improved
CV risk in a 2nd d
prevention population
Multi-institution
prospective
450
(OPUS-TIMI
16)
1,635
(TACTICS-18)
Multicenter
prospective
3,199
Hx of CAD,
stroke, PAD,
diabetes
HF, low LVEF,

nephropathy
MI, or stroke 4
wk before
enrollment
9 biomarkers on
enrollment
Combined events 4.5 y

Significant relations:
BNP, sIAM,
Microalbuminuria, sIRA-1, fibriongen
McCann 2008
18682444(63)
Role of novel
biomarkers in AMI Dx
Multicenter
prospective 664
Chest pain <24

h to 2 CCUs
Transfer from
other hospital
thrombolytics
or
anticoagulant
Biomarkers on
entry
Dx of AMI only H-FABP

challenged cTnT and
combined approach
improved -PV
-PV
H-FABP 75%
cTnT90%
Either97%
(95% CI: 91%99%)
FRISC Eggers
2009
(64)
1960803464)
Risk predicted by
multiple biomarkers
in NST-ACS
Multicenter
retrospective
analysis
877
Evaluation of CRP
fibrinogen, IL-6, TNF
1, 2, sIAM-1, s-IAM-1,
BNP, IL-1
RA microalbuminuria,
individually for MACE
Multiple biomarker
comparisons including
cTnT, H-FABP, BNP,
hs-CRP, D-dimer,
MPO, MMP-9, PAPPA, sCD40L
Evaluated: cTnI, BNP,
CRP, estimated GFR
NSTE-ACS
Biomarkers at
enrollment, 6
wk, and 6 mo
5-y follow-up
BNP strongest predictor
for mortality
BNP:
6 wk: 1.5 p<0.001
6 mo: 1.4 p=0.001
ARCHIPELAGO
Multiple biomarkers
Multicenter
Evaluated 9
NSTE-ACS
Bleeding risk,
high creatinine,
PCI in previous
6 mo, decision
for PCI before
randomization
STE-ACS,
Biomarkers at
Biomarkers for
IL-6 AUC significant
Biomarker
samples at 0 h,
12 h, 24 h
Endpoints
17
P Values,
Multivariate analysis:
High TnT:
10.8 (95% CI: 2.644.6)
High CRP
2.3 (95% CI: 1.34.0)
Fibrinogen NS
1 Biomarker+:2.1
p=0.006
2 Biomarker+:3.1
p<0.001
3 Biomarker+: 3.7
p=0.001
(6 mo)
HR: BNP 1.721<0.001
sIAM 1.46=0.0003
Microalbuminuria
1.55=0.0004
sIAM1.46=0.0003
Fibriogenen 1.31=0.02
Sens H-FABP: 73%
Sens cTnT: 55%
On admission p=0.043.
Combined improved sens:
85%; p0.04 vs. individual
values
BNP 1.7 (95% CI: 1.32.1);
p<0.00 1 5 y
only 6 wk BNP showed
significant increments to
established risk factors Cstatistic 0.69; p=0.03
IL-6: 1.69 (95% CI: 1.22.3)
Study Limitations
No evaluation of LV
function.
Use of death certificates
may misclassify.
Using binary cutpoints of
biomarkers rather than
higher levels.
Very insensitive cTn assay
Only baseline
measurements; later
analysis on frozen
specimens; for our
purposes, not an ACS study
Only single measure of
biomarker.
Outcomes before more

advanced 2 previous
measures.
Preselected population
Post-hoc analysis;
Beygui 2010
20723640(65)
for risk in NSTE-ACS
prospective trial
Post hoc
analysis
440
biomarkers:
CRP, IL-6, MPO, PL22, MMP-9, IMA,
sCD40L, BNP,
aldosterone, cTnI
Manhenke 2011
22197217 (66)
Elucidating complex
interactions between
circulated biomarkers
following AMI
Assess role of 5
biomarkers in Dx in
ACS
Multicenter
prospective trial
236
37 biomarkers
AMI
complicated by
HF
Prospective
cohort
318
Evaluated:
BNP, IMA, H-FABP,
hs-TnI, FFAu vs. cTnT
MERLIN-TIMI
Scirica 2011
21183500(68)
Incremental
prognostic value of
multiple biomarkers
in NSTE-ACS
Multicenter
prospective
4,352
CAPTURE
Oemrawsingh
2011
21558475(69)
Predictive value of 7
Biomarkers in NSTEACS
FAST II
FASTER I Eggers
2011
22456003(70)
Predictive of MI with
multiple biomarkers
Combines with hsTnT
Bhardwaj 2011
21835288(67)
planned
corresponding
interval, CHF,
hypotension,
low creatinine
Cl
Not Stated
randomization
Ischemia/HF at 2 mo
IL-6 corresponding with
Ischemia BNP,
aldosterone MMP-9 for
HF
improved model for

ischemia, 3 biomarkers +
for HF improved
performance models for
HF
BNP :3.2 (95% CI: 2.05.0)

Aldo: 1.57 (95% CI: 1.12.6)
MMP-9: 0.64 (95% CI: 0.46
0.88)
Only 2-mo follow-up

Select group of pts.
No indication of severity
of HF.
Biomarkers
median 3 d after
AMI Dx
Multiple
including
ESRD,
thrombolytic
agents,
noncardiac
chest pain
Biomarkers at
presentation
Natriuretic peptides
among others provided
significant contribution to
risk assessment
+PV
cTnT: 65%
hs-TnI: 50%
FFAu: 40%
BNP: 28%
IMA: 17%
H-FABP: 26%
Of 5 sets of biomarkers only

2 sets showed significant
prediction
Possible ACS
2 sets of biomarkers
corresponded with risk
for death and combined
death/reinfarction
Compared with cTnT,
diagnostic information
increased with BNP,
FFAu, hs-TnI, but not
IMA and H-FABP
Limited number pts

Relatively small number
events. Blood Time frame 1
d10 d post- MI
Small sample size
Incomplete biomarker
Data. Dichotamous
cutpoints rather than
multiple cutpoints
cTI
BNP
CRP
MPO
Possible
ACS
STE-ACS
ESRD
CV Shock
Short life
expectancy
Biomarkers at
presentation
Addition of biomarkers to
reference for CV
death/HF:
cTnI: 0.776
BNP: 0.790Ref: 0.749
Multicenter
prospective
1,090
Hs-CRP
MPO
sCD40L
IL-10
TnT
PIGF
PAPP-A
Possible
NSTE-ACS
Ischemia >48 h
from
enrollment
Biomarkers after
last episode of
angina
Including all biomarkers

only BNP and cTnI
associated with 12-mo
CV death
Only TnI with
reinfarction
4-y MI/death
A multimarker
model of TnT, IL-10,
MPO, and PIGF
predicted 4-y rates:
6.0% (all normal) 35.8%
(3+ abnormal)
Retrospective
cohort
360
Hs-TnT +
h-FABP
copeptin
NSTEMI
(retrospective
Classification)
STEMI
Biomarkers at
enrollment
Hs-TnT greater
accuracy in Dx of AMI
than H-FABP and
copeptin
18
TnT: 1.8 (95% CI: 1.2

2.6)
IL10: 1.7 (95% CI: 1.1
2.6)
PIGF: 1.9 (95% CI: 1.3
2.8)
CRP: 1.0 NS
sCD40L: 1.2 NS
MPO :1.5 (95% CI: 1.1
2.1)
PAPP-A: 1.1 NS
No increase in C-statistic
for hs-TnT by combining
with H-FABP 0.85 or
copeptin 0.84
Sens and PV:

BNP: 73%, 90%
Hs-TnI: 57%, 89%
FFAu: 75%, 92%
(Highest)
Increased C-statistic for
cTnT :
BNP 0.09
Hs-TnI 0.13
FFAu 0.15
All p0.001
Addition of biomarkers to
reference for CV Death:
cTnI: 0.805
BNP: 0.809
p<0.001
Ref: 0.784
Admission levels of +TnT:
HR 1.8
+IL-10:HR: 1.7
+PIGF:HR: 1.9
+Myoglobin:HR: 1.5
Significant prediction for
outcomes in multivariate
analysis
C-statistics
Hs-Tnt: 0.84
H-FABP: 0.80
p=0.04
LV function incomplete.
No serial evaluations of
biomarkers, not
generalizable to overall
population.
Not adjudicated data for MI
Dx
No info on long-term
medications
Retrospective, small
sample, from 2 different
studies.
No serial biomarkers
Meune 2012
22507551(71)
Multimarker
evaluation in
suspected AMI with
undetectable cTn
levels
Retrospective
multi-institution
325 with
undetectable
cTnT
cTnT15 biomarkers
Including CK-MB and
MPO
ACS with
undetectable
cTnT at 0 h
and 6 h.
Detectable
cTnT
Biomarkers
>6 h from
enrollment
ESRD
At mean follow-up 668

d for death/MI hs-TnT,
MR-Pro ADM and PDF15 showed increased
risk
Sens/spec for death/MI

(%)
Hs-TnT: 43,86
MR-Pro ADM: 43,76
GDF-15: 95,55
Schaub 2012
22057876(72)
Markers of plaque
instability use in AMI
Dx and risk
Prospective
multicenter
398
Possible ACS
ESRD
Biomarkers at
presentation
Diagnostic accuracy for

all non-TnT biomarkers
was low using ROC
AUC
Weber 2008
18355657(73)
Prognosis. value of
BNP with normal TnT
in ACS
Retrospective
multicenter
2,614
From 2 center
registries
1,131 and
1,483
Multimarkers:
Hs-cTnT
cTnT
MPO
PAPP-A
CRP
MRP 8/14
BNP vs. TnT
Cohorts
different, 1
higher risk
(1,131) and the
other lower risk
(1,483)
analyzed
separately
PCI within 6
mo, or C and
for reperfusion
cancer,
autoimmune
inflammatory
disease
Biomarkers at
entry
Among TnT-pts ROC

analysis yielded an
optimal cutoff of BNP
that was able to
discriminate pts at
higher risk for death at
6 mo
AUC for combination with

hs-TnT:
MPO: 0.95
MRP-8/14: 0.95
PAPP-A: 0.95
CRP: 0.95
(NS change)
Mortality rate TnT+ vs.
TnT-:
Registry 1:
8.2 vs. 3.8%
p=0.009
Registry 2:
8.6 vs. 2.8%
p=0.009
Wiviott 2004
14769678(74)
Gender and
biomarkers in ACS
Multicenter
prospective trial
off 1,865 pts in
TACTICS-TIMI
18, 34% were
women
Multiple biomarker
analysis
Men vs. women
Copeptin: 0.62
p<0.001
ROC AUC for death/MI:
Hs-TnT: 0.73 (95% CI: 0.6
0.8)
MR-Pro ADM: 0.71 (95% CI:
0.60.8)
GDF-15: 0.78 (95% CI:
0.710.86)
ROC (AUC):
MPO: 0.63
MRP8/14: 0.65
PAPP-A: 0.62
CRP: 0.59
cTnT: 0.88
hs-TnT: 0.96
Kaplian-Meier
analysis of risk for death by
BNP: Registry 1:
Log-rank: 19.01
p<0.001
Adjusted HR: 9.56 (95% CI:
2.4237.7)
p=0.001
Registry 2:
Log rank: 23.16
p<0.001
HR: 5.02 (95% CI: 2.04
12.33)
p<0.001
Women more likely to have
elevated hs-CRP
1.49 (95% CI: 1.16-1.92) and
elevated BNP 1.33 (95% CI:
1.02-1.75)
Subgroup analysis
Relatively low cardiac
events in follow-up
Biomarkers linked to factors

related to morbidity:
potentially confusing.
No info on avoiding adverse
outcomes
Retrospective study. No
serial measurements
Women with
No criteria for
Biomarkers at
Women more likely had Women with +Tn were
Cutpoints rather than
ACS with
PCI
entry: TnT
elevated CRP and BNP. more likely to have
continuum.
criteria for PCI.
TnI
Men more likely had
recurrent 6-mo MI
N/A to atypical chest pain.
Randomized to
CK-MB
elevated CK-MB and Tn whether TnI or TnT
Not designed to answer
invasive vs.
CRP
pathophysiological
conservative
BNP
questions
strategies
ACS indicates acute coronary syndrome; AMI, acute myocardial infarction; AUC, area under the curve; BNP, B-type natriuretic peptide; CAD, coronary artery disease; CHF, congestive heart failure; CRP, C- reactive protein; cTn, cardiac troponin; cTnI, cardiac troponin
I; cTnT, cardiac troponin T; CCU, cardiac care unit; CV, cardiovascular; Dx, diagnosis; ESRD, end stage renal disease; FFAu, unbound free fatty acids; GDF-15, growth differentiation factor-15; GP-BB, glycogen phosphorylase-BB; GRF, growth hormone releasing
factor; H-FABP, heart type fatty acid binding protein; HF, heart failure; Hs, high sensitivity; Hs-CRP, high sensitivity C-reactive protein; Hs-TnI, high sensitivity troponin I; Hs-cTnt, high sensitivity cardiac troponin T; Hx, history; IL, interleukin; IL-1 RA, interleukin-1
receptor antagonist; IMA, ischemia-modified albumin; LV, left ventricle; LVEF, left ventricular ejection fraction; MACE, major adverse cardiac and cerebrovascular events; MI, myocardial infarction; MMP-9, matrix metalloproteinase- 9; MPO, myeloperoxidase; MRP 8/14,
myeloid related protein 8/14; MR-pro-ADM, midregional pro-adrenomedullin; N/A, not applicable; NS, not significant; NST-ACS, non-ST- segment acute coronary syndrome; NSTE-ACS, Non-ST-Segment-Elevation Acute Coronary Syndrome; OPUS-TIMI, orbofiban in
19
patients with unstable coronary syndromes; PAD, Peripheral Artery Disease; PAPP-A, pregnancy- associated plasma protein-A; PCI, percutaneous coronary intervention; PIGF, placenta growth factor; PL-22, sectretory type II phospholipase-22; pts, patients; PV,
predictive value; RA, rheumatoid arthritis; ROC, receiver operating curve; RR, relative risk; sCD40L, soluble CD40; Sens, sensitivities; sIAM, solube intercellular adhesion molecule-1; sIRA, soluble intercellular adhesion molecule- 1; Spec, specificities; STEMI, STelevation myocardial infarction; TACTICS, Thrombolysis and Counterpulsation to Improve Cardiogenic Shock Survival; TIMI, Thrombolysis In Myocardial Infarction; Tn, troponin; TnI, troponin I; TnT, troponin T; and UA, unstable angina.
Data Supplement 8. Discharge from ED or Chest Pain Unit (Section 3.5.1)
Study Name,
Aim of study Study Type
Study
Study
Study
Author, Year
Size (N) Interventi Comparat
on Group or Group
(n)
(n)
Patient Population
Inclusion
Criteria
Exclusion
Criteria
Study
Intervention
Study
Comparator
CHEER,
Farkouh,1998
9862943(75)
Evaluate utility
of CPU
management
of low-risk pts
with CP
Singlecenter,
prospective
RCT
424
212
212
Intermediate
risk, UA
MI, instability
marked ST
changes
6-h CPU
observation
followed by
pre-D/C ETT
or Ex-MPI
with early D/C
if negative
Routine
hospital
admission
ROMIO
Gomez, 1996
8752791(76)
Test rapid
R/O MI to
time/$
Singlecenter,
prospective
RCT
100
50
N/A
CP low-risk for
MI (Goldman),
stable,
nonischemic
ECG; injury
marker data not
required
Utility of
immediate
ETT in triage
of ED CP pts
Observation
al, singlecenter
1,000
1,000
N/A
Nontraumatic
CP, negative
ECG, marker,
no arrhythmia,
stable, Hx CVD
not excluded
Rapid rule-out
MI protocol in
ED: Serial
ECGs and
CK-MB q 3-h
x 4. If
negative, PDETT
Immediate
ETT, Max/Sx/
Sign limited
Routine
hospital adm
Amsterdam,
2002
12106928(77)
<30 y, >7% MI
prob
(Goldman),
ECG, ischemia,
VT, AV Bl, new
BBB, BP
>220/120,
unstable
Abnormal
ECG, positive
marker,
clinically
unstable
N/A
Endpoints
Primary
Endpoint
(efficacy) and
Results
No significant
diff in early (30
d) and late (6
mo) MI, death,
CHF, CVA,
card arrest inhospital
admission vs.
CPU pts
No diff in low
30-d cardiac
events. ITT
analysis: LOS
shorter, $ less
in ED rule-out
pts with MI
Negative ETT
in 64% pts
enabled direct
discharge from
ED, 30-d
follow-up: NPV
98.3%.
Non-Dx: 23%
pts, 7 revasc
predischarge;
positive: 13%,
4 NSTEMI at
20
Safety
Endpoint and
Results
P Values,
OR: HR: RR &
95% CI:
Study Limitations
& Adverse Events
Relatively small
single-center,
tertiary care with
extensive
expertise/resource
s; Pts 95% white.
No. ETT/Nuc pts
not given. Study
not blinded
Small single center
study, not blinded,
shorter follow-up,
hospital charges,
and costs not
equivalent
Secondary
Endpoint and
Results
Same as 1
endpoint
CPU pts:
Fewer followup ED visits,
cardiac tests
(p<0.003).
(Also, median
LOS in CPU
9.2 h)
No significant diff in
early 30-d/late 6-mo
cardiac events.
Fewer repeat ED
visits, cardiac tests
(p<0.003)
No MI missed
Echo substudy:
low
incremental
value in rapid
rule-out
patients with
MI
No adverse
effects of ETT.
No deaths at 30
d.
No MACE at 6
mo in pts who
did not have
ACS at index
visit. Approx 40
min total time
for scan and
interpret.
Admission vs. rapid

rule-out: LOS 14 h
vs. 27 h; p<0.0001;
Initial cost: $2,089
vs. $1,108;
p>0.0001;
30-d cost: $2,253
vs. $1,237
N/A
ETT performed by
specially trained
MDs
(Noncardiologist),
7 d/12 h function.
Limitation: Includes
only pts able to do
ETT
30 d
MPI: Admission
rate <UC (RR:
0.87; 95% CI:
0.81-0.93;
p<0.001)
Udelson, 2002
12460092(78)
Does addition
of rest MPI
improve ED
triage of lowrisk CP pts to
admission or
D/C from ED
Prospective
Multicenter
(n=7) RCT
2,475
1,215
N/A
Suspected
acute ischemia
(CP or
equivalent)
present within
3 h,
nonischemic
ECG, 30 y
Hx of MI, nonDx ECG
Rest SPECT
Tc 99m
sestamibi,
results to ED
for use in
clinical
decisionmaking
Usual ED
strategy in
each
institution's
ED
Trippi, 1997
9283518(79)
Evaluate utility
of DSE
telemedicine
triage of lowrisk pts with
CP in ED
Prospective,
singlecenter, DSE
by nurse and
sonographer
139
N/A
ROMI, negative
markers, NL
ECG, No Hx
CVD. Initially:
pts obs'v'd 12 h;
later. neg DSE:
direct D/C from
ED
No Hx CAD,
screened for
exclusions by
nurse (not
specified) (LV
wall motion
abnormal =
exclusion)
3-mo follow-up:
NPV for ACS
98.5%, PPV
51.5%.
Agreement
TeleEcho/conv
ential Echo
kappa 0.78;
95% CI: 0.65
0.90
54.7% Sx with
DSE: test
terminated for
PVCs=6.3%;
CP, nausea,
SOB common
Sx
Study
prognostic
value of DSE
in low-risk CP
pts
Prospective
singlecenter,
blinded. ED
MDs blinded
to DSE
results.
377
N/A
18 y, non-Dx
ECG, present
within 6 h of CP,
neg cTt.
Arrhythmias,
HF, severe
HTN, serious
noncard
disease
DSE by nurse
&
sonographer
Card present;
later cardiol
available by
phone, ED
MDs present.
DSE
telemetry to
Card, Dx to
ED. Follow-up
confirm, ECG
DSE after 12h observation,
6.9% (26/377)
pts had Pos
DSE
N/A
Bholasingh,
2003
12598071(80)
N/A
6-mo follow-up:
1 endpoints:
Neg DSE 4%
(1 death), Pos
DSE 30.8% (1
death); OR
10.7; 95% CI:
4.028.8;
p<0.0001)
ROMICAT,
Hoffman, 2009
19406338(81)
Utility of
CCTA in
acute CP pts
Observation
al cohort
study
173
screened,
139
eligible
and
received
DSE (24
no DSE
d/t LV
wall
motion
abnormal
)
377 of
557
eligible
pts
received
DSE. No
DSE: 119
ACS, 34
other
serious
Dis., 24
rest LV
abn.
368
368
N/A
CP, neg initial

Tn, nonischemic
ECG
Hx CAD: stent
or CABG, renal
discharge
CCTA before
admission,
results not
N/A
Pts without
CAD: NPV for
ACS at 6
21
No adverse
effects of MPI
except radiation
and longer time
to discharge
from ED in
negative scan
pts.
MPI:
unnecessary
admission rate
to 42% (10%
absolute );
RR: 0.84; 95%
CI: 0.770.92;
p<0.001. 30-d
cardiac event
rate was
related to MPI
data; p<0.001
72.0% pts
D/C'd directly
from ED in
phase 4. DSE
report to ED in
2.5 h from
request. ED
MDs adm
some pts
despite neg
DSE.
See 1/ 2 endpoint
columns
May not be
generalizable to
small hospitals;
performed during
daytime. LOS
MPI>UC (5.3 vs.
4.7 h; p<0.001)
See 1/2 endpoints
No control group.
Method not
generalizable,
highly
developed/speciali
zed personnel
All DSE
completed
within 24 h of
admission;
follow-up 100%;
19.9% protocol
terminated d't
ECG changes,
CP, arrhythmia,
severe HTN,
hypotension.
Revasc: Pos
DSE 3/26 pts,
Neg DSE
7/351 pts ~5X
greater in neg
DSE
See 1/2 endpoints

Pts discharged
No control group.
DSE not performed
d/t poor window in
5.7% pts.
1 ACS in
absence of +
CCTA showing
No MACE at 6
mo in pts who
did not have
See 1 endpoint
column
Single center, wkd

h, underrepresent
of elderly d/t
(blinded)
disclosed, sig
stenosis:
>50%
ACS at index
exclusion of CAD,
visit. ~40 min
renal dis. May not
total time for
be generalizable to
scan &
smaller hospitals,
interpret
radiation
Litt, 2012
CCTA vs UC
Prospective
1370, 2:1 908
462
30 y,
Noncard sx, NL CTA was 1st
Traditional
No MI or death
CTA: higher
See 1/2 endpoint
All exclusions to
22449295(82)
to assess low- multictr (n=5) ratio to
nonischemic
angio within 1
test in CTA
care
at 60 d in the
rate of D/C
columns
CCTA not noted,
risk CP pts in
RT
CTA and
ECG, TIMI 0-2
y, contraind to
group. In
640 pts with neg from ED: 50%
young study group
ED
traditional
CTA, CrCl <60 traditional
CTA
vs. 23%, 95%
(age 50 y),
care
care pts
CI 21-32;
radiation
clinicians
shorter LOS:
decided 1st
18 h vs. 25 h,
tests
p<0.001;
higher ID of
CAD: 9.0 % vs.
3.5%, 95% CI
0-11.
ROMICAT II,
CCTA vs UC
Prospective
1000
501
499
CP, 40-74 y,
CAD, ischemic CTA
Traditional
LOS: CCTA 23 28-d follow-up:
Direct D/C from See 1 and 2
Wkd, daytime,
Hoffman, 2012 to assess low- multictr (9)
NSR
ECG, +Tn, Cr
care
h vs. UC 31 h
no missed ACS; ED: CTA 47%
endpoint columns
radiation. May not
22830462(83)
risk CP pts in
RCT
>1.5, instability,
(p<0.001)
no difference in
vs. 12%,
be generalizable to
ED
allergy to
MACE at 28 d
p<0.001; no
smaller hospitals
contrast, BMI
difference in
>40, asthma
downstream
care
1indicates primary; 2, secondary; ACS, acute coronary syndrome; BBB, bundle branch block; BMI, body-mass index; BP, blood pressure; CAD, coronary artery disease; CABG, coronary artery bypass graft; CCTA, coronary computed tomographic angiography; CTA,
computed tomographic angiography; CHF, congestive heart failure; CK, creatine kinase; CP, chest pain; CPU, chest pain unit; Cr, creatinine; CrCl, creatinine clearance; CTA, computed tomography angiography; CVA, cardiovascular accident; CVD, cardiovascular
disease; D/C, discharge; diff, difference; DSE, dobutamine stress echocardiography; Dx, diagnosis; ECG, echocardiograph; ED, emergency department; pts, patients; ETT, exercise treadmill testing; HF, heart failure; HR, hazard ratio; HTN, hypertension; Hx, history;
ITT, intention to treat; LOS, length of stay; MACE, major adverse cardiac events; MI, myocardial infarction; MPI, myocardial perfusion imaging; NPV, net present value; NSR, normal sinus rhythm; PPV, positive predictive value; PVC, premature ventricular contractions;
R/O, rule out; RCT, randomized controlled trial; ROMI, rule out myocardial infarction; TIMI, Thrombolysis In Myocardial Infarction; and UA, unstable angina.
Data Supplement 9. Nitrates (Section 4.1.2.1)
Study
Aim of Study
Study
Study
Name,
Type
Size (N)
Author,
Year
Study
Intervention
Group (n)
Study
Comparator
Group (n)
Patient Population
Inclusion
Criteria
Ambrosio
G., 2010
Investigate
whether
Multicenter
registry
52,693
10,555
(20%) pts on
42,138 (80%)
(nitrate-nave
Clinical history of
ACS,
Study
Intervention
mo=98% (95%
CI: 98%100%;
PPV=35%
(95% CI: 24%
48%)
No MI/death at
6 mo in pts with
neg CTA
(<50%
stenosis): 0%
(95% CI 00.57) (100%)
Study
Comparat
or
Exclusion
Criteria
Pts with non-CV
causes for the
Chronic
nitrates on
coronary plaque
Nitratenave
22
Endpoints
Primary
Endpoint
(efficacy) and
Results
Chronic nitrate
use was
Safety
Endpoint and
Results
N/A
P Values, OR:
HR: RR &
95% CI:
Study
Limitations &
Adverse Events
Chronic nitrate
use remained
Registry data
No data on dose
Secondary
Endpoint and
Results
Antecedent nitrate
use was
19903682
(84)
antecedent
nitrate
therapy
affords
protection
toward acute
ischemic
events
(GRACE)
Mahmarian,
1998
9610531
(85)
Investigate
the long-term
(6 mo)
efficacy of
NTG patches
on LV
remodeling in
pts surviving
a AMI
Multicenter
RCT
ISIS-4,
1995
7661937
(86)
Examine the
effect of oral
controlledrelease
RCT
chronic
nitrates on
admission
pts)
accompanied by
at least 1: ECG
complete with
ischemia, serial
increases in
cardiac markers,
documented CAD
clinical
presentation were
excluded, as
were pts in whom
initial Dx of ACS
was not
confirmed at
discharge
admission
291
214
77
Pts surviving a AQMI
Exclusion criteria:
severe CHF,
persistent
hypotension,
sustained VT, or
high-degree AVB,
UA, significant
noncardiac
illness, or either a
requirement for or
known
intolerances
Intermittent
NTG patch
therapy
initiated
within 1 wk
after AMI
and
continued for
6 mo
(0.4, 0.8,
and 1.6
mg/h)
PC
58,050
29,018
28,539
Within 24 h of Sx
onset of
suspected AMI
with no clear
Contraindications
at the clinicians
discretion (e.g.,
conditions
1 mo of oral
controlledrelease
mononitrate
PC
23
associated with
a shift away
from STEMI in
favor of NSTEACS.
Chronic nitrate
use remained
independent
predictor of
NSTE-ACS:
(OR: 1.36; 95%
CI: 1.261.46;
p<0.0001)
1 endpoint:
Change in ESVI
was significantly
reduced with 0.4
mg/h NTG
patches
NS difference in
5-wk mortality
(mononitrate vs.
PC):
associated with
significantly lower
levels of peak CKMB and Tn
(p<0.0001 for all)
(in both STEMI
and NSTEMI)
independent
predictor of
NSTE-ACS:
(OR: 1.36; 95%
CI: 1.261.46;
p<0.0001)
or duration of
antecedent Rx
Cardiac event
rates were not
significantly
different
between PC
and active
treatment
groups
The beneficial
effects seen
primarily in pts with
baseline LVEF
40% (delta ESVI,
-31 mL/m2; delta
EDVI, -33 mL/m2;
both p<0.05) and
only at the 0.4
mg/h dose
Both ESVI and

EDVI were
significantly
reduced with
0.4 mg/h NTG
patches (-11.4
mL/m2 and 11.6 mL/m2,
p<0.03)
Greater effect
early after
starting
treatment
No effect on any
subgroup studied
(age, sex, previous
MI, ECG on
5-wk mortality:
(mononitrate
vs. PC)
7.34% vs.
No associated
clinical or survival
advantage
associated with
the beneficial
remodeling
effects. Gated
radionuclide
angiography used
to assess
changes in LVEF
and cardiac
volumes no
TTE, and as such
unable to address
other aspects of
LV remodeling.
Higher NTG
doses prevented
LV remodeling to
a lesser degree
(NTG tolerance
may be limiting
efficacy at the
higher doses).
Hypotension
17.4% vs. 14.4%,
p<0.0005
(mononitrate vs.
mononitrate
on early
mortality (4
wk)
indications for, or
contraindications
to, any 1 of the
study treatments
GISSI-3,
1994
7910229
(87)
Assess the
effects of
lisinopril and
transdermal
glyceryl
trinitrate
alone and
their
combination
on 6-wk
mortality and
LVEF after
AMI
Multicenter
RCT
19,394
N/A
N/A
AMI pts within 24

h of Sx onset and
no clear
indications for or
against the study
treatments
Yusuf, 1988
2896919
(88)
Examine the
effect of IV
nitrates on
mortality in
AMI
Metaanalysis
(10 RCTs)
2,000
N/A
N/A
AMI pts
inclusions of
individual trials
associated with a
high risk of
adverse effects,
such as
cardiogenic
shock, persistent
severe
hypotension,
evidence of
severe fluid
depletion, etc.)
Or conditions
associated with
only a small
likelihood of
worthwhile benefit
N/A
(30 mg initial
dose titrated
up to 60 mg
qd)
Nitrates (IV
for the 1st 24
h, then
transdermal
GTN 10 mg
daily)
Exclusions of
individual trials
Nitrate
7.34% vs.
7.54%; p=NS
(deaths on d
01: 514
[1.77%]
mononitrate vs.
628 [2.16%]
PC; p<0.001).
presentation, HF at
entry, early after
Sx onset, etc)
No difference in
12-mo mortality
7.54%, p=NS
PC)
50%-60% had
open label nitrate
therapy.
Contraindications
were specified
not by the
protocol, but by
the responsible
clinician
PC (open
label)
No effect of
nitrate on 6-wk
mortality: OR:
0.94 (95% CI:
0.841.05)
No effect of
nitrates on the
combined
outcome
measure of
mortality and
severe
ventricular
dysfunction.
The trend toward

reduction in
cardiac events with
nitrate therapy
reached statistical
significance
among the elderly
and women.
Significant
reductions in 6-wk
mortality and
combined outcome
with lisinopril.
6-wk mortality:
GTN vs. PC:
OR: 0.94; 95%
CI: 0.841.05
Combined
outcome: GTN
vs. PC:
OR: 0.94; 95%
CI: 0.871.02
No excess of
unfavorable
clinically-relevant
events in the
treated groups
was reported. 2D
echo data were
available only for
14,209 pts (73%)
50%60% had
open label nitrate
therapy.
PC
35% reduction
(SD 10) in the
odds of death
(2p<0.001; 95%
CI of
approximately
0.166-0.50)
Systematic
combined
administration
of lisinopril and
GTN produced
significant
reductions in
overall
mortality (OR:
0.83; 95% CI:
0.700.97) and
in the
combined
endpoint (OR:
0.85; 95% CI:
0.760.94)
The greatest
reduction in
mortality
occurred
predominantly
during the 1st
wk of follow-up
Both NTG and

nitroprusside
reduced mortality,
the reduction being
NS greater with
NTG than with
nitroprusside
NS reduction
after the 1st wk
of follow-up
Publication bias
Baseline risk
heterogeneity
Different
definitions of
clinical endpoints
across the
various studies
1 indicates primary; 2D, two-dimensional; ACS, acute coronary syndrome; AMI, acute myocardial infarction; A-QMI, acute Q-myocardial infarction; AVB, auriculoventricular block; CAD, coronary artery disease; CHF, congestive heart failure; CK-MB, creatine kinaseMB; CV, cardiovascular; Dx, diagnosis; ECG, electrocardiogram; EDVI, end-diastolic volume index; ESVI, end-systolic volume index; GTN, glyceryl trinitrate; GRACE, Global Registry of Acute Coronary Events; HF, heart failure; IV, intravenous; LV, left ventricular;
24
LVEF, left ventricular ejection fraction; MI, myocardial infarction; NS, nonsignificant; NTG, intermittent transdermal nitroglycerin; NSTE-ACS, non-STE-elevation acute myocardial infarction; PC, placebo; pts, patients; qd, daily; RCT, randomized controlled trial; Rx,
prescription; SD, standard deviation; STEMI, non-ST-elevation myocardial infarction; Sx, symptoms; Tn, troponin; TTE, transthoracic echocardiography; UA, unstable angina; and VT, ventricular tachycardia.
Data Supplement 10. Analgesic Therapy (Section 4.1.2.2)
Study
Aim of
Study Type
Study
Name,
Study
Size (N)
Author,
Year
Study
Intervention
Group (n)
Study
Comparator
Group (n)
Patient Population
Inclusion
Criteria
Study
Intervention
Study
Comparator
Exclusion
Criteria
Iakobishvili,
2011
21627393
(89)
Determine
the impact
of IVM on
outcomes of
pts with
ADHF with
and without
ACSs
Observational
registry
2,336
218 (9.3%)
2,118 (90.7%)
Consecutive
pts with ADHF
participating in
a national HF
survey
N/A
IVM
No IVM
Iakobishvili,
2010
20346305
(90)
Assess the
30-d
outcomes
stratified by
IVNs use
among pts
enrolled in a
national
survey of
pts with
STEMI and
NSTE-ACS
Multicenter
retrospective
analysis from
the ACSIS
2008 database
993 pts
with
NSTEACS
97 (9.8%)
896 (90.2%)
Consecutive
pts presenting
with ACS to
any of 26 CCU
and cardiology
wards in Israel
Pts
transferred to
another
institution
IVM
No IVN
25
Endpoints
Primary
Endpoint
(Efficacy) and
Results
IM associated
with higher
unadjusted
(11.5% vs.
5.0%) and
adjusted inhospital
mortality using
logistic
regression
adjustment
No diff in 30-d
mortality with
IVN use.
Using
propensity
adjustment (95
matched NSTEACS pairs): 30-d
death rate (2.2%
for pts receiving
IVNs vs. 6.3%;
p=0.16)
Safety Endpoint
and Results
Secondary
Endpoint and
Results
IVM increased inhospital mortality
Using
adjustment with
propensity
matched
analysis, IVM
was not
associated with
increased inhospital death
(OR: 1.2; 95%
CI: 0.62.4;
p=0.55)
Using propensity
analysis, of 249
matched STEMI
pairs, 30-d
death was lower
in pts receiving
IVN; this trend
persisted after
logistic
regression
analysis (OR:
0.40; 95% CI:
0.14-1.14;
p=0.09)
N/A
P Values, OR:
HR: RR & 95%
CI:
Study
Limitations &
Adverse Events
IVM had higher

adjusted OR for
in-hospital
death: 2.0; 95%
CI: 1.1-3.5;
p=0.02) using
logistic
regression
analysis
Pts with IVM

were more likely
to have ACSs
Using logistic
regression
analysis, there
were no diff in
30-d mortality
among NSTEACS (OR: 0.56;
95% CI: 0.142.33; p=0.43)
Retrospective
On-site
catheterization
and bypass
surgery facilities
were available in
22 and 10 of the
centers only.
Relatively small
cohort. No data
regarding the
exact timing of
IVN use or the
cumulative dose
administered. Did
not specify the
types of IVN
used.
Meine,
2005
15976786
(91)
Compare
outcomes in
pts who
received
IVM vs.
those who
did not
receive IVM
Observational
registry,
GRACE
57,039
17,003
(30%)
Only a minority of
pts were treated
with IVN
Nonrandomized,
retrospective,
observational
data
Only a minority of
pts were treated
with IVM
Pts presenting
Pts who were Morphine
No morphine
Higher adjusted Increased
Relative to those In-hospital
with NSTEtransferred
within 24 h
at
risk of inadjusted OR of
receiving NTG,
death: morphine
ACS at 443
out to another of
presentation
hospital death in in-hospital death
pts treated with
vs. no morphine:
hospitals
institution
presentation
pts treated with
in all subgroups
morphine had a
adjusted (OR:
across the US
were
morphine
(including pts with higher adjusted
1.48; 95% CI:
from 01/2003 excluded,
compared with
CHF, ST
OR of death:
1.33-1.64)
06/2003
because data
no morphine
depression, <75
1.50; 95% CI:
Using propensity
Pts included in could not be
(OR: 1.48; 95%
y, positive
1.26-1.78
score matching,
the CRUSADE collected
CI: 1.33-1.64)
biomarkers,
morphine use
initiative have
nonhypotensive
was associated
ischemic Sx at
pts)
with increased
rest within 24 h
Also, increased
in-hospital
prior to
adjusted OR of
mortality (OR:
presentation
in-hospital
1.41; 95% CI:
and high-risk
adverse
1.26-1.57)
features
outcomes
including ST(death/MI; CHF;
segment
postadmission
depression,
MI; cardiac
transient STshock)
segment
elevation,
and/or positive
cardiac
markers.
ACS indicates acute coronary syndrome; ADHF, acute decompensated heart failure; CCU, cardiac care unit; CHF, congestive heart failure; CRUSADE, Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation
of the American College of Cardiology/American Heart Association Guidelines; diff, differences; GRACE, Global Registry of Acute Coronary Events; HF, heart failure; IVM, intravenous morphine; IVN, intravenous narcotics; MI, myocardial infarction; NSTE-ACS, nonST-elevation acute coronary syndrome; NTG, intermittent transdermal nitroglycerin; pts, patients; STEMI, ST-elevation myocardial infarction; Sx, symptoms; and US, United States.
Data Supplement 11. Beta-Adrenergic Blockers (Section 4.1.2.3)
Study
Study Aim
Study Type/
Intervention
Name,
Size (N)
vs.
Author,
Comparator
Year
(n)
40,036 (70%)
Patient Population
Inclusion
Criteria
TIMI-IIB
Roberts,
Immediate vs.
deferred BB
Prospective
multicenter
Immediate IV
group
AMI treated
with invasive
Study
Intervention
Exclusion Criteria
Implanted
pacemaker; resting
IV metoprolol as
soon as rt-PA
Endpoints
Primary Endpoint
& Results
Safety Endpoint
& Results
Global LVEF at time

of discharge using
No diff in
mortality in both
26
Secondary
Endpoint &
Results
Lower incidence of
reinfarction
P Values,
Adverse
Events
Study Limitations
Resting EF: immediate

51.0% vs. 50.1%
NS diff in deaths
at 6 wk or 1 y
Complexity of
interventions other
1991
1671346
(92)
therapy
1,434
720
Deferred group
714
vs.
conservative
strategy.
Susceptible to
BB therapy.
HR <55; SBP <100

mm Hg; pulmonary
edema; advanced 1st
degree or higher
heart block; asthma
or COPD.
was started
followed by oral
metoprolol or
oral metoprolol
beginning on d 6
radionuclide
ventriculography.
LVEF 50.5% at
discharge was
virtually the same in
both groups
groups. In lowrisk group there

were 7 deaths in
6 wk in deferred
group vs. none in
immediate group
Ryden,
1983
6828092
(93)
Occurrence of
ventricular
tachyarrhythm
ias in
suspected
AMI with BB.
Prospective
multicenter
2,395
Metoprolol
698
PC
697
Sx suggestive
of AMI
Contraindications for
beta-blockade; need
for beta-blockades
administrative
considerations.
Metoprolol IV
than po or PC
with admission
to CCU
Significant
ventricular
tachyarrhythmias:
More cases of VF in
the PC group
No increase in
significant heart
block with BB
Al Reesi,
2008
19019272
(94)
Effect of BB
use within 72
h of MI on 6wk mortality
vs. PC
Meta-analysis
18 studies 74
643
19662007
BB vs. PC or
no control
group
Roughly 50%
each
RCT of MI with
BB vs. PC
within 72 h of
AMI
No information on 6wk mortality.

Treatment started
after 72 h. NonEnglish speakers
Beta-1 or
nonselective BB
or PC within 72
h of MI. Followup for 6 wk
6-wk mortality:
Adding a BB had no
effect compared
with control
N/A
Subgroup analysis
that excluded highrisk pts showed
mortality benefit of
BB: 0.93 [0.88
0.99]
Janosi,
2003
14564329
(95)
Hjalmarson
1997
9375948
(96)
Emery,
2006
17161045
(97)
BB effects in
post-MI with
CHF
Multi-institute
prospective
trial
1,926
>55 RCT of
over 73,000
pts
950 metoprolol
976 PC
MI >0.28 d
before.
AMI or UA <28 d
Contraindicated to
BB.
Metoprolol or PC
for 1 y.
Withdrawal of BB
vs. PC NS.
Reduced CV death,
MI by 45%, SCD by
50%
Total mortality
p=0.0004, MACE
p<0.0001
AMI
Contraindicate to BB,
sever HF, heart
block.
BB vs. PC
Registry of 96
hospital pts
admitted for
ACS
retrospective
7,106
NSTEMI
Early BB therapy
or none
beginning <24 h
Total mortality
p<0.0001
SCD reduction
<0.0001
Hospital mortality 0.58
(95% CI: 0.420.81)
6-mo mortality 0.75
(95% CI: 0.560.997)
Freemantle
, 1999
10381708
(98)
BBs in shortterm Rx in MI
and in longer
term
Meta regression
analysis of
trials with
82 randomized
trials
Short-term:
29,260
BB in MI in PC
or alternative
Rx in controlled
trials
STEMI
Ccontraindications to
BB therapy
Transfer pts with Hx
of CHF
Cardiac arrest on
admission
N/A
Lipophilic BBs
prevent vs.
fibrillation after
MI
N/A
N/A
Use of early
BBs in
NSTEMI
Over 38,000
BB
Over 35,000
PC
5,422 early BB
1,684 None
BB reduced total
mortality by 40%,
combined MACE by
31%.
Total deaths 13%
reduction.
Short-term SCD
34% reduction.
BB therapy showed
lower hospital
mortality 6-mo
mortality also lower
Short-term: small
and NS reduction of
risk for death
Long-term:
N/A
N/A
Meta-analysis
of early BB
trials in MI
BB/PC or
alternative Rx
begun at any
stage of AMI
27
(2.7% vs. 5.1%;

p=0.02) at 6 d in
the immediate
group and less
recurrent chest
pain (18.8% vs.
24.2%; p<0.02)
BB did not
influence PVCs or
short bursts of VT
in 1st 24 h. 3-mo
mortality lower in
BB group (5.7% vs.
8.9%) p<0.03
Hospital Mortality
Killip II/III
0.39 (95% CI:
0.230.68)
delayed p=0.22
NS diff invasive or
conservatives strategy
in EF comparisons
VF: 6 in BB group, 17 in
PC group
(0.9% vs. 2.4%)
p<0.01
Requirement for
lidocaine less in BB
group 16 vs. 38
p<0.01
6-wk mortality
Reduction BB vs.
control: 0.95 (95% CI:
0.901.01) NS
With high quality
studies only: 0.96 (95%
CI: 0.911.02) NS
Short-term risk for

death
0.96 (95% CI: 0.85
0.98)
with immediate
vs. delayed BB
treatment. More
intracranial
hemorrhage in
the delayed
group
NS adverse
events with BB
vs. PC
N/A
Death from
worsening HF
educed 49% vs.
PC
N/A
than BB
administration may
have affected
results.
Use of a beta-1blocker precludes

assessment with
other type BB. No
indication of
whether deferred
BB would have
affected results.
Publication bias as
with all metaanalyses. No
evaluation of other
outcomes or
adverse events.
Mixed beta-1 and
nonselective BB.
Only 68% of postMI pts ideal
candidates for BB
N/A
N/A
Observational
No adjustment for
confounders. No
indication of dose
or brand
Usually
bradycardia or
hypotension
Multiple BB
brands, varied
follow-up, diff
times of initiation
secondary
preview
acute or past
AMI
54,234
Multicenter
randomized
PC controlled
1,959
Long-term:
24,974
pts
Carvedilol 975
PC 984
Dargie,
2001
11356434
(99)
Outcomes of
carvedilol in
AMI with LV
dysfunction
Chen, 2005
16271643
(100)
Effect of
adding BB to
current std
therapies in
AMI
BB therapy in
ACS
PCI
abciximab
Multicenter
randomized
PC controlled
45,852
McMurray,
2005
15708698
(102)
significant reduction
AMI with
LVEF40%,
use of ACE
inhibitors
<18 y, use of
diuretics or inotropes
Metoprolol
22,929
PC
22,923
<24 h of ACS
with STEMI,
NSTEMI, or
LBBB
Scheduled for PCI,

hypotension,
bradycardia, heart
block, shock
Pooled date
from 5 RCTs
2,894
1,939 BB
955 No BB
MI or UA within
48 h
Effect of BB in
reducing
arrhythmias
added to
ACEI
Multicenter
PC controlled
1,959
Post hoc
analysis of
arrhythmias
975 carvedilol
984
PC
Miller, 2007
17679127
(103)
Impact of
early use of
BB in ACS
Multiinstitutional
retrospective
analysis
72,054 at 509
hospitals
Brandler,
2010
20078433
(104)
Literature
review to
determine BB
effects on
outcome in
ACS
Meta-analysis
of RCTs
72,249
18 articles
Ellis, 2003
14562669
(101)
6.25 mg BB to
25 mg bid or PC
followed until
requisite number
of endpoints
IV then po, BB,
or PC for up to 4
wk
Death or hospital
admission for CV
problem no
difference
N/A
Death/reinfarction/
cardiacarrest
NS
Pts presenting within

24 h with ECG
change /UA
BB vs. control
through hospital
stay
PCI
30-d, 6-mo MACE

BB decreased
death during both
periods
11/1,000 more
with BB having
cardiac shock
during d 01 of
admission
N/A
321 d after MI
follow-up 1.3 y
Not stated
Carvedilol of PC
for duration of
study (average
1.3 y)
Arrhythmias over 2
y, atrial and
ventricular
arrhythmias lower in
BB group
N/A
82.5% received
acute BB vs.
no BB
Acute ischemia
<24 h, NSTE,
contrary to BB
Hospital transfer, no
+cardiac markers, no
acute medications
recorded
BB vs. no BB
Lower in-hospital
mortality,
reinfarction, shock
with BB.
No diff in CHF
N/A
Early BB
36,173 pts
with/without
PC 36,076
18+ y, ACE
within 24-h
pain onset, BB
within 8 h of
presentation
Contraindications to
BB
Early BB vs. no
BB
PC
No diff in in-hospital
mortality
N/A
28
All-cause mortality
alone
Lower in BB group
0.77 (0.600.98)
p=0.03
Less vs. fibrillation
with BB p=0.001
Less reinfarct
p=0.001
NS diff recurrent MI
Death or MI
Malignant vs.
arrhythmias:
0.9% BB
3.9% PC
0.24 (95% CI:
0.110.49)
p<0.0001
Acute BB
associated with
more invasive
procedures and
other acute therapy
In largest study
(45,852) higher
cardio shock in BB
5.0% vs. control
3.9%
p<0.0001
Long-term:
0.77 (95% CI: 0.69
0.85)
1 endpoint
0.92 (95% CI: 0.80
1.07)
and withdrawal.
N/A
Insignificant power
to detect a diff in
all-cause mortality
MACE for BB:

0.96 (95% CI: 0.90
1.01); p=0.1
NS
More cardiac
shock with BB (d
01)
Different
population groups
at centers
Death 30-d
BB vs. no BB
0.6% vs. 2.0%
p=0.017
Death 6 mo
1.7% vs. 3.7%
p=0.01
Atrial arrhythmias:
0.41 (95% CI: 0.25
0.68); p=0.0003 vs.
arrhythmias
0.34 (95% CI: 0.11
0.49); p<0.0001
NA
1 comparison not
randomized. Diff pt
populations. No
uniform definition
of ACS
AT, atrial flutter,

atrial fibrillation,
vs. tachm, vs.
fibrillation
Not prespecified
analysis. ECG
confirmation not
available
Hospital mortality:
0.66 (95% CI: 0.60
0.72)
Reinfarction
0.80 (95% CI: 0.72
0.89)
Shock
0.76 (95% CI: 0.67
0.87)
0.95 (95% CI: 0.90
1.01)
N/A
Undocumented
contraindicated to
BB use, hospital
actively seeking to
improve
performance
N/A
Single outcome
variable. No longterm evaluation.
Heterogeneous pt
population
Kontos,
2011
21570515
(105)
Registry of
BB use in
ACS
NCDR
291 hospitals
BB within 24 h
BB only: early
Very early BB use
Evidence of
NS diff between
Early vs. late use
Cardiogenic
Oral or IV?
ACTION20072008
of ACS
BB
vs. late use
increased
increased
early or late use in
cardiogenic shock:
shock with use
No infomation on
GWTG
21 822 BB
Missing data
cardiogenic shock
cardiogenic
death alone
1.54 (95% CI: 1.26
of BB in ED
type of BB or dose.
registry
and death or shock
shock with early
1.88); p<0.001
No information on
34,661 pts
use (<24 h) of BB
Death or shock:
arrhythmias.
with NSTEMI
1.23 (95 % CI: 1.08
21 822
1.40); p=0.0016
1 indicates primary; ACS, acute coronary syndrome; ACE, angiotensin- converting enzyme; ACEI, angiotensin-converting enzyme inhibitor; ACTION, Acute Coronary Treatment and Intervention Outcomes Network Registry; AMI, acute myocardial infarction; AT, atrial
tachycardia; BB, beta blocker; CCU, cardiac care unit; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; CV, cardiovascular; diff, difference; ECG, electrocardiograph; ED, emergency department; EF, ejection fraction; GWTG, Get With the
Guidelines; HF, heart failure; Hx, history; IV, intravenous; LBBB, left bundle-branch block; LV, left ventricular; LVEF, left ventricular ejection fraction; MACE, major adverse cardiac and cerebrovascular events; MI, myocardial infarction; NCDR- National Cardiovascular
Data Registry; NCDR ACTION-GWTG, National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry- Get With the Guidelines; NS, no/t significant; NSTE, non-ST-elevation; NSTEMI, non-ST-elevation MI; PC, PC; PCI,
percutaneous coronary intervention; pt, patient; PVCs, premature ventricular contractions; RCT, randomized controlled trial; Rt-PA, recombinant tissue plasminogen activator; Rx, prescription; SBP, systolic blood pressure; SCD, sudden cardiac death; std, standard;
STEMI, ST-elevation MI; UA, unstable angina; VF, ventricular fibrillation; and VT, ventricular tachycardia.
Data Supplement 12. Calcium Channel Blockers (Section 4.1.2.4)
Study
Aim of Study
Study Type
Study
Study
Name,
Size (N)
Intervention
Author,
Group (n)
Year
Study
Comparator
Group (n)
Patient Population
Inclusion
Criteria
Exclusion
Criteria
Study
Interventio
n
Study
Comparator
Endpoints
Primary
Endpoint
(Efficacy) and
Results
14-d reinfarction
9.3% in PC
5.2% in Diltiazem
Reduced by
diltiazem
Safety
Endpoint and
Results
Secondary
Endpoint and
Results
No increased
mortality with
CCB
Tolerated well
with BB
Refractory
angina
reduced by
diltiazem
Gibson,
1986
3526151
(106)
Effect of
diltiazem on
NQMI.
Multicenter
double-blind
randomized
576
Diltiazem
287
PC
289
NQMI >30 m
Ischemic
pain or ST
changes
Q waves or
conduction
disturbances AV
block
Bradycardia
Cardio shock
Diltiazem
2472 h
from
admission
Up to 14 d
PC
Lubsen,
1987
2887097
(107)
Efficacy of BB
and CCB in
UA in a CCU
Multicenter
PC control
338
Combination
of nifedipine
and
metoprolol
PC
UA not
previously on
BB
AMI
Nifediipine,
metoprolol,
or
combination
PC
Ischemia or
progression to MI
in 48 h. Only
pretreatment with
BB showed
favorable effects
with nifedipine.
No increased
mortality with
CCB.
Starting a BB
plus nifedipine
showed no
benefit from
BB initiation
alone vs. PC.
Gibson,
1987
3303886
Px effect of
dilriazem on
recurrent
Multicenter
double-blind
576
Diltiazem
287
PC
289
Confirmed
NQMI
Q waves or
conduction
disturbances
Diltiazem
24-72 h
from
PC
Incidence of early
recurrent
ischemia
N/A
N/A
29
P Values, OR:
HR: RR & 95%
CI:
Study Limitations
& Adverse Events
Reinfarction:
51.2%(90% CI:
7%67%);
p=0.0297
Refractory angina
49.7% (90% CI:
6%73%);
p=0.0345
Rate ratio for
CCB:
pretreated with
BB:
0.68 (0.47, 0.97)
Not on BB:
1.51 (0.87, 2.74)
vs. PC
CCB red of
ischemia:
28% (95% CI:
Only 4.8%
withdrawn because
of adverse effects.
No diff vs. PC in LV
failure, shock, AV
block, severe
bradycardia, or
hypotension
Equal numbers on
BB alone or
combination
developed AMI or
reversible ischemia.
N/A
(108)
ischemia
AV block
Bradycardia
Cardio shock
CHF
Hypotension
AV block
(most common)
admission
Up to 14 d
Held, 1989
2513047
(109)
CCB effect on
events
Meta-analysis
of 28 trials
19,000
8,870 CCB
8,889 control
MI 22 trials
UA 6 trials
Moss, 1991
1872266
(110)
Diltiazem and
long-term
outcome
Multicenter
PC control
2,464
No HTN
Diltiazem:
760
PC: 762
Hypertension
Diltiazem:
471
PC: 471
Furberg,
1995
7648682
(111)
Meta-analysis
of nifedipine
trials on
outcome
Meta-analysis
of 16 studies
8,350
Nifedipine
4,171
Rengo,
1996
8602564
(112)
Effect of
verapamil on
mortality after
AMI
Multicenter
prospective
trial
1,073
Verapamil
531
CCB usually
early in ACS
Control
MI treated
with diltiazem
with or
without
hypertension
CHF
Hypotension
AV block
Diltiazem at
ACS for 1252 mo
PC for same
time period
1st recurrent
cardiac event:
CCB benefit only
in hypertensives
with no
pulmonary
congestion.
Control
4,183
Nifedipine 2
prevention
trials with
mortality data
No
randomization
Nifedipine
12 AMI
3 UA
1 SA
Short-acting
PC
Effect on
mortality
Nifedipine
increased
mortality by 16%
Dose related
PC
542
Dx of AMI
Contraindication
to verapamil
Hx of severe HF
Long acting
Verapamil
7-21 d after
AMI
360 mg qd
for 24 mo
PC For 24
mo
Total mortality
and CV deaths.
No diff between
groups
30
decreased by
CCB
15.7% vs. 24.2%
Risk of death,
infarct size, or
reinfarction. No
effect by CCB vs.
PC in MI trials.
9.3%53.8%);
p=0.0103
No increase in
reinfarction or
infarct size vs.
PC by CCB
Results
similar in UA
trials
Mortality: CCB vs.

PC
1.06 (95% CI:
0.961.18) in
MI trials
+pulmonary
congestion;
CCB increased
Risk:
Hypertension/
No
hypertension
1.32 (95% CI:
0.83-2.10)
1.63 (0.99,
2.69) vs. PC
Increased
sympathy stim
and active of
RAAS
Significant
reduction in
BP and HR
with CCB
though small.
CCB benefit
hyperension
without
pulmonary
congestion
0.67 (95% CI:
0.470.96)
Total mortality
Low dose
1.06 (95% CI:
0.89-1.27)
High dose
2.83 (95% CI:
1.355.93)
Verapamil
group had
lower
reinfarction
rates (NS)
39 vs. 49
Significantly
less angina
OR: 0.8 (95%
CI: 0.5-0.9)
Total mortality
1.16 (95% CI:
1.01-1.33);
p=0.01
Heterogeneity of
clinical trial
populations
Total mortality
verapamil vs. PC
30 vs. 29 NS
Cardiac deaths
21 vs. 22 NS
No diff in
discontinuation of
therapy due to
adverse reactions.
Death rate and
number of pts
recruited were
lower than
expected and pts
were relatively
young decreasing
the power of study
No safety
issues
Usual limitation of
meta-analysis
heterogeneity of
populations and
various agents.
Adverse effects not
addressed per se
Retrospective
analysis. Post-hoc
analysis of HTN
effect. Adverse
effect of pulmonary
congestion on
diltiazem outcome
Smith, 1998
9809940
(113)
Long-term
outcome
BB + CCB in
UA
Retrospective
cohort
247
Diltiazem
188
BB
59
At discharge
with UA Dx
MI or stroke
during
hospitalization
Monotherap
y CCB for 17y
Monotherap
y BB for 1-7
y
Deaths in 51 mo
No diff between
BB and CCB
N/A
Pepine,
1998
9755379
(114)
Safety of CCB
in CV disease
Meta-analysis
14
randomized
parallel group
studies
4,000
person y
Verapamil
PC
Randomized
studies of
verapamil
and PC from
AMI
No randomization
or control group
Verapamil
PC
Outcomes with
CCBs after MI:
vs. PC
No diff in deaths
Decreased
nonfatal
MI
Decreased
death/reinfarction
Data too
limited for pts
with
hypertension
No evidence
for increased
harm with
verapamil
DAVIT
Danish
study, 1984
6383832
(115)
6 mo and 12
mo mortality
after AMI with
verapamil
Multicenter
prospective
study
3,498
Verapamil
roughly 50%
PC roughly
50%
AMI
HF, AV block,
severely
disabling
diseases,
treatment with
BB or CCB
Verapamil
120 tid for 6
mo
PC for 6 mo
NS diff in 6-mo or
12-mo mortality
rate verapamil
vs. PC
DAVIT II
Danish
study, 1990
2220572
(116)
18 mo
mortality rates
and major CV
events with
verapamil
after AMI
Multicenter
prospective
trial
1,775
Verapamil
878
PC
897
AMI
HF, AV block,
severely
disabling
diseases,
treatment with
BB or CCB
Verapamil
360 mg qd
from 2nd wk
of AMI and
up to 18 mo
PC for same
period
Long-term
treatment with
verapamil
decreased major
CV events
without
significant effect
on mortality
Higher number
of AV block in
verapamil
group not
associated with
increased
mortality. NS
decreased in
vs. fibrillation in
verapamil
group.
Significant diff
in reasons for
permanently
stopping
verapamil vs.
PC:
2nd or 3rd
degree AV
block , sinus
bradycardia,
31
Adjusted: for
CCB
NS increase in
CAD
rehospitalization/
death
1.4 (95% CI:
0.82.4)
No diff verapamil
vs. PC in angina
pts
6-mo
reinfarctions:
verapamil 7%
PC 8.3 %
NS
In pts without HF
in CCU
18-mo mortality:
verapamil vs. PC
7.7% vs. 11.8%
p=0.02
0.64 (95% CI:
0.440.94)
Major CV event
rates:
Deaths: CCB
vs. BB
1.1 (95% CI:
0.49-2.4)
Compliance issues.
No infomation on
follow-up treatment.
Relatively small
number of BB users
Combined
death/reinfarcti
on:
0.82 (95% CI:
0.700.97);
p=0.016
Death: 0.93
(95% CI: 0.78
1.1)
Reinfarction:
0.79 (95% CI:
0.650.97);
p=0.024
6-mo mortality:
12.8%
verapamil
13.9% PC
NS
12-mo
mortality:
15.2%
verapamil
16/4% PC
NS
18-mo
mortality:
verapamil vs.
PC:
11.1% vs.
13.8%; p=0.11
0.80 (95% CI:
0.611.05)
Major CV
events:
No evidence of
harm with CCB in
angina.
Dosage of
verapamil caused
significantly
increased AV block
in 1st wk
More HF in
verapamil group
p<0.005
Minor discrepancies
between resulting
confidence limits
and p values from
the Tarone-Ware
tests occurred
because HR are
based on
proportional
hazards
abdominal
pain,
constipation
14.6% vs.
18.0% vs.
assumption, not the
19.7%; p=0.01
21.6%; p=0.03 case for the
0.70 (95% CI:
0.80 (95% CI:
Tarone-Ware test
0.520.93)
0.640.99)
In HF, NS diff in
mortality or
major CV events
2 indicated secondary; ACS, acute coronary syndrome; AMI, acute myocardial infarction; AV, atrioventricular; BB, beta-blocker; BP, blood pressure; CAD, coronary artery disease; CCB, calcium channel blocker; CCU, cardiac care unit; CHF, congestive heart failure;
CV, cardiovascular; diff, difference(s); Dx, diagnosis; HF, heart failure; Hx, history; HTN, hypertension; LV, left ventricular; MI, myocardial infarction; NQMI, Non-Q Wave myocardial infarction; NS, no/t significant; PC, placebo; pts, patients; Px, prognosis; qd, once daily;
RAAS, Renin-Angiotensin-Aldosterone System; SA, stable angina; t.i.d., three times daily; and UA, unstable angina.
Data Supplement 13. Other Anti-Ischemic Inverventions (Ranolazine) (Section 4.1.2.5)
Study Name,
Aim of Study
Study Type
Study
Study
Study
Author, Year
Size (N) Intervention Comparator
Group (n)
Group (n)
Patient Population
Inclusion
Criteria
Exclusion
Criteria
Cardiogenic
shock,
persistent STE,
successful
revasc before
randomization,
clinically
significant
hepatic disease,
ESRD requiring
dialysis,
treatment with
agents known to
prolong the QT
interval, ECG
abnormal levels
interfering with
Holter
interpretation,
life expectancy
<12 mo
Cardiogenic
shock,
Wilson SR,
2009
19389561
(117)
Evaluate the
efficacy and
safety of
ranolazine in
pts with prior
chronic SA
Substudy
from a
multinational
RCT
3,565
1,789
1,776
Pts with
NSTE-ACS
within 48 h of
ischemic Sx
(between Oct
2004Feb
2007)
Eligibility
criteria: 18
y; Sx of
myocardial
ischemia; at
least 1
moderatehigh-risk
indicator
Scirica, 2007
17804441
Assess the
potential
Sub-study
from a
6,351
3,162
3,189
Pts with
NSTE-ACS
Study
Intervention
Study
Comparator
Ranolazine
PC
Ranolazine
PC
32
Endpoints
Primary
Endpoint
(Efficacy) and
Results
1 endpoint
(CV death, MI,
recurrent
ischemia) was
less frequent
with ranolazine
(HR: 0.86; 95%
CI: 0.750.97;
p=0.017)
(Follow-up was
a median of
350 d)
Ranolazine
was associated
P Values, OR:
HR: RR & 95%
CI:
Study
Limitations &
Adverse Events
Safety
Endpoint and
Results
Secondary
Endpoint and
Results
Symptomatic
documented
arrhythmias
(2.9% vs. 2.9%;
p=0.92) and
total mortality
(6.2% vs. 6.4%;
p=0.96) were
similar with
ranolazine or
PC.
CV death or MI
did not differ
between
treatment
groups (HR:
0.97; 95% CI:
0.801.16;
p=0.71)
Composite
endpoint driven
by significant
reduction in
recurrent
ischemia (HR:
0.78; 95% CI:
0.670.91;
p=0.002).
Ranolazine
reduced
worsening angina
(p=0.048) and
intensification of
antianginal
therapy (p=0.005)
Exercise duration
at 8 mo greater
with ranolazine
(p=0.002)
1 endpoint:
ranolazine vs. PC
HR: 0.86; 95%
CI: 0.75-0.97;
p=0.017
Substudy of a
RCT that did not
meet its 1
endpoint
(exploratory)
Randomization
was not stratified
by Hx of prior
angina, small diffs
in clinical
characteristics
between those
randomized to
ranolazine or PC
exist.
(numerically, but
not statistically,
Lower incidence
of pauses 3 s
VT 8 beats
(5.3% vs. 8.3%;
Substudy of a
RCT that did not
(118)
antiarrhythmic
actions of
ranolazine after
ACS
multinational
RCT
persistent STE,
with fewer
lower incidence
with ranolazine
p<0.001)
meet its 1
successful
episodes of VT of sudden
(3.1% vs. 4.3%;
SVT (44.7% vs.
endpoint
revasc before
8 beats (5.3% cardiac death in p=0. 01)
55.0%; p<0.001), (exploratory)
randomization,
vs. 8.3%;
pts treated with
New-onset AF
clinically
p<0.001), SVT ranolazine over
(1.7% vs. 2.4%;
significant
(44.7% vs.
the entire study
p=0.08)
hepatic disease,
55.0%;
period)
ESRD requiring
p<0.001), or
dialysis,
new-onset AF
treatment with
(1.7% vs.
agents known to
2.4%; p=0.08)
prolong the QT
(Continuous
interval, ECG
ECG [Holter]
abnormal levels
recording was
interfering with
performed for
Holter
the 1st 7 d after
interpretation,
randomization)
life expectancy
<12 mo
Morrow, 2007 Determine the
Multinational 6,560
3,279
3,281
Pts with
Cardiogenic
Ranolazine
PC
1 efficacy
No diff in total
No diff in the
1 efficacy
Given the
17456819
efficacy and
RCT
NSTE-ACS
shock,
(initiated IV
endpoint
mortality with
major 2 endpoint endpoint
statistically NS
(119)
safety of
within 48 h of persistent STE,
followed by
(composite of
ranolazine vs.
(CV death/MI/
(ranolazine vs.
result for the 1
ranolazine
ischemic Sx
successful
oral
CV
PC (HR: 0.99;
severe recurrent
PC):
endpoint, all
during long(between Oct revasc before
ranolazine
death/MI/recurr 95% CI: 0.80
ischemia), or in
HR: 0.92; 95%
additional efficacy
term treatment
2004 and Feb randomization,
extendedent ischemia):
1.22)
the composite of
CI: 0.831.02
analyses,
of pts with
2007)
clinically
release 1000
21.8% in the
No diff in QTc
CV death/MI.
although
NSTE-ACS
Eligibility
significant
mg 2 daily)
ranolazine
prolongation
Ranolazine was
prespecified,
criteria: 18
hepatic disease,
group vs.
requiring dose
associated with
should be
y; Sx of
ESRD requiring
23.5%, p=0.11 reduction: 0.9% reduced recurrent
considered as de
myocardial
dialysis,
Follow-up was
in pts receiving
ischemia: 13.9%
facto exploratory
ischemia; at
treatment with
a median of
ranolazine vs.
vs.16.1%; HR:
915 and 736 pts
least 1 modagents known to
350 d
0.3% in PC, p
0.87; 95% CI:
discontinued the
high-risk
prolong the QT
NS
0.760.99;
study Rx in the
indicator
interval, ECG
No difference in p=0.03).
ranolazine and
abnls interfering
symptomatic
PC arms,
with Holter
arrhythmias
respectively.
interpretation,
(ranolazine:
life expectancy
3.0% vs. PC:
<12 mo
3.1%; p=0.84)
1 indicates primary; 2, secondary; ACS, acute coronary syndrome; AF, atrial fibrillation; CV, cardiovascular; diff, difference; ECG, electrocardiograph; ESRD, end-stage renal disease; Hx, history; IV, intravenous; MI, myocardial infarction; NS, no/t significant; NSTE,
non-ST-elevation; NSTE-ACS, non-ST-elevation acute coronary syndrome; pts, patients; RCT, randomized controlled trial; revasc, revascularization; Rx, prescription; SA, stable angina; STE, ST-elevation; Sx, symptoms; SVT, sustained ventricular tachycardia; and VT,
ventricular tachycardia.
within 48 h of
ischemic Sx
(between Oct
2004Feb
2007)
Eligibility
criteria: 18
y; Sx of
myocardial
ischemia; at
least 1
moderatehigh-risk
indicator
33
Data Supplement 14. Inhibitors of the Renin-Angiotensin-Aldosterone System (Section 4.2)

Study Name,
Aim of
Study Type
Study
Study
Study
Patient Population
Author, Year
Study
Size (N)
Intervention Comparato
Group (n)
r Group (n)
Inclusion
Exclusion
Criteria
Criteria
Study
Intervention
Study
Comparator
Endpoints
Primary
Endpoint
(Efficacy) and
Results
Safety
Endpoint and
Results
Secondary
Endpoint and
Results
SAVE
Pfeffer, 1992
1386652
(120)
Captopril on
events in
AMI with LV
dysfunction
Multiinstitute
prospective
2,231
Captopril
1,115
PC
1,116
3 d after
AMI
LVEF4%
2179 y.
Contraind. to
ACEI
Creatinine >2.5
mg/dL
Captopril for
42 mo
PC
All-cause
mortality
reduced in
captopril group
vs. PC
(20% vs. 25%)
Reduction of
MACE by 21%
No prospective
safety
evaluators
Reduction of
CV death by
ACEI
37%
Reduction of
severe HF by
22%
Reduction of
recurrent MI by
25%
Ambrosioni,
1995
7990904
(121)
ACEI for
short-term
events
Multiinstitute
prospective
1,556
Zofenopril
772
PC
784
CCU with
AMI
Contraindication
to ACEI
ACEI for 6
wk
PC
6-wk death or
severe HF
reduced by 34%
with ACEI
N/A
1-y death rate

reduced by
ACEI
29%; p=0.011
CONSENSUS
II Swedberg,
1992
1495520
(122)
Long-term
reduction in
mortality
with ACEI
Multiinstitute
prospective
6,090
Enalapril
3,044
PC
3,046
<24 h after
onset of
chest pain
with ECG/
enzyme
changes
BP <100/60;
need for
vasopressors,
severe heart
block, valvular
disease,
contraindication
to ACEI, TIA
Enalapril for
6 mo
PC
1- and 6-mo
mortality
unchanged with
enalapril vs. PC
7.2% vs. 6.3% 1
mo
11.0% vs.
10.2% 6 mo
Death due to HF
4.3% ACEI
3.2% PC
p=0.06
ACEI MI Coll.
Group
1998
9631869
(123)
Use of ACEI
in early AMI
Metaanalysis of 4
clinical trials
98,496
ACEI
roughly 1/2
PC roughly
1/2
AMI-early
short-term
trials>1,000
pts
Smaller trials, no
control group
ACEI from
2842 d
PC
30-d mortality
reduction 7% by
ACEI
Hypotension
less common in
ACEI vs.
controls
9.3 vs. 17.6%
Change in
therapy due to
HF increased
in PC group.
p<0.006
NS diff in
reinfarctions or
rehospitalizatio
n due to HF
Absolute
benefit highest
in Killip 2, 3
anterior MI
34
P Values, OR: HR:

RR & 95% CI:
Study Limitations &

Adverse Events
All-cause mortality
reduction by ACEI
19% (95% CI: 3%
32%); p=0.019
MACE:
21% (95% CI: 535);
p=0.014
CV deaths
37% (95% CI: 2050);
p<0.001
Recurrent MI:
25%:(95% CI: 540);
p=0.015
6-wk death reduction:
34% (95% CI: 8%
54%); p=0.018
MACE:
46% (95% CI: 1171);
p=0.018
Mortality; p=0.26
Adverse: dizziness,
dysgeusia, cough,
diarrhea. Exclusion of
pts with symptomatic
HF
30-d mortality
reduction
7% (95% CI: 2%
11%); p<0.004
HF reduction
14.6% vs. 15.2%
Significant increase in
cardiac shock and
renal dysfunction with
ACEI
Higher 2nd-3 d AV
block.
Side effects: 6.8% PC,

8.6% ACEI
No use of initial IV ACI
to see beneficial or
adverse effects.
Early hypotension
12% ACEI and 3% PC
p<0.001
Lack of ACEI benefit
possibly due to low
dose of ACEI
AIREX
Hall, 1997
9167457
(124)
Cumulative
Mortality 3 y
after end of
AIRE trial of
MI with HF
Multiinstitute
prospective-
603 in
initial
AIRE trial
of 15 mo
Ramipril
302
PC
301
AMI with
evidence of
HF
Clinical
instability,
contraindication
to ACEI, HF of
valvular or
congenital HD,
need for open
label ACEI.
Ramipril
beginning 29 d after
admission
and up to 15
mo with 3-y
follow-up
poststudy
PC for 15
mo, then 3-y
follow-up
15-mo mortality
reduced with
ACEI and 3-y
follow-up
mortality also
reduced
N/A
N/A
Squire, 2010
20478862
(125)
Benefit of
BNP in use
of ACEI in
ACS
Observation
al cohort
study
retrospective
1,725
ACEI in all
or ARB in
some cases
Various
levels of
BNP
ACS in
CCU
44% NSTEACS
Resident pts
outside health
authority area.
ACEI or
ARB median
528 d followup.
NT-pro-BNP
values by
quartiles
MACE: only in
top quartile of
BNP was ACEI
associated with
reduction of
MACE. NS
benefit in other
BNP quartiles
ACEI treatment.
Had survival
benefit only in
pts without
diabetes mellitus
or hypertension.
Pfeffer, 2003
14610160
(126)
Effect of
ACEI and
ARB
combination
in AMI with
HF/LV
Dysfunction
Multicenter
prospective
trial
14,703
Valsartan
4,909
Captopril
4,909
Both
4,885
3-way
comparison
AMI 0.510
d
HF and/or
LVEF
<0.35 by
echo or
<0.40 by
RN
Low BP
Creatinine >2.5
ACE, ARB
or
combination
Median 24.7
mo
3-way
comparison
Total mortality:
NS diff among 3
groups
Valsartan:
hypotension,
renal
abnormalities
more common.
Captopril:
cough, rash,
dysgeusia more
common.
Death or HF:
reduced risk in
top quartile of
BNP: 0.498
(0.31, 0.80);
p=0.004
NS reduction of
death in top
BNP quartile.
Noninferiority
of valsartan vs.
captopril for
death
Pitt, 2003
12668699
(127)
Effect of
eplerenone
in AMI with
LV
dysfunction
Multicenter
prospective
trial
6,632
Eplerenone
3,319
PC
3,313
3-14 d after
AMI
LVEF
0.40
CHF on
ACEI, BB,
K+ sparing
diuretics use;
Creatinine >2.5
K+>5 meq/L
Eplerenone
mean followup 16 mo
PC
Total and CV
death
Total deaths and
CV deaths
decreased by
eplerenone vs.
BP increase less
in eplerenone
than PC
increase in
creatinine
EP>PC;
35
Reduction in
sudden death
0.79 (95% CI:
0.640.97);
p=0.03
2p=0.01
15-mo mortality:
16.9% ACEI
22.6% PC
27% (95% CI: 1140);
p=0.002
3-y post-AIRE
mortality:
27.5% ACEI
38.9% PC
36% (95% CI: 1552);
p=0.002
Reduction with ACEI.
Decreased MACE in
top quartile of BNP:
HR: 0.613 (0.46,0.82);
p=0.001
Total mortality:
valsartan vs. captopril
1.00 (97.5% CI: 0.90
1.11)
Combined vs.
captopril
0.98 (97.5% CI: 0.89
1.09)
Total deaths:
0.85 (95% CI: 0.75
0.96); p=0.008
CV deaths:
0.83 (95% CI: 0.72
0.94); p=0.005
Mortality benefit only

in 1st 24 mo after study
ended. Possibly
because more
severally ill PC pts
died before 24 mo
leaving a relatively
healthy post-PC
population.
Observational only.
Possible residual
confounding of
variables.
Demographic diff in
BNP. Single center,
but 2 hospitals.
Significant adverse
events: hypotension,
renal causes,
hyperkalemia, cough,
rash, dysgeusia,
angioedema.
Significant greater
adverse events with
combination vs.
valsartan alone.
9.0% vs. 5.8% for
permanent
discontinuation of
drug.
Low rate of D/C of EP
for adverse events. No
gynecomastia.
However, increased
incidence of serious
hyperkalemia
diuretics
Gheorghiade,
2009
19699868
(128)
PC
p<0.001
Increase in K+
greater in EP
In
rehospitalization
pts:
K+>6.0 in 10.1%
EP vs.
5.8% PC
p=0.02
Effect of
eplerenone
on
readmission
hospital stay
after MI with
LV
dysfunction
MRI study to
evaluate
eplerenone
effects on
LV after MI
Retrospectiv
e analysis of
prospective
multicenter
trial
6,632;
827
with
subseque
nt hospital
readmissi
on
Eplerenone
3,319
PC
3,313
Rehospitali
zation for
HF
827
No
rehospitalization
from original
group
5,805
Eplerenone
16-mo
follow-up
PC
Reduction of d
of
rehospitalization
by eplerenone
Prospective
cohort study
100
Eplerenone
50
PC
50
AMI 1-14 d
LVEF <040
Clinical HF, DM,

preexisting, LV
dysfunction,
elevated
creatinine, K+>
mmol/L
Eplerenone
24 wk
PC
Change in LV
systolic volume
after covariate
adjusted volume
fell by 6.1 2.7
mL/m2 vs. PC
NS diff between
eplerenone and
PC in HR, BP
changes
2/50 EP pts
developed
K+ bet, 5.6 and
5.9
Rossignol
2011,
22032706
(130)
Mechanism
of
eplerenone
benefit in
AMI
Retrospectiv
e analysis of
multicenter
study
6,080
Eplerenone
3,055
PC
3,025
K+ sparing
diuretic
Creatinne >2.5
K+>5 meq/L
Eplerenone
1-mo
evaluation
PC
Eplerenone
effects on
renal
function after
AMI
Retrospectiv
e analysis of
multicenter
study
5,792
Eplerenone
2,918
PC
2,874
K+ sparing
diuretic
Creatinine>2.5
K+>5 meq/L
Eplerenone
24 mo
follow-up
PC
Interaction
between diuretic
effects and K+
sparing effects
of eplerenone
and benefit of
CV outcome
Serial changes
in eGFR
EP had a
decline in eGFR
from 1st mo and
persisted
throughout study
Decreased rate
of CV death due
to K+ sparing
effect of EP vs.
PC
Rossignol,
2012
22128223
(131)
3-14 d after
overall AMI;
LVEF
0.40
CHF on
ACEI, BB,
diuretics
3-14 d after
AMI;
LVEF
0.40
CHF, on
ACEI, BB,
diuretics
GISSI-3, 1994
7910229(87)
Effect of
ACEI on
mortality and
LV function
Multicenter
prospective
trial
18,895
Lisinopril,
9,435
Open
control
9,460
In CCU
within 24 h
of chest
pain, ECG
Severe HF
requiring study
treatment,
hemodynamic
Lisinopril 10
mg qd for 6
wk
PC
Deaths and
combined
deaths and LV
dysfunction
Rates of
hypotension and
renal
dysfunction
Weir, 2009
19464421
(129)
36
Most salient:
early decline in
eGFR by EP vs.
PC
CV Death or Hospital:
0.87 (95% CI: 0.79
0.95); p=0.02
Total d in hospital for
HF; (reduction)
3.6 (13.316.9)
p=0.0006 vs. PC
5.5% vs. 3.9%;

p=0.002
Diastolic
volume fell EP
vs. PC
7.53.4 mL/m2
p=0.031
Increased
MMP
-9 and
decreased
MMP-2
EP vs. PC
Reduced
weight <0.0001
Plasma volume
p=0.047
Increased K+
p<0.0001
Early decline in
eGFR by>20%
associated with
worse CV
outcomes
independent of
baseline eGFR
and use of
eplerenone
Systolic volume
decreased with
EP vs. PC: p=0.027
3 eplerenone pts died,

vs. fibrillation, stroke,
recurrent AMI, NS
change in creatinine or
eGFR. Need for
covariate adjustment;
LVEF changes
between screening
TTE and MRI.
EP decreased total
mortality, CV death/
hospitalization and
hospitalization for HF
independent of K+
and diuretic effects
Post-hoc analysis
Short-term evaluation
of K+ and diuretic
effects only
Decline >20% eGFR

1st mo:
16.9% EP vs. 14.7%
PC
OR: 1.15 (95% CI:
1.021.30); p=0.017
Rates of
reinfarction,
cardiogenic
shock, and
Overall 6-wk mortality

reduction: OR: 0.88
(95% CI: 0.790.99)
Overall reduction in
Post-hoc analysis and

included
nonprespecified
subgroups
Changes focused only
on a 1-mo timepoint
At this timepoint,
deaths in eplerenone
were already lower
than PC
Relatively low dosage
of lisinopril, many
elderly and women
excluded
NS effect of
geographic
region on
results
In subset
rehospitalized: No
deaths from
hyperkalemia, 2-fold
reduction of
hypokalemia,
impotence was rare
after MI
ISIS-4, 1995
7661937(86)
Effect of
ACEI on 5wk mortality
after AMI
changes
and no
contraindic
ations to
study med
Multicenter
prospec trial
58,050
Captopril
29,028
PC
29,022
In CCU
within 24 h
of chest
pain
deterioration,
bilateral renal
artery stenosis,
other life
threatening
disorders
Hypotension,
cardiogenic
shock, fluid
depletion
Lisinopril
reduced
mortality and
combined
outcome
Captopril 50
mg bid for
28 d
PC
higher with ACEI
stroke did not

differ
death plus decreased.

LV dysfunction:
0.90 (0.84-0.98)
Concern about slightly

increased creatinine
and hypotension with
ACEI
5-wk mortality
lower with ACE
inhibitor
Rates of
Somewhat
5-wk mortality:7.19%
Possible contending
hypotension
fewer deaths
ACI vs. 7.69% PC
effects of magnesium
increased with
1st 2 d of
2p=0.02
and nitrates in regard
ACEI, renal
treatment with
to results
dysfunction
ACEI vs. PC
No excess of
deaths with
lower BPs on
ACEI
ACS indicates acute coronary syndrome; ACEI, angiotensin-converting enzyme inhibitor; AIRE Trial, Acute Infarction Ramipril Efficacy Trial; AMI, acute myocardial infarction; ARB, angiotensin receptor blocker; AV,block, atrioventricular block; BB, beta blocker; bid,
twice a day; BNP, B-type Natriuretic Peptide; BP, blood pressure; CCU, cardiac care unit; CHF, congestive heart failure; CV, cardiovascular; diff, diference(s); D/C, discharge; ECG, electrocardiograph; eGFR, estimated glomerular filtration rate; EP, eplerenone; HD,
heart disease; HF, heart failure; IV, intravenous; LV, left ventricular; LVEF, left ventricular ejection fraction; MACE, major adverse cardiac events; MI, myocardial infarction; MMP-2, matrix metalloproteinase-2; MMP-9, matrix metalloproteinase-9; MRI, magnetic
resonance imaging; NS, no(t) significance; NSTE, non-ST-elevation; NSTE-ACS, non-ST-elevation-acute coronary syndrome; NT-pro-BNP, N-terminal pro-brain natriuretic peptide; PC, placebo; pts, patients; RN, radionuclide; and TTE, transthoracic echocardiography.
Data Supplement 15. Oral and Intravenous Antiplatelet Therapy in Patients With Likely or Definite NSTE-ACS Treated With Initial Invasive or Conservative Strategy (Section 4.3.1)
Study
Study Aim
Study Type /
Intervention
Patient Population
Study
Endpoints
Name,
Size (N)
vs.
Intervention
Author,
Comparator
Year
(n)
Inclusion Criteria
Exclusion Criteria
Primary Endpoint &
Safety
Secondary
Results
Endpoint & Endpoint & Results
Results
Baigent
Low-dose ASA
Meta-analysis
ASA vs. no
1 or 2 prevention
1 prevention trials
ASA or no ASA
Serious vascular events Major bleeds 2 prevention trials
2009
is of definite
N=95,000 pts at ASA
trials eligible only if
excluded individuals
(MI, stroke, or vascular
0.10% vs.
ASA allocation
19482214
and substantial low avg risk
they involved
with any Hx of
death)
0.07% per y;
yielded greater
(132)
net benefit for
randomized
occlusive disease at
0.51% vs 0.57%
p<0.0001
absolute reduction in
people who
comparison of ASA
entry
serious vascular
already have
vs. no ASA (with no
events (6.7% vs.
occlusive
other antiplatelet
8.2% per y;
vascular
drug in either group).
p<0.0001) with NS
disease.
increase in
Assessed the
haemorrhagic stroke
benefits and
but reductions of
risks in 1
about a 1/5 in total
prevention.
stroke (2.08% vs.
2.54% per y;
37
P Values,
OR: HR: RR: &
95 CI:
p=0.0001
Adverse Events
N/A
Study
Limitations
N/A
CURE
Yusuf
2001
11519503
(133)
Compare
efficacy and
safety of the
early and longterm use of
clopidogrel plus
ASA with those
of ASA alone in
pts with ACS
and no STE
Randomized,
double-blind, PC
trial N=12,562
pts
Clopidogrel
vs. PC in
addition to
ASA
Pts were eligible for

study if they had
been hospitalized
within 24 h after
onset of Sx and no
STE
PLATO
Mahaffey
2011
21709065
(134)
Prespecified
subgroup
analysis
showed
significant
interaction
between
treatment and
region
(p=0.045), with
less effect of
ticagrelor in NA
than in ROW.
Exploratory
analyses
performed to
identify
potential
explanations for
observed
region-bytreatment
interaction.
Investigate age
dependency of
Observed
regional
interaction
driven by
interaction of
randomized
treatment with
78% of NA pts in
US compared
with ROW pts
(p=0.01 vs.
p=0.045 for
interaction using
NA). Analyses
focus on
comparison of
US and ROW,
with Canadian
pts included in
ROW group.
Reasons for
the interaction
were explored
independently
by 2 statistical
groups.
Prospective
observational
Clopidogrel
and age
Gremmel
2010
Clopidogrel (300
mg immed
followed by 75
mg od) vs. PC in
addition to ASA
Death from CV causes,

nonfatal MI, or stroke
9.3% vs 11.4%
Pts with
major
bleeding
3.7% vs.
2.7%;
p=0.001
RR: 1.38
N/A
antithrombotic or
antiplatelet therapy,
high risk for bleeding
or severe HF, taking
oral anticoagulants,
had undergone
coronary revasc in
the previous 3 mo or
received IV GP
IIb/IIIa receptor
inhibitors in the
previous 3 d
N/A
2 independently
performed
analyses
identified
statistical
interaction with
ASA
maintenance
dose as possible
explanation for
regional
difference.
Lowest risk of CV
death, MI or
stroke with
ticagrelor
compared with
clopidogrel is
associated with
low-maintenance
dose of
concomitant ASA
Large number of
subgroup analyses
performed and result
numerically favoring
clopidogrel in at least 1
of the 4 prespecified
regions could occur
with 32% probability.
More pts in US (53.6%)
than in the rest of the
world (1.7%) took
median ASA dose 300
mg qd. Of 37 baseline
and postrandomization
factors explored, only
ASA dose explained
substantial fraction of
the regional interaction.
N//A
Pts on dual
antiplatelet therapy
Known
acetylsalicylic acid or
LD of 300 mg
(n=116; 60.7%)
ADP-inducible platelet
reactivity increased
N/A
38
p=0.002) and in
coronary events
(4.3% vs 5.3% per y;
p<0.0001).
1st1 outcome or
refractory ischemia
16.5% vs 18.8% RR:
0.86; CI: 0.790.94;
p<0.001
Percentage of pts
with in-hospital
refractory or severe
ischemia, HF, and
revasc procedures
were significantly
lower with
clopidogrel.
Pts taking low-dose
maintenance ASA,
ticagrelor associated
with better outcomes
compared with
clopidogrel, with
statistical superiority
in the rest of the
world and similar
outcomes in US
cohort.
N/A
p<0.001
RR: 0.80
CI: 0.720.90
Clopidogrel was
not associated with
excess rate of any
other type of
adverse event that
necessitated
discontinuation of
study drug
N/A
N/A
N/A
N/A
p=0.003 for LTA

and p<0.001 for
N/A
Lack of clinical
outcome data,
19818001
(135)
clopidogrel
mediated
platelet
inhibition
study
N=191 pts
CAPRIE
1996
8918275
(136)
Assess
potential benefit
of clopidogrel
compared with
ASA in
reducing risk of
ischaemic
stroke, MI, or
vascular death
in pts with
Randomized
N=19,185 pts
N=9577
clopidogrel
(75 mg od)
plus PC
n=9,566 ASA
(325 mg od)
plus PC
after angioplasty and

stenting for CVD
clopidogrel
intolerance (allergic
reactions and
gastrointestinal
bleeding), therapy
with VKA (warfarin,
phenprocoumon and
acenocoumarol),
treatment with
ticlopidine,
dipyridamol or
NSAID, a family or
personal Hx of
bleeding disorders,
malignant
paraproteinemias,
myeloproliferative
disorders or
heparininduced
thrombocytopenia,
severe hepatic
failure, known
qualitative defects in
thrombocyte
function, a major
surgical procedure
within 1 wk before
enrollment, a platelet
count <100, 000 or
>450, 000 lL-1 and
hematocrit <30%.
or 600 mg (n=50;
26.2%) of
clopidogrel prior
intervention
followed by 75
mg of clopidogrel
od
Pts received daily
acetylsalicylic
acid therapy (100
mg qd).
Ischaemic stroke
(including retinal
origin and lacunar
infarction); MI;
Atherosclerotic PAD
Severe cerebral
deficit likely lead to
pts being bedridden
or demented;
Carotid
endarterectomy after
qualifying stroke;
Qualifying stroke
induced by carotid
endarterectomy or
Clopidogrel (75
mg od)
ASA (325 mg od)
linearly with age after

adjustment for CV risk
factors, type of
intervention,
medication, CRP and
renal function [using
LTA 0.36% of maximal
aggregation per y, 95%
CI: 0.080.64%;
p=0.013; using the
VerifyNow P2Y12 assay
3.2
P2Y12 reaction units
(PRU) per y, 95% CI:
1.984.41 PRU;
p<0.001. ADP-inducible
platelet reactivity
significantly higher in
pts 75 y or older
compared with younger
pts (p=0.003 for LTA
and p<0.001 for
VerifyNow P2Y12
assay). High ontreatment residual ADPinducible platelet
reactivity significantly
more common among
pts 75 y or older
(p=0.02 for LTA and
p<0.001 for VerifyNow
P2Y12 assay).
Pts treated with
clopidogrel had annual
5.32% risk of ischaemic
stroke, MI, or vascular
death compared with
5.83% with ASA.
Significant (p=0.043)
relative-risk reduction of
8.7% in favor of
clopidogrel (95% Cl:
39
the VerifyNow
P2Y12 assay
There were
no major
differences in
terms of
safety
N/A
p=0.043
RR reduction of
8.7% in favor of
clopidogrel
Cl: 0.316.5
the relatively
small number of
patients on
chronic
clopidogrel
therapy and pts
were not
studied again
under
maintenance
therapy with
clopidogrel.
Reported adverse
experiences in the
clopidogrel and
ASA groups judged
to be severe
included rash
(0.26% vs. 0.10%),
diarrhoea (0.23%
vs. 0.11%), upper
gastrointestinal
N/A
recent
ischaemic
stroke, recent
MI, or PAD.
Gollapudi
2004
15613671
(137)
Provide
diagnostic
strategy for
evaluating and
treating pts with
ASA sensitivity,
with additional
consideration
for issues
specific to pts
with CAD.
Literature review
N/A
N/A
angiography; Pts
unlikely to be
discharged after
qualifying event;
Severe comorbidity
likely to limit pts life
expectancy to less
than 3 y,
Uncontrolled
hypertension,
Scheduled for major
surgery,
study drugs; Women
of childbearing age
not using reliable
contraception,
Currently receiving
investigation drug;
Previously entered in
other clopidogrel
studies.
N/A
0.3-16.5).
Corresponding ontreatment analysis
yielded RR reduction of
9.4%.
N/A
Prevalence of ASAexacerbated respiratory

tract disease
approximately 10% and
for ASA-induced
urticaria prevalence
varies 0.07% to 0.2% of
general population.
ASA sensitivity most
often manifested as
rhinitis and asthma or
urticaria/angioedema
induced by crossreacting NSAID that
inhibit cyclooxygenase
1. 1 mechanism of
sensitivity less often
related to drug-specific
IgE antibody production
leading to
40
discomfort (0.97%
vs. 1.22%),
intracranial
haemorrhage
(0.33% vs. 0.47%),
and gastrointestinal
haemorrhage
(0.52% vs. 0.72%).
10 pts (0.10%) in
clopidogrel group
with significant
reductions in
neutrophils (<1.2 x
10(9)/L) and 16
(0.17%) in ASA
group.
N/A
N/A
N/A
N/A
N/A
TRITON
TIMI 38
Wiviott
2007
17982182
(138)
Compare
regimens of
prasugrel and
clopidogrel
N=13,608 pts
with ACS with
scheduled PCI
Prasugrel
n=6813
(60 mg LD
and 10 mg qd
maintenance
dose) or
Clopidogrel
n=6795 (300
mg LD and 75
mg qd
maintenance
dose), for 615 mo
Pts with UA NSTEMI,

TIMI risk score 3,
either ST-segment
deviation of 1 mm or
more or elevated
levels of a cardiac
biomarker of
necrosis. Pts with
STEMI could be
enrolled within 12 h
after onset of Sx if 1
PCI was planned or
within 14 d after
receiving medical
treatment for STEMI
Increased risk of
bleeding, anemia,
thrombocytopenia, a
Hx of pathologic
intracranial findings,
or use of any
thienopyridine within
5 d before
enrollment.
Prasugrel or
clopidogrel
urticaria/angioedema
and rarely to
anaphylaxis. Most pts
with acetylsalicylic acid
sensitivity are able to
undergo desensitization
therapy safely and
successfully except in
cases of chronic
idiopathic urticaria.
Experience with
acetylsalicylic acid
desensitization in pts
with CAD very limited.
nonfatal MI, or nonfatal
stroke
12.1% clopidogrel vs
9.9% prasugrel
rates of MI
9.7% clopidogrel vs.
7.4% prasugrel;
p<0.001)
urgent target-vessel
revasc 3.7% vs. 2.5%;
p<0.001
stent thrombosis
2.4% vs. 1.1%; p<0.001
41
Major
bleedingTIMI major
bleeding not
related to
CABG, nonCABG
related TIMI
life
threatening
bleeding, and
TIMI major or
minor
bleeding
2.4%
prasugrel vs.
1.8%
clopidogrel
HR: 1.32;
95% CI:
1.031.68;
p=0.03
rate of lifethreatening
bleeding
1.4% vs.
0.9%; p=0.01
including
Stent thrombosis
and composite of
death from CV
causes, nonfatal MI,
nonfatal stroke, or
rehospitalization due
to a cardiac ischemic
event.
Rate of MI with
subsequent death
from CV causes
0.7% vs. 0.4% HR:
0.58; CI:0.36 - 0.93;
p=0.02
p<0.001
HR: 0.81
CI: 0.73 - 0.90
More pts treated

with prasugrel
2.5% vs. 1.4%
clopidogrel;
p<0.001
discontinued the
study drug owing to
adverse events
related to
hemorrhage; rate
of serious adverse
events not related
to hemorrhage was
similar 22.5% vs
22.8%
p=0.52
N/A
PLATO
Wallentin
2009
19717846
(139)
Determine
whether
ticagrelor is
superior to
clopidogrel for
the prevention
of vascular
events and
death in broad
population of
pts presenting
with ACS.
N=18,624 pts
with ACS with or
without STE
Ticagrelor
n=9333 (180
mg LD, 90 mg
bid thereafter)
or clopidogrel
(n=9291)
(300-600 mg
LD, 75 mg
daily
thereafter)
Hospitalized for ACS

with or without STE;
with an onset of Sx
during the previous
24 h. Pts who had
ACS NSTE at least 2
of the following 3
criteria had to be
met: ST changes on
ECG indicating
ischemia; positive
test of biomarker,
indicating myocardial
necrosis; one of
several risk factors
(age60 y; previous
MI or CABG; CAD
with stenosis of
50% in at least 2
vessels; previous
ischemic stroke, TIA,
carotid stenosis of at
least 50% or cerebral
revasc; DM; PAD;
chronic renal
dysfunction, defined
as a creatinine
clearance of <60
ml/min per 1.73 m2
of body surface area
with STE the
following 2 inclusion
Any contraindication
against the use of
clopidogrel,
fibrinolytic therapy
within 24 h before
randomization, a
need for oral
anticoagulation
therapy, an
increased risk of
bradycardia, and
concomitant therapy
with a strong
cytochrome P-450
3A inhibitor or
inducer
Ticagrelor or
clopidogrel
Composite of death
from vascular causes,
MI, or stroke 9.8% of
pts receiving ticagrelor
vs 11.7% clopidogrel
(HR: 0.84; 95% CI:
0.770.92; p<0.001).
42
nonfatal
bleeding
1.1% vs.
0.9%;
HR: 1.25;
p=0.23
fatal bleeding
0.4% vs.
0.1%;
p=0.002
Major
bleeding
11.6% vs
11.2%,
p=0.43
ticagrelor
was
associated
with a higher
rate of major
bleeding not
related to
CABG 4.5%
vs. 3.8%,
p=0.03),
including
more
instances of
fatal
intracranial
bleeding and
fewer of fatal
bleeding of
other types
MI alone
5.8% vs. 6.9%,
p=0.005
Death from vascular
causes
4.0% vs. 5.1%,
p=0.001
Stroke alone 1.5%
vs. 1.3%, p=0.22
The rate of death
from any cause
4.5% vs. 5.9%,
p<0.001
p<0.001
HR: 0.84
CI: 0.77-0.92
Discontinuation of
the study drug due
to adverse events
7.4% ticagrelor vs
6.0% clopidogrel
p<0.001
Dyspnea 13.8% vs.
7.8%;
Higher incidence of
ventricular pauses
in 1 wk but not at
30 d in ticagrelor
group than
clopidogrel group
Geographic
differences
between
populations of
pts or practice
patterns
influenced the
effects of the
randomized
treatments
Mehta
2010
20818903
(140)
Clopidogrel and
ASA are widely
used for pts
with ACS and
those
undergoing
PCI. However,
evidence-based
guidelines for
dosing have not
been
established for
either agent.
N=25,086 pts
Pts randomly
assigned to
double-dose
clopidogrel
received 600
mg LD
followed by
150 mg od d
2-7. Pts
assigned to
standarddose
clopidogrel
received 300
mg LD before
angiography
followed by
75 mg od
days 2-7. D 830 both
double-dose
and standarddose groups
received 75
mg of
clopidogrel
od. Pts
randomly
assigned to
lower-dose
ASA received
75-100 mg
daily on d 230. Those
criteria had to be
met: persistent STE
of at least 0.1 mV in
at least 2 contiguous
leads or a new left
bundle-branch block,
and the intention to
perform 1 PCI.
18 yand presented
with a NSTE, ACS or
STE MI. Either ECG
changes compatible
with ischemia or
elevated levels of
cardiac biomarkers;
coronary
angiographic
assessment, with
plan to perform PCI
as early as possible
but no later than 72 h
after randomization
Increased risk of
bleeding or active
bleeding and known
allergy to clopidogrel
or ASA
22 factorial
design. Pts were
randomly
assigned in
double blind
fashion to
double-dose
regimen of
clopidogrel or
standard-dose
regimen. In the
2nd component of
factorial design
pts were
randomly
assigned in open
label fashion to
higher-dose ASA
or lower-dose
ASA.
Time to CV death, MI,

or stroke whichever
occurred 1st, up to 30 d.
Primary outcome
occurred in 4.2% of pts
assigned to doubledose clopidogrel
compared with 4.4%
assigned to standarddose clopidogrel
HR: 0.94, 95%
CI: 0.83-1.06
p=0.30
NS difference between
higher-dose and lowerdose ASA respect to 1
outcome
4.2% vs. 4.4%
HR: 0.97: 95% CI: 0.861.09; p=0.61
43
Major
bleeding
occurred in
2.5% of pts in
double-dose
group and
2.0% in
standarddose group
HR: 1.24;
95% CI:
1.051.46;
p=0.01
NS difference
between
higher-dose
and lowerdose ASA
with respect
to major
bleeding
(2.3% vs.
2.3%; HR:
0.99; 95% CI:
0.84-1.17;
p=0.90).
Composite of death
from CV causes, MI,
stroke, or recurrent
ischemia; the
individual
components of 1
outcome; death from
any cause; Definite
or probable stent
thrombosis. Doubledose clopidogrel
associated with
significant reduction
in 2 outcome of
stent thrombosis
among the 17,263
pts who underwent
PCI (1.6% vs. 2.3%;
HR: 0.68; 95% CI:
0.550.85; p=0.001).
p=0.30
HR=0.94
CI=0.831.06
N/A
Nominally
significant
reduction in 1
outcome was
associated with
use of higherdose clopidogrel
in subgroup of
17,263 study
participants who
underwent PCI
after
randomization
(69%). Test for
interaction
between pts
who underwent
PCI and those
who did not
undergo PCI
(p=0.03) did not
meet
prespecified
threshold of
p<0.01 for
subgroup
interactions. 13
prespecified
subgroup
analyses were
performed for
the clopidogrel
dose
comparison; this
Plato
James
2011
21685437
(141)
Evaluate
efficacy and
safety
outcomes in pts
in PLATelet
inhibition and
pts outcomes
(PLATO) trial
who at
randomization
were planned
for a noninvasive
treatment
strategy.
Randomized
N=5216 pts
ISARREACT 2
Kastrati
16533938
(142)
Assess whether
abciximab is
associated with
clinical benefit
in high-risk pts
with ACS
undergoing PCI
after
Randomized
N=2,022 pts
randomly
assigned to
higher-dose
ASA received
300 to 325
mg daily d 230.
Ticagrelor
n=2601 vs.
clopidogrel
n=2615
Abciximab
n=1012 vs
PCn=1010
result could
have been due
to the play of
chance.
Admitted to hospital
with STE ACS
scheduled for PCI or
NSTE-ACS, with
onset of Sx during
the previous 24 h. At
least two of the
following three
criteria were required
for NSTE-ACS: STE
depression or
transient elevation of
at least 1 mm in 2
contiguous leads; a
positive biomarker
indicating myocardial
necrosis; and 1
additional risk
indicator, including
age >60 y, previous
MI or CABG, CAD,
previous ischaemic
stroke. TIA, carotid
stenosis, cerebral
revasc, DM, PAD, or
chronic renal
dysfunction
High-risk ACS pts
undergoing PCI
Contraindication to
clopidogrel,
fibrinolytic treatment
within 24 h, need for
oral anticoagulation
treatment, need for
dialysis, and
clinically important
anaemia or
thrombocytopenia
ticagrelor or
clopidogrel
CV death, MI, and

stroke; their individual
components; and
PLATO defined major
bleeding during 1 y
12.0% (n=295)
ticagrelor vs. 14.3%
(n=346) clopidogrel HR
0.85, 95% CI 0.73 to
1.00; p=0.04).
Incidence of
total major
bleeding
11.9% vs.
10.3%, HR:
1.17; 95% CI:
0.981.39;
p=0.08
non-CABG
related major
bleeding
4.0% vs.
3.1%; HR:
1.30; 95% CI:
0.951.77;
p=0.10
Overall mortality
6.1% vs. 8.2% HR:
0.75; 95% CI: 0.61
0.93; p=0.01
p=0.04
HR: 0.85
95% CI: 0.73
1.00
N/A
N/A
STE-AMI
Abciximab (0.25
mg/kg bolus,
followed by a
0.125microg/kg/min
max, 10
mcg/min) infusion
for 12 h plus
Death, MI or UTVR at
30 d
8.9% vs. 11.9%
NS
differences
between 2
groups
regarding risk
of major and
minor
bleeding as
N/A
p=0.03
RR: 0.75
95% CI: 0.58
0.97
N/A
Cannot exclude
possibility that
greater benefit
from abciximab
might have
been present
had therapy
been initiated
44
pretreatment
with 600 mg of
clopidogrel
PURSUIT
Trial
2010
9705684
(143)
Inhibition of
platelet
aggregation
with eptifibatide
would have
incremental
benefit beyond
that of heparin
and ASA in
reducing
frequency of
adverse
outcomes in pts
with ACS who
did not have
persistent STE.
Double blind
N=10,948 pts
Bolus and
infusion of
eptifibatide or
PC n=1487
low-dose
eptifibatide
group n=4722
high-dose
eptifibatide
group
n=4739 PC
group
Pts who had

presented with
ischemic chest pain
within previous 24 h
and who had either
ECG changes
indicative of ischemia
(but not persistent
STE) or high serum
concentrations of
CK-MB isoenzymes
Persistent STE of
more than 1 mm,
active bleeding or a
Hx of bleeding
diathesis,
gastrointestinal or
genitourinary
bleeding within 30 d
before enrollment,
systolic blood
pressure above 200
mmHg or diastolic
blood pressure
above 110 mmHg, a
Hx of major surgery
within the previous 6
wk, a Hx of
nonhemorrhagic
stroke within
previous 30 d or any
Hx of hemorrhagic
stroke, renal failure,
pregnancy, the
planned
administration of
platelet GP IIb/IIIa
receptor inhibitor or
thrombolytic agent,
or receipt of
heparin, 70 U/kg
or PC (PC bolus
and infusion of
12 h, plus
heparin bolus,
140 U/kg). All pts
received
clopidogrel 600
mg at least 2 h
prior to
procedure as well
as 500 mg oral or
IV ASA
Eptifibatide or PC
bolus dose of
180 mcg/kg of
body weight,
followed by
infusion of 1.3
mcg/kg/min or
bolus dose of
180 mcg/kg
followed by
infusion of 2.0
mcg/kg/min or
bolus and
infusion of PC
well as need
for
transfusion.
Composite of death and

nonfatal MI occurring
up to 30 d after index
event compared with
PC group. Eptifibatide
group had 1.5%
absolute reduction in
incidence of 1 endpoint
(14.2% vs. 15.7% in PC
group; p=0.04) Effect
was consistent in most
major subgroups except
for women (odds ratios
for death or nonfatal MI,
0.8 (95% CI: 0.7-0.9) in
men and 1.1 (95% CI:
0.9-1.3) in women
45
Bleeding
complications
More red-cell
transfusions
among the
pts treated
with
eptifibatide
11.6% vs.
9.2%; RR:
1.3; 95% CI:
1.1-1.4
Study would
be stopped in
lower-dose
group after
independent
DSMB
conducted
interim
review of
safety data,
provided the
higher dose
had
acceptable
safety profile.
After 3,218
pts been
earlier prior to
the cath lab
Mortality from all

causes within 30 d
after the index event,
a 1st for recurrent MI
within 30 d,
composite endpoint
(death or nonfatal
MI) at 96 h and 7 d
p=0.04
Bleeding was more

common in
eptifibatide group,
although there was
no increase in the
incidence of
hemorrhagic
stroke.
N/A
thrombolytic therapy
within previous 24 h
PRISMPLUS
1998
9599103
(144)
Evaluate
tirofiban, a
specific inhibitor
of platelet GP
IIb/IIIa receptor,
in treatment of
UA and nonQwave MI
Double-blind
N=1915 pts
Tirofiban,
heparin, or
tirofiban plus
heparin
Prolonged anginal
pain or repetitive
episodes of angina at
rest or during
minimal exercise in
previous 12 h and
new transient or
persistent ST-T
ischemic changes on
ECG, or elevation of
plasma levels of CK
and CK-MB fraction
EARLY
ACS
Giugliano
2009
19332455
(145)
Determine
optimal timing
for initiation of
treatment with
GP IIb/IIIa
inhibitors in pts
who have ACS
without STE
and undergoing
invasive
procedures
Randomized
N=9492 pts
Early, routine
administration
of Eptifibatide
n=4722 vs.
delayed
Eptifibatide
n=4684
Pts
ACS NSTEMI
undergoing invasive
strategy
STE lasting more

than 20 min,
thrombolysis in
previous 48 h,
coronary angioplasty
within previous 6 m
or bypass surgery
within previous mo,
angina caused by
identifiable factors, a
Hx of a platelet
disorder or
thrombocytopenia,
active bleeding or a
high risk of bleeding,
and stroke within
previous y. Pts who
had serum creatinine
values above 2.5
mg/dL (220 mol/L)
or a platelet count
below 150,000/m3
N/A
Tirofiban,
heparin, or
tirofiban plus
heparin. Study
drugs were
infused for mean
(SD) of 71.320
h, during which
time coronary
angiography and
angioplasty were
performed when
indicated after 48
h
Death, MI, or refractory

ischemia within 7 d
lower among pts who
received tirofiban plus
heparin than among
those who received
heparin alone (12.9%
vs. 17.9%; RR: 0.68;
95% CI: 0.530.88;
p=0.004).
Early, routine
administration of
Eptifibatide or
delayed
Eptifibatide after
angiography but
before the pts
underwent PCI
Composite of death, MI,

recurrent ischemia
requiring urgent revasc
or occurrence of
thrombotic complication
during PCI at 96 h
9.3% vs. 10.0%
46
randomly
assigned to
treatment
groups,
committee
recommende
d dropping to
lower dose
Study was
stopped
prematurely
for group
receiving
tirofiban
alone
because of
excess
mortality at 7
d (4.6%,
compared
with 1.1% for
pts treated
with heparin
alone
Major
bleeding
Pts in early
eptifibatide
group had
significantly
higher rates
of bleeding.
There was
NS difference
between 2
groups in
Death, MI, or
refractory ischemia
within 48 h and 30 d
after randomization,
the three
components of this
end point as
separate measures,
and composite of
death and MI.
Tirofiban plus
heparin vs.
heparin alone
p=0.004
RR=0.68
CI=0.530.88
Major bleeding
occurred in 3.0% of
pts receiving
heparin alone and
4.0% of pts
receiving
combination
therapy p=0.34
N/A
Rate of death or MI
at 30 d 11.2% vs.
12.3%; OR=0.89;
95% CI: 0.791.01;
p=0.08
p=0.23
OR=0.92
95% CI=0.80
1.06
N/A
Convergence of
use of
eptifibatide
during PCI in 2
study groups
probably
reduced the
difference in
efficacy. Could
not assign pts to
strict PC group
since guidelines
ACUITY
subgroup
analysis
Stone
2007
17368152
(146)
Assess
anticoagulation
with the direct
thrombin
inhibitor
bivalirudin
during PCI in
individuals with
moderate- and
high-risk ACS
Randomized
N=7789 pts
n=2561
heparin
(unfractionate
d or
enoxaparin)
plus GP
IIb/IIIa
inhibitors
n=2609
bivalirudin
plus GP
IIb/IIIa
inhibitors
n=2619
bivalirudin
alone
Pts undergoing PCI

after angiography,
new ST-segment
depression; raised
TnI, TnT, or CK-MB
isozyme; known
CAD; or all 4 other
UA risk criteria defi
ned by TIMI study
group
Included - STE AMI

or shock; bleeding
diathesis or major
bleeding episode
within 2 wk;
thrombocytopenia;
CrCl <30 mL/min
Heparin
(unfractionated or
enoxaparin) plus
GP IIb/IIIa
inhibitors,
bivalirudin plus
GP IIb/IIIa
inhibitors, or
bivalirudin alone
30-d endpoints of
composite ischemia
(death, MI, or
unplanned revasc for
ischemia), major
bleeding, and net
clinical outcomes
(composite ischemia or
major bleeding)
Bivalirudin plus GP
IIb/IIIa inhibitors vs.
heparin plus GP IIb/IIIa
inhibitors - composite
ischemia 9% vs. 8%;
major bleeding 8% vs.
7%; net clinical
outcomes 15% vs. 13%
BRILINTA
(ticagrelor)
tablets
AstraZene
ca LP
(147)
BRILINTA is
indicated to
reduce rate of
thrombotic CV
events in pts
with ACS, UA,
NSTEMI or
STEMI
N/A
N/A
N/A
N/A
N/A
N/A
rates of
severe
bleeding or
nonhemorrha
gic serious
adverse
events.
N/A
Daily
maintenance
dose of ASA,
coadminister
ed with
BRILINTA,
should not
exceed 100
mg
Increased
risk of
bleeding
Decreased
efficacy with
BRILINTA
(ticagrelor) in
47
N/A
Composite
ischemia
p=0.16;
major bleeding
p=0.32;
net clinical
outcomes p=0.1
N/A
N/A
N/A
N/A
at time of
planning trial
strongly
endorsed use of
GP IIb/IIIa
inhibitors during
PCI
Randomization
occurred before
angiography,
study drugs
were
administered at
median of 4 h
before PCI. PCI
subgroup
represents
subset of 56%
of all pts
enrolled in
ACUITY, and
randomization
was not
stratified by
treatment
assignment
N/A
GUSTO
IV-ACS
Ottervange
r
2003
12551868
(148)
Investigate long
term effects of
GP IIb/IIIa
inhibitor
abciximab in
pts with ACS
without STE
who were not
scheduled for
coronary
intervention
Randomized
N=7800 pts
n=2590
abciximab for
24 h
n=2612
abciximab for
48 h
n=2598 PC
Pts with ACS without

persistent STE
including NSTEMI
and UA. < 21 y and
should have had 1
episodes of angina
lasting at least 5 min
within 24 h before
admission. Either
abnormal cardiac
TnT or TnI test or at
least 0.5 mm of
transient or
persistent STsegment depression.
N/A
PCI-CURE
Mehta
2001
11520521
(149)
Find out
whether in
addition to ASA
pretreatment
with clopidogrel
followed by
long-term
therapy after
PCI is superior
to strategy of
no pretreatment
and short-term
therapy for only
4 wk after PCI
Randomized
N=2658 pts
clopidogrel
(n=1313) or
PC (n=1345)
N/A
N/A
Abciximab for 24h (0.25 mg/kg

bolus followed by
0.125
mcg/kg/min
infusion up to
max of 10
mcg/min for 24
h), followed by
24-h PC infusion;
abciximab for 48
h (same bolus
and infusion for
total duration of
48 h); matching
PC (bolus and
48-h infusion)
Clopidogrel vs.
PC
Death (of any cause) or

MI within 30 d
Follow-up data obtained
up to 1 y for 7746 pts
(99.3%). Overall 1-y
mortality rate 8.3% (649
pts). 1-y mortality was
7.8% PC, 8.2% in the
24-h abciximab, and
9.0% in 48-h abciximab
Composite of CV death,
MI, or urgent targetvessel revasc within 30
d of PCI.
4.5% vs. 6.4%
Long-term
administration of
clopidogrel after PCI
associated with a lower
rate of CV death, MI, or
any revasc (p=0.03),
and of CV death or MI
(p=0.047). Overall
(including events before
and after PCI) there
was 31% reduction CV
death or MI (p=0.002).
Less use of GP IIb/IIIa
inhibitor in clopidogrel
group (p=0.001)
48
combination
with ASA
doses
exceeding
100 mg
N/A
At follow-up,
there was NS
difference in
major
bleeding
between
groups
p=0.64
N/A
24-hour
abciximab HR:
1.1; 95% CI:
0.861.29), and
48-h abciximab
HR: 1.2; 95%
CI: 0.951.41
N/A
N/A
N/A
p=0.03
RR: 0.70
95% CI: 0.50
0.97
N/A
N/A
Petersen
2004
18056526
(150)
Systematically
evaluate end
points of allcause death
and nonfatal
MI, transfusion,
and major
bleeding
observed in the
6 randomized
controlled trials
comparing
enoxaparin and
UFH in
treatment of
ACS
Systematic
overview
N=21946 pts
ESSENCE, A to
Z, and
SYNERGY, TIMI
11B, ACUTE II,
and INTERACT
Performed using
a randomeffects empirical
Bayes model
N/A
All 6 RCTs
comparing
enoxaparin and UFH
in NSTE ACS were
selected for analysis
N/A
N/A
Enoxaparin is more
effective than UFH in
preventing combined
endpoint of death or MI
NS difference found in
death at 30 d for
enoxaparin vs UFH
(3.0% vs. 3.0%; OR:
1.00; 95% CI: 0.851.17).
Statistically significant
reduction in combined
endpoint of death or
nonfatal MI at 30 d
observed for
enoxaparin vs. UFH in
overall trial populations
(10.1% vs 11.0%; OR:
0.91; 95% CI: 0.830.99).
endpoint of death or MI
at 30 d observed for
enoxaparin in
populations receiving
no prerandomization
antithrombin therapy
(8.0% vs 9.4%; OR:
0.81; 95% CI: 0.70
0.94).
49
NS difference
found in
blood
transfusion
(OR: 1.01;
95% CI:
0.89-1.14) or
major
bleeding
(OR: 1.04;
95% CI:
0.831.30) 7
d after
randomizatio
n
N/A
10.1% vs 11.0%
OR: 0.91
CI: 0.830.99
N/A
Systematic
overviews do
not replace
RCTs but
provide
important
insights through
analyses of
totality of data.
Trial
populations are
not identical
with respect to
baseline
characteristics,
duration of
study treatment,
time to revasc,
or use of
concomitant
medical
therapies in
management of
UA/NSTEMI
ACS.
Imprecision
exists in
frequency of
events as
protocols for
data collection
and definitions
of efficacy and
safety events
varied among
studies. Not
having the
individual pt
data from all
trials precluded
more
sophisticated
PRINCIPL
E-TIMI 44
Wiviott
2007
18056526
(150)
Compare
prasugrel with
higher than
currently
approved 300mg LD and 75mg/d MD of
clopidogrel
Randomized,
double-blind, 2phase crossover
study
N=201 subjects
Prasugrel
compared
with highdose
clopidogrel in
pts
18 y and scheduled
to undergo cardiac
catheterization with
planned PCI for
angina and at least
one of the following:
coronary
angiography within
14 d with at least 1
lesion amenable to
PCI, a functional
study within 8 wk
with objective
findings of ischemia,
or prior PCI or CABG
surgery
Planned PCI for

immediate treatment
of MI, any
thienopyridine within
5 d, GP IIb/IIIa
inhibitor within 7 d or
planned use (bailout
was permitted), high
risk of bleeding,
thrombocytopenia,
or anemia.
Prasugrel
compared with
high-dose
clopidogrel
1 endpoint of LD phase
(prasugrel 60 mg vs.
clopidogrel 600 mg)
was IPA with 20
mumol/L ADP at 6 h
IPA at 6 h significantly
higher in subjects
receiving prasugrel
(meanSD;
74.813.0%) compared
with clopidogrel
(31.821.1%;
p<0.0001).
N/A
TRILOGY
ACS
Roe
2012
22920930
(151)
Evaluate
whether ASA
plus prasugrel
is superior to
ASA plus
clopidogrel for
long term
therapy in pts
with UA or MI
without STE
who were <75 y
Double-blind,
randomized trial
N=7243 pts <75
y
N=2083 pts >75
y
ASA
prasugrel (10
mg daily) vs.
clopidogrel
(75 mg qd).
Low dose 5
mg of
prasugrel
versus 75 mg
of clopidogrel
ACS consisting of UA
or MI without STE.
Pts were eligible if
selected for final
treatment strategy of
medical management
without revasc within
10 d after index
event. Pts required to
have at least one of
four risk criteria: an
age 60 y, presence
of DM, previous MI,
or previous revasc
Hx of TIA or stroke,
PCI or CABG within
the previous 30-d,
renal failure
requiring dialysis,
and concomitant
treatment with an
oral anticoagulant
Prasugrel or
clopidogrel.
Prasugrel (10 mg
daily) adjusted to
(5 mg qd) pts
>75 y.
Clopidogrel (75
mg/d)

MI, or stroke among pts
<75 y occurred in
13.9% of prasugrel
group and 16.0% of the
clopidogrel group (HR
prasugrel group: 0.91;
95% CI: 0.791.05;
p=0.21).
Rates of
severe and
intracranial
bleeding
similar in 2
groups in all
age groups.
NS between
group
differences in
frequency of
nonhemorrha
gic serious
adverse
50
Pts with PCI entered

the maintenance
dose phase, a 28-d
crossover
comparison of
prasugrel 10 mg/d
vs. clopidogrel 150
mg qd with a 1
endpoint of IPA after
14 d of either drug.
IPA with 20 mumol/L
ADP was higher in
subjects receiving
prasugrel
(61.317.8%)
compared with
clopidogrel
(46.121.3%;
p<0.0001). Results
were consistent
across all key 2
endpoints; significant
differences emerged
by 30 min and
persisted across all
time points
Prespecified
analysis of multiple
recurrent ischemic
events (all
components of 1
endpoint) suggested
lower risk for
prasugrel among pts
<75 y (HR: 0.85;
95% CI: 0.721.00;
p=0.04).
p<0.0001
CI: 38.048.4
N/A
P=0.21
Prasugrel
group,
HR: 0.91
95% CI: 0.79
1.05
Higher frequency
of HF in clopidogrel
group
statistical
analyses.
LTA requires
very precise
sample
conditions and
processing.
Significant
proportion of
samples did not
meet
prespecified
conditions and
were excluded
from analyses.
Absence of a
washout period
between MD
treatments also
could be
considered
limiting.
N/A
PLATO
Trial
Becker
2011
22090660
(152)
Determine the
rate, clinical
impact, and
predictors of
major and fatal
bleeding
complications
in the PLATO
study
Randomized,
double-blind,
active control
N=18,624 pts
Ticagrelor
n=9235 or
clopidogrel
n=9186 in
addition to
ASA
Valgimigli
2010
19755402
(153)
To perform a
thorough and
updated
systematic
review of
randomized
clinical trials
comparing
tirofiban vs. PC
or vs.
abciximab.
Meta analysis
31 studies
involving 20,006
pts
12,874
comparing
tirofiban vs.
heparin plus
PC or
bivalirudin
alone, and
7132 vs.
abciximab
ACUITY
Stone
2007
17299194
(154)
To determine
optimal strategy
for use of GP
IIb/IIIa inhibitors
in pts with
moderate and
Randomized
N=9207 pts
Routine
upstream
(n=4605)
deferred
selective
(n=4602) GP
with either PCI or

CABG.
Pts admitted to
hospital with either
STE or NSTE-ACS
events.
N/A
Ticagrelor oral
LD of 180 mg,
followed by 90
mg bid
Clopidogrel 300
mg oral LD
followed by
maintenance
dose of 75 mg
daily. All pts
received ASA at
dose of 75100
mg daily
PLATO major bleeding

(11.6 vs. 11.2%;
p=0.43), TIMI major
bleeding (7.9 vs. 7.7%,
p=0.56) and GUSTO
severe bleeding (2.9 vs.
3.1%, p=0.22)
Fatal
bleeding and
transfusion
rates did not
differ
between
groups
Pts undergoing
treatment for various
CAD conditions
N/A
N/A
N/A
Moderate- and highrisk ACS pts

undergoing invasivetreatment strategy
Included STE AMI or

shock; bleeding
diathesis or major
bleeding within 2 wk;
thrombocytopenia;
CrCl <30 mL/min
Routine
upstream or
deferred
selective GP
IIb/IIIa inhibitor
administration
Tirofiban associated at
30 d with significant
reduction in mortality
compared with PC (OR:
0.68; 95% CI: 0.54
0.86; p=0.001) and
death or MI (OR: 0.69;
95% CI: 0.580.81;
p<0.001)
Compared with
abciximab, mortality at
30 d did not differ (OR:
0.90; 95% CI: 0.53
1.54; p=0.70)
In overall group
tirofiban tended to
increase the composite
of death or MI
(OR=1.18; 95% CI:
0.961.45; p=0.11)
Composite ischemic
events (death, MI, or
ischemia) at 30 d
7.1% vs. 7.9%
51
N/A
Procedure related
bleeding rates were
also similar. NonCABG major
bleeding (4.5 vs.
3.8%, p=0.02) and
nonprocedure
related major
bleeding (3.1 vs.
2.3%, p=0.05) were
more common in
ticagrelor treated
pts, primarily after 30
d on treatment.
N/A
PLATO major
bleeding p=0.43
TIMI major
bleeding
p=0.56)
GUSTO severe
bleeding p=0.22
N/A
N//A
N/A
N/A
Heterogenity in
pt populations,
different study
drug regimens,
and variable
endpoint
definitions
across studies
Noninferiority or
superiority of major
bleeding and net
clinical outcomes
(composite ischemia
or major bleeding).
p=0.044 for
noninferiority;
p=0.13 for
superiority RR:
1.12
95% CI: 0.97
N/A
Open label
design of the
trial, a result of
the logistic
complexities of
the study
high-risk ACS
undergoing an
early invasive
treatment
strategy
IIb/IIIa
inhibitor
administration
30-d rates of major

1.29
design,
bleeding 6.1% vs.
introducing the
4.9%
potential for
p<.001 for
bias.
noninferiority; p=009
for superiority
Net clinical
outcomes (11.7% vs.
11.7%; p<.001 for
noninferiority; p=0.93
for superiority).
1 indicates primary; 2, secondary; A to Z, AGGRASTAT to ZOCOR; ACS, acute coronary syndrome; ACUTEAcute Catheterization and Urgent Intervention Triage strategy; ADP, adenosine diphosphate; ASA, aspirin; bid, twice daily; CABG, coronary artery bypass
graft; CAD, coronary artery disease; CI, confidence interval; CK, creatine kinase; CK-MB, creatine kinase-MB; CRP, C-reactive protein; ;DM, diabetes mellitus; DSMB, Data and Safety Monitoring Board; ECG, electrocardiography; ESSENCE, Efficacy and Safety of
Subcutaneous Enoxaparin in NonQ wave Coronary Events; GP, glycoprotein; GUSTO, Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries; HF, heart failure; HR, hazard ratio; Hx, history; IgE, Immunoglobin E;
INTERACT, Intensive blood pressure reduction in acute cerebral haemorrhage trial; IPA; IV, intravenous; LD, loading dose; pts, patients; LTS, ;MI, myocardial infarction; OD, once daily; NA, North America; NS, no(t) significant; NSAID, nonsteroidal anti-inflammatory
drugs; NSTE, non-ST elevation; NSTEMI, non-ST-elevation myocardial infarction; PAD, peripheral arterial disease; PC, placebo; PCI, percutaneous coronary intervention; PLATO, Platelet Inhibition and Patient Outcomes; qd, daily; Revasc, revascularization; ROW,
rest of the world; RR, relative risk; STE, ST elevation; STEMI, ST-elevation myocardial infarction; SYNERGY, Superior Yield of the New Strategy of Enoxaparin, Revascularization and Glycoprotein IIb/IIIa Inhibitors; Sx, symptoms; TIA, transient ischemic attack; TIMI,
thrombolysis in MI; TnI, troponin I; TnT, troponin T; UA, unstable angina; US, United States; UTVR, Urgent Target Vessel Revascularization; and VKA, vitamin K antagonist.
Data Supplement 16. Combined Oral Anticoagulant Therapy and Antiplatelet Therapy in Patients With Definite NSTE-ACS (Section 4.3.2)
Study
Study Aim
Study Type/ Intervention vs.
Patient Population
Study Intervention
Name,
Size (n)
Comparator (n)
Author,
Year
Inclusion Criteria
Exclusion Criteria
Primary Endpoint
& Results
CURE
Compare the
Randomized Clopidogrel vs.
Pts were eligible
Contraindications to Clopidogrel
Death from CV
Yusuf 2001 efficacy and
, doublePC in addition to for the study
antithrombotic or
(300 mg
causes, nonfatal MI,
(133)
safety of early
blind, PCASA
hospitalized within antiplatelet therapy, immediately
or stroke
11519503
and long-term
controlled
24 h after the
high risk for
followed by 75 mg
use of clopidogrel trial
onset of Sx and
bleeding or severe
once daily) vs. PC
9.3% vs. 11.4%
plus ASA with
12,562 pts
did not have STE
HF, taking OACs,
in addition to ASA
those of ASA
had undergone
alone in pts with
coronary revasc in
ACS and no STE
the previous 3 mo
or had received IV
GP IIb/IIIa receptor
inhibitors in the
previous 3 d
ASPECT-2 Investigate
Randomized LDASA n=336,
Men or nonEstablished
LDASA, high
1st occurrence of MI,
van Es
whether ASA or
N=999 pts
Coumadin-high
pregnant women
indications for
intensity OAC, or
stroke, or death
2002
OACs is more
intensity OAC
admitted with
treatment with OAC, combined LDASA
9% vs. 5% vs. 5%
52
Endpoints
Safety Endpoint
& Results
Pts with major
bleeding 3.7% vs.
2.7% p=0.001
RR: 1.38
Major bleeding
1% ASA, 1% on
OAC
Secondary
Endpoint & Results
1 outcome or
refractory ischemia
16.5% vs. 18.8%
RR: 0.86;
95% CI: 0.790.94;
p<0.001
% of pts with inhospital refractory or
severe ischemia, HF,
and revasc
procedures were also
significantly lower
with clopidogrel
N/A
P Values,
OR: HR: RR: &
95 CI:
Adverse
Events
Study
Limitations
p<0.001
RR: 0.80
95% CI: 0.72
0.90
Clopidogrel not
associated with
excess rate of
any other type
of adverse
event that
necessitated
discontinuation
of study drug
N/A
ASA vs.
coumadin HR:
0.55; 95% CI:
N/A
N/A
(155)
12126819
effective in the
long term after
ACS, and
whether the
combination of
ASA and OAC
offers greater
benefit than either
of these agents
alone, without
excessive risk of
bleeding
Karjalainen
2008
(156)
18346963
Determine the
safety and
efficacy of various
periprocedural
antithromboticstra
tegies in pts on
long-term OAC
with warfarin
undergoing PCI
to assess the
safety of the
simplistic UAC
strategy
BAAS
ten Berg
2001
(157)
11319192
Study the
intensity and the
duration of AC as
predictors of
thrombotic and
bleeding events
n=325,
combined
LDASA and
coumadinmoderate
intensity OAC
n=332
AMIMI or UA within
preceding 8 wk
Retrospectiv
e analysis
n=523 pts
IAC group;
UAC group
All consecutive pts

on warfarin therapy
referred for PCI in
4 centers with a
main policy to IAC
before PCI and in
3 centers with a
long experience on
UAC during PCI
N=530 pts
ASA plus
coumarins
Pts who were

prospectively
randomized to the
use of coumarins
as part of the
BAAS study
contraindications for
the study drug,
planned revasc
procedure, serious
comorbidity,
increased risk of
bleeding, abnormal
blood platelets or
erythrocytes,
anemia, Hx of
stroke, and inability
to adhere to the
protocol
N/A
and moderate
intensity OAC
ASA vs. coumadin

HR: 0.55; 95%
CI=0.30-1,00;
p=0.0479
ASA vs. combined
HR=: 0.50; CI: 0.270.92; p=0.03
(HR: 103; 95%

CI: 021-508;
p=1.0), and 2%
on combination
therapy HR: 2.35;
95% CI: 0.619.10; p=0.2
IAC vs. UAC
N/A
N/A
N/A
Major bleeding,
stroke, accesssite
complications
N/A
ASA (300 mg LD;

then 100 mg qd)
and coumarins
(acenocoumarol or
Sintrom at 6 mg on
1 d, 4 mg on 2 d, 2
mg on 3 d and after
Major bleeding,
access-site
complications, and
MACE (death, MI,
target vessel
revasc, and stent
thrombosis)
Major bleeding
5.0% vs. 1.2%,
p=0.02 and after
adjusting for
propensity score
OR: 3.9; 95% CI:
1.0-15.3; p=0.05)
Access-site
complications
11.3% vs. 5.0%,
p=0.01
After adjusting for
propensity score
OR: 2.8; 95% CI:
1.3-6.1; p=0.008
Thrombotic events death, MI, target
lesion revasc, and
thrombotic stroke
17 early thrombotic
events (3.2%), 7
early bleeding
Bleeding
complications hemorrhagic
stroke, major
extracranial
bleeding, and
false aneurysm
N/A
N/A
N/A
53
0.30-1.00;
p=0.0479
ASA vs.
combined HR:
0.50; 95% CI:
0.27-0.92;
p=0.03
Inherent
limitations of a
retrospective
study including
individual riskbased decision
making in the
treatment
choices;
outcome
assessment
was not
blinded;
sample size
may not be
sufficient to
cover small,
but clinically
significant diff
in bleeding and
thrombotic
complications
N/A
until intervention)
started 1 wk before
intervention
Target INR 2.1-4.8
during angioplasty
and 6 mo follow-up
INR was measured
on the morning
before PTCA and
daily thereafter until
discharge
ACCF/ACG
/AHA report
Bhatt 2008
(158)
19017521
Ruiz-Nodar
2009
(159)
19246502
Not a study but a

report with
recommendations
N/A
N/A
N/A
N/A
N/A
Evaluate the
safety and
efficacy of use of
DES vs. BMS in a
cohort of pts with
AF
Retrospectiv
e cohort
study
N=604 pts
DES (n=207) vs.

BMS (n=207)
Pts with AF who

had undergone
PCI with stent
N/A
DES or BMS
episodes (1.3%),
and 10 false
aneurysms (1.9%)
61 late thrombotic
events occurred
(11.6%)
Optimal AC was an
independent
predictor of late
thrombotic events
(RR: 0.33; 95% CI:
0.19-0.57) and was
associated with a
0.21 mm (95% CI:
0.17-0.42) larger
vessel lumen 6 mo
N/A
Late bleeding
episodes (1.4%)
lowest in pts in
the target range
N/A
N/A
N/A
N/A
N/A
All bleeding
episodes,
thromboembolism,
and MACE; i.e.
death, AMI, TVF.
Incidence density of
MACE as well as
the incidence of allcause mortality in
both groups was
similar. Higher
incidence of major
bleeding in DES
group (2.26 vs.
1.19/10,000 d of
exposure; p=0.03)
Major bleeding
was higher in the
DES group (2.26
vs. 1.19/10,000 d
of exposure,
p=0.03)
Rate of definitive
and probable
thrombosis was
similar in both
DES and BMS
groups (0.43 vs.
0.06/10,000 d of
exposure,
p=0.09)
N/A
N/A
N/A
Limited by its
registry design
and as well as
being the
experience of
only 2
European
centers; study
may not be
adequately
powered
enough to
detect diff in
clinical
outcomes; the
retrospective
design of the
study could
explain an
underreporting
of minor
54
Lip 2010
(160)
20447945
WARSS
Mohr 2001
(161)
11794192
CARS
Peverill
1997
(162)
15687136
Not a study but a

summary report
Full consensus
document
comprehensively
reviews published
evidence and
presents
consensus
statement on
best practice
antithrombotic
therapy guideline
for management
of antithrombotic
therapy in AF pts
Investigate
whether warfarin,
which is effective
and superior to
ASA in the
prevention of
cardiogenic
embolism, would
also prove
superior in the
prevention of
recurrent
ischemic stroke in
pts with a prior
noncardioembolic
ischemic stroke
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
bleeding; the
exact length of
triple treatment
in BMS and
DES groups
N/A
Multicenter,
double-blind,
randomized
Warfarin (dose
adjusted INR of
1.4-2.8)
n=1,103
vs. ASA (325
mg qd) n=1,103
Pts were 30-85 y,

considered
acceptable
candidates for
warfarin therapy,
had ischemic
stroke within
previous 30 d, and
had scores of 3
on GOS
Baseline INR above

normal range (>1.4),
stroke that was due
to procedure or
attributed to highgrade carotid
stenosis which
surgery was
planned, or stroke
associated with an
inferred
cardioembolic
source
Warfarin (dose
adjusted INR 1.42.8) vs. ASA (325
mg qd)
Combined recurrent
ischemic stroke or
death from any
cause within 2 y
Death or recurrent
ischemic stroke
17.8% vs. 16.0%
p=0.25; HR: 1.13;
95% CI: 0.92-1.38
Major
hemorrhage
2.22 per 100 pt-y
vs. 1.49 per 100
pt-y
N/A
p=0.25 HR:1.13
95% CI: 0.921.38
N/A
N/A
Commentary
Fixed low-dose
warfarin (1-3
mg) combined
ASA (80 mg)
N/A
N/A
Fixed low-dose
warfarin (1-3 mg)
combined ASA (80
mg)
Reinfarction, stroke,
or CV death.
Provides no
reduction in
reinfarction beyond
N/A
N/A
N/A
N/A
N/A
55
that achievable with

160 mg ASA
Rossini
Assess long-term N=102
Triple
Pts undergoing
Pts requiring OAC
Triple antiplatelet
Bleeding
N/A
MACE
N/A
N/A
N/A
2008
outcomes
antiplatelet
coronary stenting
therapy because of
therapy ASA and
10.8% vs. 4.9%,
5.8% vs. 4.9%, p=0.7
(163)
associated with
therapy ASA
treated with dual
mechanical valve
clopidogrel and
p=0.1
19064015
the use of tripleand clopidogrel
antiplatelet therapy prosthesis
OAC or control
INR values were
therapy in pts
and OAC
also requiring OAC
group: dual
higher in pts with
undergoing
n=102
antiplatelet therapy
bleeding (2.8+1.1
coronary stenting
Control group:
ASA and clopidogrel vs. 2.3+0.2,
and evaluate how
dual antiplatelet
INR targeted to
p=0.0001)
these may be
therapy ASA
lower therapeutic
INR values within
affected by
and clopidogrel
range (2.0-2.5)
target range risk of
targeting INR
n=102
bleeding was lower
values to the
compared with pts
lower therapeutic
who did not (4.9 vs.
range
33%, p=0.00019)
and in control group
(4.9%)
Sarafoff
Investigate the
N=515 pts
n=306 pts
Pts on chronic
N/A
Clopidogrel and
Composite of death, Major bleeding 2
N/A
N/A
N/A
Lack of
2008
efficacy and
continued OAC
OAC who
ASA
MI, stent thrombosis y 1.4% (n=4,
randomization;
(164)
safety of 2
(triple therapy)
underwent DES
or stroke
triple therapy) vs.
diff regarding
18624903
regimens of
and n=209 pts
implantation
During SRAT 13 pts 3.1% (n=6, dual
indication for
antithrombotic AC
discontinued
in group with triple
therapy, p=0.34)
OAC amongst
therapy in pts
OAC (dual
therapy vs. 15 pts in
both groups;
who present for
therapy) they
the group with dual
study may be
DES implantation
received
therapy
underpowered
whilst on OAC
antiplatelet
KaplanMeier
therapy with
estimates 4.2% and
clopidogrel and
7.2%, OR: 0.61,
ASA
95% CI: 0.29-1.28;
p=0.19.
2 y follow-up, 35 pts
triple therapy vs. 36
pts dual therapy
(KaplanMeier
estimates 14.1%
and 18.0%, OR:
0.76, 95% CI: 0.481.21; p=0.25).
1 indicates primary; AC, anticoagulants; ACS, acute coronary syndrome; AF, atrial fibrillation; AMI, acute myocardial infarction; ASA, aspirin; BAAS, Balloon Angioplasty and Anticoagulation Study; BMS, bare metal stents; CV, cardiovascular; DES, drug-eluting stents;
diff, difference(s); GOS, Glascow Outcome Scale; GP, glycoprotein; HF, heart failure; Hx, history; IAC, interrupted anticoagulation; INR, internationalized normalized ratio; IV, intravenous; LDASA, low-dose aspirin; MACE, major adverse cardiac events; MI, myocardial
56
infarction; N/A, not applicable; NSTE, non-ST-segment elevation; OAC, oral anticoagulant(s); OR, odds ratio; PC, placebo; PCI, percutaneous coronary intervention; PTCA, percutaneous coronary angioplasty; pt, patient; revasc, revascularization; RR, relative risk;
STE, ST-segment elevation; SRAT, stent-related antithrombotic treatment; Sx, symptoms; TVF, target vessel failure; UA, unstable angina; and UAC, uninterrupted anticoagulation.
Data Supplement 17. Parenteral Anticoagulant and Fibrinolytic Therapy (Section 4.3.3)
Study
Study Aim
Study Type /
Intervention vs.
Patient Population
Name,
Size (N)
Comparator (n)
Author,
Year
Inclusion Criteria
Exclusion Criteria
PLATO
Mahaffey
2011
(134)
21709065
Prespecified
subgroup
analysis
showed
significant
interaction
between
treatment and
region
(p=0.045),
with less effect
of ticagrelor in
North America
than in rest of
world.
Additional
exploratory
analyses
performed to
identify
potential
explanations
for observed
region by
treatment
interaction.
Observed
regional
interaction
driven by
interaction of
randomized
treatment with
78% of North
American pts
in US
compared with
the ROW pts
(p=0.01 vs.
p=0.045
interaction
using NA),
analyses focus
on comparison
of US and rest
of world with
Canadian pts
included in the
rest of world
group.
Reasons for
interaction
explored
independently by
2 statistical
groups.
N/A
N/A
Study
Intervention
Endpoints
Primary Endpoint &

Results
Regional
interaction could
arise from
chance alone.
Results of 2
independently
performed
analyses
identified
underlying
statistical
interaction with
ASA
maintenance
dose as possible
explanation for
regional
difference.
Lowest risk of CV
death, MI, or
stroke with
ticagrelor
compared with
clopidogrel
associated with
low maintenance
dose of
concomitant
ASA.
Cox regression
analyses performed to
quantify how much of
regional interaction
could be explained by
pt characteristics and
concomitant
treatments, including
ASA maintenance
therapy. Landmark
Cox regressions at 8
timepoints evaluated
association of
selected factors,
including ASA dose,
with outcomes by
treatment. Systematic
errors in trial conduct
ruled out. Given large
number of subgroup
analyses performed
and that result
numerically favoring
clopidogrel in at least
1 of 4 prespecified
regions could occur
with 32% probability,
chance alone cannot
be ruled out. More pts
in US (53.6%) than
rest of world (1.7%)
57
Safety
Endpoint &
Results
N/A
P Values,
OR: HR: RR: &
95 CI:
Secondary
Endpoint &
Results
Both Cox
regression with
median
maintenance dose
and landmark
techniques showed
pts taking low-dose
maintenance ASA,
ticagrelor
associated with
better outcomes
compared with
clopidogrel with
statistical
superiority in ROW
and similar
outcomes in US
cohort.
N/A
Adverse
Events
N/A
Study
Limitations
N/A
PLATO
Wallentin
2009
(139)
19717846
Determine
whether
ticagrelor is
superior to
clopidogrel for
prevention of
vascular
events and
death in broad
population of
pts presenting
with ACS
N=18,624
Pts with ACS
with or without
STE
Ticagrelor
(n=9333)
(180-mg LD, 90
mg bid after) or
clopidogrel
(n=9291) (300600 mg LD, 75
mg daily after)
Hospitalized for ACS,

with or without STE, with
onset of Sx during the
previous 24 h.
Pts who had ACS
NSTE, at least two of
following three criteria
had to be met: ST
changes on ECG
indicating ischemia;
positive test of
biomarker indicating
myocardial necrosis; or
one of several risk
factors (age 60 y; prev
MI or CABG; CAD with
stenosis of 50% at
least 2 vessels; prev
ischemic stroke, TIA,
carotid stenosis 50%,
or cerebral revasc; DM;
PAD; chronic renal
dysfunction, defined as
CrCl of <60 mL/min per
1.73 m2 of body surface
area).
With STE following two
inclusion criteria had to
be met: persistent STE
0.1 mV at least 2
contiguous leads or new
LBBB, and intention to
perform 1 PCI.
Contraindication
against use of
clopidogrel,
fibrinolytic therapy
within 24 h before
randomization, need
for oral
anticoagulation
therapy, increased
risk of bradycardia,
and concomitant
therapy with strong
cytochrome P-450
3A inhibitor or
inducer
Ticagrelor or
clopidogrel
took median ASA

dose 300 mg qd.
Only ASA dose
explained substantial
fraction of regional
interaction in 37
baseline and
postrandomization
factors explored.
Composite of death
from vascular causes,
MI, or stroke
9.8% pts receiving
ticagrelor vs. 11.7%
clopidogrel (HR: 0.84;
95% CI: 0.770.92;
p<0.001).
58
Major bleeding
11.6% vs.
11.2%,
p=0.43
Ticagrelor
associated
with higher
rate of major
bleeding not
related to
CABG 4.5%
vs. 3.8%,
p=0.03,
including more
instances of
fatal
intracranial
bleeding and
fewer fatal
bleeding of
other types
MI alone
5.8% vs. 6.9%,
p=0.005
Death from
vascularcauses
4.0% vs. 5.1%,
p=0.001
Stroke alone 1.5%
vs. 1.3%, p=0.22
Rate of death from
any cause 4.5% vs.
5.9%, p<0.001
p<0.001
HR=0.84
95% CI=0.770.92
Discontinuatio
n of study
drug due to
adverse
events 7.4%
ticagrelor vs.
6.0%
clopidogrel
p<0.001
Dyspnea was
13.8% vs.
7.8%
Higher
incidence of
ventricular
pauses in 1
wk but not at
30 d in
ticagrelor
group than in
clopidogrel
group
Geographic
differences
between
populations of pts
or practice
patterns
influenced effects
of the randomized
treatments
Mehta
2010
(140)
20818903
Clopidogrel
and ASA
widely used
for pts with
ACS and
those
undergoing
PCI.
Evidencebased
guideline for
dosing not
been
established for
either agent.
25,086 pts
Pts randomly
assigned to
double-dose
clopidogrel
received LD of
600 mg 1 d
followed by 150
mg od on 2-7 d.
Pts assigned to
standard-dose
clopidogrel
received 300 mg
LD 1 d before
angiography
followed by 75
mg od 2-7 d. 830 d both
double-dose and
standard-dose
groups received
75 mg of
clopidogrel od.
Pts randomly
assigned to
lower-dose ASA
received 75 to
100 mg daily 2-7
d and those
randomly
assigned to
higher-dose ASA
received 300325 mg daily on
d 2-30.
18 y and presented
with NSTE ACS or
STEMI. ECG changes
compatible with
ischemia or elevated
levels of cardiac
biomarkers; coronary
angiographic
assessment, with plan to
perform PCI early as
possible but no later
than 72 h after
randomization
Increased risk of
bleeding or active
bleeding and known
allergy to clopidogrel
or ASA
22 factorial
design pts
randomly
assigned in
double-blind
fashion to
double-dose
regimen of
clopidogrel or to
standard-dose
regimen. 2nd
component of
factorial design,
pts were
randomly
assigned in open
label fashion to
higher-dose ASA
or lower-dose
ASA.
Time to CV death, MI,

or stroke, whichever
occurred 1st, up to 30
d. Primary outcome
occurred in 4.2% of
pts assigned to
double dose
clopidogrel as
compared with 4.4%
assigned to standarddose clopidogrel (HR:
0.94; 95% CI: 0.83
1.06; p=0.30).
No significant
difference between
higher-dose and
lower-dose ASA with
respect to 1 outcome
(4.2% vs. 4.4%; HR:
0.97; 95% CI: 0.86
1.09; p=0.61)
Major bleeding
occurred in
2.5% of pts in
double dose
group and in
2.0% in
standard-dose
group (HR,
1.24; 95% CI:
1.051.46;
p=0.01).
No significant
difference
between
higher-dose
and lowerdose ASA with
respect to
major bleeding
(2.3% vs.
2.3%; HR:
0.99; 95% CI:
0.841.17;
p=0.90).
Composite of death
from CV causes,
MI, stroke, or
recurrent ischemia;
individual
components of 1
outcome; death
from any cause;
Definite or probable
stent thrombosis.
Double-dose
clopidogrel
associated with
significant
reduction in 2
outcome of stent
thrombosis among
the 17,263 pts who
underwent PCI
(1.6% vs. 2.3%;
HR: 0.68; 95% CI:
0.550.85;
p=0.001).
p=0.30
HR: 0.94
CI: 0.831.06
N/A
ACUITY
subgroup
analysis
Stone
2007
(146)
17368152
Assess
anticoagulatio
n with direct
thrombin
inhibitor
bivalirudin
during PCI in
Randomized
n=7789 pts
n=2561
Heparin
(unfractionated
or enoxaparin)
plus GP IIb/IIIa
inhibitors
n=2609
Pts undergoing PCI after

angiography, ST
depression; raised TnI,
TnT, or CK-MB isozyme;
known CAD; or all 4
other UA risk criteria as
defined by TIMI study
Included - STE AMI

or shock; bleeding
diathesis or major
bleeding episode
within 2 wk;
thrombocytopenia;
CrCl <30 mL/min
Heparin
(unfractionated or
enoxaparin) plus
GP IIb/IIIa
inhibitors,
bivalirudin plus
GP IIb/IIIa
30-d endpoints of
composite ischemia
(death, MI, or
ischemia), major
bleeding, and net
clinical outcomes
N/A
N/A
Composite
ischemia
p=0.16; major
bleeding
p=0.32; net
clinical
outcomes p=0.1
N/A
59
Nominally
significant
reduction in 1
outcome
associated with
use of higherdose clopidogrel
in subgroup of
17,263 study
participants who
underwent PCI
after
randomization
(69%). Test for
interaction
between pts who
underwent PCI
and those who
did not undergo
PCI (p=0.03) did
not meet
prespecified
threshold of
p0.01 for
subgroup
interactions since
13 prespecified
subgroup
analyses were
performed for
clopidogrel dose
comparison,
result could have
been due to play
of chance.
Randomization
occurred before
angiography,
study drugs were
administered at
median of 4 h
before PCI. PCI
individuals
with moderateand high-risk
ACS.
Petersen
2004
(165)
15238596
Systematically
evaluate
endpoints of
all-cause
death nonfatal
MI,
transfusion,
and major
bleeding
observed in 6
RCT
comparing
enoxaparin
and UFH in
treatment of
ACS
Systematic
overview
N=21946 pts
ESSENCE, A
to Z, and
SYNERGY,
TIMI 11B,
ACUTE II, and
INTERACT
performed
using random
effects
empirical
Bayes model
Bivalirudin plus
GP IIb/IIIa
inhibitors, or
n=2619
bivalirudin alone.
group
N/A
All 6 RCT comparing

enoxaparin and
unfractionated heparin in
NSTE ACS selected for
analysis
inhibitors, or
bivalirudin alone
N/A
N/A
(composite ischemia
or major bleeding)
bivalirudin plus GP
IIb/IIIa inhibitors vs.
heparin plus GP
IIb/IIIa inhibitors composite ischemia
9% vs. 8%; major
bleeding 8% vs. 7%;
net clinical outcomes
15% vs. 13%
Combined endpoint of
death or MI
enoxaparin more
effective than UFH in
preventing combined
MI. NS difference
found in death at 30 d
for enoxaparin vs
UFH (3.0% vs 3.0%;
OR: 1.00; 95% CI:
0.851.17).
nonfatal MI at 30 d
observed for
enoxaparin vs. UFH in
overall trial
populations (10.1%
vs. 11.0%; OR, 0.91;
95% CI, 0.83-0.99).
MI at 30 d also
observed for
enoxaparin in
populations receiving
no prerandomization
antithrombin therapy
60
subgroup
represents subset
of 56% of all pts
enrolled in
ACUITY,
randomization not
stratifi ed by
treatment
assignment.
NS difference
was found in
blood
transfusion
(OR: 1.01;
95% CI: 0.89
1.14) or major
bleeding (OR,
1.04; 95% CI:
0.831.30) at
7 d after
randomization
N/A
10.1% vs.
11.0%
OR: 0.91
CI: 0.83-0.99
N/A
Systematic
overviews do not
replace RCT but
provide important
insights through
analyses of
totality of the
data. Trial
populations are
not identical with
respect to
baseline
characteristics,
duration of study
treatment, the
time to revasc or
the use of
concomitant
medical therapies
in management of
UA/NSTEMI
ACS. Some
imprecision exists
in frequency of
events as
protocols for data
collection and
definitions of
efficacy and
safety events
varied among
(8.0% vs. 9.4%; OR:

0.81; 95% CI: 0.70
0.94)
Hochman
1999
(166)
10426845
Evaluate
regimens that
reduced
heparin
dosage for low
body weight
on weight
adjusted basis
in prospective,
nonrandomize
d cohort pts
with UA and
MI who did not
receive
thrombolytic
agents
Nonrandomize
d
N=80 pts
Heparin
Group 1 n=23
Group 2 n=19
Group 3 n=38
Pts admitted with UA

and NSTEMI
Exclusion criteria
included Hx of
bleeding, Coumadin
or thrombolytic
therapy, and failure
to comply exactly
with dosing regimen
Garcia
2012
(167)
22315264
Pharmacology
of approved
parenteral
anticoagulants
including
indirect
anticoagulants
, UFH, LMWH,
fondaparinux,
and
danaparoid,
and direct
Parenteral
Anticoagulants
EvidenceBased Clinical
Practice
Guidelines
N/A
N/A
N/A
Standard (group
1) non weight
adjusted 5000-U
IV bolus/1000
U/hr infusion.
2 weight adjusted
heparin regimens
group 2
70 U/kg IV bolus;
15 U/kg/h pts
<70 kg and a
fixed 5000-U IV
bolus/1000 U/hr
for pts who
weighed >70 kg)
(group 3)
60 U/kg IV bolus,
12 U/kg/hr
infusion pts <70
kg and capped
4000-U IV bolus;
900 U/hr infusion
pts >70 kg.
N/A
Proportion of pts
achieving a target
aPTT at 6 h. Pts
treated with lower
dose of weight
adjusted heparin
group 3 more often
within the target range
for aPTT at 6 h (34%
vs. 5% vs. 0%)
required fewer
heparin infusion
changes (1.0 1.0 vs.
1.9 1.0 vs. 2.0
0.9) within 1st 24 h
compared with other
regimens. Pts in
groups 1 and 2 above
target range at 6 h
(95% and 84%
compared with 48% in
group 3)
N/A
N/A
N/A
61
Proportion of pts
achieving a target
aPTT at 24 h and
number of times
heparin dose
adjusted within 1st
24 h. 52% pts in
group 1 within
target range
compared with 79%
in group 2 and 74%
in group 3
significantly fewer
changes in infusion
rate required over
24 h period in
group 3 compared
with other regimens
(1.05 1.0 for
group 3 vs. 2 0.9
for group 1 vs. 1.9
1.0 in group 2;
p<0.001).
N/A
Significantly
higher
proportion of pts
above target
range in groups
1 (95%) and 2
(84%) versus
group 3 (47%)
(p<0.0005)
No major
complications
in any group
N/A
N/A
studies. Not
having individual
pt data from trials
precluded more
sophisticated
statistical
analyses.
Pts not randomly
assigned, and the
2 weight adjusted
regimens were
not concurrently
tested. At
initiation of 2nd
weight-adjusted
nomogram the
target aPTT
changed to 45-70
s from 50-75 s
N/A
TIMI 11B
Antman
1999
(168)
10517729
OASIS-5
trial Mehta
2007
(169)
17964037
thrombin
inhibitors
hirudin,
bivalirudin,
and
argatroban.
Test benefits
of strategy of
extended
course of
uninterrupted
antithrombotic
therapy with
enoxaparin
compared with
standard
treatment with
UFH for
prevention of
death and
cardiac
ischemic
events in pts
with UA/NQMI
Study reports
prospectively
planned
analysis of pts
with ACS who
underwent
early PCI in
the OASIS-5
trial
Randomized
N=3910 pts
UFH n=1957 vs.

enoxaparin
n=1953
Pts with UA/NQMI

ischemic discomfort of
>5 min duration at rest;
Hx of CAD (abnormal
coronary angiogram,
prior MI, CABG surgery,
or PTCA), ST deviation,
or elevated serum
cardiac markers
Double-blind,
randomized
20,078 pts
n=1,414
subcutaneous
fondaparinux
2.5 mg od or
n=1,420
subcutaneous
enoxaparin 1
mg/kg bid
Pts with UA or NSTEMI;

at least 2 of following
criteria: age >60 y,
positive cardiac
biomarkers, or ECG
changes compatible with
ischemia.
Planned revasc
within 24 h, treatable
cause of angina,
evolving Q-wave MI,
Hx of CABG surgery
within 2 mo or PTCA
within 6 mo,
treatment with
continuous infusion
of UFH for >24 h
before enrollment,
Hx of heparinassociated
thrombocytopenia
with or without
thrombosis, and
contraindications to
anticoagulation
Contraindication to
low molecular weight
heparin,
hemorrhagic stroke
within last 12 mo,
indication for
anticoagulation other
than ACS, revasc
procedure already
performed for
qualifying event, and
severe renal
insufficiency
UFH >3 d
followed by
subcutaneous
PC injections or
enoxaparin (30
mg IV bolus
followed by
injections of 1.0
mg/kg every 12
h)
Outpatient phase
(injections every
12 h of 40 mg pts
<65 kg, 60 mg
>65 kg)
Composite of allcause mortality,

recurrent MI, or urgent
revasc at 8 d 14.5%
vs. 12.4% OR: 0.83;
95% CI: 0.691.00;
p=0.048 at 43 d
19.7% vs. 17.3%
OR: 0.85; 95% CI:
0.721.00; p=0.048
Major
hemorrhage,
bleed in
retroperitoneal
, intracranial,
or intraocular
location;
hemoglobin
drop of >3
g/dL;
requirement of
transfusion of
>2 U blood 72
h no difference
Individual elements
of 1 endpoint and
composite of death
or nonfatal MI
8d
p=0.048
OR=0.83
95% CI: 0.691.00 at 43 d
p=.048
OR= 0.85
95% CI= 0.72
1.00
Stroke (1.0%
vs. 1.2%), TIA
(0.3% vs.
0.3%), or
thrombocytop
enia (2.1%
vs. 1.9%)
N/A
Fondaparinux or
enoxaparin total
of 12,715 pts
underwent heart
catheterization
during the initial
hospitalization,
and 6,238 pts
underwent PCI.
Rates of major
bleeding and efficacy
by evaluating
composite of death,
MI, or stroke at 9, 30,
180 d
Fondaparinux vs.
enoxaparin reduced
major bleeding by
>0.5 (2.4% vs. 5.1%;
HR: 0.46, p<0.00001)
at 9 d with similar
rates of ischemic
events resulting in
superior net clinical
benefit (death, MI,
stroke, major
bleeding: 8.2% vs.
Catheter
thrombus
more common
in pts receiving
fondaparinux
(0.9%) than
enoxaparin
alone (0.4%),
but largely
prevented by
using UFH at
the time of PCI
without
increase in
bleeding
N/A
p<0.00001
HR: 0.46
N/A
Randomized
treatments may
have influenced
which pts
underwent PCI.
Types of pts
undergoing PCI
and number and
timing of PCI
procedures
similar in 2
randomized
treatment groups.
Number of pts
who received
open-label UFH
before PCI in
OASIS-5 trial
62
OASIS-5
Yusuf
(170)
16537663
Compare the
efficacy and
safety of
fondaparinux
and
enoxaparin in
high-risk pts
with UA or
NSTEMI
Randomized,
double-blind,
double-dummy
trial
N=20,078 pts
n=10,057
fondaparinux vs.
n=10,021
enoxaparin
Pts with UA or NSTEMI;

60 y, elevated level of
troponin or CK-MB
isoenzyme, or ECG
changes indicative of
ischemia.
low molecular weight
heparin, recent
hemorrhagic stroke,
indications for
than ACS or serum
creatinine level of 3
mg/dL (265 mol/L)
Fondaparinux
(2.5 mg d) or
enoxaparin (1
mg/kg od) for
mean of 6 d
FUTURA/
OASIS-8
Steg
2010
(171)
20805623
Compare
safety of 2
UFH regimens
during PCI in
high-risk pts
with NSTE
Double-blind
randomized
parallel group
N=2,026 pts
Low-dose UFH
n=1024 vs.
standard-dose
UFH n=1002
Pts undergoing PCI

within 72 h
Hx consistent with new
or worsening ischemia,
occurring at rest or with
minimal activity;
<21 y;
UFH or
fondaparinux;
contraindications for
angiography; pts
IV low-dose UFH,
50 U/kg ,
regardless of use
of GpIIb-IIIa
inhibitors or
standard-dose
10.4%; HR: 0.78,

p=0.004).
Fondaparinux
reduced major
bleeding 48 h after
PCI irrespective of
whether PCI was
performed <6 h of the
last enoxaparin dose
(1.6% vs. 3.8%; HR:
0.42, p<0.0001) or >6
h when UFH was
given (1.3% vs. 3.4%;
HR: 0.39, p<0.0001).
Death, MI, or
refractory ischemia at
9d
1 outcome events
similar in 2 groups
(5.8% (579 events)
with fondaparinux vs.
5.7% (573 events)
enoxaparin HR=1.01;
95% CI, 0.90-1.13);
composite of 1
outcome and major
bleeding at 9 d
favored fondaparinux
(737 events) 7.3% vs.
(905 events) 9.0%;
HR=0.81; p<0.001.
Composite of major
bleeding, minor
bleeding, or major
vascular access-site
complications up to 48
h after PCI
63
modest.
Rate of major
bleeding at 9 d
markedly
lower with
fondaparinux
than with
enoxaparin
(217 events)
2.2% vs. 412
events 4.1%;
HR: 0.52;
p<0.001
Major bleeding
or minor
bleeding
Major bleeding
no difference
minor bleeding
Death, MI, or
refractory ischemia;
and individual
components of
composite
outcomes at 30 d
and at end of study
NS trend toward
lower value in
fondaparinux group
at 30 d (805 vs.
864, p=0.13) and at
end of study (1222
vs. 1308, p=0.06).
Fondaparinux
associated with
significantly
reduced number of
deaths at 30 d (295
vs. 352; p=0.02)
and at 180 d (574
vs. 638; p=0.05).
Composite of major
bleeding at 48 h
5.8% vs. 3.9%; OR:
1.51; 95% CI:
1.002.28; p=0.05
death, MI, or target
HR: 1.01
CI: 0.90-1.13
N/A
N/A
p=0.27
OR: 0.80
95% CI: 0.541.19
Catheter
thrombus
0.5% vs.
0.1%
p=0.15
FUTURA still
underpowered to
conclusively rule
out moderate, but
important,
reductions in
acss initially
treated with
fondaparinux
Grosser
2013
(172)
23212718
Determine
commonality
of
mechanisticall
y consistent,
stable, and
specific
phenotype of
enrollment within 48 h of
most recent Sx; planned
coronary angiography,
with PCI if indicated,
within 72 h; at least 2 of
following criteria: >60 y,
TnT or TnI or CK-MB
above upper limit of
normal; ECG changes
compatible with
ischemia
N=400
Group 1 (n=40)
received regular,
immediate
release ASA
response was
assessed 8 h
after dosing.
Group 2 (n=210)
Healthy, nonsmoking
volunteers (aged 1855
y)
requiring urgent
coronary
angiography due to
refractory or
recurrent angina
associated with
dynamic ST
changes, HF, lifethreatening
arrhythmias,
hemodynamic
instability; treatment
with other injectable
anticoagulants
hemorrhagic stroke
within 12 mo;
indication for
than acss; women
pregnant,
breastfeeding, or of
childbearing
potential not using
contraception; life
expectancy <6 mo;
receiving
experimental
pharmacological
agent; revasc
procedure for
qualifying event
already performed;
creatinine clearance
< 20 mL/min.
N/A
UFH, 85 U/kg (60

U/kg with GpIIbIIIa inhibitors),
adjusted
by blinded ACT
4.7% vs. 5.8%

OR: 0.80; 95% CI:
0.541.19; p=0.27
0.7% vs. 1.7%

;
OR: 0.40; 95%
CI: 0.160.97;
p=0.04)
vessel revasc
within 30 d
4.5% vs. 2.9%;
OR: 1.58; 95% CI:
0.982.53; p=0.06
Single oral dose

of 325-mg
immediate
release ASA or
enteric coated
ASA
Pharmacological
resistance to ASA is
rare; study failed to
identify single case of
true drug resistance.
Variable absorption
caused high
frequency of apparent
N/A
Pseudoresistance,
reflecting delayed
and reduced drug
absorption,
complicates enteric
coated but not
immediate release
ASA
64
bleeding from use

of low-dose UFH.
Based on
observed 5.8%
event rate of 1
endpoint, a
sample size of
11, 542 pts
needed to have
80% power to
detect 20% RR
reduction
N/A
N/A
N/A
true
pharmacologic
al resistance
to ASAsuch
as might be
explained by
genetic
causes
FUTURA/
OASIS 8
Steg
(173)
21146654
Evaluate
safety of 2dose regimens
of adjunctive
IV UFH during
PCI in highrisk pts with
NSTE-ACS
initially treated
with
fondaparinux
and referred
for early
coronary
angiography.
International
prospective
cohort study
N=4,000
received enteric
coated ASA
response was
measured 8 h
after dosing.
Group 3 (n=150)
received enteric
coated ASA,
response was
assessed at 4 h
4,000 high-risk
pts treated with
fondaparinux as
initial medical
therapy
Within cohort,
2,000 pts
undergoing PCI
enrolled into
double-blind
international
randomized
parallel-group
trial evaluating
standard ACT
guided doses of
IV UFH versus a
non-ACT-guided
weight-adjusted
low dose.
resistance to single
dose of 325 mg
enteric coated ASA
(up to 49%) but not to
immediate release
ASA (0%).
UA or NSTEMI; be
enrolled within 48 h of
the onset of most recent
episode of Sx; planned
coronary angiography
with PCI if indicated
within 72 h of enrolment;
at least 2 of following:
age 60 y, TnT or TnI or
CK-MB above upper
limit of normal; ECG
changes compatible with
ischemia.
Age <21 y;
contraindication to
UFH or
fondaparinux;
contraindication for
angiography or PCI;
subjects requiring
urgent (<120 min)
coronary
angiography
because of
refractory or
recurrent angina
associated with
dynamic ST
changes, HF, lifethreatening
arrhythmias, and
hemodynamic
instability; subjects
already receiving
treatment with other
injectable
anticoagulants for
treatment of
qualifying event,
unless the last dose
was 8 h for LMWH,
60 min for
bivalirudin, 90 min
for UFH;
hemorrhagic stroke
N/A
Composite of peri-PCI
major bleeding, minor
bleeding, or major
vascular access site
complications
65
Major and
minor
bleeding;
major vascular
access site
complications
Composite of periPCI major bleeding

with death, MI, or
target vessel
revasc at 30 d.
N/A
N/A
N/A
ACUITY
Stone
2006
(174)
17124018
Examine
usefulness of
bivalirudin as
part of early
invasive
strategy with
optimal
antiplatelet
therapy in pts
with acss
Randomized
N=13,819 pts
n=4603 UFH or
enoxaparin plus
a GP IIb/IIIa
inhibitor
n=4604
bivalirudin plus
GP IIb/IIIa
inhibitor
n=4612
bivalirudin alone
Pts with Sx of UA lasting

10 min within
preceding 24 h eligible
for enrollment if one or
more following criteria
were met: new STsegment depression or
transient elevation of at
least 1 mm; elevations in
the TnI, TnT, CK-MB
levels; known CAD; or
all four other variables
for predicting TIMI risk
scores for UA.
within last 12 mo;

indication for
than ACS;
pregnancy, women
who are
breastfeeding or
childbearing
potential who are not
using effective
method of
contraception;
comorbid conditions
with life expectancy
<6 mo; currently
receiving an
experimental
pharmacologic
agent; revasc
procedure for
qualifying event
already performed;
and severe renal
insufficiency
MI associated with
acute STE or shock;
bleeding diathesis or
major bleeding
episode within 2 wk
before episode of
angina;
thrombocytopenia; a
calculated creatinine
clearance rate of
<30 mL/min; recent
administration of
abciximab, warfarin,
fondapar inux,
fibrinolytic agents,
bivalirudin, 2 doses
of LMWH; and
allergy to any study
UFH or
enoxaparin plus
a GP IIb/IIIa
inhibitor,
bivalirudin plus a
GP IIb/IIIa
inhibitor, or
bivalirudin alone
Composite ischemia
endpoint (death, MI,
or unplanned revasc
for ischemia), major
bleeding, and net
clinical outcome,
defined as
combination of
composite ischemia or
major bleeding.
Bivalirudin plus GP
IIb/IIIa inhibitor, as
compared with
heparin plus GP
IIb/IIIa inhibitor,
associated with
noninferior 30-d rates
of composite ischemia
66
N/A
N/A
N/A
N/A
Logistic
complexities of
trial necessitated
an open-label
design,
introduced
potential for bias;
59% of study
cohort presented
with NSTEMI.
Significant
proportion of pts
pretreated with
either UFH or
LMWH before
randomization;
25% noninferiority
margin used may
drugs or to iodinated
contrast medium that
could not be
controlled in
advance with
medication.
Fibrinolytic
Therapy
Trialists'
(FTT)
Collaborati
ve Group
1994
(175)
7905143
Systematic
overview of
effects of
treatment on
mortality and
on major
morbidity in
various pt
categories in 9
trials designed
to randomize
>1000 pts with
AMI between
fibrinolytic
Collaborative
overview
N=58600 pts
All trials of fibrinolytic

therapy vs. control that
randomized >1000 pts
with suspected AMI
GISSI-1, ISAM, AIMS,
ISIS-2, ASSET, USIM,
ISIS-3, EMERAS, LATE
N/A
Streptokinase,
anistreplase, tPA,
urokinase
endpoint (7.7% and

7.3%, respectively),
major bleeding (5.3%
and 5.7%), and net
clinical outcome
endpoint (11.8% and
11.7%). Bivalirudin
alone, compared with
heparin plus GP
IIb/IIIa inhibitor,
associated with
noninferior rate of
composite ischemia
endpoint (7.8% and
7.3%, respectively;
p=0.32; RR=1.08;
95% CI=0.93-1.24)
significantly reduced
rates of major
bleeding (3.0% vs.
5.7%; p<0.001;
RR=0.53; 95%
CI=0.43-0.65) net
clinical outcome
endpoint (10.1% vs.
11.7%; p=0.02;
RR=0.86; 95%
CI=0.77-0.97).
Deaths during 1st 5 wk
and major adverse
events occurring
during hospitalization
10.5% deaths
1.0% strokes
0.7% major noncerebral bleeds
Fibrinolytic therapy
excess of deaths
during 0-1 d
(especially among pts
presenting >12 h after
Sx and in the elderly)
67
be considered
wide
N/A
Benefit in 45,000
pts presenting with
STE or BBB
irrespective of age,
sex, blood
pressure, HR, or
previous MI or D
greater earlier
treatment began
Relation between
benefit and delay
from Sx onset
indicated highly
significant absolute
N/A
Fibrinolytic
therapy
associated
with 4 extra
strokes per
1000 during
0-1 d
N/A
TIMI IIIB
1994
(176)
8149520
Eikelboom
2000
(147)
therapy and
control
GISSI-1,
ISAM, AIMS,
ISIS-2,
ASSET, USIM,
ISIS-3,
EMERAS,
LATE
TIMI III
focused on UA
and NQMI.
Determine by
coronary
arteriography
the incidence
of coronary
thrombi in
these
conditions and
response of
these thrombi
to 0.8 mg/kg
dose (max 80
mg) of TPA.
Determine
effects of
thrombolytic
therapy and
early invasive
strategy on
clinical
outcome (TIMI
IIIB). Provide
further
understanding
of natural Hx
of UA and
NQMI
Systematic
overview of
randomized
Much larger benefit

during 2-35 d
mortality reductions
30 per 1000
within 0-6 h; 20 per
1000 presenting 712 h; statistically
uncertain benefit 10
per 1000 within 1318 h
Randomized
using 22
factorial design
N=1473 Pts
Compare TPA
vs. PC as initial
therapy and an
early invasive
strategy (early
coronary
arteriography
followed by
revasc when
anatomy was
suitable) vs.
early
conservative
strategy
(coronary
arteriography
followed by
revasc if initial
medical therapy
failed).
Pts seen within 24 h of

ischemic chest
discomfort at rest,
considered to represent
UA or NQMI.
Treatable cause of
UA, experienced MI
within preceding 21
d, undergone
coronary
arteriography within
30 d, PTCA within 6
mo, CABG anytime,
or if, at enrollment,
were in pulmonary
edema, had SBP
>180 mm Hg or DBP
>100mm Hg,
contraindication to
or heparin, LBBB, a
coexistent severe
illness, woman of
child-bearing
potential, receiving
oral anticoagulants.
TPA versus PC
Early invasive
strategy vs. early
conservative
strategy
TPA-PC comparison
(death, MI, or failure
of initial therapy at 6
wk) occurred in 54.2%
of the TPA-treated pts
and 55.5% of PCtreated pts (p=NS).
Fatal and nonfatal MI
after randomization
(reinfarction in NQMI
pts) occurred more
frequently in TPAtreated pts (7.4%)
than in PC-treated pts
(4.9%, p=0.04,
Kaplan-Meier
estimate).
N/A
Endpoint for
comparison of the
two strategies
(death, MI, or
unsatisfactory Sxlimited exercise
stress test at 6 wk)
occurred in 18.1%
of pts assigned to
early conservative
strategy and 16.2%
of pts assigned to
the early invasive
strategy (p=NS).
p=NS
4 intracranial
hemorrhages
occurred in
TPA-treated
group vs.
none in PC
treated group
(p=.06).
N/A
Meta-analysis
12 trials,
n=17,157 pts
UFH or LMWH
or PC
Trials had to be
randomized; include pts
with UA or NQMI; and
Studies were
excluded:
Randomized
UFH or LMWH or
PC
Composite of death or
MI at 7 d (OR: 0.53
95% CI: 0.380.73;
1 safety
outcome major
bleeding
2 outcomes of
interest were
recurrent angina
N/A
N/A
Large numbers of
pts randomized to
receive short-
68
trials to assess
effect of UFH
and LMWH on
death, MI, and
major
bleeding.
ACCF/
ACG/
AHA
report
Bhatt
2008
(158)
19017521
Karjalainen
2008
(156)
18346963
ACCF/ACG/A
HA 2008
Expert
Consensus
Document on
Reducing the
Gastrointestin
al Risks of
Antiplatelet
Therapy and
NSAID Use
Determine
safety and
efficacy of
various
periprocedural
antithrombotic
strategies in
pts on longterm OAC with
warfarin
undergoing
PCI. Assess
safety of
include ASA-treated pts

randomly assigned to
UFH or LMWH or to PC
or untreated control
N/A
N/A
N/A
Retrospective
analysis
n=523 pts
IAC and UAC

group
All consecutive pts on

warfarin therapy referred
for PCI in four centers
with a main policy to IAC
before PCI and in three
centers with a long
experience on UAC
during PCI.
comparison heparin
vs. ASA, heparin
plus ASA vs.
combined
antiplatelet therapy,
or heparin vs. nonASA control;
nonrandomized
comparison
reported; doseranging uncontrolled
study; pts alternately
allocated to LMWH
or UFH therapy; lack
of clarity as to
whether study was
properly
randomized.
N/A
N/A
p=0.0001)
Short term LMWH vs
UFH (OR: 0.88; 95%
CI: 0.691.12;
p=034). Long-term
LMWH (up to 3 mo)
vs PC or untreated
control (OR: 098;
95% CI: 0.811.17;
p=080
Long-term
LMWH
OR=226,
95% CI=1.63
3.14,
p<0.0001
and need for

revasc.
N/A
N/A
N/A
N/A
N/A
N/A
N/A
IAC vs. UAC
Major bleeding,
access-site
complications, and
major adverse cardiac
events (death, MI,
target vessel revasc,
and stent thrombosis)
Major bleeding 5.0%
vs. 1.2%, p=0.02 and
after adjusting for
propensity score
(OR:3.9, 95% CI: 1.0
15.3, p=0.05)
N/A
N/A
N/A
Major
bleeding,
stroke,
access-site
complications
Inherent
limitations of
retrospective
study including
individual riskbased decision
making in
treatment
choices; outcome
assessment not
blinded; sample
size may not be
sufficient to cover
69
term therapy who

did not continue
therapy long term
may have
reduced power of
studies to detect
significant
difference. Pts
who did not
receive long-term
LMWH were
those at highest
risk for recurrent
events.
simplistic UAC
strategy.
BAAS
ten Berg
2001
(157)
11319192
Study intensity
and duration
of
anticoagulatio
n as predictors
of thrombotic
and bleeding
events
N=530 pts
ASA plus
coumarins
Pts who were

prospectively
randomized to use of
coumarins as part of
BAAS study
N/A
RE-DEEM
Oldgren
2011
(177)
21551462
Evaluate the
safety and
indicators of
efficacy of four
dose regimens
of dabigatran
etexilate
compared with
PC when
given in
addition to
dual
antiplatelet
Double-blind,
PC-controlled,
doseescalation trial
N=1861 pts
Dabigatran vs.
PC
Pts age 18 y,
hospitalized with
NSTEMI or STEMI
within last 14 d, and
receiving treatment with
dual antiplatelet therapy
(ASA and clopidogrel or
another thienopyridine).
1 risk factor for
subsequent CV
complications: age >65
y, DM on treatment,
previous MI, LBBB,
Ongoing or planned
treatment with VKAs,
severe disabling
stroke within
previous 6 mo or any
stroke within
previous 14 d,
conditions
associated with
increased risk of
bleeding such as
major surgery
(including bypass
ASA (LD, 300

mg; then 100 mg
qd) and
coumarins
(acenocoumarol
or Sintrom at 6
mg 1 d, 4 mg on
2 d, 2 mg on 3 d
and after until
intervention)
started 1 wk
before
intervention
Target INR was
2.1-4.8 during
angioplasty and
6-mo follow-up
INR measured on
morning before
PTCA and daily
after until
discharge
Dabigatran
initially one of
two lower doses
(50 mg bid n=369
and 75 mg bid)
n=368
vs. PC n=371
N=406 110 mg
dose in 2nd stage
n=347 150 mg
dosegroup in
third stage
Access-site
complications (11.3%
vs. 5.0%, p=0.01)
After adjusting for
propensity score
(OR=2.8, 95% CI:
1.36.1, p=0.008)
Thrombotic events Death, MI, target
lesion, revasc, and
thrombotic stroke
17 early thrombotic
events (3.2%), 7 early
bleeding episodes
(1.3%), and 10 false
aneurysms (1.9%).
61 late thrombotic
events occurred
(11.6%). Optimal
anticoagulation an
independent predictor
of late thrombotic
events (RR: 0.33;
95% CI: 0.19-0.57)
and associated with
0.21 mm (95% CI:
0.17-0.42) larger
vessel lumen at 6 mo
Composite of major or
clinically relevant
minor bleeding during
6 mo treatment
period.Composite of
major or clinically
relevant minor
bleeding events 3.5,
4.3, 7.9, and 7.8% in
respective 50, 75,
110, and 150 mg
dabigatran groups,
compared with 2.2%
70
small but clinically

significant
differences in
bleeding and
thrombotic
complications
Bleeding
Complications,
hemorrhagic
stroke, major
extracranial
bleeding, and
false
aneurysm
Late bleeding
episodes
(1.4%) lowest
in pts in target
range.
N/A
N/A
N/A
N/A
N/A
Indicators of
efficacy such as
reduction in Ddimer levels and
incidences of CV
ischaemic events.
D-dimer
concentrations
reduced in all
dabigatran dose
groups by an
average of 37 and
45% at wk 1 and 4,
p<0.001 for
linear trend
HR 1.77 (95%
CI: 0.704.50)
for 50 mg;
HR=2.17 (95%
CI: 0.885.31)
for 75 mg;
HR=3.92 (95%
CI: 1.728.95)
for 110 mg; and
HR=4.27 (95%
CI: 1.869.81)
14(3.8%) pts
died, had a
MI or stroke
in PC group
compared
with 17
(4.6%) in 50
mg, 18 (4.9%)
in 75 mg, 12
(3.0%) in 110
mg, and 12
(3.5%) in the
150 mg
N/A
treatment in
pts with recent
STEMI or
NSTEMI at
high risk of
new ischaemic
CV events.
Uchino
2012
(178)
22231617
Systematically
evaluated risk
of MI or ACS
with use of
dabigatran.
Meta-analysis
Seven trials
were selected
N=30,514
N/A
congestive HF requiring
treatment or LVEF 40%,
PAD, moderate renal
insufficiency (CrCl 30
60 mL/min), or no
revasc for the index
event.
surgery) in previous
mo, Hx of severe
bleeding,
gastrointestinal
haemorrhage with in
past y,
gastroduodenal ulcer
in previous 30 d,
fibrinolytic agents
within 48 h of study
entry, uncontrolled
hypertension,
haemoglobin ,10
g/dL or platelet
count ,100 109/L,
normal coronary
arteries at
angiogram for index
event, congestive
HF New York Heart
Association Class
IV, and severe renal
impairment (CrCl ,30
mL/min).
Searched PubMed,
Scopus, and Web of
Science for randomized
controlled trials of
dabigatran that reported
on MI or ACS as 2
outcomes.
N/A
Fixed-effects MH used to
evaluate the
effect of
dabigatran on MI
or ACS.
Expressed
associations as
OR and 95% CIs.
in the PC group,
p<0.001 for linear
trend. 96 1 outcome
events, compared
with PC a dose
dependent increase
with dabigatran, HR
1.77 (95% CI: 0.70
4.50) for 50 mg;
HR=2.17 (95% CI:
0.885.31) for 75 mg;
HR=3.92 (95% CI:
1.728.95) for 110
mg; and HR=4.27
(95% CI: 1.869.81)
for 150 mg.
Compared with PC,
D-dimer
concentrations
reduced in all
dabigatran dose
groups by average of
37 and 45% at wk 1
and 4, respectively
(p=0.001).
Dabigatran was
significantly
associated with higher
risk of MI or ACS than
seen with agents used
in control group
(dabigatran, 237 of 20
000 [1.19%] vs.
control, 83 of 10 514
[0.79%]; ORM-H, 1.33;
95% CI: 1.03-1.71;
p=.03).
71
N/A
respectively
(p<0.001).
for 150 mg.
dabigatran
groups
N/A
p=.03
ORM-H, 1.33
CI=1.03-1.71
N/A
Dominant effect
of RE-LY trial on
results of metaanalysis. Other 6
trials had cohort
sizes of 515-3451
with durations of
6mo. In RE-LY,
18,113
participants
monitored for
median of 2 y.
Owing to sample
size and duration
of study, RE-LY
comprised 59% of
the cohort and
Alexander
2011
(179)
21780946
Determine
whether in
high-risk pts
with ACS
benefit of
apixaban in
reducing
ischemic
events
outweigh
increased risk
of bleeding.
Randomized,
double-blind,
PC-controlled
N=7392
n=3705
apixaban, 5 mg
bid vs. n=3687
PC
Mega
2012
(180)
22077192
N/A
Double-blind,
PC-controlled
trial
N=15,526 pts
bidbid doses of
either 2.5 mg or
5 mg of
rivaroxaban or
PC
ACS (MI, NSTEMI,

STEMI, or UA) within
previous 7 d, Sx of MI
lasting 10 mo or more
with pt at rest plus either
elevated levels of
cardiac biomarkers or
dynamic ST-segment
depression or elevation
of 0.1 mV. 2 or more of
the following high-risk
characteristics: age 65
y, DM, MI within
previous 5 y,
cerebrovascular
disease, peripheral
vascular disease, clinical
HF or LVEF of <40% in
association with index
event, impaired renal
function with calculated
creatinine clearance <60
ml/min and no revasc
after index event.
Within 7 d after hospital
admission for ACS.
Condition of pts needed
to be stabilized before
enrollment with initial
management strategies
(e.g., revasc) completed
N/A
Apixaban 5 mg
bid PC, in
addition to
standard
antiplatelet
therapy
CV death, MI, or
ischemic stroke
Median follow-up of
241 d
7.5% pts assigned to
apixaban
7.9% assigned to PC
HR=0.95; 95% CI:
0.80-1.11; p=0.51
Major bleeding
according to
TIMI definition
occurred in
1.3% pts who
received
apixaban and
in 0.5% pts
who received
PC
HR=2.59; CI,
1.50-4.46;
p=0.001.
Greater
number of
intracranial
and fatal
bleeding
events
occurred with
apixaban than
PC.
N/A
P=0.51
HR=0.95
CI=0.80-1.11
N/A
N/A
bid doses of
either 2.5 mg or 5
mg of
rivaroxaban or
PC
Composite of death
from CV causes, MI,
or stroke.
Rivaroxaban
compared with PC,
8.9% and 10.7% (HR
in rivaroxaban group,
0.84; 95% CI: 0.740.96; p=0.008),
significant
improvement for both
bid 2.5-mg dose
(9.1% vs. 10.7%,
p=0.02) and bid 5 mg
dose (8.8% vs.
10.7%, p=0.03).
Compared
with PC,
rivaroxaban
increased
rates of major
bleeding not
related to
CABG (2.1%
vs. 0.6%,
p<0.001) and
intracranial
hemorrhage
(0.6% vs.
0.2%,
p=0.009),
without
bid 2.5-mg dose of

rivaroxaban
reduced rates of
death from CV
causes (2.7% vs.
4.1%, p=0.002) and
from any cause
(2.9% vs. 4.5%,
p=0.002),
p=0.008
HR=0.84
CI=0.74-0.96
Rates of
adverse
events that
were not
related to
bleeding
similar in
rivaroxaban
and PC
groups
72
74% of the
events.
N/A
N/A
Warkentin
2012
(181)
22383791
Eerenberg
2011
(182)
21900088
Report
timeline of
bleeding,
hemostatic
parameters,
and
dabigatran
plasma levels
(by HPLC) in
response to
emergency
management
with rFVIIa
and
hemodialysis.
Evaluated
potential of
PCC to
reverse
anticoagulant
effect of
rivaroxaban
and
dabigatran
Single patient
case
N/A
N/A
N/A
N/A
Pts developed
massive postoperative
bleeding resulting
from elective cardiac
surgery performed
with therapeutic
dabigatran levels.
This illustrates
importance of
adjusting the number
of d off dabigatran
before surgery
according to current
renal function.
Randomized,
double-blind,
PC-controlled
N=12
Rivaroxaban 20
mg bid (n=6) or
dabigatran 150
mg bid(n=6)
Twelve healthy male

subjects
N/A
Rivaroxaban 20
mg bid (n=6) or
dabigatran 150
mg bid. (n=6) for
2.5 d followed by
either single
bolus 50 IU/kg
PCC or similar
volume of saline.
After washout
period procedure
Rivaroxaban induced
significant
prolongation of
prothrombin time
(15.8+1.3 vs.
12.3+0.7 s at
baseline; p<0.001)
that was immediately
and completely
reversed by PCC
(12.8+1.0;
73
significant
increase in
fatal bleeding
(0.3% vs.
0.2%, p=0.66)
or other
adverse
events. bid
2.5-mg dose
resulted in
fewer fatal
bleeding
events than
bid 5-mg dose
(0.1% vs.
0.4%, p=0.04).
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
No major or
clinically
relevant
bleeding
complications
occurred
during
treatment, no
serious
adverse
events.
Small size of
study population
accounting for
variation in
results of a few
coagulation tests.
No
measurements
performed
between 6-24 h
after infusion of
repeated with
other
anticoagulant
treatment.
p<0.001).
PCC or PC. If
Endogenous thrombin
PCC had any
potential inhibited by
effect of reversal
rivaroxaban (51+22%;
for dabigatran it
baseline, 92+22%;
may have been
p<0.002) normalized
missed; any
with PCC (114+26%;
rebound effect on
p<0.001), saline had
anticoagulant
no effect. Dabigatran
activity of
increased activated
rivaroxaban in
partial thromboplastin
that same period
time, ECT, and
could not be
thrombin time.
observed.
Administration of PCC
did not restore these
coagulation tests.
1 indicates primary; 2, secondary; ACCF, American College of Cardiology Foundation; ACS, acute coronary syndrome; ACT, activated clotting time; ACUITY, Acute Catheterization and Urgent Intervention Triage strategY; ACUTE II, Assessment of Cardioversion
Using Transesophageal Echocardiography; ADP, adenosine diphosphate; AGC, ; AHA, American Heart Association; AIMS, APSAC Intervention Mortality Study; aPTT, Activated Partial Thromboplastin Time; ASA, aspirin; ASSET, Anglo-Scandinavian Study of Early
Thrombolysis; BID, twice daily; CABG, coronary artery bypass graft; CAD, coronary artery disease; CI, confidence interval; CK, creatine kinase; CK-MB, creatine kinase-MB; CRP, C-reactive protein; DBP, diastolic blood pressure; DM, diabetes mellitus; ECG,
electrocardiography; ECT, ecarin clotting time; EMERAS, Estudio Multicentrico Estreptoquinasa Republicas de America del Sur; ESSENCE, Efficacy and Safety of Subcutaneous Enoxaparin in NonQ wave Coronary Events; FUTURA, The Fondaparinux Trial With
Unfractionated Heparin During Revascularization in Acute Coronary Syndromes ; GISSI-1, Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto miocardico acuto-1; GP, glycoprotein; HF, heart failure; HR, hazard ratio; Hx, history; IAC, Interrupt anticoagulation;
IgE, Immunoglobin E; ISAM, Intravenous Streptokinase in Acute Myocardial Infarction; ISIS, International Study of Infarct Survival; INTERACT, Intensive blood pressure reduction in acute cerebral haemorrhage trial; ISAM, Intravenous Streptokinase in Acute
Myocardial Infarction; IV, intravenous; LATE, Late Assessment of Thrombolytic Efficacy Study; LBBB, left bundle-branch block; LD, loading dose; LMWH, low molecular weight heparins; LVEF, left ventricular ejection fraction; MH, Mantel-Haenszel test; MI, myocardial
infarction; NQMI, nonQ-wave myocardial infarction; NS, not significant; NSAID, nonsteroidal anti-inflammatory drugs; NSTE, non-ST elevation; NSTEMI, non-ST-elevation myocardial infarction; OAC, Oral anticoagulation; OASIS, Organization for the Assessment of
Strategies for Ischemic Syndromes; OD, once daily; OR, odds ratio; PAD, peripheral arterial disease; PC, placebo; PCC, prothrombin complex concentrate, PCI, percutaneous coronary intervention; PLATO, Platelet Inhibition and Patient Outcomes trial; pts, patients;
RCT, randomized clinical trials; Revasc, revascularization; RE-LY, Randomized Evaluation of Long-Term Anticoagulant Therapy Trial; ROW, rest of the world; RR, relative risk; SBP, systolic blood pressure; STE, ST elevation; STEMI, ST-elevation myocardial
infarction; Sx, symptoms; TIMI, thrombolysis in MI; TnI, troponin I; TnT, troponin T; TPA, ; UA, unstable angina; UAC, Uninterrupted anticoagulation; UFH, unfractionated heparin; US, United States; and USIM, Urochinasi per via Sistemica nell'Infarto Miocardico.
Data Supplement 18. Comparison of Early Invasive and Initial Conservative Strategy (Section 4.4.4)
Study
Study Aim
Study Type /
Intervention
Patient Population
Name,
Size (n)
vs.
Author,
Comparator
Year
(n)
Inclusion Criteria
Exclusion Criteria
TIMI IIIB,
1994
8149520
(176)
To determine
the effects of
an early
invasive
strategy on
clinical
RCT 1,473
Intervention:
740;
Comparator:
733
Chest discomfort at
rest caused by
ischemia that lasted
>5 min but <6 h. The
discomfort must
have occurred within
Pts were excluded if

they had a treatable
cause of UA, had
experienced a MI
within the preceding
21 d, had undergone
Study Intervention
The protocol called for

pts assigned to the early
invasive strategy to
have cardiac
catheterization, LVA,
and coronary
Study
Comparator
Pts randomized
to the early
conservative
strategy were to
have
angiography
74
Endpoints
Primary
Endpoint &
Results
Death,
postrandomization
MI, or an
unsatisfactory
ETT performed at
the time of the 6-
Safety
Endpoint &
Results
None
Secondary
Endpoint &
Results
Analyses for
differences and
interactions in the
results of invasive
vs. conservative
strategies for death
P Values,
OR: HR: RR: &
95 CI:
Study Limitations
& Adverse Events
1 endpoint
occurred in
16.2% of the
pts randomized
to the early
invasive
Significant
crossover with
64% in the
conservative arm
undergoing
angiography by 42
outcome
24 h of enrollment
and accompanied by
objective evidence
of ischemic HD, i.e.,
either new or
presumably new
ECG evidence of
ischemia in at least
2 contiguous leads
or documented CAD
MATE, 1998
Mccullogh et
al,
(183)
9741499
To determine
if early
revasc
favorably
affects
clinical
outcomes in
pts with
suspected
AMI
RCT 201
Intervention:
201;
Comparator:
90
Pts 18 y and older

who presented to
the ED with an acute
chest pain syndrome
consistent with AMI
VANQWISH,
Boden et al
1998
(184)
9632444
To compare
an invasive
with a
conservative
strategy in
pts with
acute NQMI
RCT 920
Intervention:
462;
Comparator:
458
Eligible pts had to

have evolving AMI, a
level of (CK-MB
isoenzymes that was
more than 1.5 the
ULN for the hospital,
and no new
abnormal Q waves
coronary
arteriography within
30 d, PTCA within 6
mo, CABG at any
time, or if, at
enrollment, they
were in pulmonary
edema, had a
systolic arterial
pressure >180
mmHg or a diastolic
pressure >100
mmHg, a
contraindication to
or heparin. LBBB, a
coexistent severe
illness, were a
woman of childbearing potential, or
were receiving OAC.
Exclusion criteria
were Sx lasting for
more than 24 h or an
absolute indication
or contraindication to
cardiac
catheterization
arteriography 18-48 h
after randomization
carried out only

after failure of
initial therapy
wk visit
Subjects randomized to
triage angiography were
taken as soon as
possible directly to the
catheterization
laboratory from the ED.
All triage angiography
pts underwent
catheterization within 24
h of arrival to the
hospital
Composite
endpoint of all
recurrent ischemic
events or death
Pts were excluded if

they had serious
coexisting
conditions, ischemic
complications that
placed them at very
high risk while in the
CCU (persistent or
Pts assigned to the

early invasive strategy
underwent coronary
angiography as the
initial diagnostic test
soon after
randomization.
Thereafter, the
Subjects
randomized to
the conservative
arm were
admitted to a
monitored bed
and received
continued
medical therapy
and noninvasive
evaluation
encouraged by
the protocol
Pts assigned to
the early
conservative
strategy
underwent RNV
to assess LV
function as the
initial noninvasive
Death or nonfatal
MI
75
or MI were carried
out on several
prespecified
subgroups
strategy vs.
18.1% of those
assigned to the
early
conservative
strategy (p=NS)
None
2 endpoints
including LOS and
hospital costs
The composite
endpoint of all
recurrent
ischemic events
or death
occurred in 14
(13%) and 31
(34%), yielding
a 45% risk
reduction (95%
CI 27-59%,
p=0.0002)
High crossover
rate (60%). No
long-term benefit
in cardiac
outcomes
compared with
conservative
medical therapy
with revasc
prompted by
recurrent ischemia
Major
procedural
complications
after
coronary
angiography
or myocardial
revasc
Overall mortality
A total of 152 1
endpoint events
occurred in the
invasivestrategy group,
as did 139
cardiac events
in the
The trial was

conducted before
coronary stents or
platelet GP IIb/IIIa
receptor
antagonists were
widely available
(or R waves) on
serial
electrocardiograms
FRISC II,
1999
(185)
10475181
To compare
an early
invasive with
a noninvasive
treatment
strategy in
UCAD
Prospective,
randomized,
multicenter trial
2,457
Intervention:
1,222;
Comparator:
1,235

inclusion if they had
Sx of ischaemia that
were increasing or
occurring at rest, or
that warranted the
suspicion of AMI,
with the last episode
within 48 h
TACTICS TIMI 18,

Cannon et al
2001
(186)
11419424
To compare
an early
invasive
strategy to a
more
conservative
approach
Prospective,
randomized,
multicenter trial
2,220
Intervention:
1,114 vs.
Comparator:
1,106
Pts 18 y if they had

had an episode of
angina (with an
accelerating pattern
or prolonged [>20
min] or recurrent
episodes at rest or
recurrent ischemia at
rest despite intensive
medical therapy or
severe HF that
persisted despite
treatment with IV
diuretics,
vasodilators, or both
Exclusion criteria
were raised risk of
bleeding episodes,
anaemia, or
indication for or
treatment in the past
24 h with
thrombolysis,
angioplasty in the
past 6 mo, being on
a waiting list for
coronary revasc,
other acute or
severe CD, renal or
hepatic insufficiency,
known clinically
relevant
osteoporosis, other
severe illness,
hypersensitivity to
randomized drugs,
anticipated
difficulties with
cooperation or
participation in this
or another clinical
trial
Persistent STE, 2
angina, a Hx of PCI
or CAB grafting
6 mo, factors
associated with an
increased risk of
management guidelines
of the TIMI IIIB for
revasc were followed
test; this was

followed before
discharge by a
Sx-limited
treadmill exercise
test with thallium
scintigraphy
The direct invasive

treatments were
within a few d of
enrollment, aiming for
revasc within 7 d of the
start of open-label
treatment
Non-invasive
treatment
included coronary
pts with refractory
or recurrent Sx,
despite max
medical
treatment, or
severe ischaemia
on a Sx-limited
exercise test
before discharge
Composite
endpoint of death
and MI after 6 mo
Bleeding
Total death, MI, Sx

of angina, need for
late coronary
angiography and
revasc, bleeding
episodes, and
stroke
There was a
significant
22.0% relative
and 2.7%
absolute
decrease in
death and MI in
the invasive
compared with
the noninvasive group
after 6-mo RR:
0.78 (95% CI:
0.620.98),
p=0.031
Revasc window of
7 d longer than
actual
contemporary
practice
Pts assigned to the

were to undergo
between 4 h and 48 h
after randomization and
revasc when
Pts assigned to
the early
conservative
strategy were
treated medically
and, if their
condition was
Combined
incidence of
death, nonfatal
MI, and
rehospitalization
for an ACS at 6
mo
Bleeding
Death, death or MI,

fatal or nonfatal MI,
reshospitaliztion
for MI
At 6 mo, the
rate of the 1
endpoint was
15.9% with use
of the early
invasive
strategy and
Study excluded pts

with severe
comorbid
conditions or other
serious systemic
illness
76
conservativestrategy group
(p=0.35) during
an average of
23 mo of followup
VINO,
Spacek et al
2002
(120)
11792138
To compare
1st d
angiography/
angioplasty
vs. early
conservative
therapy of
evolving MI
without
persistent
STE
RCT 131
Intervention:
64 vs.
Comparator:
67
RITA -2, Fox

et al, 2002
To compare
interventional
RCT 1,810
Intervention:
895 vs.
with minimal effort)

24 h, were
candidates for
coronary revasc,
and had at least 1 of
the following: a new
finding of STsegment depression
of at least 0.05 mV,
transient (<20 min)
STE of at least 0.1
mV, or T-wave
inversion of at least
0.3 mV in at least 2
leads; elevated
levels of cardiac
markers; or coronary
disease, as
documented by a Hx
of catheterization,
revasc, or M
Rest ischaemic
chest pain, lasting
<20 min, within the
last 24 h before
randomization; ECG
evidence of AMI
without STE (STsegment
depressions
minimally 0.1 mm in
at least 2 contiguous
leads and/or
negative T waves or
documented old
LBBB/RBBB; CKMB higher than 1.5
X ULN and/or
positive TnI assay
inclusion if they had
bleeding, LBBB or
paced rhythm,
severe CHF or
cardiogenic shock,
serious systemic
disease, a serum
creatinine level of
<2.5 mg/dL (221
mol/L), or current
participation in
another study of an
investigational drug
or device
appropriate on the basis

of coronary anatomical
findings
stable, underwent
an exercisetolerance test
(83% of such
tests included
nuclear perfusion
imaging or
echocardiography
performed
according to the
protocol of the
institution) before
being discharged
Unstable postinfarction angina

pectoris resistant to
maximal
pharmacotherapy;
cardiogenic shock;
acute LBBB or
RBBB or STE 2 mm
in 2 leads; QMI or IV
thrombolysis >1 mo;
coronary angioplasty
or bypass surgery >6
mo; any concomitant
disease which may
have possible
influence on 1-y Px;
lack of pt
cooperation
All those with
probable evolving
1st d
angiography/angioplasty
treatment strategy
guidelines were
characterized by a
coronary angiogram as
soon as possible after
randomization followed
by immediate coronary
angioplasty of the culprit
coronary lesion + stent
implantation whenever
suitable
Conservative
treatment
strategy
guidelines were
characterized by
initial medical
treatment with
coronary
angiography and
subsequent
revasc only in the
presence of
recurrent
myocardial
ischaemia
Composite of
death or nonfatal
RMI 6 mo after
the randomization
None
Length of the initial

hospitalization and
the number of
subsequent
hospitalizations for
UAP
The primary
endpoint
(death/
reinfarction) at
6 mo occurred
in 6.2% vs.
22.3%
(p<0.001). 6 mo
mortality in the
1st d
angiography/
angioplasty
group was 3.1%
vs. 13.4% in the
conservative
group (p<003).
Small sample size,

interventions were
done in only one
high volume
tertiary center
Pts assigned to the

interventional treatment
Pts assigned to
the conservative
The coprimary
trial endpoints
Bleeding
Death, MI,
refractory angina
At 4 mo, 86
(9.6%) of 895
Primary endpoint
driven by reduction
77
19.4% with use

of the
conservative
strategy (OR:
0.78; 95% CI:
0.620.97;
p=0.025).
(187)
12241831
strategy and
conservative
strategy in
pts with
unstable
CAD
ICTUS, de
Winter et al,
2005
(188)
16162880
To compare
an early
invasive
strategy to a
selectively
invasive
strategy for
pts who have
ACS without
STE and with
an elevated
cTnT level
Comparator:
915
RCT 1,200
Intervention:
604 vs.
Comparator:
596
suspected cardiac
chest pain at rest
and had
documented
evidence of CAD
with at least 1 of the
following: evidence
of ischaemia on
ECG (ST-segment
depression, transient
STE, LBBB
[documented
previously], or Twave inversion);
pathological Q
waves suggesting
previous MI; or
arteriographically
proven CAD on a
previous arteriogram
Eligible pts had to
have all 3 of the
following: Sx of
ischemia that were
increasing or
occurred at rest, with
the last episode
occurring no more
than 24 h before
randomization; an
elevated cTnT level
(0.03 g/L); and
either ischemic
changes as
assessed by ECG
(defined as STsegment depression
or transient STE
exceeding 0.05 mV,
or T-wave inversion
of 0.2 mV in 2
contiguous leads) or
MI, including those

for whom reperfusion
therapy was
indicated, were
ineligible. Those in
whom new
pathological Q
waves developed, or
those with CK or CKMB concentrations
2 the ULN before
randomization, were
excluded. Also
excluded were those
with MI within the
previous mo, PCI in
the preceding 12 mo,
or CABG at any
time.
strategy were managed

with optimum
antianginal and
antiplatelet treatment
(as for the conservative
group), and enoxaparin
1 mg/kg subcutaneously
2 for 2-8 d. The
protocol specified that
coronary arteriography
should be done as soon
as possible after
randomization and
ideally within 72 h
strategy were
managed with
antianginal and
antithrombotic
medication
were: a combined
rate of death,
nonfatal MI, or
refractory angina
at 4 mo; and a
combined rate of
death or nonfatal
MI at 1 y
Exclusion criteria
were an age >18 y or
<80 y, STEMI in the
past 48 h, an
indication for primary
PCI or fibrinolytic
therapy,
hemodynamic
instability or overt
CHF, the use of oral
anticoagulant drugs
in the past 7 d,
fibrinolytic treatment
within the past 96 h,
PCI within the past
14 d, a
contraindication to
treatment with PCI or
GP IIb/IIIa inhibitors,
recent trauma or risk
of bleeding,
hypertension despite
Pts assigned to the

were scheduled to
undergo angiography
within 24-48 h after
randomization and PCI
when appropriate on the
basis of the coronary
anatomy
Pts assigned to
the selectively
invasive strategy
were treated
medically. These
pts were
scheduled to
undergo
angiography and
subsequent
revasconly if they
had refractory
angina despite
optimal medical
treatment,
hemodynamic or
rhythmic
instability, or
clinically
significant
ischemia on the
predischarge
The primary
endpoint was a
composite of
death, RMI, or
rehospitalization
for angina within 1
y after
randomization
78
Bleeding
as individual
endpoints
pts in the
intervention
group had died
or had a MI or
refractory
angina,
compared with
133 (14.5%) of
915 pts in the
conservative
group (RR:
0.66; 95% CI:
0.510.85;
p=0.001).
of refractory
angina with no
difference in hard
clinical endpoints
Percentage of pts
free from anginal
Sx
The estimated
cumulative rate
of the primary
endpoint was
22.7% in the
group assigned
to early invasive
management
and 21.2% in
the group
assigned to
selectively
invasive
management
(RR: 1.07; 95%
CI: 0.87-1.33;
p=0.33).
Revasc rates were

high in the 2
groups in our study
(76% in the earlyinvasive-strategy
group and 40% in
the selectivelyinvasive-strategy
group during the
initial
hospitalization,
and 79% and 54%,
respectively, within
1 y after
randomization
a documented Hx of
CAD as evidenced
by previous MI,
findings on previous
coronary
angiography, or a
positive exercise test
treatment (i.e.,
exercise test.
systolic pressure
>180 mmHg or
diastolic pressure
>100 mmHg), weight
<120 kg, or inability
to give informed
consent
Italian Trial J To determine RCT 313
Intervention:
Eligible were pts
Excluded were pts
Pts enrolled in the trial
IC therapy, in
The primary
Bleeding
Individual
The 1outcome
The main limitation
Am Coll
the risk vs.
154 vs.
with NSTE-ACS and with 2 causes of
were randomly assigned which case pts
endpoint was the
components of the occurred in 43
of this study is its
Cardiol Intv
bebefut ratio
Comparator : an age of 75 y,
myocardial ischemia, to either: 1) an EA
had to be
composite of
primary endpoint
pts (27.9%) in
relative lack of
2012;5:906of an EA
159
with cardiac
ongoing myocardial
strategy of coronary
managed with
death, MI,
the EA group
power, because
16)
approach in
ischemic Sx at rest
ischemia or HF
angiography within 72 h medical therapy,
disabling stroke,
and 55 (34.6%) our original sample
(189)
elderly pts
within 48 h before
despite optimized
and, when indicated,
and coronary
and repeat
in the IC group
size was amended
22995877
with NSTErandomization,
therapy, PCI or
coronary revasc by
angiography
hospital stay for
(HR: 0.80; 95% due to slow
ACS
together with
CABG within 30 d
either PCI or CABG
during index
CV causes or
CI: 0.5 1.19;
enrollment
ischemic ECG
before
according to coronary
hospital stay was severe bleeding
p=0.26)
changes and/or
randomization,
anatomy, pt preference, allowed in the
within 1 y
elevated levels of
serum creatinine
and local skills; or 2) IC
case of refractory
either Tn or CK-MB
>2.5 mg/dL, a
therapy
ischemia,
cerebrovascular
myocardial
accident within the
(re)infarction, HR
previous mo, recent
of ischemic
transfusions,
origin, or
gastrointestinal or
malignant
genitourinary
ventricular
bleeding within 6 wk
arrhythmias
before
randomization,
platelet count 90,000
cells/ l, ongoing oral
anticoagulation,
severe obstructive
lung disease,
malignancy, or
neurological deficit
limiting follow-up
1 indicates primary; 2, secondary; ACS, acute coronary syndrome; AMI, acute myocardial infarction; CAB, coronary artery bypass; CABG, coronary artery bypass graft; CAD, coronary artery disease; CCU, cardiac care unit; CD, cardiac disease; CHF, congestive
heart failure; CK, creatine kinase; CK-MB, creatine kinase-MB; cTnT, cardiac troponin T; CV, cardiovascular; EA, early invasive; ECG, electrocardiograph; ETT; exercise treadmill test; GP, glycoprotein; HD, heart disease; HF, heart failure; Hx, history; IC, initially
conservative; IV, intravenous; LBBB, left bundle branch block; LOS, length of stay; LV, left ventricular; LVA, left ventricular angiography; MI, myocardial infarction; NQMI, Non Q-wave myocardial infarction; NS, no(t) significant; OAC, oral anticoagulants; PCI,
percutaneous coronary intervention; PTCA, percutaneous transluminal coronary angioplasty; pts, patients; Px, prognosis; QMI, Q-wave myocardial infarction; RBBB, right bundle branch block; RCT, randomized controlled trial; revasc, revascularization; RMI; recurrent
MI;RNV, radionuclide ventriculogram; STE, ST-segment elevation; Sx, symptom(s); TIMI, thrombolysis in MI; TnI, troponin I; UA, unstable angina; UAP, unstable angina pectoris; UCAD, unstable coronary artery disease; and ULN, upper limits of normal.
79
Data Supplement 19. Comparison of Early Versus Delayed Angiography (Section 4.4.4.1)
Study Name,
Study Aim
Study
Intervention
Patient Population
Author, Year
Type/
vs. Comparator
Size (N) (n)
Inclusion Criteria
Exclusion Criteria
ISAR-COOL,
Neumann et al
2003
14506118
(190)
To test the
hypothesis that
prolonged
antithrombotic
pretreatment
improves the
outcome of
catheter
intervention in
pts with acute
unstable
coronary
syndromes
compared with
early intervention
RCT
410
Intervention:
207 vs.
Comparator:
203
Pts with AP at rest or

with minimal
exertion, with the last
episode occurring
24 h before study
entry
TIMACS,
Mehta et al,
2009
(191)
19458363
To study efficacy
of an early
invasive strategy
(within 24 h of
presentation)
compared with
delayed invasive
strategy (anytime
36 h after
presentation)
RCT
3,031
Intervention:
1,593 vs.
Comparator:
1,438
Presentation to a
hospital with UA or
MI without STE
within 24 h after
onset of Sx and if 2
of the following 3
criteria for increased
risk are present: age
60 y, cardiac
biomarkers above
ULN, or results on
ECG compatible with
ischemia (i.e., STsegment depression
1 mm or transient
Pts with evidence of

large MI, including
STE of at least 1 mV
in 2 or more
contiguous leads or
elevation of the
catalytic activity of
creatine kinase and its
MB isoenzyme to 3
the ULN; those with
hemodynamic
instability; those with
study medication; or
those unable to
provide written
informed consent for
participation
Pt who is not a
suitable candidate for
revasc
Study
Intervention
Study Comparator
With the early

intervention
strategy
investigators
performed
coronary
angiography as
soon as possible,
at least within 6
h, during which
time
antithrombotic
pretreatment was
instituted
With the prolonged

antithrombotic
pretreatment
strategy,
investigators
continued
pretreatment for at
least 3 d, to a max of
5 d, after which all
pts underwent
coronary
angiography
Among pts who

were randomly
assigned to the
early-intervention
group, coronary
angiography was
to be performed
as rapidly as
possible and
within 24 h after
randomization
Pts who were

assigned to the
delayed-intervention
group underwent
coronary
angiography after a
min delay of 36 h
after randomization
80
Endpoints
Primary
Endpoint &
Results
Composite
30-d
incidence of
large nonfatal
MI or death
from any
cause
Safety Endpoint
& Results
Composite of
death, MI, or
stroke at 6 mo
Bleeding
Bleeding,
thrombocytopenia
Secondary
Endpoint &
Results
Death, nonfatal
MI
1st occurrence
of the
composite of
death, MI, or
refractory
ischemia and
the composite
of death, MI,
stroke,
refractory
ischemia, or
repeat
intervention at 6
mo
P Values,
OR: HR: RR: & 95
CI:
Study
Limitations &
Adverse Events
1 endpoint was
reached in 11.6%
(3 deaths, 21
infarctions) of the
group receiving
prolonged
antithrombotic
pretreatment and in
5.9% (no deaths,
12 infarctions) of
the group receiving
early intervention
(RR: 1.96; 95% CI:
1.013.82; p=0.04)
Small sample
size
At 6 mo, 1
outcome (death,
new MI, or stroke)
occurred in 9.6% of
pts in the earlyintervention group,
as compared with
11.3% in the
delayedintervention group
(HR: 0.85; 95% CI:
0.68-1.06; p=0.15)
The trial may

have been
relatively
underpowered.
Heterogeneity
was observed in
the 1 endpoint,
with pts in the
highest tertile
experiencing a
sizeable risk
reduction and
suggesting a
potential
advantage of
STE or T-wave
inversion >3 mm)
ABOARD,
Montalescot et
al
(192)
19724041
To determine if
immediate
intervention on
admission can
result in
reduction of MI
vs. delayed
intervention
RCT
352
Intervention:
175 vs.
Comparator:
177
Presence of at least
2 of the following:
ischemic Sx, ECG
abnormalities in at
least 2 contiguous
leads, or positive Tn,
TIMI risk score 3
Hemodynamic or
arrhythmic instability
requiring urgent
catheterization,
chronic oral
anticoagulation, or
thrombolytic therapy in
the preceding 24 h
An immediate
invasive strategy
The primary
endpoint did not
differ between the 2
strategies (median
[IQR] TnI value, 2.1
[0.3-7.1] ng/mL vs.
1.7 [0.3-7.2] ng/mL
in the immediate
and delayed
intervention groups,
respectively;
p=0.70)
1 indicates primary; 2, secondary AP, angina pectoris; ECG, electrocardiograph; IQR, interquartile range; MB, myocardial band; MI, myocardial infarction; non-ST-elevation myocardial infarction; pts, patients; RCT, randomized controlled trial; revasc, revascularization;
RR, relative risk; STE, ST- segment elevation; Sx, symptom(s); TIMI; thrombolysis in myocardial infarction; Tn, troponin; TnI, troponin I; UA, unstable angina; and UA/NSTEMI, unstable angina/ non-ST-elevation MI.
Data Supplement 20. Risk Stratification Before Discharge for Patients With Conservatively Treated NSTE-ACS (Section 4.5)
Study Name, Study Aim
Study
Intervention
Patient Population
Study
Author, Year
Type/ Size vs.
Intervention
(n)
Comparator
(n)
Inclusion Criteria
Exclusion
Criteria
An invasive strategy
scheduled on the
next working d
Study
Comparator
Primary
endpoint was
peak Tn value
during
hospitalization
Endpoints
DANAMI,
Valeur et al
2004
(193)
15618067
To test the
prognostic
importance of
predischarge
maximal Sxlimited ET
following AMI in
the era of
aggressive
reperfusion
Post hoc
subgroup
analysis of
a RCT
1,164
N/A
In the DANAMI-2
study, pts with
STEMI were
randomized to 1
angioplasty (PCI) or
fibrinolysis
N/A
N/A
N/A
Primary
Endpoint &
Results
1 endpoint was a
composite of
death and reinfarction
INSPIRE,
Mahmarian et
al 2006
To test whether
gated ADSPECT
could accurately
Cohort
study
728 pts
N/A
The study cohort

consisted of 728
stabilized pts 18 y of
N/A
Event rates were

assessed within
prospectively
Pt risk and
subsequent
therapeutic
Composite of
death, MI, or
stroke at 6 mo
Bleeding
81
Safety
Endpoint
& Results
N/A
Secondary
Endpoint &
Results
N/A
N/A
N/A
2 endpoints
were composite
of death, MI, or
urgent revasc at
1-mo follow-up
early revasc in
this high-risk
subgroup
Immediate (at a
median of 70 min)
vs. delayed (at a
median of 21 h)
angiography and
revasc in UA/
NSTEMI pts
conferred no
advantage with
regard to the
primary endpoint
P Values,
Study Limitations &

Adverse Events
ST-depression was predictive of

the clinical outcome (RR: 1.57
[1.00- 2.48]; p<0.05) in
multivariable analysis, there was
a significant association
between ST-depression and
outcome in the fibrinolysis group
(RR: 1.95 [1.11- 3.44]; p<0.05),
but not in the 1 PCI group (RR:
1.06 [0.47-2.36]; p=NS).
However, the p-value for
interaction was 0.15.
Total cardiac events/death and
reinfarction significantly
increased within each INSPIRE
Post hoc analysis.

Exercise capacity was
a strong prognostic
predictor of death and
re-infarction
irrespective of
treatment strategy,
whereas the prognostic
significance of STdepression seems to be
strongest in the
fibrinolysis-treated pts.
Investigators did not
track the percentage of
eligible pts who were
(194)
17174181
define risk and

thereby guide
therapeutic
decision making
in stable
survivors of AMI
COSTAMI -II,
Decidari et al
To compare in a
prospective,
randomized,
multicenter trial
the relative merits
of predischarge
exercise ECG
and early
pharmacological
stress
echocardiography
concerning risk
stratification and
costs of treating
pts with
uncomplicated
AMI
age who had either

QAMI or NQAMI and
were prospectively
enrolled
RCT
262
Intervention:
132;
Comparator:
130
262 pts from 6

participating centers
with a recent
uncomplicated MI
were randomly
assigned to early (d
3-5)
pharmacological
stress
echocardiography
(n=132) or
conventional
predischarge (d 7-9)
maximum Sx limited
exercise ECG (n
=130)
defined INSPIRE
risk groups based
on the
adenosineinduced LV
perfusion defect
size, extent of
ischemia, and EF
Pharmacological
stress
echocardiography
risk group from low (5.4%,

1.8%), to intermediate (14%,
9.2%), to high (18.6%, 11.6%)
(p<0.01). Event rates at 1 y
were lowest in pts with the
smallest perfusion defects but
progressively increased when
defect size exceeded 20%
(p<0.0001).
1 endpoint was
cost effectiveness
of the diagnostic
strategies. The 2
endpoint was
quality of life
evaluation. Pts
were seen at 1
and 6 mo and 1 y
after discharge.
Cardiac events,
use of resources,
costing, and
quality of life were
recorded.
82
N/A
2 endpoints
were
composite of
death, MI, or
urgent
revasc at 1mo follow-up
enrolled in the INSPIRE

trial so there may be
selection bias. The
perfusion results
significantly improved
risk stratification
beyond that provided
by clinical and EF
variables. The low-risk
INSPIRE group,
comprising 1/3 all
enrolled pts, had a
shorter hospital stay
with lower associated
costs compared with
the higher-risk groups
(p<0.001).
No complication occurred during Early pharmacological

either stress echocardiography
stress
or exercise ECG. At 1-y followechocardiography and
(195)
up there were 26 events (1
conventional
15657220
death, 5 nonfatal reinfarctions,
predischarge Sx limited
20 pts with UA requiring
exercise ECG have
hospitalization) in pts randomly
similar clinical outcome
assigned to early stress
and costs after
echocardiography and 18
uncomplicated
events (2 reinfarctions, 16 UA
infarction. Early stress
requiring hospitalization) in the
echocardiography may
group randomly assigned to
be considered a valid
exercise ECG (NS). The
alternative even for pts
negative predictive value was
with interpretable
92% for stress
baseline ECG who can
echocardiography and 88% for
exercise.
exercise ECG (NS). Total costs
of the two strategies were
similar (NS).
1 indicates primary; 2, secondary; ADSPECT, adenosine Tc-99m sestamibi single-photon emission computed tomography; AMI, acute myocardial infarction; AV, atrioventricular; DANAMI-2, Danish Multicenter Study of Acute Myocardial Infarction 2; ECG,
electrocardiograph; EF, ejection fraction; ET, exercise test; INSPIRE, Investigating New Standards for Prophylaxis in Reduction of Exacerbations; LBBB, left bundle branch block; LV, left ventricular; LVEF, left ventricular ejection fraction; NS, non/t significant; NQAMI,
non-Q-wave myocardial infarction; PCI, percutaneous coronary intervention; PDS, perfusion defect size; pts, patients; Px, prognosis; QAMI, Q-wave myocardial infarction; RCT, randomized controlled trial; revasc, revascularization; STEMI, ST-elevation myocardial
infarction; SVT, sustained ventricular tachycardia; Sx, symptom (s); UA, unstable angina; and VF, ventricular fibrillation.
Exclusion
criteria were
age >75 y,
serious
arrhythmias
(VF, SVT, or
fixed 2nd or 3rd
degree AV
blocks), LBBB,
pericarditis,
insufficient
acoustic
window, and
poor short-term
Px because of
concomitant
disease
decision
making were
prospectively
defined by
specific
ADSPECT
variables. Pts
with a small
(<20%)
ischemic PDS
were classified
as low risk and
most had a
LVEF of 35%
(96%) and an
ischemic PDS
of <10%
(97%).
Maximum Sx
limited exercise
ECG
Data Supplement 21. RCTs and Relevant Meta-Analyses of GP IIb/IIIa Inhibitors in Trials of Patients With NSTE-ACS Undergoing PCI (Section 5)
Trial
Study Drug /
Population
Primary Endpoint
Results
Comparator
Elective (stable) and urgent (ACS) patients enrolled (without routine clopidogrel pretreatment)
EPILOG
Abciximab vs. PC
2,792 pts with stable ischemia or
Death, MI or UTVR at 30 d
5.2% vs. 11.7%
(196)
UA
HR: 0.43
9182212
ACS/high risk (without routine clopidogrel pretreatment)
CAPTURE
Abciximab
1,265 pts with refractory UA
11.3% vs. 15.9%
(197)
(administered for 18-24 undergoing PCI 18-24 h after
10341274
h before PCI) vs. PC
diagnostic catheterization
EPIC
Abciximab vs. PC
Pts at high risk for abrupt vessel
Death, MI, UTVR, IABP, or
Bolus only: 11.4%
(198)
closure
unplanned stent placement Bolus + infusion: 8.3%
8121459
at 30 d
PC: 12.8%
RESTORE
Tirofiban (std dose) vs.
2,139 pts with ACS undergoing
Death, NFMI, UTVR, or
10.3% vs. 12.2%
(199)
PC
PTCA or DCA
stent placement at 30 d
9315530
ACS/high risk or mixed study population (with routine clopidogrel pretreatment)
ISAR-REACT 2
Abciximab vs. PC
2,022 high-risk ACS pts
(142)
undergoing PCI
16533938
ADVANCE
(200)
15234398
Tirofiban (high-dose)
vs. PC
202 pts undergoing elective or

urgent PCI (1/3 with stable angina;
1/2 with ACS)
Statistics
Comments
95% CI: (0.30-0.60); p<0.001
N/A
p=0.012
Significant reduction in MI rate both before and during PCI with

abciximab therapy. No diff in 6-mo composite endpoint
p=0.009 overall;
p=0.008 for bolus + infusion vs.
PC
p=0.160
N/A
Composite endpoint was statistically lower at 2 and 7 d follow-up
(but not at the 30-d 1 endpoint)
8.9% vs. 11.9%

RR: 0.75
p=0.03
95% CI: 0.580.97
RR: 0.71 in +Tn pts; RR: 0.99 in -Tn pts
Death, NFMI, UTVR or

bailout GPI therapy at
median of 185 d
20% vs. 35%

HR: 0.51
p=0.01
95% CI: 0.290.88
Pts pretreated with either ticlopidine or clopidogrel

Death/MI/TVR at 6-mo lower (HR: 0.57; 95% CI: 0.99-0.33;
p=0.48)
Pannu
GP IIb/IIIa vs. PC
5,303 pts undergoing PCI
Death, MI or TVR
OR: 0.84
95% CI: 0.581.22;
N/A
Meta-analysis
p=0.35
(201)
18458661
1 indicates primary; ACS, acute coronary syndrome; DCA, directional coronary atherectomy; diff, difference; GP, glycoprotein; GPI, glycoprotein IIb/IIIa inhibitors; IABP, intraaortic balloon pump; MI, myocardial infarction; NFMI, nonfatal myocardial infarction; PC,
placebo; PCI, percutaneous coronary intervention; PTCA, percutaneous transluminal coronary angioplasty; pts, patients; RR, relative risk; std, standard; Tn, troponin; +Tn, positive troponin; -Tn, negative troponin; TVR, target vessel revascularization; UA, unstable
angina; and UTVR, urgent target vessel revascularization.
Data Supplement 22. Studies of Culprit Lesion Versus Multivessel (Culprit and Nonculprit) PCI in Patients with NSTE-ACS (Section 5)
Study
Aim of Study
Type of Study
Study Size
Patient
Primary Endpoint
Population
Brener SJ, 2008
To compare outcomes of culprit
Post hoc database 105,866 pts NCDR database
Multiple endpoints
(202)
only PCI to multivessel PCI in
analysis
analyzed
18082505
NSTE-ACS pts
Shishehbor MH, 2007
Examination of the safety and
Post hoc database 1,240 pts
NSTE-ACS pts in
Death, MI or TVR
(203)
efficacy of nonculprit multivessel analysis
institutional
Median follow-up 2.3 y
83
Outcome
Procedural success: 91% culprit PCI vs. 88% multivessel PCI (p<0.001)
In-hospital mortality: 1.3% culprit PCI vs. 1.2% multivessel PCI (p=0.09; adjusted OR: 1.11; 95% CI:
0.971.27)
Multivessel PCI associated with lower death/MI/TVR rate; adjusted HR: 0.80 (95% CI: 0.640.99;
p=0.04); propensity matched analysis HR: 0.67 (95% CI: 0.510.88; p=0.004)
17320742
Zapata GO, 2009
(204)
19515083
Palmer ND, 2004
(205)
15152143
PCI with culprit-only PCI in pts

with NSTE-ACS
To investigate MACE at 1-y
follow-up in pts with NSTE-ACS
and multivessel CAD who
underwent either culprit vessel
PCI or multivessel PCI
Compare short and mediumterm outcomes of complete
revasc PCI vs. culprit revasc in
NSTE-ACS pts
database
Lower revasc rate with multivessel PCI drove endpoint differences
Post hoc database

analysis
609 pts
NSTE-ACS pts in
institutional
database
MACE at 1 y
MACE lower with multivessel PCI than culprit vessel PCI (9.45% vs.16.34%; p=0.02; no OR given)
Revasc lower with multivessel PCI than culprit vessel PCI (7.46 vs. 13.86%; p=0.04; no OR given)
No diff in death or death/MI between groups
Retrospective
database review
with additional pt
follow-up
151 pts
NSTE-ACS pts
treated at a tertiary
care institute
Multiple endpoints
analyzed
Compared to multivessel PCI, culprit lesion only PCI resulted in:

More pts with residual angina (22.8% vs. 9.9%; p=0.041; no OR given)
More pts required further PCI (17.5% vs. 7.0%; p=0.045; no OR given)
Trend towards more readmissions for UA
Greater use of long-term antianginal medications (52.6% vs. 38.0%; p=0.043; no OR given)
NS diff between the 3 groups at either 30-d or 6-mo follow-up for any of the endpoints: death; MI; and
MACE
Brener, 2002
(206)
12231091
To compare 30-d and 6-m

Post hoc trial
427 pts
NSTE-ACS pts in
In-hospital and 6-mo
outcome in NSTE-ACS pts
analysis
TACTICS-TIMI 18
MACE
undergoing PCI with (1) 1 VD
and culprit PCI; (2) multivessel
disease and culprit PCI; and (3)
multivessel disease and
multivessel PCI
ACS indicates acute coronary syndrome; CAD, coronary artery disease; diff, difference(s); MACE, major adverse coronary events; MI, myocardial infarction; NCDR, National Cardiovascular Data Registry; NS, no(t) significance; NSTE, non-ST-elevation; NSTE-ACS,
non-ST-elevation acute coronary syndrome; PCI, percutaneous coronary intervention; pts, patients; revasc, revascularization; TACTICS, Treat Angina with Tirofiban and Determine Cost of Therapy with an Invasive or Conservative Strategy; TACTICS-TIMI, Treat
Angina with Tirofiban and Determine Cost of Therapy with an Invasive or Conservative Strategy-Thrombolysis In Myocardial Infarction; TIMI, Thrombolysis In Myocardial Infarction; UA, unstable angina; VD, vascular disease; and TVR, target vessel revascularization.
Data Supplement 23. Risk Reduction Strategies for Secondary Prevention (Sections 6.3.)
Study
Aim of study
Study
Study
Study
Study
Patient Population
Name,
Type
Size
Intervent Comparat
Author,
(n)
ion
or Group
Year
Group
(n)
(n)
Inclusion
Exclusion Criteria
Criteria
6.3.1 Physical activity
Munk, 2009 To evaluate high
(207)
intensity interval
19853690
training on instent restenosis
following PCI for
stable or UA
RCT
40
20
20
Had PCI with

implantation
of a stent
History of MI or
CABG, significant
valvular heart
disease, >80 y,
inability to give
informed consent,
inability to
participate in
Study
Intervention
Study
Comparator
Endpoints
Primary
Endpoint
(efficacy)
and Results
Highintensity
interval
training
program
Usual care,
no exercise
intervention
84
Restenosis was
smaller in the
treatment group
(0.10 mm)
compared to the
control group
(0.39) p-value
(0.01)
P Values,
OR: HR: RR &
95% CI:
Safety
Endpoint
and
Results
Secondary
Endpoint
and
Results
N/A
Peak oxygen
uptake increased
by 16.8% (T) and
7.8% (C) (p<0.01).
Flowmediated
dilation improved
by 5.2% (T) and 0.1% (C) (p=0.01).
Unknown
Study Limitations &

Adverse Events
Limitations: small sample

size and large interquartile
ranges; heterogeneity of
stents implanted.
There were no serious
training-related adverse
events.
regular training, any

known chronic
inflammatory
disease other than
atherosclerosis, or
planned surgery in
next 6 mo.
Depression and other psychological conditions
Tisminetzky To ID Sx profiles
Randomiz
2011
of depression and ed trial
(208)
anxiety in pts with
22409097
ACS and examine
changes over
time
6.3.4 Nonsteroidal anti-inflammatory drugs
Lee, 2007
To compare the
Adjusted
(209)
use of celecoxib
indirect
17051359
and rofecoxib on
compariso
CV risk
n of 2
published
RCTs
(APPROV
e and
APC
trials)
6.3.6 Antioxidant vitamins and folic acid
Galan,
To determine if
Double
2010
vitamin B &
blind RCT
(210)
omega 3 fatty
21115589
acids can prevent
CV events in pts
with Hx of heart
disease or stroke.
Levels of high-sens
C-reactive protein
decreased by -0.4
mg/L (T) and
increased by 0.1
mg/L (C) (p=0.03
for trend)
79
45
34
Age 35+,
hospitalized
with ACS,
mild/medium
anxiety
and/or
depression
Mental healthcare
in prior 3 mo,
psychoactive drug
use in past y, Dx
substance abuse in
past y
4-6 30 min
cognitive
behavioral
therapy
sessions
Booklet on
coping with
cardiac
illness, and
told to
contact PCP
if depressed
26% of treatment
Sx improved vs.
10% in control
group
N/A
N/A
N/A
Limitations: findings do not

apply to high-risk
individuals because they
were excluded from study,
short duration of follow-up
and small sample size.
APPR
OVe=2
,586
APC=
2,035
APPROV
e=1287
APC=685
(200 mg
group)
671 (400
mg
group)
APPROVe
=1299
APC=679
History of
colorectal
neoplasia/
adenomas
None mentioned
APPROVe:
25 mg
rofecoxib for
3y
APC: Either
200mg or
400mg of
celecoxib for
3y
PC
N/A
There
were NS
differenc
es in CV
events
N/A
RR (95% CI) pvalue

Celecoxib vs.
200mg rofecoxib
0.74-1.38
(0.96)
Celecoxib vs.
400mg rofecoxib
1.09 0.81 1.45
(0.57)
Limitations: interpretation of
adjusted indirect
comparison should be done
with caution
2,501
G1=622
(Vitamin
B + PC)
626
Personal Hx
of MI, UA, or
ischaemic
stroke
<45 or >80 y; ill

defined Dx of CV
disease; inability
or unwillingness to
comply with study
treatment
Vitamin B:
560 mg 5
methyltetrah
ydrofolate, 3
g B-6, 20
mcg B-12
Omega 3:
600 mg of
eicosapenta
noic acid and
docosahexa
enoic acid at
a ratio of 2:1
Double PC
1st major CV
event, NS for
Vitamin B or
Omega 3
N/A
Significant 2
endpoints: Vitamin
B use associated
with fewer strokes
(HR: 0.57; 95% CI:
0.33-0.97; p=0.04);
and a higher risk of
death from any
cause (HR: 1.55;
95% CI: 1.072.25;
p=0.02)
Vitamin B:
HR: 0.9
95% CI: 0.661.23 (0.5)
Omega 3:
HR: 1.08
95% CI: 0.791.47 (0.6)
Limitations: number of
participants, short duration
(4.7 y) to provide statistical
power to detect effects on
major vascular events.
G2 =
633
(omega 3
+ PC)
G3 =
620
(vitamin
B+
omega 3)
85
Imasa,
2009
(211)
19515873
To determine the
effect of folic acid
supplementation
on prevention of
ACS
RCT
240
116
124
UA or
NSTEMI in
previous 2
wk
Hemodynamic
1 mg folic
PC
Re-hospitalization N/A
N/A
RR (95% CI), p
Limitations: small sample
instability, liver
acid,
and composite of
value all-cause
size; compliance rate=60%;
disease, renal
400mcg B12,
death, nonfatal
mortality 1.18
adverse events in
disease, <18 y,
10 mg B6
ACS, and re(0.68- 2.04), 0.54 treatment group: skin
pregnant,
daily
hospitalization
Nonfatal ACS
irritation, dyspnea,
Hemoglobin <10
were significantly
1.28 (0.64-2.54),
dizziness
g/dL, high-output
increased in the
0.5
failure, inability to
treatment group
Re-hospitalization
provide adequate
5.11 (1.14-23.0),
self-care,
0.016
malignancy or any
Composite
terminal illness, and
endpoint 1.20
geographic location
(1.00-1.44), 0.04
ACS indicates acute coronary syndrome; APC, Adenoma Prevention with Celecoxib trial; APPROVe, Adenomatous Polyp Prevention on Vioxx trial; CABG, coronary artery bypass graft; CV, cardiovascular; Dx, diagnosis; ID, identification; MI, myocardial infarction; N/A,
not applicable; NSTEMI, non-ST-elevation myocardial infarction; PCI, percutaneous coronary intervention; PCP, primary care physician; Pts, patients; RCT, randomized controlled trials; and UA, unstable angina.
Data Supplement 24. Older Patients (Section 7.1)
Study Name,
Author, Year
Alexander
2007
(212)
17502590
Aim of
study
Summarize
evidence on
pt
heterogeneit
y, clinical
presentation
, and
treatment of
NSTE-ACS
in relation to
age (65-74,
75-84, and
85 y)
Study
Type
Summary or
5 pooled
NSTE-ACS
clinical trials
and 3 large
NSTE-ACS
registries to
assess and
grade
evidence
and provide
descriptive
finding and
compare pts
in clinical
trials vs
those not
Study
Size (N)
Clinical
Trials
n=34266
(18.1%
75 y);
Registries
n=114572
7 (38.3%
75 y)
Study
Interventio
n Group (n)
N/A
Study
Comparator
Group (n)
N/A
Patient Population
Inclusion
Criteria
Exclusion
Criteria
Clinical trial and

registry
specific- pooled
(VIGOUR)
included
GUSTO IIb,
PARAGON A
and B,
PURSUIT,
GUSTO IV-ACS
Registries=NR
MI 2-4,
CRUSADE,
GRACE
Clinical trial and

registry specific
Study
Interventio
n
Study
Comparator
Endpoints
Primary
Endpoint
(efficacy)
and Results
Clinical trial
specific
Clinical trial
specific
86
Too numerous
to list
Safety
Endpoint
and Results
Secondary
Endpoint
and Results
Serum
creatinine
inadequately
assesses agerelated renal
function
decline- CrCl
should be
calculated in all
older NSTEACS pts.
Excess
bleeding
related to
excess AP/AT
dose
Summarizes
available
evidence of
presentation,
treatment and
outcomes of
OA in RCTs
and
registries.
P Values,
OR: HR: RR
& 95% CI:
Study Limitations
& Adverse Events
Too
numerous to
list
Not a trial but an

important paper on
understanding mgt of
older pts. Older
NSTE-ACS are
underrepresented in
clinical trials and are
younger and have
less comorbidities vs.
older pts in registries
(and likely real
world) warranting
cautious
extrapolation of
results.
Gale 2012
(213)
22009446
Assess
difference in
risk factors,
presentation
,
managemen
t and
outcomes
across age
groups and
trends over
7 y in MI pts
in United
Kingdom
Devlin 2008
(214)
18387940
Determine
whether
increasing
age impacts
in-hosp and
6-mo
outcome of
revasc
therapy in
high-risk
NSTE-ACS
pts
included
Mixedeffects
regression
analysis
using data
from MINAP
registry in
United
Kingdom.
Comparison
across older
age groups
and over 7 y
Retrospectiv
e multiple
logistic
regression
analyses on
NSTE-ACS
pts in
GRACE
registry by
age groups
N=616
011 ACS
pts: age
<55
y=23%;55
64y=20%;
65-74
y=40%;
75-84
y=39%;
85
y=29%
N/A
N/A
ACS pts in
National Audit
registry with
outcomes
linked to
national
database. Pts
included if met
ACS definition
on admission
(diagnosis was
adjudicated but
did not exclude
pt if not ACS).
Missing data or
follow-up
N/A
N/A
Compared to
younger NSTEACS pts, older
pts had sig
higher in-pt
mortality rates,
longer rates of
stay and were
prescribed less
GDMT (med
and procedures)
despite same or
better efficacy
vs. young.
These age
discrepancies
have decreased
over time.
N/A
Too
numerous to
list include
effect of age
on presenting
symptoms,
comorbidities,
use of GDMT,
PCI,
outcome, and
trends over
time.
N=18466
NSTEACS pts
(27% 7080 y
elderly;1
6% >80 y
very
elderly)
Data
assessed by
use of GDMT
and early
invasive
treatment
(cath with
approp
revasc) by 3
age groups
In-hospital
and 6-mo
outcomes
compared for
age group
and by
intervention
GRACE registry
pts meeting
criteria for
NSTE-ACS who
had data during
hospitalization
and 6 mo after
discharge.
(STEMI data
also reported
but omitted
here)
Pts with non-CV

causes for the
clinical
presentation
such as trauma,
surgery, or
aortic aneurism,
were excluded.
Pts who
underwent
revasc during
initial
hospitalizatio
n classified
under revasc
included highrisk pts with
dynamic ECG
changes or
recurrent
ischemiaregardless of
timing of
revasc
strategy
Medical
therapy types
were
specifically
recorded for
comparison.
Age and
intervention
strategy were
compared.
In NSTE-ACS
pts, revasc vs.
medical therapy
sig lowered 6mo MACE
(stroke, death,
MI) and 6-mo
mortality. Older
NSTE-ACS pts
were sig less
likely to undergo
revasc (and
GDMT) than
younger pts.
N/A
Elderly and
very elderly
pts less likely
than younger
pts to receive
GDMT
87
Inpatient
mortality from
2003-2010
across all age
groups
including pts
85 y age:
OR, 95% CI:
2004: 0.94,
0.881.01;
2010: 0.52,
0.440.61;
7584 y age:
2004: 0.98,
0.931.03;
2010: 0.52,
0.450.60,
and pts ,55 y
age: 2004:
0.94, 0.79
1.13; 2010:
0.64, 0.44
0.93
Revasc vs.
no revasc 6mo MACE
<70 yo
OR=0.69,
95% CI 0.56
0.86; 70-80 y
OR=0.60,
95% CI 0.47
0.76; >80 y
OR=0.72,95
% CI,0.54
0.95
Revasc vs.
no revasc 6mo mortality:
<70 y
OR=0.52,
Diverse sample of
hospital in United
Kingdom but less in
Wales- not all pts
entered into MINAP.
Approx. 4% missing
data.
Although study
reports benefit of
early invasive
therapy, pts who
underwent
PCI/CABG during
admission were
included including
those who underwent
revasc >24 h after
admission and highrisk pts were also
included (including
dynamic ST changes,
recurrent ischemia)
Damman 2012
(215)
21930723
To assess
the impact
of early
invasive vs.
early
conservative
stragety on
long term
outcomes (5
y) in older
NSTE-ACS
pts
Metaanalyses of
FRISC II,
ICTUS and
RITA-3
studies
N=5467
NSTEACS pts
(51.3%
<65 y,
33.3%
65-74 y,
15.3%
75 y)
Early
Invasive:
<65 y=1383
65-75 y=901
75 y=437
Selective
invasive (EC):
<65 y =1424
65-75 y=920
75 y=402
Pts enrolled in
FRISC II,
ICTUS and
RITA-3 with
follow-up data
were included.
Those with
missing data for
specific
analyses
Routine
invasive
strategy
defined as
card cath
within 24-48 h
in ICTUS trial,
within 72 h in
RITA-3 trial
and within 7 d
with
subsequent
revasc when
appropriate.
Initial medical
treatment
with card
angio and
revasc only if
refractory
angina
despite OMT,
hemodynamic
instability or
positive
stress
(ICTUS and
FRISC II)
Routine invasive
strategy sig
reduced 5-y
MACE
(death/MI) in 6574 and 75 y
but not in those
<65 y.
Bach 2004
(216)
15289215
To assess
impact of
age and
early
invasive vs.
initial
conservative
strategy on
outcomes in
NSTE-ACS
pts
Prespecified
subgroup
analyses by
age strata of
TACTICS
TIMI 18, a
RCT
evaluating
Early
Invasive vs.
Initial
Conservativ
e strategy in
NSTE-ACS
pts
N=2220
NSTEACS pts:
<65
y=1258
65
y=962
Early
Invasive:
<65 y=623
65 y=491
Early
Conservative:
<65 y=635
65 y=471
Pts with NSTEACS eligible for

card
cath/revasc
Persistent STE;
2 angina; PCI
or CABG within
previous 6 mo;
contain to AP
and GP meds.
Stroke/TIA;
LBBB or paced
rhythm, CHF or
cardiogenic
shock; clinically
important
systemic
disease; SCr
>2.5 mg/dL)
Coronary
angiography
4-48 h after
randomizatio
n and have
revasc when
appropriate
All pts
received ASA
325 mg, UFH
and tirofiban.
Pt received
ASA 325 mg,
UFH and
tirofiban,
treated
medically
and, if stable,
underwent
ETT before
discharge.
Card angio in
pts w failure
of OMT or
stressinduced
ischemia
Among pts 75
y, Early Invasive
vs. Initial
Conservative
strategy
conferred an
absolute
reduction
(10.8% vs.
21.6%; p=0.016)
and relative
reduction of
56% in death or
MI at 6 mo.
RR=0.61 in
death/MI at 6
mo for Early
88
In-hosp
bleeding rates
sig higher in
older pts: <65
y=1.7%; 65-74
y=2.2%; 75
y=6.1%
(p<0.001 for
trend).
Bleeding rates
higher in each
age group with
Routine
invasive vs.
Selective
Invasive
strategy but all
p>0.1
Major bleeding
rates higher
with Early
Invasive vs.
Initial
Conservative
strategy in pts
75y (16.6%
vs. 6.5%;
p=0.009); Sig
higher minor
bleeding rates
and trasfusions
w Early
Invasive vs.
Initial
Conservative
The benefits
were smaller
for women
than for men
but sample
size small
(esp 75)
underpowere
d for gender
and age
analyses
Sig reduction
in 30-d
outcomes of
MI, death/MI,
ACS Rehosp
and MACE
for NSTEACS pts 75
y (none were
sig for pts
<65 y)
95% CI 0.37
0.72; 70-80
OR=0.38,95
%CI 0.26
0.54; >80 y
OR=0.68,9%
CI 0.490.95
Routine
Invasive vs.
Selective
Invasive on 5y death/MI:
<65 y (HR
1.11, 95% CI
0.90 to 1.38),
65-74 y (HR
0.72, 95% CI
0.58-0.90);
75 y (HR
0.71, 95% CI
0.55-0.91)
NSTE-ACS
pts 75 y
Early Invasive
vs. Initial
Conservative
6-mo
outcomes:
Death/MI:
RR=0.61
(0.410.92)
MI: 0.49
(0.290.81)
Death:
RR=0.88
(0.511.53)
ACS Rehosp:
RR=0.75
Trials had different

time windows for
routine invasive
strategy (up to 7 d in
FRISC II) and other
between trial
heterogeneity exists
TACTICS-TIMI 18
excluded pts with
multiple comorbidities and
marked renal
dysfunction (included
older pts with mild
renal dysfunction by
CrCl). Underpowered
for many
comparisons in older
pts. Additional age
group beyond single
65-y stratification
were not prespecified
and done post hoc
Yourman
(217)
22235089
Assess
quality and
limitations of
prognostic
indices for
mortality in
older adults
through
systematic
review.
Extensive
literature
review of
prognostic
indices for
mortality (6
m-5 y) in pts
age 60 y
N=21,593
titles
reviewer
N/A
N/A
Prognostic
indiex studies
included if they
validated and
predicted
absolute risk of
mortality in pts
whose average
age 60 y
Studies were
excluded if
prognostic index
estimated
intensive care
unit, diseasespecific, or inhospital
mortality.
N/A
N/A
Fenning 2012
(218)
Compare
utility of
palliative
care
prognostic
tool GSF
and GRACE
score, to
help identify
patients
approaching
EoL
Single site
study of
consecutive
pts admitted
with NSTEACS ptscompared
12-mo
outcome vs.
prog tool
estimate of
EoL care.
N=172
NSTEACS pts,
of these
compared
n=40 pts
identified
by GSF
with n=32
by
GRACE
score
N/A
N/A
172
consecutive,
unselected pts
admitted for
NSTE-ACS to
urban hosp
over 8 wk
Pts admitted
with ACS who
died in hospital
were excluded
from analysis.
N/A
N/A
22530044
89
Invasive vs.
Initial
Conservative in
NSTE-ACS pts
65 y but no sig
diff in 6-mo
outcome seen in
pts <65 y
16 prognostic
indices identified
predicting
overall mortality
(6 m-5 y) in diff
pt groups/
settings
including
community,
nursing home
and hospital. 2
were validated.
in 75 y
N/A
Reports
potential
sources of
bias for each
measure
GSF identified
40 pts (23%)
meeting criteria
for approaching
EoL (GSF+
older, more
comorb vs.
GSF-). 1-y
mortality: GSF+
vs. GSF- (20%
vs. 7%, p=0.03).
GRACE
identified 32
(19%) pts with
10% risk of
N/A
GSF and
GRACE
positive score
both
independently
associated
with
increased
number of
comorbidities,
readmissions,
older age.
(0.501.11)
MACE
RR=0.75
(0.541.03)
None of 6 mo
outcomes sig
in NSTE-ACS
pt <65 y
Identified
mortality
predictors for
older adults
need
additional
external
validation but
may be useful
in comparing
efficacy of
treatment/inte
rvention
recommendat
ion (time to
benefit) vs.
life
expectancy in
older pts.
GRACE
score 12-mo
mortality
prediction (Cstatistic 0.75)
+ prev hosp
adm and
stroke (Cstatistic 0.88).
GRACE
(upper
tertile)+GSF
Sens=78%,
Spec=89%,
NPV= 97%,
N/A
Single-center study,
additional validation
studies needed.
death within 6
mo. GRACE
score at
discharge highly
predictive of 12mo mortality and
associated with
readmission
during subseq y.
Improved by
adding prev
hosp adm and
prev stroke hx.
Tinetti 2004
(219)
15625341
Corsonello
2010
(220)
20015034
Trifiro 2011
(221)
21495972
Alexander
2005
(222)
16380591
PPV=44%
This is a very relevant expert/consensus opinion paper, but is not a study which can be put into a data supplement table.
This reference is an extensive review and summary of major PD/PK changes with aging and their relevance to CV drugs. However, it is not amenable to list in data supplement format.
This reference is an extensive review and summary of major PD/PK changes with aging and their relevance to CV drugs. However, it is not amenable to list in data supplement format.
Investigation
of
relationship
between
UFH, LMWH
and GPI
excess
dosing and
major
outcomes
Retrospectiv
e
exploratory
analysis of
CRUSADE
registry
N=30,136
NSTEACS pts
who
received
AT
agents
N/A
N/A
NSTE-ACS pts
in CRUSADE
registry who
had received
AT agents
Pts with missing

weight (n=826)
or missing
creatinine
clearance
(n=1120) data
excluded from
dosing
calculations that
required these
variables. Pt
who were
transferred or
underwent
CABG excluded
from bleeding
anal.
N/A
N/A
90
42% of NSTEACS pts

received 1
initial dose of AT
agent outside
rec range.
Excess doses
per agent:
UFH+32.8%,
LMWH=13.8%
and GPI=26.8%.
Excess dose
assoc with older
age, female, low
body wt, DM
and CHF. Pt
who received
excess AT dose
had higher
15% of major
bleeding in
NSTE-ACS pts
attributable to
excess AT
dosing
Higher adjust
mortality in
those
receiving
excess vs.
recomm dose
of GPI
(OR=1.50,
95% CI 1.012.17). LOS
sig longer in
pts given
excess vs.
rec doses of
UFH, LMWH
and GPI.
Adjusted OR
for major
bleeding with
excess
dosing (vs. no
excess
dosing):
UFH: OR:
1.08 (0.941.26)
LMWH: OR:
1.39 (1.111.74)
GPI: OR:
1.36 (1.101.68)
Dosing categories
based on weight and
renal function dosing
(dependent on
recorded data)
studied population
may vary from those
with missing data in
addition to limited
generalizability to
general NSTE-ACS
pts in real world, esp
older.
Lincoff 2003
(223)
12588269
Determine
efficacy of
bivalrudin
+GPI vs.
GPI+UFH
for PCI on
periproc
ischemia
and
bleeding
RCT,
double-blind
trial in pt
undergoing
urgent or
elective PCIprespecified
for noninferiority
N=6010
Bival+GPI2999
UFH+GPI=30
11
Pts 21 y
undergo PCI
with approved
device
PCI performed
as reperfusion
therapy for AMI,
poorly controlled
Htn, unprotected
LM, PCI w/I past
mo., risk for
bleeding, serum
Cr >4 mg/dL,
prior heparin tx.
Lopes RD,
2009
(224)
19298914
Evaluate
impact of
age on
antithrombot
ic strategy
and
outcomes in
moderate
and highrisk NSTEACS pts
Prespecified
analysis of
30-d and 1-y
outcomes in
4 age
groups,
overall and
among
those
undergoing
PCI
Of 13,819
ACUITY
pts, 3,655
(26.4%)
were <55
y, 3,940
(28.5%)
were 5564 y,
3,783
(27.4%)
were 6574 y, and
2,441
(17.7%)
were 75
y.
Of the pts in
each age
group (prev
column), 1/3
were
randomized
to receive
bival alone
Of the pts in
each age
group (4th
column), 1/3
were
randomized
to receive
Hep+GPI
NSTE-ACS pts
at moderate or
high risk for
adverse clinical
outcomes at 30
d. All pts
underwent cath
w/I 72 h of
admission
Pts excluded for

any of following:
STEMI, recent
bleeding, CrCl
<30 mg/mL,
thrombocytopeni
a, shock, recent
use of
abciximab,
warfarin,
fondaparinux,
bival, LMWH,
fibrinolytics
Bivalrudin
0.75 mg/kg
bolus + 1.75
mg/kg/hr inf
during PCI
with
provisional
GPI
Pts received
ASA and
thienopyridine
for 30 d
post PCI
Bivalrudin
alone
All pts- ASA+
mtn
Clopidogrel
post PCI 1
y
Clopidogrel
load per
invest
UFH 65 U/kg
bolus+ GPI
(abciximab or
eptifibitide)
Pts received
ASA and
thienopyridine
for 30 d
post PCI
Bivalrudin+
GPIrandomized
(22 factorial)
to upstream
or cath lab
GPI admin
Heparin +GPI
randomized
(22 factorial)
to upstream
or cath lab
GPI admin
All pts- ASA+
mtn
Clopidogrelpo
st PCI 1-y
Clopidogrel
load per
invest
91
bleeding rate,
mortality and
length of stay
vs. those given
rec dose.
Provisional GPI
given to 7.2%
Bil pts.
Noninferiority
statistically
achieved in 30 d
endpoint:
MI/death/
revasc/ in-hosp
major bleeding
between
BiV+GPI vs.
UFH+GPI
Mortality and
composite
ischemic
outcomes at 30
d and 1 y were
not statistically
different in pts
randomized to
bivalirudin alone
or randomized
to heparin with
GP IIb/IIIa
inhibitors across
all age
categories.
In Hosp major
bleeding rates
sig lower in
Biv+GPI vs.
UFH+GPI
(2.4% v 4.1%,
p<0.001)
30 d
death/MI/reva
sc: no diff in
MACE
BiV+GPI vs.
UFH+GPI
(OR=0.90,
p=0.4)
30 d
death/MI/reva
sc/in-hosp
major
bleeding:no
diff in MACE
in BiV+GPI v
UFH+GPI
(OR=0.92,
p=0.32).
Included elective PCI

NSTE-ACS pts
approx. 42% each
arm + 30% positive
stress test; 13% 75
y
Major bleeding
increased in
each age
group
regardless.
Major bleeding
rates were
higher in PCI
pts in the age
groups: 3.4%,
5.1%, 5.5%,
and 11.8%, for
ages <55, 5564, 65-74, and
75 y,
respectively.
Rates were
signif lower in
those treated w
Bivalrudin
alone in each
age group
Older pts had

more comorb,
were more
often female,
weighed less,
and had more
hypertension,
prior cerebral
vascular
disease, renal
insufficiency
(creatinine
clearance
50 mL/min),
and prior
CABG
Number
needed to
treat with
bivalirudin
alone to avoid
1 major
bleeding
event was
lower in pts
75 y (23
overall and
16 for PCItreated pts)
than in any
other age
group.
N/A
Lemesle G,.
2009
(225)
19360860
Analyze
impact of
replacing
heparin with
bivalirudin in
octogenaria
ns
undergoing
PCI on postprocedure
hemorrhage
and 6-mo
mortality.
Single
center
retrospectiv
e
observation
al analyses
of
consecutive
pts 80 y
who
underwent
PCI
N=2766
N=1,207
(43.6%)
received
bivalrudin
N=1,559
(56.4%).recei
ved UFH
Consecutive pts
80 y at single
center who
underwent
PCI/stent from
2000-2007
None
Summaria F,
2012
(226)
22476002
To
explorefeasi
bility and
safety of
PCI via
transradial
approach
and
intraprocedu
ral
bivalirudin in
>70 y MI pts
Retrospectiv
e analyses
of data from
consecutive
ACS pts >70
y with Early
Invasive
strategy via
transradial
approach
with
bivalrudin as
AT.
N=84 pts
(22 male;
52 pts
>80 y)
STEMI=5
3,
NSTEMI=
31
All pts were

treated with
bivalrudin and
via tranradial
approach
N/A
Consecutive pt
>70 y with ACS
treated with EI
strategy using
tranradial
approach and
bivalrudin as AT
regimen.
None
McKellar SH,
2008
(227)
18825133
To assess pt
characteristi
cs,
procedural
success,
Systematic
review and
metaanalyses of
66 studies of
N=66
studies
(65,376
pts, 56%
male)
35 CABG
studies
32 PCI
studies
Studies which
included
baseline
characteristic
and outcomes
Studies that
reported
combined CABG
and valve
operations or
Bivalrudin
(dose not
reported) at
operators
discretion.
GPI given at
operators
discretion.
ACT target
>250 s
All pts
received ASA
325 mg,
clopidogrel
300 mg load
then 75 mg
qd mtn
advised for 1
y
Bivalrudin
bolus dose of
0.75 mg/kg
immediately
followed by
continuous
infusion of
1.75 mg/kg/h.
All pts
received ASA
300 mg,
clopidogrel
600 mg, UFH
bolus and
infusion in
emer dept
stopped 6 h
prior to PCI
CABG
without
additional
procedure
(i.e. valve
UFH (dose
not reported)
at operators
discretion.
GPI given at
operators
discretion.
ACT target
>250 s
All pts
received ASA
325 mg,
clopidogrel
300 mg load
then 75 mg
qd mtn
advised for 1
y
Overall inhospital
bleeding and 6mo mortality
rates were 4.6%
and 11.8%,
respectively.
Bival vs. UFH
reduced 6 mo
mort (8.8% vs.
13.4%,
p=0.003). Bival
was assoc with
sig less in-hosp
bleeding rate
(2.2% vs. 6.8%,
p< 0.001).)
After
propensity
score
matching, bival
sign reduced
periproc
bleeding vs.
UFH
(HR=0.38,
95% CI=0.22
0.65, p=0.001).
Bival vs. hep
reduced 6 mo
MACE (10.1%
vs. 20.2%,
p<0.001)
In-hospital
major
bleeding
assoc with 6mo mortality
HR=2.5,
95%CI=1.6
3.9, p<0.001)
N/A
Transradial
approach
successful in
100%, manual
thrombus aspir
in 52% of
NSTEMI pts.
Transfusions=0,
sign bleeding
events=1 (GI
bleed), in-pt
mort=0,30 d
MACE=5 (6%, 1
death, 2 MI, 2
TLR)
N/A
PCI with last

enrollment
1997
30-d mort CABG

vs. PCI (7.2% v
5.4%). 1-y
survival:
CABG=86%
3 y survival
CABG 78%
(74%82%) v
PCI 78%
(68%87%), 5
92
Non-randomized
observational study.
Doses not reported.
Differences in
baseline
characteristicspropensity analyses
used.
N/A
Bival vs. UFH

reduced 6-m
mortality
HR=0.6, 95%
CI=0.40.9,
p=0.01) Inhosp bleeding
Bival vs.
UFH: HR=
0.41, (95%
CI=0.23
0.73,
p=0.003) by
MRL anal.
and by
multivar COX
(HR=0.6,
95% CI= 0.4
0.9, p=0.01)
N/A
Greater
number of
reintervention
s post PCI vs.
CABG.
Univariate
analysis
showed that
CABG, male
gender,
Clinical trials
comparing PCI vs.
CABG enrolled
younger pts of lower
risk with less
Pilot feasibility study

in very elderly cohort.
Single center, no
comparison group.
Kimura T,
2008
(228)
18824755
complication
s and
outcomes of
80 y who
undergo PCI
vs. CABG
coronary
revasc in
80 y
(subgroup
anal by
revasc type)
Assess
long-term
outcomes
between
PCI vs.
CABG in
younger and
older pts
(75 y)
Retrospecitv
e analyses
of
multicenter
registry
(CREDOKyoto) of
consecutive
pts
undergoing
1st PCI or
N=9,877
enrolled,
5420
(PCI:
3712,
CABG:
1708) had
multivess
el disease
without
left main
CABG=1,708
75 y, (21%)
80 y (6%)
PCI=3,712
75 y (27%)
80 y (12%)
in 80 y
undergoing
revasculariztion
(PCI vs. CABG)
with 30-d
survival
(English lang)
studies where
baseline clinical
data or
outcomes were
not reported
separately were
excluded.
replacement),
last enrolled
1996
Consecutive pts
undergoing 1st
PCI or CABG
and excluding
those pts with
AMI within wk
before index
procedure.
Pts undergoing
concomitant
valvular, left
ventricular, or
major vascular
operation were
excluded from
the current
analysis. Pts
with disease of
the left main
N/A
N/A
93
(83%88%) vs.
PCI 87%
(84%91%)
y survival
CABG 68%
(62%73%) v
PCI 62%
(46%77%),
75 y of age: 3y survival
adjusted for
baseline char
favored CABG
(HR for death
PCI vs. CABG
HR=1.23 (0.991.53, p=0.06),
but not for
younger pts
Stroke rate
higher in 4 y
follow-up in
CABG vs PCI
75 y: Adj
HR for death
PCI vs.
CABG
prespecifieds
ubgroups:
DM HR= 1.85
(1.13.12)
p=0.02
All-cause
death cum
multivessel
disease, and
abnormal
LVEF
predicted 30d mortality.
Being treated
more
recently,
having
nonelective
status, and
having DM
were
protective.
The only
univariate
predictor of
decreased
survival at 1 y
was CABG
(p=0.005); a
more recent
date of
enrollment
(p=0.003)
and diabetes
(p<0.001)
were
protective
factors.
75 y of age:
3-y survival
adjusted for
baseline char
favored
CABG HR for
death PCI vs.
CABG
HR=1.23
[0.99-1.53,
p=0.06], but
comorbidities, 65 of
66 studies
observational, Older
studies w/o DES
Nonrandomized
Meta-analyses
performed in BMS
era, non-urgent
cases only
Dacey LJ,
2007
(229)
18036905
Compare
long-term
survival after
PCI vs.
CABG in
80 y
CABGstratified by
age <75 vs.
75 y
involveme
nt.
Retrospectiv
e
observation
al analyses
of regional
(New
England)
registries of
consecutive
80-89 y pts
(1992-2001)
who
underwent
PCI or
CABG but
eligible for
both
N=1693 (
57% 2V
CAD,
42.3% 3V
CAD
without
LM
disease.
coronary artery
and with singlevessel disease
were excluded.
CABG=991
(2VCAD=443,
3VCAD=548)
80-84 y=83%
85-89=17%
PCI=702
(2VCAD=532,
3VCAD=170)
80-84 y=72%
85-89=27%
Pts undergoing
emergent
procedure or
<24 h of MI,
those with left
main disease, or
sig valve
disease.
N/A
BMS era
incidence:
1 y: PCI 9%
vs. CABG
8.8%
2 y: PC
15.4% vs.
CABG 12.2%
3 y: PCI
20.7% vs.
CAGB 13.3%
4y: PCI
22.7% vs.
15.5%
CABG pts
were more
freq male,
had more
PVD and
CHF and less
renal failure
and prior MI.
not for
younger pts
(HR=1.09,
p=0.55)
In-hospital
N/A
In-hospital
Nonrandomized
mortality:
mortality:
PCI=3.0% vs.
PCI=3.0% vs. Analyses performed
CABG= 5.9%
CABG= 5.9% in BMS era. Regional
(p=0.005). 6-mo
(p=0.005). 6- data. Limited data in
survival: CABG
mo to 8-y
older half of cohort
vs. PCI
survival- all
and those with
(HR,1.32;
pts: CABG
3VCAD.Various
p=0.135).
vs. PCI (HR,
revasc indications.
6-mo to 8-y
0.72;
survival- all pts:
p=0.005)
CABG vs. PCI
(HR, 0.72;
p=0.005) and for
pts with 2VCAD
(HR, 0.68;
p=0.016).
3VCAD
(HR=0.75,
p=0.17)
2 indicates secondary; 2VCAD, double-vessel coronary artery disease ; 3VCAD, triple-vessel coronary artery disease; ACC-NCDR indicates American College of Cardiology National Cardiovascular Data Registry; ACE, angiotensin-converting enzyme; ACS, acute
coronary syndromes; ACUITY, Acute Catheterization and Urgent Intervention Triage Strategy; AMI, acute myocardial infarction; AP, antiplatelet; ASA, aspirin; AT, antithrombins; BARI, Bypass Angioplasty Revascularization Investigation; BEIR, Biological Effects of
Ionizing Radiation; BMS, bare metal stent; CHF, congestive heart failure; CABG, coronary artery bypass graft; CAD, coronary artery disease; CANRACE, Canadian Registry of Acute Coronary Events; cath, catheterization; CHF, congestive heart failure; CR, creatinine;
CrCl, creatinine clearance; CREDO-Kyoto, Coronary Revascularization Demonstrating Outcome Study in Kyoto; CRUSADE, Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the American College of
Cardiology/American Heart Association Guidelines; CT, computed tomography; CTCA, Cancer Treatment Centers of America; DES, drug-eluting stent; DM, diabetes mellitus; EoL, end of life; EPR, electronic patient record; EPS, electrophisiology study; ETT, Exercise
tolerance testing; FRISC, Framingham and Fast Revascularization During Instability in Coronary Artery Disease; GDMT, guideline-directed medical therapy; GI, gastrointestinal; GP, glycoprotein; GPI, glycoprotein IIb/IIIa inhibitors; GRACE; Global Registry of Acute
Coronary Events; GSF, Gold Standards Framework; GUSTO, Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries; HF, heart failure; HTN, hypertension; Hx, history; ICTUS, Invasive versus Conservative Treatment in
Unstable Coronary Syndromes; LAR, life attributable risk; LBBB, left bundle branch block; LOS; length of stay; LVEF, left ventricular ejection fraction; MACE, major adverse cardiac event; MI, myocardial infarction; MINAP, Myocardial Ischaemia National Audit Project;
MPI, myocardial perfusion imaging; MUGA, Multigated Wall Motion Study; N/A, not applicable; NPV, negative predictive value; NS, not significant; NRMI, National Registry of Myocardial Infarction; NSTE-ACS, non-ST-elevation acute coronary syndrome; NSTEMI, non American Heart Association, Inc and American College of Cardiology Foundation
Pts included
were 80-89 y
with 2 or 3
VCAD (>70%
stenosis),
eligible for 1st
PCI or CABG.
(BARI criteria)
(HR=1.09,
p=0.55); 3VCAD
Cox survival
favors CABG vs.
PCI (p=0.004)
94
ST-elevation myocardial infarction; OA, osteoarthritis; OMT, optimal medical therapy; PCI, percutaneous coronary intervention; PET, positron emission tomography; PPV, positive predictive value; pts, patients; PVD, peripheral vascular disease; RITA, Randomized Trial
of a Conservative Treatment Strategy Versus an Interventional Treatment Strategy in Patients with Unstable Angina; RBC, red blood count; revasc, revascularization; RR, relative risk; Rx, prescription; SCr, serum creatinine; Sx, symptom(s); TACTICS, Treat Angina
With Tirofiban and Determine Cost of Therapy With an Invasive or Conservative Strategy; TIA, transient ischemic attack, TIMI, Thrombolysis In Myocardial Infarction; UFH, unfractionated heparin; U.S., United States; and VIGOUR, Virtual Coordinating Center for Global
Collaborative Cardiovascular Research.
Data Supplement 25. Heart Failure (Section 7.2)
Study Name,
Aim of study
Study
Type
Author, Year
Study
Size (n)
Study
Intervention
Group (n)
Study
Comparator
Group (n)
Patient Population
Inclusion
Criteria
Study
Interventi
on
Study
Comparat
or
Exclusion
Criteria
Endpoints
Primary Endpoint
(efficacy)
and Results
Boersma 2000
(2)
10840005
Develop a
model for
predicting 30d death and
myocardial
(re)infarction
in pts without
STE-ACS
Retrospecti
ve analysis
of pts with
NSTE-ACS
enrolled in
PURSUIT
trial
(n=9,461;
3.6% with
1
outcome)
N/A
Pts enrolled
in PURSUIT
trial
Pts not
enrolled in
PURSUIT
trial; pts with
STE on initial
ECG
N/A
1 outcome: 30d death; 2

outcome:
composite of 30d death and
myocardial
(re)infarction;
More than 20
variables were
found to be
predictive of 1
and 2
outcomes
N/A
N/A
There were 7 factors

most predictive of
death: age (adjusted
[]2=95), heart rate
([]2=32), SBP
([]2=20), STsegment depression
([]2=20), signs of
HF ([]2=18), and
cardiac markers
([]2=15); The Cindex for the
mortality model was
0.814
Granger 2003
(3)
Develop a
regression
Retrospecti
ve
N/A
Inclusion in
GRACE or
Not included
in these trials
N/A
Adverse event
defined as in-
N/A
N/A
The discrimination
ability of the
95
Safety
Endpoint
and
Results
N/A
N/A
P Values,
OR: HR: RR &
95% CI:
Study Limitations
& Adverse Events
Develop a model
for predicting 30-d
death and
myocardial
(re)infarction in
pts without STEACS
Retrospective
analysis of pts with
NSTE-ACS enrolled
in PURSUIT trial
(n=9,461; 3.6% with
1 outcome)
Develop a
regression model
Retrospective
observational study
Secondary
Endpoint
and Results
Regression
model
developed in pts
with diagnosed
ACS and not
designed to be
applied
indiscriminately
to
undifferentiated
chest pain pts;
difficult to
calculate;
original model
requires
preexisting
programmed
calculator;
simplified
version requires
print-out of
scoring system
for each variable
with
corresponding
figure to
interpret data
Regression
model
14581255
model in pts
with
diagnosed
ACS
(including pts
with STEMI)
for in-hospital
mortality
observation
al study
utilizing pts
from
GRACE
(n=11,389;
509
deaths);
validation
set
included a
subsequent
cohort of
3,972 pts
enrolled in
GRACES
and 12,142
pts enrolled
in GUSTOIIb trial
Pollack 2006
(13)
16365321
Validation in
an ED
population
with chest
pain
Attempt to
add creatinine
to TIMI risk
score
Across all
ACS
spectrum
Convenien
ce sample
N=3,326
without
new STE
Single
center
N=798
N/A
Chest Sx and
ECG
obtained
New STE
N/A
Death/MI/revasc
over 30 d
N/A
In-hospital
and 14-d
events
N/A
Ischemic Sx
within 48 h
STEMI
N/A
N/A
N/A
Multicenter
RCT with
N=1,491
N/A
NSTE, ACS
and STEMI
N/A
N/A
CV death, MI,
urgent revasc or
Sx and elevated
biomarkers
6-mo death and
MI
N/A
N/A
Go 2011
(14)
21691204
Huynh 2009
(15)
19960136
GUSTO-IIb
trial
hospital
mortality;
Regression
model identified
the following 8
independent risk
factors:accounte
d age, Killip
class, SBP, STsegment
deviation,
cardiac arrest
during
presentation,
serum creatinine
level, positive
initial cardiac
enzyme
findings, and
heart rate
96
simplified model was

excellent with Cstatistics of 0.83 in
the derived
database, 0.84 in the
confirmation GRACE
data set, and 0.79 in
the GUSTO-IIb
database; OR for the
8 independent risk
factors were: age (
OR: 1.7 per 10 y),
Killip class (OR: 2.0
per class), SBP (OR:
1.4 per 20 mmHg
decrease), STsegment deviation
(OR: 2.4), cardiac
arrest during
presentation (OR:
4.3), serum
creatinine level (OR:
1.2 per 1 mg/dL
[88.4 mol/L]
increase), positive
initial cardiac
enzyme findings
(OR: 1.6), and heart
rate (OR: 1.3 per 30
beat/min increase)
Graded relationship
between score and
events
Renal dysfunction
increased risk but
not enough to add
variable to system
2 mm ST deviation
increased risk and
risk was less
developed in
patients with
diagnosed ACS
(including
STEMI pts) and
was not
designed to be
applied
indiscriminately
to
undifferentiated
chest pain pts;
difficult to
calculate;
original model
requires preexisting
programmed
calculator;
simplified
version requires
print-out of
scoring system
for each variable
with
corresponding
nomogram
in pts with
diagnosed ACS
(including pts with
STEMI) for inhospital mortality
utilizing pts from

GRACE (n=11,389;
509 deaths);
validation set
included a
subsequent cohort
of 3,972 pts enrolled
in GRACES and
12,142 pts enrolled
in GUSTO-IIb trial
N/A
Used parts of
score to define
management
Validation in an
ED population
with chest pain
Convenience
sample N=3,326
without new STE
N/A
Small and only

9% with eGFR,
30
Attempt to add
creatinine to TIMI
risk score
Single center N=798
N/A
All high-risk pts
Across all ACS

spectrum
Multicenter RCT with

N=1,491 from
angiographic arm
Eagle 2004
(16)
15187054
Eggers 2010
(17)
20598977
Original
GRACE
validation
Incremental
prognostic
value of
multiple
biomarkers in
NSTE-ACS
Cannon 2001
(186)
11419424
To compare
an early
invasive
strategy to a
more
conservative
approach
from
angiographi
c arm
Registry
N=17,141
regardless of score
with less
N/A
All ACS
N/A
N/A
6-mo all-cause
mortality
N/A
N/A
p<0.25 into
multivariate model
N/A
Single
center trial
of 453
chest pain
pts
NTproBNP,
cystatin
GDF-15
Possible ACS
N/A
Biomarkers
at
presentation
All-cause
mortality at 6 mo
N/A
ROC analysis
N/A
Prospective
,
randomized
,
multicenter
trial 2,220
Interventi
on: 1,114
vs.
Compara
tor:
1,106
Pts 18 y if
they had
episode of
angina (with
accelerating
pattern or
prolonged
[>20 min] or
recurrent
episodes at
rest or with
minimal
effort) within
preceding 24
h, candidates
for coronary
revasc, and
at least 1 of
the following:
new finding of
ST-segment
depression of
at least 0.05
mV, transient
(<20 min)
STE of at
least 0.1 mV,
or T-wave
inversion of
Persistent
STE, 2
angina, Hx of
PCI or CAB
grafting within
preceding 6
mo, factors
associated
with increased
risk of
bleeding,
LBBB or
paced rhythm,
severe CHF
or cardiogenic
shock, serious
systemic
disease, a
serum
creatinine
level of <2.5
mg/dL (221
mol/L), or
current
participation in
another study
of an
investigational
drug or device
Pts assigned
to early
invasive
strategy were
to undergo
coronary
angiography
between 4 h
and 48 h
after
randomizatio
n and revasc
when
appropriate
on the basis
of coronary
anatomical
findings
Pts assigned to
early
conservative
strategy were
treated
medically and, if
their condition
was stable,
underwent an
exercisetolerance test
(83% of such
tests included
nuclear
perfusion
imaging or
echocardiograp
hy performed
according to the
protocol of the
institution)
before being
discharged
Combined
incidence
of death,
nonfatal
MI, and
rehospitali
zation for
an ACS at
6 mo
NT-proBNP
not
additive,
cystatin
minimally
and GDF15 helpful
Bleeding
Death, death or MI,

fatal or nonfatal MI,
rehospitalization for
MI
At 6 mo,
the rate of
the 1
endpoint
was 15.9%
with use of
the early
invasive
strategy
and 19.4%
with use of
the
conservativ
e strategy
(OR: 0.78;
95% CI:
0.62-0.97;
p=0.025).
97
Registry data,
200 pts without
6 mo follow-up
Small but 92
deaths.
Original GRACE
validation
Registry N=17,141
Incremental
prognostic value
of multiple
biomarkers in
NSTE-ACS
Single center trial of

453 chest pain pts
Study excluded
pts with severe
comorbid
conditions or
other serious
systemic illness
To compare an
early invasive
strategy to a more
conservative
approach
Prospective,
randomized,
multicenter trial
2,220
de Winter 2005
(188)
16162880
To compare
an early
invasive
strategy to a
selectively
invasive
strategy for
pts who have
ACS without
STE and with
an elevated
cTnT level
RCT 1,200
Interventi
on: 604
vs.
Compara
tor: 596
at least 0.3
mV in at least
2 leads;
elevated
levels of
cardiac
markers; or
coronary
disease, as
documented
by Hx of cath,
revasc, or M
Eligible pts
have all 3 of
the following:
Sx of
ischemia that
were
increasing or
occurred at
rest, with the
last episode
occurring no
more than 24
h before
randomizatio
n; elevated
cTnT level
(0.03 g/L);
and either
ischemic
changes as
assessed by
ECG (defined
as STsegment
depression or
transient STE
exceeding
0.05 mV, or
T-wave
inversion of
Exclusion
criteria were
an age >18 y
or <80 y,
STEMI in past
48 h,
indication for
1 PCI or
fibrinolytic
therapy,
hemodynamic
instability or
overt CHF,
the use of oral
anticoagulant
drugs in past
7 d, fibrinolytic
treatment
within past 96
h, PCI within
the past 14 d,
contraindicatio
n to treatment
with PCI or
GP IIb/IIIa
inhibitors,
recent trauma
or risk of
bleeding,
hypertension
Pts assigned
to early
invasive
strategy were
scheduled to
undergo
angiography
within 24-48
h after
randomizatio
n and PCI
when
appropriate
on the basis
of the
coronary
anatomy
Pts assigned to
the selectively
invasive
strategy were
treated
medically. Pts
were scheduled
to undergo
angiography
and subsequent
revasc only if
they had
refractory
angina despite
optimal medical
treatment,
hemodynamic or
rhythmic
instability, or
clinically
significant
ischemia on the
predischarge
exercise test.
1
endpoint
was
composite
of death,
RMI, or
rehospitali
zation for
angina
within 1 y
after
randomizat
ion
Bleeding
98
Percentage of pts
free from anginal Sx
Estimated
cumulative
rate of 1
endpoint
was 22.7%
in the
group
assigned
to early
invasive
manageme
nt and
21.2% in
the group
assigned
to
selectively
invasive
manageme
nt (RR:
1.07; [0.871.33];
p=0.33).
Revasc rates
were high in the
2 groups in our
study (76% in
the earlyinvasivestrategy group
and 40% in the
selectivelyinvasivestrategy group
during the initial
hospitalization,
and 79% and
54%,
respectively,
within 1 y after
randomization
To compare an
early invasive
strategy to a
selectively
invasive strategy
for pts who have
ACS without STE
and with an
elevated cTnT
level
RCT 1,200
Fox KA 2002.
(187)
12241831
To compare
interventional
strategy and
conservative
strategy in pts
with unstable
CAD
RCT 1,810
Interventi
on: 895
vs.
Compara
tor: 915
0.2 mV in 2
contiguous
leads) or
documented
Hx of CAD as
evidenced by
previous MI,
findings on
previous
coronary
angiography,
or a positive
exercise test
Pts eligible
for inclusion if
they had
suspected
cardiac chest
pain at rest
and had
documented
evidence of
CAD with at
least 1 of the
following:
evidence of
ischaemia on
ECG (STsegment
depression,
transient
STE, LBBB
[documented
previously],
or T-wave
inversion);
pathological
Q waves
suggesting
previous MI;
or
arteriographic
despite
treatment (i.e.,
systolic
pressure >180
mmHg or
diastolic
pressure >100
mmHg),
weight <120
kg, or inability
to give
informed
consent
All those with
probable
evolving MI,
including
those for
whom
reperfusion
therapy was
indicated,
were
ineligible.
Those in
whom new
pathological Q
waves
developed, or
those with CK
or CK-MB
concentration
s 2 the ULN
before
randomization
, were
excluded.
Also excluded
were those
with MI within
the previous
mo, PCI in the
Pts assigned
to
interventional
treatment
strategy were
managed
with optimum
antianginal
and
antiplatelet
treatment (as
for the
conservative
group), and
enoxaparin 1
mg/kg
subcutaneou
sly 2 for 2-8
d. Protocol
specified that
coronary
arteriography
should be
done as soon
as possible
after
randomizatio
n and ideally
within 72 h
Pts assigned to
the conservative
strategy were
managed with
antianginal and
antithrombotic
medication
Coprimary
endpoints
were: a
combined
rate of
death,
nonfatal
MI, or
refractory
angina at 4
mo; and a
combined
rate of
death or
nonfatal MI
at 1 y
Bleeding
99
Death, MI, refractory

angina as individual
endpoints
At 4 mo,
86 (9.6%)
of 895 pts
in
interventio
n group
had died or
had a MI or
refractory
angina,
compared
with 133
(14.5%) of
915 pts in
the
conservativ
e group
(RR: 0.66,
[0.51-0.85],
p=0.001).
1 endpoint
driven by
reduction of
refractory
angina with no
difference in
hard clinical
endpoints
To compare
interventional
strategy and
conservative
strategy in pts
with unstable
CAD
RCT 1,810
Spacek 2002
(120)
11792138
To compare
1-d
angiography
/angioplasty
vs. early
conservative
therapy of
evolving MI
without
persistent
STE
RCT 131
Interventi
on: 64
vs.
Compara
tor: 67
Hochman 1999
(230)
10460813
Evaluate early
revascularizat
ion in pts with
cardiogenic
shock
Multicenter
RCT
302 pts
ally proven
CAD on a
previous
arteriogram
Rest
ischaemic
chest pain,
lasting <20
min, within
last 24 h
before
randomizatio
n; ECG
evidence of
AMI without
STE (STsegment
depressions
minimally 0.1
mm in at
least 2
contiguous
leads and/or
negative T
waves or
documented
old LBBB/
RBBB; CKMB higher
than 1.5 X
ULN and/or
positive TnI
assay
152 pts
randomized
to emergency
revasc
preceding 12
mo, or CABG
at any time.
Unstable postinfarction
angina
pectoris
resistant to
maximal
pharmacother
apy;
cardiogenic
shock; acute
LBBB or
RBBB or STE
2 mm in 2
leads; QMI or
IV
thrombolysis
>1 mo;
coronary
angioplasty or
bypass
surgery >6
mo; any
concomitant
disease which
may have
possible
influence on 1
y Px; lack of
pt cooperation
150 pt-initial
medical
stabilization
1-d
angiography
/angioplasty
treatment
strategy
guidelines
characterized
by coronary
angiogram
as soon as
possible after
randomizatio
n followed by
immediate
coronary
angioplasty
of the culprit
coronary
lesion + stent
implantation
whenever
suitable
Conservative
treatment
strategy
guidelines were
characterized by
initial medical
treatment with
coronary
angiography
and subsequent
revasc only in
the presence of
recurrent
myocardial
ischaemia
Composite
of death or
nonfatal
RMI 6 mo
after the
randomizat
ion
None
Length of the initial

hospitalization and
the number of
subsequent
hospitalizations for
UAP
1 endpoint
(death/
reinfarction
) at 6 mo
occurred in
6.2% vs.
22.3%
(p<0.001).
6-mo
mortality in
1-d
angiograph
y/
angioplasty
group was
3.1% vs.
13.4% in
the
conservativ
e group
(p<0.03).
Small sample
size,
interventions
were done in
only one high
volume tertiary
center
To compare 1-d
angiography/
angioplasty vs.
early conservative
therapy of
evolving MI
without persistent
STE
RCT 131
STEMI, new
LBBB,
posterior
infarction
with anterior
ST segment
depression
and
cardiogenic
N/A
N/A
N/A
Mortality from all

causes at 30 d
At 30-d mortality
p=0.11
Revasc 46.7%
Medical therapy
56.0%
N/A
6-mo survival
6-mo mortality
p=0.027
Revasc 50.3%
Medical therapy
63.1%
N/A
Emergency revasc
did not significantly
reduce overall
mortality at 30 d.
However, at 6 mo
significant survival
benefit
100
Bhatt 2004
(231)
15523070
Determine
use and
predictors of
early invasive
management
strategies in
high-risk pts
with NSTEMI
Registryobservation
al study
trial
17,926
with
NSTEMI
8,037
(44.8%)
underwe
nt early
cardiac
cath <48
h
8,037 (44%)
underwent
early cardiac
cath <48 h
N/A
shock 2 to
LV
dysfunction
NSTEMI pts
presenting to
248 US
hospitals with
cardiac cath
facilities and
PCI or CABG
availability
N/A
N/A
N/A
Use of early invasive

management within
48 h of presentation
Predictors of early
invasive
management
N/A
N/A
N/A
Predictors of early
invasive
management: lowerrisk pts with lack of
prior or current CHF,
renal insufficiency,
positive biomarkers
Pts treated with
early invasive
strategy had lower
in-hospital mortality
2.5% vs 3.7%,
p<0.001
1 indicates primary; 2 indicates primary; ACS, acute coronary syndromes; AMI, acute myocardial infarction; BNP, B-type natriuretic peptide; CHF, congestive heart failure; CAB, coronary artery bypass; CABG, coronary artery bypass graft; CAD, coronary artery
disease; CI, confidence interval; CK-MB, creatine kinase MB; cTnT, cardiac troponin T; CV, cardiovascular; ECG, electrocardiography; ED, emergency department; eGFR, estimated glomerular filtration rate; GDF, growth differentiation factor; GP, glycoprotein; GRACE;
Global Registry of Acute Coronary Events; GUSTO, Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries trial; HF, heart failure; Hx, history; LBBB, left bundle-branch block; MI, myocardial infarction; NSTE-ACS, nonSTelevation acute coronary syndrome; NSTE, nonST-elevation; NSTEMI, nonST-elevation myocardial infarction; NT-pro, N-terminal pro; PCI, percutaneous coronary intervention; PURSUIT, Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using
Integrilin Therapy; Pt, patient; Px, prognosis; QMI, q-wave myocardial infarction; RBBB, right bundle-branch block; RCT, randomized clinical trial; RMI, recognized myocardial infarction; ROC, receiver operating characteristic; RR, relative risk; SBP, systolic blood
pressure; STEMI, ST-elevation myocardial infarction; Sx, symptom; TIMI, Thrombolysis In Myocardial Infarction trial; TnI, troponin I; ULN, upper limit normal; US, United States.
Data Supplement 26. Cardiogenic Shock (Section 7.2.2)
Study
Aim of study
Study
Study Size
Name,
Type
(N)
Author,
Year
Study
Interventio
n Group
(n)
Study
Comparator
Group (n)
Patient Population
Inclusion
Criteria
Study group
Comparator
group
Exclusion
Criteria
Endpoints
Major Study
Findings
101
Additional Findings
Conclusions
Study Limitations &

Adverse Events
Jacobs A. et
al, 2000
(232)
10985710
Determine the
outcomes of
pts with
cardiogenic
shock
complicating
NSTEMI
Registry
Substudy of
the
SHOCK
trial
881
152 pts with

NSTEMI
and
cardiogenic
shock
729 pts with

STEMI and
cardiogenic
shock
Cardiogen
ic shock
due to LV
failure
Excluded pts
with missing
ECG +
cardiogenic
shock due to
mechanical
complications,
tamponade,
cardiac
catheter
laboratory
complication,
isolated RV
dysfunction,
severe valvular
heart disease
NSTEMI +
cardiogenic
shock
STEMI +
cardiogenic
shock
In-hospital
mortality similar in
the 2 groups
(62.5% for
NSTEMI vs.
60.4% STEMI).
After adjustment,
STEMI did not
independently
predict in-hospital
mortality (OR:
1.30; 95% CI:
0.83-2.02;
p=0.252)
Compared with shock pts who

had STEMI, pts with NSTEMI
were older and more likely to
have comorbid disease, prior
infarctions and MVD
Left circumflex artery was the
culprit vessel in 34.6% of nonST-elevation vs. 13.4% of STelevation MI pts (p<5 0.001)
Similar LVEF in-hospital, and
similar revascularization
Pts with cardiogenic

shock and NSTEMI
have a higher-risk
profile than shock
pts with ST-segment
elevation, but similar
in-hospital mortality.
No hemodynamic or LV
function data
Registry data subject to
confounding
Holmes DR
et al., 1999
(233)
10562262
Assess the
incidence and
outcomes of
cardiogenic
shock
developing
among pts with
and without
ST-segment
elevation
Prespecified
sub-study
from the
GUSTOIIb trial
12, 084 (of

those 4,092
or 34% had
NSTEMI)
200 pts
developed
cardiogenic
shock (out
of 7,986
NSTEMI
pts)
2.5%
173 pts
developed
cardiogenic
shock (out of
4,087 STEMI
pts)
4.2%
Pts who
developed
shock
after
enrollment
in GUSTO
GUSTO
eligibility
criteria:
chest pain
of
myocardia
l ischemia
within 12 h
+ STE or
STdepressio
n, or
persistent
T-wave
inversion
Pts who had

shock on
presentation
(n=58) + 11 pts
with missing
data
Also excluded
pts with STEMI
who were not
candidates for
thrombolytic
therapy
NSTEMI
(incidence/
outcome of
cardiogenic
shock)
STEMI
(incidence/
outcome of
cardiogenic
shock)
Lower OR of
developing
cardiogenic shock
in NSTEMI
compared with
STEMI
Incidence: 4.2%
vs. 2.5% (OR:
0.58; 95% CI:
0.47-0.72;
p<0.001)
High 30-d
mortality in both:
63% among pts
with STEMI with
shock vs. 73% in
NSTEMI with
shock (p NS)
Pts without ST-segment

elevation were older, more
frequently had DM and 3vessel disease, but had less
TIMI grade 0 flow at
angiography
Shock developed significantly
later among pts without STsegment elevation
No STE was significant
predictor of 30-d mortality
(p=0.048)
Pts without STE

developed shock
much later than
those with STEMI
suggesting a
window of
opportunity to
prevent shock
Shock pts without
STE had more highrisk clinical
characteristics, more
extensive CAD, and
more frequent
recurrent ischemia
and MI before the
development of
shock
Regardless of the
initial ECG findings,
Shock was
associated with a
marked increase in
mortality.
GUSTO-IIb is a
thrombolytic trial
(excluded pts ineligible for
thrombolytics)
Subgroup analysis
Different baseline risk
102
1 indicates primary; CAD, coronary artery disease; DM, diabetes mellitus; ECG, electrocardiogram; GUSTO, Global Use of Strategies To Open Occluded Coronary Arteries; LV, left ventricular; LVEF; left ventricular ejection fraction; MVD, multi-vessel disease; NS,
nonsignificant; NSTEMI, non-ST-elevation myocardial infarction; OR, odds ratio; Pts, patients; RV, right ventricular; SHOCK, Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock; STE, ST-elevation; STEMI, ST-elevation myocardial
infarction; and TIMI, Thrombolysis In Myocardial Infarction.
Data Supplement 27. Diabetes Mellitus (Section 7.3)
Study
Aim of study
Study
Study
Name,
Type
Size
Author,
(N)
Year
Cannon
2001
(186)
11419424
To compare
an early
invasive
strategy to a
more
conservative
approach
Prospecti
ve,
randomiz
ed,
multicente
r trial
2,220
Interve
ntion:
1,114
vs.
Compa
rator:
1,106
Study Intervention
Group (n)
Pts 18 y if they had

had an episode of
angina (with an
accelerating pattern or
prolonged [>20 min]
or recurrent episodes
at rest or with minimal
effort) within the
preceding 24 h, were
candidates for
coronary revasc, and
had at least 1 of the
following: a new
finding of ST-segment
depression of at least
0.05 mV, transient
(<20 min) STE of at
least 0.1 mV, or Twave inversion of at
least 0.3 mV in at
least 2 leads; elevated
levels of cardiac
markers; or coronary
disease, as
documented by a Hx
of catheterization,
revasc, or M
Study
Comparator
Group (n)
Persistent STE,
2 angina, a Hx
of PCI or CABG
within the
preceding 6 mo,
factors
associated with
an increased risk
of bleeding,
LBBB or paced
rhythm, severe
CHF or
cardiogenic
shock, serious
systemic
disease, a serum
creatinine level of
<2.5 mg/dL (221
mol/L), or
current
participation in
another study of
an investigational
drug or device
Patient Population
Inclusion
Criteria
Exclusion
Criteria
Pts assigned
to the early
invasive
strategy were
to undergo
coronary
angiography
between 4 h
and 48 h
after
randomizatio
n and revasc
when
appropriate
on the basis
of coronary
anatomical
findings
Pts assigned to
the early
conservative
strategy were
treated
medically and, if
their condition
was stable,
underwent an
(83% of such
tests included
nuclear
perfusion
imaging or echo
performed
according to the
protocol of the
institution)
before being
discharged
Study
Interventio
n
Combined
incidence of
death,
nonfatal MI,
and
rehospitaliz
ation for an
ACS at 6
mo
Study
Comparat
or
Bleeding
103
Endpoints
Primary
Endpoint
(efficacy)
and Results
Death, death or
MI, fatal or
nonfatal MI,
reshospitaliztion
for MI
Safety
Endpoint
and Results
Secondary
Endpoint
and Results
At 6 mo, the rate

of the 1
endpoint was
15.9% with use
of the early
invasive strategy
and 19.4% with
use of the
conservative
strategy (OR:
0.78; 95% CI:
0.62-0.97;
p=0.025).
Study
excluded pts
with severe
comorbid
conditions or
other serious
systemic
illness
P Values,
OR: HR: RR &
95% CI:
Study
Limitations &
Adverse Events
To compare an
early invasive
strategy to a
more
conservative
approach
Prospective,
randomized,
multicenter trial
2,220
FRISC II
(185)
10475181
Compare
early invasive
with a
noninvasive
treatment
strategy in
unstable CAD
Multicente
r RCT of
2,457 pts
2,457
pts,
21.4%
diabeti
c
Early invasive
strategy N=1,222
Study
comparator
group:
noninvasive
strategy n=1,235
Inclusion:
UA, NSTEMI
Pts with DM
21.4% of
total but not
analyzed
separately
N/A
N/A
N/A
Norhammar
2004
(234)
14975468
Evaluate
influence of
DM in
outcome of
unstable CAD
Randomiz
ed clinical
trial
299 pts
with
diabete
s
mellitus
and
2,158
without
Rando
mizatio
n to
early
invasiv
e or a
noninv
asive
strateg
y
299 pts with DM
2,158 patients
without DM
UA, NSTEMI
Pts with DM
defined as
treated with
diet, oral
agents, or
insulin
Pts with DM
were at
higher
baseline risk
more prior
MI, CHF,
PAD, HBP,
more 3VD
N/A
N/A
N/A
104
6-mo composite
of death or MI
9.4% in invasive
vs. 12.1% in
noninvasive
group (RR: 0.78,
95% CI: 0.62
0.98, p=0.031)
Decrease in MI
alone 7.8% in
invasive vs.
10.1% in
conservative
group (RR: 0.77
95% CI: 0.60
0.99; p=0.045)
Nonsignificant
decrease in death
1.9% vs. 2.5%
(HR: 0.65, 95%
CI: 0.391.09;
p=0.10)
1 composite of
death or MI.
ITT.
DM remained a
strong
independent
predictor of death
and MI in
multivariable
analyses
Invasive strategy
reduced
composite of
death or MI in pts
with DM from
29.9% to 20.6%
(OR 0.61; CI
0.361.04,
p=0.066)
Invasive strategy
N/A
Angina at 6
mo
In pts with
DM invasive
strategy
improved
anginal Sx
24% for
invasive vs.
41% for
noninvasive
RR: 0.59
(0.410.84)
N/A
Early invasive
strategy
preferred in most
pts with unstable
CAD who have
signs of
ischemia or have
NSTEMI
Benefit is
greatest in pts at
higher risk at
entry
N/A
N/A
N/A
An invasive
strategy
improved
outcomes for
both patients
with and without
DM with
unstable CAD
DM is an
independent risk
factor for dearth
and MI in both
invasive and
noninvasive
groups
Farkouh
2012
(235)
23121323
Compare
strategy of
aggressive
medical
therapy and
DES vs.
CABG for pts
with DM and
multivessel
CAD
Multicente
r
randomiz
ed clinical
trial
1,900
pts
Aggressive medical
therapy plus DES,
n=953
CABG, n=947
Pts with DM
with
angiographic
ally
confirmed
MVD of 2
major
epicardial
vessels
LMCA lesions
excluded
Minimum followup 2 y
N/A
N/A
reduced
composite of
death or MI in
nondiabpatients
without DM from
12.0% to 8.9%
(OR 0.72; CI
0.540.95
p=0.019)
Composite of
death from any
cause, nonfatal
MI or nonfatal
stroke
Composite 5-y
rate 26.6% in PCI
vs. 18.7% in
CABG; p=0.005
5-y rate death
from any cause
16.3% vs. 10.9%;
p=0.049 PCI vs.
CABG
5-y rate MI 13.0
vs. 6.0%;p<0.001
PCI vs. CABG
Rate stroke
increased with
CABG 5.2% CABG vs. 2.4%
PCI; p=0.03
No subgroup
analysis of pts
with ACS
N/A
MACE at 30
d and 12 mo
N/A
For pts with DM

and severe CAD
undergoing
revascularization
, CABG was
associated with
significant
reduction in
death and MI,
but with a
significant
increase in
stroke compared
with PCI
Limitations:
Trial not blinded
Some
prespecified
subgroups had
very low
prevalence
1 indicates primary; 2, secondary; 3VD, three-vessel disease; ACS indicates acute coronary syndrome; CABG, coronary artery bypass graft; CAD, coronary artery disease; CHF, congestive heart failure; DES, drug-eluting stents; DM, diabetes mellitus; HBP, high
blood pressure; Hx, history; ITT, intention to treat; LBBB, left bundle-branch block; LMCA, left main coronary artery disease; MACE, major adverse cardiac events; MI, myocardial infarction; MVD, multi-vessel disease; N/A, not applicable; NSTEMI, non-ST-elevation
myocardial infarction; PAD, peripheral arterial disease; PCI, percutaneous coronary intervention; Pts, patients; RCT, randomized controlled trial; RR, relative risk; Sx, symptom(s); UA, unstable angina.
105
Data Supplement 28. Post-CABG (Section 7.4)

Study Name,
Aim of study
Study
Type
Author, Year
Study Size
(N)
Study
Intervention
Group (n)
Study
Comparator
Group (n)
Patient Population
Inclusion
Criteria
Kavsak 2006
16824840 (23)
Impact of new
classification of
MI
Retrospecti
ve analysis
using CKMB vs. TrI
analysis for
MI def. 258
pts with
ACS
Multicenter
observation
al
prospective
Registry
(GRACE)
26,267
ACS pts
Goodman 2006
16504627 (25)
Diagnostic and
prognostic
impact of new
UDMI
Eggers 2011
20869357 (26)
Clinical
implications of
relative change
in cTnI levels
with chest pain
Retrospecti
ve study of
454 ACS
pts within
24 h of
admission
with 5.8 y
follow-up
Giannitsis 2010
(33)
20167697
Dx, perf. of hscTnT for

detection. of
NSTEMI in ACS
Retrospecti
ve cohort
analysis
57 with UA
Study
Intervention
Study
Comparator
TrI vs. CKMB Dx

based on
MONICA or
AHA def of
MI
2 SPSS CKMB, TrI

20%
change using
99% TrT
cutoff
N/A
2 specimens
CK-MB, TrI
drawn at
least 6 h
apart
AMI
prevalence
MONICA CKMB 19.4%
AHA 19.8%.
TnI increase.
to 35.7%
N/A
TrI vs. CKMB p<0.001

for increase
MI def using
TnI
Primary
Endpoint
(efficacy)
and Results
cTnI
35.7% (30.141.7)
Relative inc
84%
Use of CK
and -Tn
16,797 vs.
CK-MB and
Tn
10,719 for
hospital.
fatality,
14,063 vs.
8,785 for 6mo mortality
UDMI with
presp cTnI
changes
from 20%,
50%, 100%
>18 y with
possible ACS
with ECG
abnormal or
CAD history.
CK, CK-MB.
Tn
NS
comorbity,
trauma,
surgery, lack
of 1
biomarker
CK
CK-MB
Tn
Follow-up for
6 mo
Tn+ levels
demonstrated
higher in
hospital and 6mo mortality
rates than
higher CK
levels
N/A
In entire
population,
Tn+ status
vs. CK
status 6-mo
mortality:1.6
(1.4-1.9)
Hospital fatality
rates higher
with Tn+ vs.
CK+: 2.2 (1.62.9) with
Tn+/CK-MB-:
2.1 (1.4-3.2)
N/A
cTnI <99th
percentile
cTnI levels
Peak cTnl
level 99th
percentile +
change 20%
in 160. 25 had
no AMI by
ESC/ACC
criteria
N/A
N/A
Baseline vs.
and serial
conc. at 3 h
and 6 h
UA or
NSTEMI with
initial -cTnT
Immed PCI
or kidney
dysfunction
Hs-cTnT
baseline,3,6
h
delta change
Hs cTnt Dx
61% at
baseline to
100% at 6 h.
N/A
Doubling of
hs-Tnt with
initial 99% +
pos
Exclusion
Criteria
Endpoints
106
Safety
Endpoint
and
Results
N/A
P Values,
OR: HR: RR &
95% CI:
Study Limitations
& Adverse Events
Secondary
Endpoint
and Results
Exclusion of
nonischemic
diseases
causing Tr
elevation
Impact of new
classification of
MI
Retrospective
analysis using CKMB vs. TrI analysis
for MI def. 258 pts
with ACS
N/A
34% in GRACE
registry
excluded
because of use
of 1 biomarker
only
Diagnostic and
prognostic impact
of new UDMI
Multicenter
observational
prospective
Registry (GRACE)
26,267 ACS pts
All 160 had

significant
raised mortality
HR: 2.5 (1.73.8) Higher TnI
deltas were not
associated with
higher
mortalities
NA
Clinical
implications of
relative change in
cTnI levels with
chest pain
Retrospective
study of 454 ACS
pts within 24 h of
admission with 5.8
y follow-up
Delta changes
and ROC opt.
values spec
100% with
N/A
Analysis of
assay could
not be
validated by hs
Tr assay.
No review of
pts records for
type I or 2 AMI
No long-term
risk
assessment
Admission to
chest pain unit
more selective
than typical ED
Dx, perf. of hscTnT for

detection. of
NSTEMI in ACS
Retrospective
cohort analysis
57 with UA and
evolving NSTEMI
and
evolving
NSTEMI
>20%,or
ROC
optimized
value >117%
3 h, or 246%
6h
N/A
Dx inc by 34%
above std
cTnT
N/A
predicted
value 100%
neg
predicted
value 88%
sens 69% and

76%
N/A
N/A
N/A
N/A
N/A
N/A
N/A
+hs-TnT 1-y
mortality 9,2%
vs. 1.6%
p=0.001
For by both
assays
Death, death or
MI, fatal or
nonfatal MI,
rehospitalizatio
n for MI
N/A
Pts with higher

pretest risk
than typical
chest pain pts
in ED
Hs-cTnT
comparison with
std cTnT for risk
assessment
Prospective cohort
1,452
At 6 mo,
the rate of
the 1
endpoint
was
15.9%
with use
of the
early
invasive
strategy
and
19.4%
with use
of the
conservati
ve
strategy
(OR: 0.78;
95% CI:
0.62-0.97;
p=0.025).
Study excluded
pts with severe
comorbid
conditions or
other serious
systemic
illness
To compare an
early invasive
strategy to a
more
conservative
approach
Prospective,
randomized,
multicenter trial
2,220
Ie 2004
(236)
15528943
Lindahl 2010
(32)
20691825
N/A
N/A
N/A
N/A
N/A
Hs-cTnT
comparison with
std cTnT for risk
assessment
Prospective
cohort
1,452
Effect of
pos. by both
assays vs.
only 1 assay
ACS pts
No coronary
angiography
within 12 h
Both cTnT
collected 48
h after
randomizatio
n
+hs-TnT same
1-y mortality.
Whether + or
with st-TnT
N/A
For death or
AMI at 30 d
+ only for hsTnT had
interim risk
Cannon 2001
(186)
11419424
To compare an
early invasive
strategy to a
more
conservative
approach
Prospective
,
randomized
,
multicenter
trial
2,220
Intervention:
1,114 vs.
Comparator:
1,106
Pts 18 y if
they had had
an episode of
angina (with
an
accelerating
pattern or
prolonged
[>20 min] or
recurrent
episodes at
rest or with
minimal
effort) within
the preceding
24 h, were
candidates
for coronary
revasc, and
had at least 1
of the
following: a
new finding
of STsegment
depression of
at least 0.05
Persistent
STE, 2
angina, a Hx
of PCI or
CABG within
the
preceding 6
mo, factors
associated
with an
increased
risk of
bleeding,
LBBB or
paced
rhythm,
severe CHF
or
cardiogenic
shock,
serious
systemic
disease, a
serum
creatinine
level of <2.5
mg/dL (221
Pts assigned
to the early
invasive
strategy were
to undergo
coronary
angiography
between 4 h
and 48 h
after
randomizatio
n and revasc
when
appropriate
on the basis
of coronary
anatomical
findings
Pts assigned
to the early
conservative
strategy were
treated
medically and,
if their
condition was
stable,
underwent an
(83% of such
tests included
nuclear
perfusion
imaging or
echocardiogra
phy performed
according to
the protocol of
the institution)
before being
discharged
Combined
incidence of
death, nonfatal
MI, and
rehospitalizatio
n for ACS at 6
mo
Bleeding
107
admissions
Fox 2002
(187)
12241831
To compare
interventional
strategy and
conservative
strategy in pts
with unstable
CAD
RCT 1,810
Intervention:
895 vs.
Comparator:
915
mV, transient
(<20 min)
STE of at
least 0.1 mV,
or T-wave
inversion of
at least 0.3
mV in at least
2 leads;
elevated
levels of
cardiac
markers; or
coronary
disease, as
documented
by a Hx of
catheterizatio
n, revasc, or
M
Pts were
eligible for
inclusion if
they had
suspected
cardiac chest
pain at rest
and had
documented
evidence of
CAD with at
least 1 of the
following:
evidence of
ischaemia on
ECG (STsegment
depression,
transient
STE, LBBB
[documented
previously],
mol/L), or
current
participation
in another
study of an
investigation
al drug or
device
All those with

probable
evolving MI,
including
those for
whom
reperfusion
therapy was
indicated,
were
ineligible.
Those in
whom new
pathological
Q waves
developed,
or those with
CK or CKMB
concentration
s 2 the ULN
before
Pts assigned
to the
interventional
treatment
strategy were
managed
with optimum
antianginal
and
antiplatelet
treatment (as
for the
conservative
group), and
enoxaparin 1
mg/kg
subcutaneou
sly 2 for 2-8
d. The
protocol
specified that
coronary
Pts assigned
to the
conservative
strategy were
managed with
antianginal
and
antithrombotic
medication
The coprimary
trial endpoints
were: a
combined rate
of death,
nonfatal MI, or
refractory
angina at 4 mo;
and a
combined rate
of death or
nonfatal MI at 1
y
108
Bleeding
Death, MI,
refractory
angina as
individual
endpoints
At 4 mo,
86 (9.6%)
of 895 pts
in the
interventio
n group
had died
or had a
MI or
refractory
angina,
compared
with 133
(14.5%) of
915 pts in
the
conservati
ve group
(RR: 0.66,
[0.510.85],
p=0.001).
1 endpoint
driven by
reduction of
refractory
angina with no
difference in
hard clinical
endpoints
To compare
interventional
strategy and
conservative
strategy in pts
with unstable
CAD
RCT 1,810
or T-wave
inversion);
pathological
Q waves
suggesting
previous MI;
or
arteriographi
cally proven
CAD on a
previous
arteriogram
Spacek 2002
(120)
11792138
To compare 1st
d angiography/
angioplasty vs.
early
conservative
therapy of
evolving MI
without
persistent STE
RCT 131
Intervention:
64 vs.
Comparator:
67
Rest
ischaemic
chest pain,
lasting <20
min, within
the last 24 h
before
randomizatio
n; ECG
evidence of
AMI without
STE (STsegment
depressions
minimally 0.1
mm in at
least 2
contiguous
leads and/or
negative T
waves or
documented
old LBBB/
RBBB; CKMB higher
than 1.5 X
ULN and/or
positive TnI
assay
randomizatio
n, were
excluded.
Also
excluded
were those
with MI within
the previous
mo, PCI in
the
preceding 12
mo, or CABG
at any time.
Unstable
postinfarction
angina
pectoris
resistant to
maximal
pharmacothe
rapy;
cardiogenic
shock; acute
LBBB or
RBBB or
STE 2 mm in
2 leads; QMI
or IV
thrombolysis
>1 mo;
coronary
angioplasty
or bypass
surgery >6
mo; any
concomitant
disease
which may
have
possible
influence on
arteriography
should be
done as soon
as possible
after
randomizatio
n and ideally
within 72 h
1st d
angiography/
angioplasty
treatment
strategy
guidelines
were
characterized
by a
coronary
angiogram
as soon as
possible after
randomizatio
n followed by
immediate
coronary
angioplasty
of the culprit
coronary
lesion + stent
implantation
whenever
suitable
Conservative
treatment
strategy
guidelines
were
characterized
by initial
medical
treatment with
coronary
angiography
and
subsequent
revasc only in
the presence
of recurrent
myocardial
ischaemia
Composite of
death or
nonfatal RMI 6
mo after the
randomization
109
None
Length of the
initial
hospitalization
and the
number of
subsequent
hospitalizations
for UAP
1
endpoint
(death/
reinfarctio
n) at 6 mo
occurred
in 6.2%
vs. 22.3%
(p<0.001).
6 mo
mortality
in the 1st d
angiograp
hy/
angioplast
y group
was 3.1%
vs. 13.4%
in the
conservati
ve group
(p<003).
Small sample
size,
interventions
were done in
only one high
volume tertiary
center
To compare 1st d
angiography/
angioplasty vs.
early
conservative
therapy of
evolving MI
without persistent
STE
RCT 131
1-y Px; lack

of pt
cooperation
1 indicates primary; 2, secondary; 3VD, three-vessel disease; ACS indicates acute coronary syndrome; AMI acute myocadial infarction; CABG, coronary artery bypass graft; CAD, coronary artery disease; CHF, congestive heart failure; CK, creatine kinase;; CK-MB,
creatine kinase MB; Dx, diagnosis; ECG, electrocardiograph; ESC, European Society of Cardiology; GRACE, Global Registry of Acute Coronary Events; HBP, high blood pressure; Hs-cTnT, high-sensitivity cardiac troponin I; Hx, history; IV, intravenous; LBBB, left
bundle-branch block; MI, myocardial infarction; MONICA, Multinational MONItoring of trends and determinants in CArdiovascular disease; NS, no(n) significance; PCI, percutaneous coronary intervention; Pt, patient; Px, prognosis; QMI, Q-wave myocardial infarction;
RBBB, right bundle-branch block; RCT, randomized controlled trials; revasc, revascularization; ROC, receiver operating characteristic;RMI; RR, relative risk; cTnT, cardiac troponin T; SSPS; STE, ST-elevation; Tn, troponin; TnI, troponin I; UAP; UDMI, Universal
Definition of Myocardial Infarction; and ULN, upper limit of normal.
Data Supplement 29. Chronic Kidney Disease (Section 7.6)
Study Name,
Aim of study
Study Type Study Size (N)
Author, Year
Study
Intervention
Group (n)
Study
Comparator
Group (n)
Patient Population
Inclusion Criteria
Wright 2002
12353943
(237)
Compare
outcomes after
AMI in pts with
varying degrees
of renal function
Retrospectiv
e cohort
study
4,426
n=3,106 with:
endstage renal
disease, severe
renal
insufficiency
CrCl <35
mL/min,
moderate renal
insufficiency
CrCl 35, 50
mL/min, mild
renal
insufficiency
CrCl > 50
mL/min
n=1,320 with
normal renal
function
Consecutive pts
with acute infarction
between 1988 and
2000. Renal
function estimated
according to the
Cockcroft-Gault.
Endpoints
Exclusion Criteria
N/A
110
Primary Endpoint
(efficacy)
and Results
Safety
Endpoint
and Results
Short- and long-term

survival compared after
pts were stratified by
CrCl.
In-hospital mortality :
2% in pts with normal
renal function, 6% in pts
with mild renal failure,
14% in pts with
moderate renal failure,
21% in pts with severe
renal failure, and 30%
in pts with endstage
renal disease; p<0.001
Post-discharge mortality
in abnormal renal
function vs. normal
renal function
Mild renal failure HR:
2.4 (CI 1.73.3;
p<0.001)
Moderate renal failure
HR: 2.2 (CI: 1.53.3;
p<0.001)
Pts with renal

failure received
reperfusion
therapy less
frequently than
pts with normal
renal function;
p<0.001. Postdischarge death
less likely in pts
who received
acute reperfusion
therapy. OR: 0.7
(CI: 0.60.9)
ASA OR: 0.7 (CI:
0.50.8)
BB OR: 0.7 (CI:
0.60.9)
P Values,
OR: HR:
RR &
95% CI:
Study Limitations &

Adverse Events
Secondary
Endpoint
and Results
N/A
N/A
Retrospective Analysis
Potential referral bias
Single center study
Shlipak 2002
12353942
(238)
Determine how
pts with renal
insufficiency are
treated during
MI
Determine
association of
renal
insufficiency on
survival after MI
All
nongovernm
ental U.S.
hospitals
cohort study
130,099 older
pts with MI
1994-1995
Mild renal
insufficiency: Cr:
1.5-2.4 mg/dL
n=36,756
Moderate renal
insufficency: Cr:
2.5-3.9 mg/dL
n=10,888
No renal
insufficiency: Cr
<1.5 mg/dL
n=82,455
All older (age 65 y)

Medicare
beneficiaries with
AMI 1994-1995
6,790 pts with

severe renal
insuffieciency Cr
4.0 mgm/dL
10,570 pts with no
information on
estimating CrCl
111
Severe renal failure HR:

1.9 (CI: 1.23.0;
p=0.006)
End-stage renal
disease HR: 5.4 (CI:
3.09.7; p<0.001)
Primary: pts with
moderate renal
insufficiency less likely
to receive aspirin, BB,
thrombolytic therapy,
angiography or PCI
N/A
1 y-mortality
24% with no
renal
insufficiency
46% with mild
renal
insufficiency
66% with
moderate
renal
insuffieciency
Secondary:
after
adjustment for
pt and
treatment
characteristic
s, renal
insufficiency
was
associated
with elevated
risk of death
after MI
Mild renal
insufficiency:
HR: 1.68
(95% CI:
1.681.73)
Moderate
renal
insufficiency:
HR: 2.35
(95% CI:
2.262.45)
N/A
No measurement of true
GFR
Size of data collected from
1994-1995
Focus on patients 65 y
Solomon 1994
7969280 (239)
Evaluate effect
of saline,
mannitol on
renal function in
pts undergoing
coronary
angiography
RCT
78
n=28, 45%
saline alone for
12 h before and
12 h after
n=25
1) 45% saline
plus mannitol
n=25
2) 45% saline
plus furosemide
78 pts with chronic

renal insufficiency
undergoing
coronary
angiography
Serum Cr measure
prior to and 48 h
after angiography
N/A
Charytan
2009
19423566
(240)
Evaluate
effectiveness of
an early
invasive
strategy or
conservative
strategy in pts
with CKD
admitted with
UA/NSTEMI
Collaborative
metaanalysis of
RCT
5 randomized
studies of
1,453 pts with
CKD
Early invasive
strategy of
routine coronary
angiography
Conservative
strategy of
selective
coronary
angiography
Total 1,453 pts with

CKD in 5 RCT
stages 3a, 3b, and
4-5
GFR calculated
using modification
of diet in renal
disease
Serum Cr measure
prior to and 48 h
after angiography
N/A
Szummer
2009
19704097
(241)
Evaluate
influence of
renal function
on effects of
early
revascularizatio
n in NSTEMI
Nationwide
registry
23,262
consecutive
NSTEMI pts
80 y old
treated from
2003-2006
Pts
revascularized
within 14 d of
admission,
N=12,030
Patients not
revascularized
within 14 d of
admission,
n=11,232
23,262 consecutive
pts 80 y with
NSTEMI
Subdivision in 5
groups
eGFR 90
n=6,064
eGFR 60-89
n=11,509
eGFR 30-59
n=4,839
eGFR 15-29
n=572
eGFR <15/dialysis
N=278
N/A
An increase in baseline
serum Cr of 0.5
mgm/dL within 48 h of
angiography
11% with saline
28% with saline +
mannitol
40% with saline +
furosemide
p=0.05
1-y mortality
Invasive strategy
associated with:
Nonsignificant reduction
in all-cause mortality
RR: 0.76; 95% CI:
0.491.17; p=0.21
Nonfatal MI RR: 0.78;
95% CI: 0.521.16;
p=0.22
Death or nonfatal MI
RR: 0.79; 95% CI:
0.531.18; p=0.24
Significant reduction in
rehospitalization RR:
0.76; 95% CI: 0.66
0.87; p<0.0001
After adjustment overall
1-y mortality was 36%
lower (HR: 0.64; 95%
CI: 0.560.73; p<0.001)
with invasive strategy
Magnitude of survival
difference similar in
normal to moderate
renal function groups
Lower mortality
observed with invasive
therapy declined with
lower renal function
No difference in
mortality in pts with
112
N/A
N/A
N/A
Hydration with 0.45% saline

provides better protection
against CIN than hydration
plus either mannitol or
furosemide
Limitations:
Small sample size
N/A
In-hospital
death, MI,
death/MI, 1-y
MI,
rehospitalizati
on, combined
death/MI
N/A
Routine coronary
angiography should be
considered for pts with CKD
who are admitted with
NSTEMI
Limitations:
Publication bias
Small number trials
Small number of stage 4-5
CKD
N/A
N/A
N/A
Early invasive therapy is

associated with greater 1-y
survival in pts with NSTEMI
and mild-moderate renal
insufficiency. Benefit
declines with lower renal
function.
Limitations:
Registry study
Selection bias
Arbitrary cut point 14 d
Pts 80 y
Cox regression
kidney failure or in
model with
those dialysis p=0.15,
adjustment for
HR: 1.61; 95% CI:
propensity score
0.843.09
and discharge
medication to
assess association
between early
revascularization
and 1-y mortality
AMI indicates acute myocardial infarction; BB, beta blocker; CKD, chronic kidney disease; CIN, contrast induced nephropathy; Cr, creatinine; CrCl, creatinine clearance; eGFR, estimated glomerular filtration rate; GFR, glomerular filtration rate; MI, myocardial infarction;
N/A, nonapplicable; NSTEMI, NonST-elevation myocardial infarction; PCI, percutaneous coronary intervention; pts, patients; RCT, randomized controlled trial; RR, relative risk; UA, unstable angina; and U.S., United States.
Data Supplement 30. Women (Section 7.7)
Study Name,
Aim of study
Study
Author, Year
Type
HutchinsonJaffe AB,
Goodman SG,
Yan RT, et al.
Comparison of
baseline
characteristics
, management
and outcome
of patients
with non-STsegment
elevation
acute
coronary
syndrome in
versus not in
clinical trials.
Am J Cardiol.
2010;106:138
9-96.
Characterize
differences in
clinical
characteristics
and clinical
management
between pts
with NSTEACS in clinical
trials and not in
clinical trials
Retrospecti
ve casecontrol of
several
large
NSTE-ACS
registries
Study Size
(N)
N=13,556
pts with
NSTE-ACS
(8.3% in
clinical
trials)
Study
Intervention
Group (n)
None
Study
Comparator
Group (n)
None
Patient Population
Inclusion
Criteria
Exclusion
Criteria
Pts with NSTEACS in 4 large

prospectively
collected
registries:
Canadian ACS I
(1999 to 2001),
ACS II (20022003), GRACE
(2004-2007),
and CANRACE
(2008) over 10
y, 18 y age,
within 24 h of
NSTE-ACS
presentation
Pts with NSTEACS with ACS

precipitated or
accompanied
by a serious
concurrent
illness, such as
trauma or GI
bleeding
Study
Intervention
N/A
Study
Comparato
r
N/A
113
Endpoints
Primary
Endpoint
(efficacy)
and Results
Pts enrolled in
clinical trials were
younger, more
likely to be men,
and had fewer
comorbidities.
Clinical trial pts
were more likely
to be on several
GDMT, undergo
invasive
procedures (all
p<0.001).
Unadjusted inhospital mortality
nonclinical vs.
clinical trials
(2.1% vs. 0.7%,
p<0.001) and 1-y
(8.9% vs. 6.3%,
p=0.037) In
Safety
Endpoint
and
Results
N/A
P Values,
OR: HR: RR &
95% CI:
Secondary
Endpoint
and
Results
N/A
Results too
numerous to list
Study Limitations
& Adverse Events
N/A
21059426
(242)
Akhter N,
Milford-Beland
S, Roe MT, et
al. Gender
differences
among
patients with
acute
coronary
syndromes
undergoing
percutaneous
coronary
intervention in
the American
College of
CardiologyNational
Cardiovascula
r Data
Registry
(ACC-NCDR).
Am Heart J.
2009;157:1418.
19081410
(243)
To assess
clinical and
angiographic
characteristics,
procedural and
treatment
patterns, and
in-hospital
outcomes
between men
and women
Retrospecti
ve casecontrol of
registry
data
N=199,690
pts, 55,691
women
presented
with NSTEUA vs.
101,961
men
All pts
underwent
PCI (index)
None
Men and women

with NSTE-ACS
who underwent
PCI in ACCNCDR Registry
1/104-3/30/06;
index PCI only
Not fitting
predefined
NSTE-ACS
definition or not
undergoing PCI
N/A
N/A
114
multivariable
analysis, pts who
were older,
women, had Hx of
CHF failure, and
increased CrCr
levels on
presentation were
less likely to be
enrolled in clinical
trials.
Women presented
more often with
NSTE-ACS than
men (82% vs.
77% of men,
<0.0001). Women
with NSTE-ACS
had more
comorbidities, but
fewer high-risk
angiographic
features than
men. Women
were less likely to
receive ASA, GPI,
and less often
discharged on
ASA or statin. Inhospital mortality,
was similar for
women and men
(OR: 0.97, p=0.5).
Women had
higher rates of
cardiogenic
shock, CHF, any
bleeding (7.6 vs.
3.6%, p<0.01),
and any vascular
complications, but
subacute stent
N/A
Too
numerous
to list
Too numerous to
list
Limited extrapolation
all subjects are
registry NSTE-ACS
pts
Blomkalns AL,
Chen AY,
Hochman JS,
et al. Gender
disparities in
the Dx and
treatment of
non-STsegment
elevation
acute
coronary
syndromes:
large-scale
observations
from the
CRUSADE
National
Quality
Improvement
Initiative. J Am
Coll Cardiol.
2005;45:8327.
To examine
differences of
gender in
treatment and
outcomes
among pts with
NSTE ACS
Retrospecti
ve casecontrol of
registry
data
N=35,875
pts (41%
women)
None
None
35,875 pts with

NSTE-ACS
(14,552 women)
at 391 U.S.
hospitals
participating in
the CRUSADE
initiative
between March
31, 2000, and
December 31,
2002
Pts excluded
from this
analysis
included those
who were
transferred to
another
hospital, (3,210
men and 1,827
women), and
pts with
missing gender
status (n=66)
N/A
N/a
To examine
gender impact
on
antithrombotic
therapy for
Retrospecti
ve analysis
of ACUITY
trial
(prespecifie
4,157
women with
NSTE-ACS
(31% of
total
Overall
women =4,
157
GPI +
heparin
Overall men
=9,662
GPI +
heparin
(UFH or
Men and women

enrolled in
ACUITY trial,
randomized to
open-label AT
Missing
data/follow-up
AT Strategy:
GPI +
heparin
Bivalirudin +
GPI
1) Men vs.
women
PCI
bleeding,
net
15766815
(244)
Lansky AJ,
Mehran R,
Cristea E, et
al. Impact of
gender and
115
thrombosis rates
were less in
women compared
to men (0.43% vs.
0.57%, p=0003).
Women were
older (median age
73 vs. 65 y) and
more often had
DM and HTN.
Women were less
likely to receive
acute heparin,
ACE-I, and GPI
and ASA, ACE-I,
and statins at
discharge. Men
underwent more
angiography/
revere then
women, but
among pts with
significant CAD,
PCI was
performed
similarly in men
and women. NS
gender difference
was seen in
adjusted rates of
in-hospital death,
reinfarction, HF,
and stroke. RBC
transfusion rates
were higher in
women (OR: 1.17;
CI: 1.09-1.25)
No gender
difference in 30 d
composite
ischemia; women
significantly
N/A
Too
numerous
to list
Too numerous to
list
Limited
generalizability from
registry data
In women:
bivalirudin
alone
significantly
less
Same as 1
endpoint
findings at
1 y and
PCI
30-d composite
ischemia:
women=7%,
men=8% p=NS;
30-d bleeding:
Although
prespecificed gender
analysis, study was
underpowered to
detect difference so
antithrombin
strategy on
early and late
clinical
outcomes in
patients with
non-STelevation
acute
coronary
syndromes
(from the
ACUITY trial).
Am J Cardiol.
2009;103:119
6-203.
19406258
(245)
Alexander KP,
Chen AY,
Newby LK, et
al. Sex
differences in
major bleeding
with
glycoprotein
IIb/IIIa
inhibitors:
results from
the CRUSADE
initiative.
Circulation.
2006;114:138
0-7.
ischemia vs.
bleeding in pts
with NSTEACS in
ACUITY trial
To examine
gender impact
on GPI use,
dose, bleeding
in pts with
NSTE-ACS in
CRUSADE
d but not
powered)
Retrospecti
ve analysis
of
CRUSADE
registry
enrolled)
N=32,601
total; GPI
Rx=18,436
(6,084
women,
12,352
men)
(UFH or
enoxaparin)
n=1,354
women vs.
bivalirudin +
GPI=1,386
women vs.
bivalirudin
=1,417
women
PCI=1,190
women
No PCI
=2,967
women
enoxaparin)
vs.
bivalirudin +
GPI vs.
bivalirudin
Use of GPIdose was

evaluated
based on
pts CrCl
Rate of
dosing,
excessive
dosing,
bleeding and
outcome
were
compared by
gender
treatment
Bivalirudin
Intervention:
PCI
Non-PCI
ischemia,
and overall
clinical
benefit at
30-d
2) AT
strategy on
outcome in
women
PCI at 30 d
higher 30-d
bleeding; net
clinical outcome
30 d worse in
women due to
bleeding
Those
treated with
GPI vs. not;
women vs.
men
Those
treated with
GPI vs. not;
women vs.
men
For GPI Rx: Rate

of bleeding
significantly
higher in women
vs. men (15.7%
vs. 7.3%;
p<0.0001);
For those NOT
GPI Rxd: women
had significantly
higher bleeding
rates than men
(8.5 vs. 5.4%;
p<0.0001)
PCI=3,838
men
No
PCI=5,824
men
All enrolled
CRUSADE pts
Jan.-Dec. 2004
Contraindicated
to GPI; those
without
complete data
including GPI
dose, CrCl,
follow-up
16982940
(246)
116
bleeding
than GPI +
heparin
(5% vs.
10%,
p<0.0001)
with no
difference
in
composite
ischemia
(7% vs.
6%); no
difference
in
bivalirudin
+ GPI and
GPI +
herparin
Despite NS
difference
in serum
Cr, women
had mean
CrCl
significantly
lower (20
mg/min) vs.
men;
excess GPI
dose given
to women
significantly
more than
men (46.4
vs. 17.2%;
p<0.0001)
Excess GPI
dose
associated
with
increased
bleeding.
Women
(OR: 1.72;
95% CI:
1.30-2.28)
Men (OR:
1.27; 95%
CI: 0.971.66)
GPI
bleeding
attributed
risk=25%
women,
4.4% men;
Excess GPI
dose for
women vs.
women=8% vs.
men=3%;
p<0.0001; 30-d net
clinical outcome
women=13% vs.
men=10%;
p<0.0001
regression analysis
performed to
account for baseline
difference
N/A
N/A
Bhatt DL, Roe

MT, Peterson
ED, et al.
Utilization of
early invasive
management
strategies for
high-risk
patients with
non-STsegment
elevation
acute
coronary
syndromes:
results from
the CRUSADE
Quality
Improvement
Initiative.
JAMA.
2004;292:209
6-104.
15523070
(231)
O'Donoghue
M, Boden WE,
Braunwald E,
et al. Early
invasive vs
conservative
treatment
strategies in
women and
men with
unstable
angina and
non-ST-
Determine use
and predictors
of early
invasive
management
strategies in
high-risk pts
with NSTEMI
To compare
the effects of
an invasive vs.
conservative
strategy in
women and
men with NSTE
ACS
Registryobservation
al study trial
17,926 with
NSTEMI in
CRUSADE
(women
=7,353)
8,037 (44%)
underwent
early cardiac
cath <48 h
N/A
8,037
(44.8%)
underwent
early
cardiac
cath <48 h
(women
=2,842)
Metaanalysis of
RCTs
(19704/2008)
with
genderspecific
analyses
Data
combined
from8 trials
(3,075
women and
7,075 men).
Women:
Early
invasive
=1,571
Men:
Early
invasive:
3,641
Initial
conservative
=1,581
Initial
conservative
: 3,619
Pts with
NSTEMI
presenting to
248 UShospitals
with cardiac cath
facilities and PCI
or CABG
availability
Pts with NSTEACS in 8 RCTs

evaluate early
invasive vs.
selective
invasive (if
recurrent Sx) or
positive stress
test after initial
pharmacological
test
N/A
Pts with
missing
biomarker data
excluded from
high-risk
analyses
N/A
N/A
N/A
N/A
117
Use of early
invasive
management
within 48 h of
presentation;
predictors of early
invasive
management; inhospital mortality
Propensity
matched analyses
revealed OR: 0.8
significantly favors
early invasive
over selective
invasive in women
N/A
Women had lower

MACE with early
invasive vs. initial
conservative as
did men without
significant gender
interaction.
Biomarkerpositive women.
Early invasive vs.
initial conservative
for death/MI/ACS
(OR: 0.67; 95%
N/A
men=3.81
(95% CI:
3.394.27)
Female sex
as predictor
of early
invasive
OR: 0.86
(95% CI:
0.80-0.92);
Registry data
estimating real
world practice
with usual
limitations of
generalizability
Predictors of early
invasive
management: lowerrisk pts with lack of
prior or current CHF,
renal insufficiency,
positive biomarkers
Pts treated with early
invasive strategy
had lower in-hospital
mortality 2.5% vs.
3.7%; p<0.001
In men:
early
invasive vs.
initial
conservativ
e for
MACE.
Biomarker
positive:
OR: 0.56)
(95% CI:
0.46-0.67)
Biomarker
MACE early
conservative:
Women: OR: 0.81
(95% CI: 0.651.01)
Men: OR: 0.73
(95% CI: 0.550.98)
Results persisted for

12-m follow-up.
Heterogeneity
between trials; trials
not individually
powered for sexspecific analyses
segment
elevation
myocardial
infarction: a
meta-analysis.
JAMA.
2008;300:7180.
18594042
(247)
Dolor RJ,
Melloni C,
Chatterjee R,
et al.
Treatment
Strategies for
Women With
Coronary
Artery Disease
[Internet].2012
CI: 0.50-0.88), but

not in biomarker
negative women
and 35% higher
risk of death/MI
(OR: 1.35; 95%
CI: 0.78-2.35)
To determine
efficacy and
safety of early
invasive vs.
initial
conservative
strategy in
women with
NSTE-ACS
Metaanalyses of
RCTs and
systematic
reviews of
observation
al studies
7 studies
early
invasive vs.
initial
conservativ
e for
women with
NSTEACSMI
N=17,930
pts, of
which 6,084
(34%) were
women
Analyses run
separately
for different
time points
(6 mg, 1 y, 5
y); n=4,030
(36%
women) for
risk modifier
studies;
n=2,220
(34%
women) for
safety
studies
N/A
Pts with NSTEACS in RCT of

early invasive
vs. initial
conservative
studies including
FRISC-II,
TACTICS-TIM18, GUSTO-IVACS, ICTUS,
RITA-3, TIMIIIIB
Those with
missing data
Early
invasive vs.
initial
conservative
N/A
To determine
sex differences
in baseline
characteristics
and outcome in
ACS and if
women benefit
from early
invasive
strategy
Analyses of
data from
TACTIC
TIMI-18 by
gender
(multivariab
le logistic
regression
of sex as
predictor of
outcome
prospective
N=2,220
(women
=757)
Early
invasive
=1,114
Angiography
4-48 h after
randomizatio
n with
PCI/revasc
as indicated
Initial
conservative
=1,106
medical
therapy
angiography/
PCI if
recurrent Sx
or positive
stress test
Pts with NSTEACS without

contraindications
to angiography;
pt received ASA
(325 mg), UFH,
tirofiban
Missing data,
lack of followup (6 mo and 1
y)
Early
invasive
=angiograph
y 4-48 h
after
randomizatio
n with
PCI/revasc
as indicated
Initial
conservativ
e =medical
therapy
angiograph
y/PCI if
recurrent
Sx or
positive
stress test
23016160
(248)
Glaser R,
Herrmann HC,
Murphy SA, et
al.
Benefit of an
early invasive
management
strategy in
women with
acute
coronary
syndromes.
118
Women showed
trend toward
benefit from early
conservative at 6
mo and 1 y
(death/MI) OR:
0.78; OR: 0.77,
respectively), but
at 5 y the trend
favored initial
conservative
(1.05; CI: 0.811.35); Troponinpositive women
benefit from early
conservative (OR:
0.56; CI: 0.320.97)
Women were
older, had more
HTN, less Hx
CAD, and less
positive
biomarkers, no
difference in TIMI
risk score.
Women had less
severe CAD.
Women benefit
from early
Negative
OR: 0.72
(95% CI:
0.51-1.01)
Increased
bleeding in
women vs.
men in
NSTE-ACS
pts
undergoing
PCI
(adjusted
OR: 3.6;
95% CI:
1.6-8.3)
Women
who
underwent
PCI had
higher
bleeding
rate vs.
men (8.3%
vs. 2.9%,
OR: 3.6,
1.6-8.3).
Rates of
Early
invasive
showed
benefit
(death/MI)
over initial
conservativ
e in men at
6 m (OR:
0.65; CI:
0.52-0.82;
p=0.0002).
Results for
these at 1y
(OR: 0.88;
CI: 0.641.20); 5 y
(OR: 0.91;
CI: 0.531.56)
For women
with NSTEACS
troponin
negative
OR: 1.46
(CI: 0.78,
2.72); TIMI
Risk 0-2
OR: 1.59
(CI: 0.693.67), no
N/A
N/A
Early invasive vs.

initial conservative
for MACE
Women: OR: 0.45
(95% CI: 0.240.88) adjusted for
baseline difference
Men: OR: 0.6 (95%
CI: 0.47- 0.88)
(p=0.6 for gender
interaction)
This subanalysis
may not be
adequately powered
to detect differenced
among women.
JAMA.
2002;288(24):
3124-9.
RCT of
early
invasive vs.
initial
conservativ
e strategy)
12495392
(249)
Chen J,
Einstein AJ,
Fazel R, et al.
Cumulative
exposure to
ionizing
radiation from
diagnostic and
therapeutic
cardiac
imaging
procedures: a
populationbased
analysis. J Am
Coll Cardiol.
2010;56:70211.
20619569
(250)
Einstein AJ,
Weiner SD,
Bernheim A,
et al. Multiple
testing,
cumulative
radiation dose,
and clinical
indications in
patients
undergoing
myocardial
perfusion
imaging.
To determine
the cumulative
dose of ionizing
radiation
exposure of
cardiac
imaging over 3
y
Retrospecti
ve,
observation
al.
Administrati
ve claims
used to
identify
insured
adults
undergoing
cardiac
imaging
N=952,420
enrollees,
n=90,121
1 cardiac
imaging
procedure
Determine
cumulative
dosecardiac
procedure=
myocardial
perfusion
imaging (CT
or PET),
cardiac CT,
diagnostic
cath/PCI,
cardiac PET,
MUGA, EPS/
ablation
2005-7 vs.
background
radiation
level
3 categories
were 3
mSv/y
background
level of
naturally
absorbed
radiation in
the U.S; 320 mSv/y,
and 20
mSv/y
(upper
annual limit
for
occupational
exposure for
at-risk
workers/ 5 y)
Insured adults
(18-65) with 3 y
data member
1 of 5 health
care markets
having 1
cardiac imaging
procedure
N/A
N/A
N/A
To characterize
procedure
counts,
cumulative
estimated
effective
radiation
doses, and
clinical
indications for
pts undergoing
MPI
Retrospecti
ve cohort
study of
consecutive
pts
undergoing
MPI single
centerindex exam
linked to all
radiation
studies pre
(18 y)/post
(2 y) follow-
N=1,097
pts with
index exam
in 2006;
(51.5%
women)
MPI
N/A
Consecutive
inpts and outpts
in single center
undergoing
single-photon
emission CT
MPI (index
procedure) in
2006- EPR
linked records
1988-2008
Radiotherapy
procedures
excluded
N/A
N/A
119

conservative in
MACE (OR: 0.72;
95% CI: 0.471.11) overall but
OR: 0.47 (95% CI:
0.26-0.83) for
elevated troponin
9.5% underwent
having 1 cardiac
imaging
procedure within 3
y. Mean
cumulative
dose=23.1 mSv
(range 1.5 mSv544 mSv). MPI
accounted for
74%; 80/100 rec
>3-20 mSv;
3.3/1,000 rec >20
mSv
bleeding
and stroke
showed in
women
undergoing
CABG no
different
from men
Myocardial
imaging
studies
account for
most of
radiationidentifies
potential to
reduce
radiation
with
alternate
imaging
ST
segment
changes
OR: 1.00
(CI: 0.611.65)
Radiation
levels for
comparable
procedure
higher in
doctors
office vs.
hospital.
Higher in
men and
increasing
exposure
with age.
N/A
Radiation estimates,
insured younger
adult population
studied, not specific
to those with NSTEACS
Median
procedures=15
(IQR 6-32), 4
were high-dose
ionizing radiation;
31% received
cumulative dose
>100 mSv.
Multiple MPIs
performed on
39% pts, MPI
accounted for
majority of
radiation
N/A
Women
underwent
more
ionizing
radiation
procedures
than men,
even
excluding
mammogra
m, but
cumulative
effectivedose higher
Multiple outcomesdoses/types of
testing. Multiple
MPI performed on
individual pats with
highest radiation
dose associated
Likely
underestimation of
longitudinal radiation
exposure if scans
could not be assess
(other institutions,
not known); changes
in technology over
time, some date
imputed, single
center experience.
JAMA.
2010;304:213
7-44.
21078807
(251)
up
exposure.
in men.
More
procedure/d
ose in
White>Blac
ks and
Hispanics
N/A
Einstein AJ,
To determine
Monte
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Doses of 8 CTCA N/A
RR of attributable
Models for single
Henzlova MJ,
the LAR of
Carlo
protocols given for
cancer vs. 80 y
CTCA scans without
Rajagopalan
cancer
simulation
organs; younger
shielding
S. Estimating
incidence
estimation
women had a
Male: 20 y
risk of cancer
associated with of organ
significantly
associated
64-slice CTCA
doses from
higher LAR of
Female RR: 23, 40
with radiation
radiation
64 slice
cancer, especially
y
exposure from exposure and
CTCA- age
breast and lung,
64-slice
determine
and sexfrom single CTCA
Female OR: 11.5,
computed
influence of
specific
60 y
tomography
age, sex, and
LAR of
Female OR: 7.0 for
coronary
scan protocol
cancer
heart scan (slightly
angiography.
using BEIR
higher for
JAMA. 2007
VII
heart/aorta scan)
Jul
18;298(3):31723.
17635892
(252)
ACC-NCDR indicates American College of Cardiology National Cardiovascular Data Registry; ACE, angiotensin-converting enzyme; ACS, acute coronary syndromes; ACUITY, Acute Catheterization and Urgent Intervention Triage Strategy trial; ASA, aspirin; AT,
antithrombins; BEIR, Biological Effects of Ionizing Radiation VII; CHF, congestive heart failure; CABG, coronary artery bypass graft; CAD, coronary artery disease; CANRACE, Canadian Registry of Acute Coronary Events; cath, catheterization; Cr, creatinine; CrCl,
creatinine clearance; CRUSADE, Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the American College of Cardiology/American Heart Association Guidelines; CT, computed tomography; CTCA,
Cancer Treatment Centers of America; DM, diabetes mellitus; EPR, electronic patient record; EPS, electrophisiology study; FRISC, Framingham and Fast Revascularization During Instability in Coronary Artery Disease trial; GDMT, guideline-directed medical therapy;
GI, gastrointestinal; GPI, glycoprotein IIb/IIIa inhibitors; GRACE; Global Registry of Acute Coronary Events; GUSTO-IV-ACS, Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries IV-acute coronary syndrome trial; HF,
heart failure; HTN, hypertension; Hx, history; ICTUS, Invasive Versus Conservative Treatment in Unstable Coronary Syndromes trial ; IQR, interquartile range; LAR, life attributable risk; MACE, major adverse cardiac event; MI, myocardial infarction; MPI, myocardial
perfusion imagin; MUGA, Multigated Wall Motion Study; N/A, not applicable; NS, not significant; NSTE-ACS, nonST-elevation acute coronary syndrome; NSTEMI, nonST-elevation myocardial infarction; PCI, percutaneous coronary intervention; PET, positron
emission tomography; pts, patients; RCTs, randomized controlled trials; RITA, Randomized Trial of a Conservative Treatment Strategy Versus an Interventional Treatment Strategy in Patients with Unstable Angina-3 trial; RBC, red blood count; revasc,
revascularization; RR, relative risk; Rx, prescription; Sx, symptom(s); TACTICS, Treat Angina With Tirofiban and Determine Cost of Therapy With an Invasive or Conservative Strategy; TIMI, Thrombolysis In Myocardial Infarction; UFH, unfractionated heparin; and U.S.,
United States.
Data Supplement 31. Anemia, Bleeding, and Transfusion-Relationship Between Transfusion and Mortality (Section 7.8)
Study
Aim of Study
Type of Study
Study Size
Patient Population
Alexander KP 2008
To describe the association between Post hoc registry analysis
44,242
CRUSADE registry of
18513518 (253)
transfusion nadir HCT and outcome
NSTE-ACS pts
Primary Endpoint
Numerous endpoints. Most
relevant: adjusted OR for
mortality with transfusion for
120
Outcome
Adjusted OR:
HCT 24%: 0.67 (0.45-1.02)
HCT 24.1%-27%: 1.01 (0.79-1.30)
Comments
Transfusion only beneficial at HCT
24%
HCT range
Yang 2007
17711710 (254)
Rao 2004
15467057 (255)
To assess transfusion patterns and

in-hospital outcomes in pts receiving
transfusions
To determine the association
between blood transfusion and
mortality in pts with ACS
Clinical guideline from the AABB on
RBC transfusion
Post hoc registry analysis
74,271
CRUSADE registry of
NSTE-ACS pts
Post hoc analysis of data

from 3 randomized trials
24,112
GUSTO-IIb, PURSUIT,
and PARAGON pts with
ACS
Published randomized
trials; various pt
populations
Various trials in context of
surgery, acute blood
loss/trauma, coronary care
unit pts, or leukemia pts
Relevant endpoints:
Death and death or MI
HCT 27.1%-30%: 1.18 (0.92-1.50)

HCT >30%: 3.47 (2.30-5.23)
Adjusted OR:
Death: 1.67 (1.48-1.88)
Death or MI: 1.44 (1.30-1.60)
Adjusted HR:
3.94 (3.26- 4.75)
N/A
30-d mortality rates in

Transfusion associated with
transfused and nontransfused
increased mortality for Hct >25%
pts
Carson 2012
Analysis of all randomized
19 trials; 30-d mortality
Numerous endpoints
N/A
Restrictive transfusion strategy: 6.9%
22751760 (256)
trials of restrictive vs. liberal available in 11 trials
assessed. Most relevant: 30-d Liberal transfusion strategy: 8.0%
transfusion strategies
mortality
RR: 0.85 (0.7- 1.03)
Carson 2012
Cochrane Database Systematic
Analysis of randomized
19 trials
Numerous endpoints
Hospital mortality OR: 0.77 (0.62- 0.95) N/A
22513904 (257)
Review
trials of restrictive vs. liberal
assessed. Restrictive
30-d mortality OR: 0.85 (0.70- 1.03)
transfusion strategies
transfusion strategy
MI OR: 0.88 (0.38-2.04)
compared to liberal
transfusion strategy
AABB indicates American Association of Blood Banks; ACS, coronary artery syndrome; CRUSADE, Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines Registry; GUSTO IIb,
GUSTO, Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries trial; HCT, hematocrit; MI, myocardial infarction; N/A, nonapplicaple; NSTE-ACS, non-ST-elevation-acute coronary syndrome; PARAGON, Platelet IIb/IIIa
Antagonism for the Reduction of Acute Coronary Syndrome Events in a Global Organization Network trial; Pts, patients; PURSUIT, Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy; and RBC, red blood cell.
Data Supplement 32. Anemia, Bleeding, and Transfusion Studies for Weight-Based and Renally-Adjusted Dosing of Anticoagulants (Section 7.8)
Study
Aim of Study
Type of Study
Study Size
Patient Population
Alexander 2005
Investigation of relationship between
Exploratory registry
3,354
NSTE-ACS pts in
16380591 (258)
UFH, LMWH and GPI excess dosing and analysis
CRUSADE registry
major outcomes
Primary Endpoint
Major clinical outcomes and
bleeding
Melloni 2008
18657648 (259)
Exploratory analysis of CRUSADE

registry examining relation between UFH
dosing and bleeding
Post hoc analysis of

registry
31,445
NSTE-ACS pts in
CRUSADE registry
Excess dosing percent;

factors associated with
excess dosing; major bleeding
LaPointe 2007
17646609 (260)
Exploratory analysis of CRUSADE

registry examining relation between
enoxaparin dosing and bleeding
Chart review assessing incidence of
bleeding in CKD pts with incorrectly
dosed bivalirudin or GPI
Post hoc analysis of

registry
10,687
NSTE-ACS pts in
CRUSADE registry
Inappropriate dosing percent;

major bleeding and death
Chart review
199
Pts undergoing PCI
Incidence and extent of

bleeding (TIMI or GUSTO)
Taylor LA 2012
22170973 (261)
121
Outcome
Adjusted OR for major bleeding with excess dosing (vs. no excess
dosing):
UFH: OR: 1.08 (0.94 1.26)
LMWH: OR: 1.39 (1.11 1.74)
GPI: OR: 1.36 (1.10 1.68)
Dosing of UFH above recommended weight-based dosing
associated with increased major bleeding
Excess bolus OR: 1.03 (1.00 1.06)
Excess infusion dosing OR: 1.16 (1.05 1.28)
Excess dosing associated significantly associated with increased
risk of major bleeding (adjusted OR: 1.43; CI: 1.18 1.75)
Eptifibatide:
Incorrectly dosed in 64%
Incorrectly dosed pts experienced more overall bleeding (64% vs.
35%; p=0.04), numerically more TIMI major bleeding (19% vs. 5%;
no p value given), and a greater extent of bleeding (p=0.03 for TIMI
bleeding and p=0.009 for GUSTO bleeding)
Bivalirudin:
Incorrectly dosed in 28%
Bleeding rates (incorrect vs. correct) 37% vs. 21% (p=0.055)
Extent of bleeding greater with incorrect bleeding (p=0.013 for
GUSTO bleeding; p=0.058 for TIMI bleeding)
Becker 2002
12040334 (262)
Pharmacokinetic/dynamic study of
Pharmacokinetic/pharm
TIMI 11A study of ACS pts Relationship of pt factors and
Pts with creatinine clearance <40 mL/min had sig higher trough and
enoxaparin and anti-Xa activity and
acodynamic substudy
anti-Xa levels
peak anti-Xa levels (numerous statistically significant p values for
factors that affect anti-Xa levels
multiple comparisons)
ACS indicates acute coronary syndrome; CKD, chronic kidney disease; CRUSADE, Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines Registry; GPI, glycoprotein; GUSTO,
Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries; LMWH, low molecular weight heparin; N/A, not applicable; NSTE-ACS, non-ST-elevation-acute coronary syndrome; PCI, percutaneous coronary intervention; Pts,
patients; TIMI, Thrombolysis In Myocardial Infarction; and UFH, unfractionated heparin.
Data Supplement 33. Cocaine and Methamphetamine Users (Section 7.10)
Study Name,
Study Aim
Study Type/
Intervention
Author, Year
Size (N)
vs.
Comparator
(n)
Patient Population
Inclusion
Criteria
Exclusion
Criteria
Study Intervention
Potentiation of
cocaine-induced
vasoconstriction by
beta-blockade
Lange RA et al.
1990
1971166 (263)
To determine
whether betablockade
augments
cocaine-induced
coronary
vasoconstriction
Prospective;
N=30
Intracoronary
propranolol
(n=15)
vs. saline
(n=15)
Pts referred
for coronary
arteriogram
for chest pain
HTN, recent
MI
Quantitative
angiography
performed before
and 15 min after
intranasal saline or
cocaine; repeat
measurements
obtained following
intracoronary
propranolol
BB associated with
reduced risk of MI
after cocaine use
Dattilo PB et al.
2008
17583376 (264)
Determine if rates
of MI increased
with BB treatment
after recent
cocaine use
Retrospective
N=348 (60
with recent
cocaine use)
BB treatment
vs. no BB
treatment
Admitted pts
with positive
urine drug
screen for
cocaine who
received BB
Cardiac
markers not
obtained; pt
on oral BB
N/A
Endpoints
P Values,
OR: HR: RR: & 95
CI:
Adverse
Events
Study Limitations
Primary Endpoint &

Results
Safety
Endpoint
& Results
Secondary Endpoint
& Results
Heart rate, arterial

BP, coronary sinus
blood flow, epicardial
left coronary arterial
dimensions;
Intracoronary
propranolol caused
no change in BP or
heart rate, but
decreased coronary
sinus blood flow and
increased coronary
vascular resistance
In-hospital MI after
BB use; lower
incidence of MI after
administration of BB
N/A
None
Decrease in
coronary blood flow
(p<0.05); increase
in coronary vascular
resistance (p<0.05)
N/A
Small n; not
randomized; intranasal
cocaine during
catheterization does
not apply to real world
pts presenting with
cocaine induced chest
pain; intracoronary
propranolol does not
pertain to intravenous
BB
N/A
In-hospital mortality;
trend for lower
mortality in pts
receiving BB
Incidence MI in BB
vs. no BB 6.1% vs.
26.0% (95% CI:
10.3% 30.0%);
Mortality 1.7%
vs.4.5% (95% CI: -
N/A
Included pts without

ACS Sx (56% with
chest pain);
retrospective; did not
take into consideration
time of cocaine use;
122
during current
hospitalization
BB for chest pain

associated with
recent cocaine use
Rangel C et al
2010
20498415 (265)
Determine if rates
of adverse
advents
associated with
BB treatment in
chest pain pts with
recent cocaine
use
Retrospective
Benzodiazepines and
Nitroglycerine in
treatment of cocaine
chest pain
Honderick T et al
2003
12563578 (266)
To compare the
use of lorazepam
and nitroglycerine
in treatment of
cocaine chest pain
Prospective,
randomized,
singleblinded
controlled
trial; N=27
331 (151
received BB)
BB treatment
vs. no BB
treatment
NTG (n=15)
vs. NTG +
lorazepam
(n=12)
Chest pain
pts with urine
drug screen
positive for
cocaine
Chest pain
and selfreported
cocaine use
in the
preceding 72
h
1.2% 6.7%
No chest
pain; urine
drug screen
not
performed
or urine drug
screen
negative for
cocaine
N/A
Age >45 y,
chest pain
duration >72
h,
documented
CAD,
pretreatment
with NTG
NTG vs. NTG +

lorazepam
Death on long-term
follow-up of National
Death Registry
(median 972 d)
N/A
ED BP; Peak Tn
levels, ventricular
fibrillation/tachycardia,
intubation, or
vasopressor agents
BB use associated
with 70% reduction
in risk of CV death
(HR: 0.29; 95% CI:
0.09 0.98)
N/A
Kruskal-Wallis
testing showed a
sig difference in
pain relief between
the 2 study groups
(p=0.003) with
greater pain relief
noted at 5 and 10
min in the NTG +
lorazepam group
None
Pts receiving BB had

larger decrease in
SBP in ED even after
adjusting for other
anti-HTN agents
administered; there
were no differences in
any of the secondary
outcome measures
Chest pain relief as

assessed on a 0- 10
ordinal scale was
greatest in the pts
treated with the
combination of NTG
and lorazepam.
123
N/A
N/A
did not check serum

cocaine levels; urine
drug screen only
detects pts with
cocaine use within 4872 h. Selection bias as
pts receiving BB were
older, more frequent
Hx of HBP and CHF,
higher SBP, and higher
glucose levels;
mortality mainly due to
non-ACS causes
Retrospective;
unknown how recent
was time of cocaine
use; patients treated
with BB more likely to
be given nitrates in ED
which may have
ameliorated any
cocaine induces
spasm; unknown what
factors may have
influenced clinican to
treat or not treat with
BB (note: clinicians
most commonly were
treating pt without
knowledge of cocaine
use as results of drug
screen pending)
Small n; none of the
pts diagnosed with MI;
lorazepam only
subgroup not
investigated
Diazepam,
Nitroglycerin, or both
for treatment of
cocaine ACS
Baumann BM et al
2010
10958127 (267)
To compare
diazepam,
nitroglycerin, or
both in treatment
of pts with
potential cocaineassociated ACS
Randomized
doubleblinded trial;
N=40.
Diazepam
(n=12) vs.
NTG (n=13)
vs. both
(n=15)
Chest pain
and cocaine
use within the
preceding 24
h
<18 y age;
>60 y age
Diazepam vs. NTG

vs. both
Chest pain resolution

as measured by a
visual analog scale
Chest
pain
resolution
equivalent
in all 3
groups
Changes in BP, pulse

rate, cardiac output,
cardiac index, stroke
volume, and stroke
index
ACS in chest pain pts

after amphetamine
use
2003
Turnipseed SD et al.
12745036 (268)
Determine
frequency of ACS
in pts presenting
with
methamphetamine
induced chest
pain
Retrospective
N/A
Nontraumatic
chest pain,
positive
amphetamine
on urine drug
screen
Not admitted
for MI rule
out;
abnormal
CXR
N/A
ACS defined as MI,

ischemia on cardiac
stress testing, or
70% stenosis on
cardiac cath
N/A
Cardiac arrhythmias
(V-tach, V-fib, SVT)
(p=0.02 and 0.005

respectively)
Hemodynamic
parameters
equivalent in all
subgroups.
Outcomes: though
not statistically sig,
changes in mean
arterial pressure for
diazepam,
diazepam + NTG,
and NTG
respectively were
2.1, -12.1, and -8.4
mm Hg respectively
(p=0.08)
ACS diagnosed in 9
pt visits (25%; 95%
CI: 11%- 48%)
None
Retrospective; small n;
only investigated
N=36 visits in
results in admitted pts
33 pts (3 with
and thus ACS rate
CV events)
3 pt visits with
over-estimated; urine
arrhythmias (8%;
drug testing in
95% CI: 2%- 24%)
admitted pts not done
routinely
ACS indicates acute coronary syndrome; BB, beta blocker(s); BP, blood pressure; CAD, coronary artery disease; CHF, congestive heart failure; CV, cardiovascular; CXR, chest x-ray; Dx, diagnosis; ED, emergency department; HBP, high blood pressure; HTN,
hypertension; Hx, history; MI, myocardial infarction; N/A, not applicable; NTG, nitroglycerin; pt(s), patient(s); SBP, systolic blood pressure; SVT, supraventricular tachycardia; Sx, symptoms; Tn, troponin; UA, unstable angina; V-fib, ventricular fibrillation;and V-tach,
ventricular tachycardia.
124
N/A
Small n; only 3 pts had

MI and 5 pts Dx of UA
Additional Data Supplement Tables

(These tables were created during the evidence review process but do not support a specific section of recommendations in the guideline. They are provided for transparency and completeness.)
Data Supplement A. Other (Newer) Biomarkers
Study Name,
Study Aim
Study Type/Size
Author, Year
(N)
Intervention vs.
Comparator (n)
Patient Population
Inclusion Criteria
Exclusion Criteria
Study Intervention
Endpoints
Primary Endpoint &
Results
P Values,
Secondary
Endpoint &
Results
Occurrence of
MACE reduced
with PCI with
highest
PGF-15 levels:
0.49 (0.33-0.73)
p=0.001
Among Trpts, (79% of
cohort)
high FH-FA bp
identify pts at high
risk
FRISC-II
Wollert 2007
(269)
17848615
Effect of PGF-15 on
ACS outcomes in
invasive vs.
conservative
strategy
Multicenter
prospective study
(FRISC II)
2,079
PGF-15 in
intervention vs.
conservative
treatment
outcomes
ACS with criteria for

PCI or conservative
strategy with PGF15 levels
Previous heart
surgery, PCI within 6
mo, bleeding
tendency, high
creatinine
PGF-15 with PCI or

conservative strategy
2-y MACE.
PGF independently
predicted outcomes in
conservative strategy only
C-NET
Viswanathan 2010
(270)
20513600
Px value of H-FABP
in low-int. risk ACS
pts
Prospective
observational
cohort
955
H-FABP vs. Tn
Chest pain
Non-cardiac
Chest pain. Age <18
y
H-FABP/Tn
12-24 h from Sx onset
Death/MI
12 mo H-FABP predicted
outcome after multivariate
adjustment
Charpentier 2010
(271)
20078436
Detection of AMI by
H-FABP and IMA
Prospective.
observational
cohort
677
H-FABP vs. IMA
Chest pain and

suspected NSTEMI
Age <18 y
Skeletal muscle
injury, trauma, renal
impairment.
H-FABP and IMA on

admission
Dx NSTEMI
IMA not predictor of ACS
Dx H-FABP predictor
H-FABP did not

add info to std
predicted model
Haaf 2011
(272)
21531234
BNP in Dx and risk

in chest pain pts
Prospective
multicenter
1,075
BNP vs. TnT
Possible ACS
ESRD with dialysis
BNP and TnT at

admission and 1 h, 2 h,
3 h, 6 h
Dx accuracy of BNP for MI

lower than Tn
Keller 2010
(273)
20447532
Copeptin in Dx of
AMI
Prospective
multicenter
1,386
Copeptin vs. TnI
Possible ACS
Trauma, major
surgery, IV drug
abuse, anemia
Copeptin and TnT on

admission
TnT vs. combined Cstatistic vs. TnT alone:

0.93 vs.0.84
BNP predicted 24
mo outcome
more accurate
than TnT
AUC 0.81 vs. 0.76
p<0.001
C-statistic within 3
h chest pain
combined 0.90 T
alone 0.77
125
Study Limitations
2-y MACE prediction

with PGF-15 levels
p=0.016
PGF-15 not
independently related
to ST depression or Tn
levels
HR:2.62 (1.30- 5.28)

p=0.0007
H-FABP for adverse
events
ROC 0.79 (0.74- 0.84)
ROC TnI
0.77 (0.72- 0.82)
IMA OR
1.23 (0.87-1.81)
H-GFABP OR
4.65 (2.39-9.04)
Sens 96.8%
Spec 98.1%
Only 53% of eligible

pts enrolled because
of timing.
Statistical modeling/
adjustment
BnP Dx: AUC:

0.74 (0.70-0.78)
TnT:
0.88 (0.84-0.92)
p<0.001
Relatively low
enrollment.
Some lack of
agreement on Dx by 2
physicians.
Possible
misclassification of UA
pts.
No serial testing.
Clinical benefit of risk
stratification
BNP levels linked to
factors related to
outcome confusing.
Combination of
copeptin and TnT
superior to all single or
other marker detm.
Using Tn for Dx might

favor tested Tr
compared with
copeptin
p<0.001
Peacock 2011
(274)
22093206
MPO for Dx of AMI
Prospective
multicenter
1,018
MPO vs. TnI
Possible ACS <8 h

Sx
<18-y non-cardiac
chest pain
MPO and TnT on

admission
Using 90% spec. cutpoint

MPO had insufficient
accuracy
Iversen 2009
(275)
19932776
PAPP-A as risk
marker in ACS
Prospective
cohort
123 NSTEMI
PAPP-A vs. std Dx

(TnT)
Possible ACS
NSTE
STE-ACS (evaluated
separately)
PAPP-A on admission
and every 6 h to 8 h
Risk for MI and death 2.66

y to 3.47 y
PAPP-A related to risk for
both in NSTEMI
RISCA
Bogaty 2008
(276)
18549920
CRP in pred 1-y

outcome in ACS
Prospective
cohort
1,210
CRP
No comparator
Dx of UA or AMI
Transfer from other

hospital
CRP on admission
discharge and 1 mo
later
MACE at 1-y multivariate

analysis: NS predictability
NS pred of UA,
MI, or death
individually
Kuch 2008
(277)
18940277
MONICA/KORA
CRP and TnT in

short term Px in
NSTEMI
Prospective
cohort 697
NSTEMI (612
with STEMI)
CRP vs. Tn in 28-d

mortality event
Dx of NSTEMI
STEMI separately
evaluated
CRP and TnT on

admission
Multivariate analysis
Both CRP+ and TnT+
showed pred of 28 d
mortality
Schaub 2012
(278)
22205695
GDF-15 in early Dx
and risk in AMI
Prospective
multicenter
646
GDF-15 vs. TnT

and BNP
ACS Sx
ESRD
Assays on admission
to ED
Mega 2008
(279)
18565400
Px of TpP in ACS
Prospective
multicenter
2,349 with ACS
TpP+ vs. TpP in

predicted.
Compared with Tn
NSTEMI
UA
STEMI evaluated
separately
Assay at median 40 h
from presentation
ROC for MIAUC

GDF-15 0.69
Hs-TnT 0.96
BNP 0.74
10-mo MACE
TpP significant pred risk
for comparative events as
well as death or MI
In NSTEMI
CRP+ but not Tr+
pred mortality:
4.59 (1.68
12.5) vs.
1.75 (0.55
5.54)
GDF-15 pred 26mo mortality >TnT
and BNP
Saraf 2010
(280)
20447533
Px significant of
ETA in ACS
Prospective
cohort 300 with
ACS on dual
Use of GTT
ACS
Sepsis, malignancy
blood, Dyscrasia,
anticoagulant
Assay time not stated

Evaluation OT and LT
126
12-mo death, MI, or stroke

by LT pred MACE
and CV death
MPO C-statistic:
ACS vs. NCCP
0.623
AMI vs. NCCP
0.666
N/A
Weak correlation
of TpP with TnI,
BNP, and Hs-CRP
R<0.15 for each
No correlation
between OT and
MACE
(myocardial, CK-MB,
BNP)
MPO sens
18% -PV 69%,
+PV 0.47 to diff ACS
from non-cardiac chest
pain.
PAPP-A risk
MI p =0.02
Death p=0.03
Multivariable:
combined risk
2.65 (1.40-5.03)
in NSTEMI
Adjusted OR for
MACE admission:1.04
(0.91-1.14)
Discharge: 0.90 (0.771.06)
1 m. 1.12 (0.93-1.34)
Tr+
OR 1.99 (1.15-3.44)
CRP+
OR 2.05 (1.09-3.84)
For 28-d mortality
prediction
26-mo mortality AUC
GDF-15: 0.85
TnT: 0.77 p=0.002
BNP: 0.75 p=0.007
HR for MACE:
1.45 (1.201.95)<0.001
adjusted for Cl.
characteristic and
other biomarkers:
1.51 (1.19-1.91)
<0.001
LT predicted MACE:
2.52 (1.344.71)=0.004
Spectrum bias
Physician Dx bias
Differing local
Tn platforms
Long time between
sample collection (6 h
to 8 h)
Not stated
Possible CRP
influenced by larger
myocardial necrosis or
longer prehospital
delay
Clinical benefit of imp.
risk strategy
TpP not measured at
presentation
Possible that study
median inflated TpP
levels
Antiplatelet effects of
ASA and Clopidogrel.
Heparin effects.
antiplatelet
therapy
CV Death:
Diurnal variation of
4.2 (1.13TpP
15.62)=0.033
Body 2010
Effect of P-selectin
Prospective
P-selectin vs. TnT
Suspected ACS
Chest trauma,
Assay time at present.
Only P-selectin and PAPP- 30-d MACE
C-statistic for MI
No serial evaluation
(281)
on Dx of AMI and
cohort
with 5 other novel
ESRD, pregnancy,
for P-selectin
A Dx AMI
prediction: only P- P-selectin: 0.68 (0.6321167826
risk
713
biomarkers
prisoners
selectin
0.73)
1.84 (1.1-3.1)
PAPP: 0.57 (0.51<0.001
0.63)
Wang 2007
Presence of PMAs
Prospective
PMAs and other
ACS SAP
Renal, hepatic,
Assay at presentation
Pts with ACS have higher
PMA, CRP, IL-6
Regression analysis
Small observational
(282)
and other novel
cohort
novel biomarkers
hematologic,
included IL-6, IL-8,
levels of PMAs compared
Each confer risk
ACS and biomarkers
study
16887214
biomarkers in ACS
132
immunologic
MCP-1, sCD40L
with SA
for ACS
PMA 1.33 (1.05-1.68)
74 ACS
disorders
CRP 2.64 (1.01-6.89)
58 SAP
IL-6 1.03 (1.001- 1.06)
ACS indicates acute coronary syndrome; ACS NSTE, acute coronary syndrome non-ST elevation; AMI, acute myocardial infarction; ASA, aspirin; AUC, area under the curve; BNP, B-type natriuretic peptide; BP, blood pressure: CK-MB, creatine kinase- MB; CRP, Creactive protein; CV, cardiovascular; Dx, diagnosis; ED, emergency department; ESRD, end stage renal disease; ETA, End Thrombosis Act; FRISC, Fragmin During Instability in Coronary Artery Disease; GDF- 15, growth differentiation factor- 15; GTT, global
thrombosis test; H-FABP, heart fatty acid- binding protein; hs-CRP, high sensitivity C-reactive protein; hs-TnT, high-sensitivity troponin T; IL, interleukin; IMA, ischemia-modified albumin; IV, intravenous; LT, lysis time; MACE, major adverse cardiac events; MCP,
monocyte chemaatractive protein; MI, myocardial infarction; MPO, myeloperoxidase; N/A, not applicable; NS, not significant; NSTEMI, non-ST elevation MI; NCCP, non-cardiac chest pain; OT, occluded time; PAPP-A, pregnancy-associated plasma protein A; PCI,
percutaneous coronary intervention; PMA, platelet-monocyte aggregates; Pts, patients; Px, prognosis; ROC, receiver operator curve; SA, stable angina; SAP, stable agina pectoris; sCD40L, soluble CD40 ligand; Sens, sensitivities; Spec, specificities; Std, standard;
STE-ACS, ST-elevation acute coronary syndrome; Sx, symptoms; Tn, troponin; TnI, troponin I; TnT, troponin T; TpP, thrombus precursor protein; and UA, unstable angina.
Data Supplement B. Other Anticoagulants
Study Name, Aim of study
Study Type
Author, Year
Study
Size (N)
Study
Intervention
Group (n)
Study
Comparato
r Group (n)
Patient Population
Inclusion
Criteria
Exclusion
Criteria
Severe stroke
Bleeding
diathesis
Recent GI ulcer
Uncontrolled
HTN
Anemia
Recent
fibrinolytic
agents
Not stated
Oldgren 2011
(283)
21551462
RE-DEEM
Safety and
efficacy of
dabigatr in
ACS
Multictr
Prosp.
Dose
Escalation
trial
1,861 on
dual
platelet
therapy
Dabigatran
bid.
50 mg 369
75
368
110
406
150
347
PC
371
Both groups
ASA and
clopidogrel
AMI <14 d
Dual
antiplatelet
therapy at
least 1 risk
factor for CV
complication
s
Uchino 2012
(178)
22231617
AMI risk with

dabigatrn
Meta-analysis
of 7 trials
30,514
Dabigatran
20,001
Warfarin
7,357
Enoxaparin
RCTs
including
stroke, AFIB,
Study
Intervention
Study
Comparator
4 doses of
dabigatran
for 6 mo
PC
Dabigatran
6-10 d
28- 35 d
Warfarin,
enoxaparin,o
r PC
127
Endpoints
Primary
Endpoint
(efficacy)
and Results
6-mo bleeding
Dose dependent
Increase with
Dabigatran
Sig with 110 mg
and 150 mg dose
Risk of ACS with

Dabigatran higher
than control
Safety
Endpoint
and Results
P Values,
OR: HR: RR &
95% CI:
Study Limitations
& Adverse Events
Bleeding
Dabigatran vs.
Warfarin
Significant:
Dabigatran 110
m:
3.92 (1.71,8.95)
Dabigatran 150
mg
4.27 (1.86,9.81)
Dabigatran risk :
1.33 (1.03,1.71)
p=0.03
Dose-dependent
increase in bleeding
significant at 110
and 150 mg qd
Dabigatran.
Secondary
Endpoint
and Results
3.8% PC pts
had stroke,
MI, or death
vs., 3.0%4.9%
Dabigatran
(not dose
related)
Dabigatran
reduced Ddimer in all
dose groups
Not
analyzed
Dabigatran
risk with
exclusion of
Dominant effect of
RE-LY
trial on results of
2,851 Or PC
371
ACS, DVT,
acute
embolus
Apixaban
2.5 bid 317
10 qd 318
10 bid248
20 qd 221
(611 total)
PC
611
MI within 7 d
with at least
1 additional
risk factor for
recurrent
events
Planned PCI
ASA allergy
Significant. HTN
Bleeding
diathesis
Recent stroke
Pericardial
effusion
1 of 4 doses
of apixaban
26-wk followup on ASA
PC
Planned PCI,
ASA allergy,
Significant HTN
Bleeding
diathesis
Recent stroke
Pericardial
effusion
Bleeding
diathesis
Planned PCI
Recent stroke
Renal or hepatic
Insufficiency
Allergy to study
drug
Apixaban
5 mg bid
Median
follow-up
241 d ASA
Low platelet
count
Low hematocrit
Renal
dysfunction
Recent GI bleed
Hx of
intracranial
bleed
APPRAISE
2009
(284)
19470889
Safety and
efficacy of
apixaban in
ACS
Multcenter
prospective
trial
1,715
Alexander
2011
(179)
21780946
Risk of
events with
Apixaban in
ACS
Multicenter
prospective
trial
7,392
Apixaban
3705
PC
3687
Median 6 d
after ACS
with
significant
risk factors:
prior MI, DM,
HF
RUBY-1
Steg 2011
(285)
21878434
Safety and
tolerability of
darexaban
Multicenter
prospective
trial
1,258
PC
319
ACS <7 d
from event
ATLAS
ACS-2
TIMI-51Mega
2012
(180)
CV outcomes
with
Rivaroxaban
in ACS
Multicenter
prospective
trial
15,526
Darexaban
Multiregimen
939
5 mg bid
10 mg qd
15 mg bid
30 mg qd
30 mg bid
60 mg qd
Rivaroxaban
2.5 mg bid
(5,174)
Rivaroxaban
5 mg bid
(5,176)
PC
(5,176)
ACS <7 d
from event
22077192
12 wk
6 mo
group.
Risk similar when
eliminating shortterm trials.
Clinically relevant
bleeding:
Apixaban
increased
bleeding at 10 mg
qd
Similar liver
enzyme
elevations
Apixaban and
PC
PC
ASA
MACE:
NS difference
between apixaban
and PC
Trial stopped
because of
major
bleeding with
apixaban
One of 6
regimens
Darexaban
26-wk followup
PC
26 wk
Bleeding
numerically higher
in all darexaban
arms than PC.
Dose response
effect
Safety was
primary
outcome
1 of 2
rivaroxaban
regimens
Mean 13 mo
follow-up
PC
Mean 13mo
follow-up
MACE
Rivaroxaban
lower than PC
Increased
major
bleeding
2.1% vs, 0.6%
p<0.01
On ASA
128
short-term
trials:
1.33 (1.03
1.72)
p=0.03
Apixaban
2.5 mg bid
and 10
mg qd trend
toward
decreased
ischemic
events
Bleeding
Apixaban vs.
PC
1.3% vs.
0.5%
2.59
(1.5,4.46)
p=0.001
Sl Increase
in efficacy
outcomes
Darexaban
5.6%
PC
4.4%
Decreased
total
mortality
9.2% vs.
11.0%
HR:0.84
(0.740.95)p=0.00
6
meta-analysis. MI
events few and
infrequent in other
studies.
Bleeding with 10
mg
2.45 (1.31
4.61)
p=0.005
Reduced
ischemia
0.61 (0.35
1.04)
p=0.07
One intracranial
hemorrhage with
apixaban. 2 higherdose Apixaban arms
discontinued
because of excess
bleeding.
MACE:
Apixaban vs. PC.
0.95 (0.80- 1.11)
p=0.051
Only high-risk pts.

No pts undergoing
revascularization.
Pooled bleeding
rate for
darexaban:
2.275 (1.13- 4.60)
p=0.022
Dose response:
6.2,6.2,9.3%
Sig for 30 bid
p=0.002
Primary endpoint
8.9% vs. 10.7%
0.84 (0.74, 0.96)
9=0.008
2.5 mg dose
CV death
2.7% vs. 4.1%
p=0.002
Total mortality:
Limited power for

efficacy.
Only relevant with
dual platelet
treatment
Increased major
bleeding unrelated
to CABG
Large missing data
Stroke/TIA with
antiplatelets
Reduced
2.9% vs. 4.5%
stent-throm
p=0.002
0.69 (0.51,
0.93) p0.002
Meta-analysis Bleeding,
Meta-anlysis
31,286
Apixaban
PC or
ACS
Trials of
OAC with
Antiplatelet
Increase major
Major
Net clinical
Mixed clinical
2012 (7)
outcomes in
Dabigatran
warfarin
(4-71%)
parental AC,
antiplatelet
with PC or
bleeding:
Bleeding
benefit
conditions
ACS
Darexaban
<6 to <14 d
VKA
6-31 mo
warfarin
3.03 (2.200.98 (0.90Only 58% (avg)
Rivaroxaban
from event
Decrease stent
4.16) <0.01
1.06)
ACS
Ximelagatran
thrombosis,
Ischemic
<pst;y PC but
ischemic events,
events
also warafarin
no difference in
0.73 (0.63control
overall death, net
0.84)<0.001 Ximelagatran no
clinical benefit
Mortality
longer active
0.90 (0.76Newer antiplatelet
1.06)
drugs not
Stent
adjuncts
thrombosis
0.73 (0.540.98)
ACS indicates acute coronary syndrome; AMI, acute myocardial infarction; ASA, aspirin; AFIB, atrial fibrillation; bid, twice daily; CABG, coronary artery bypass graft; CV, cardiovascular; DM, diabetes mellitus; DVT, deep vein thrombosis; GI, gastrointestinal; HF, heart
failure; HTN, hypertension; Hx, history; MACE, major adverse cardiovascular events; MI, myocardial infarction; NS, nonsignificant; OAC, oral anticoagulant; PC, placebo; PCI, percutaneous coronary intervention; Pts, patients; qd, daily; RE-LY, Randomized Evaluation
of Long-Term Anticoagulant Therapy; RCT, randomized controlled trial; TIA, transient ischemic attack; and VKA, vitamin K antagonist.
Data Supplement C. Lipid Management
Study Name,
Aim of Study
Author, Year
study
Type
Study
Size
(N)
Study
Intervention
Group (n)
Study
Comparator
Group (n)
Patient Population
Inclusion
Criteria
Cannon 2006
(286)
15687136
Efficac
y of
high
dose
vs.
standar
d
dosing
for CV
Metaanalysi
s
4 trials
27,548
High-dose
statin
13,798
Standarddose statin
13,750
Stable CAD
or ACS
Intensive vs.
standard
statin >1000
pts each
Study
Intervention
Study
Comparator
Exclusion
Criteria
Not stated
High-dose
statin
Standarddose statin
Endpoints
Primary
Endpoint
(efficacy)
and Results
High dose
produced a
significant 16%
reduction in
coronary death or
MI
Significant 16%
reduction in
129
Safety
Endpoint
and Results
Secondary
Endpoint
and Results
High-dose:
Rhabdomyoly
sis
0.13% A to Z
trial
CK>10 ULN
0.15%
PROVE-IT
AST or ALT
Trend
toward
decreased
CV mortality
with high
dose
p=0.054
P Values,
OR: HR: RR &
95% CI:
Study Limitations &

Adverse Events
Coronary death
or MI
0.84 (0.77- 0.91)
p<0.00001
Coronary death
or CV events
0.84 (0.80- 0.89)
p<0.0000001
Underpowered for CV
death and total death.
Different duration and
treatments. No individual pt
data. No evaluation of
benefit from statin or LDL
C level.
outcom
e
Spencer 2007
(287)
17826369
GRACE
Robinson 2009
(288)
19161879
Hulten 2008
(289)
17000936
Sattar 2007
(290)
20167359
coronary death or
any CV event
Use of
statin
at
hospita
l
dischar
ge with
ACS
NonHDLC
reducti
on and
CV risk
Registr
y
Retros
pective
analysi
s
8,492
Metaanalysi
s 30
trials
11,254
1
Effect
of
statin
therapy
in ACS
Metaanalysi
s
13
trials
17,963
Risk of
DM
with
statins
Metaanalysi
s
13
statin
trials
4,278
Statin use
with LDL-C
<100 mg/dL
or 100
mg/dL at
discharge
5,710
No statin at
discharge
2,782
Non-HDLC
change
14 statin
100,827
7 fibrate
21,667
6 niacin
4,445
3 others
5,102
Change in risk
Early statin in
ACS
No statin, PC
or usual care
Approximatel
y 50%
Approximately
50%
Statin use
2,226
No statin
2,052
ACS
ACS not
precipitated by
non-CV
comorbidities
Statin use
with LDLC<100 or
100 mg/dL
Control
Randomized
PC or active
control trials
<2-y trial
No serious nonCV disease
Change in
lipid level
Change in
risk
Statin<14 d
of
hospitalizatio
n for ACS
Standard attain
dose
Intensive
statin
PC or
standard
statin
2-y rate of death

and CV events
reduced with
intensive statin
therapy
Comparable
tolerability for
intensive
statins and
control. Only
3 cases of
rhabdomyolys
is.
PROVE-IT:
3.3% hepatitis
in high-dose
GP.
Statin
Trials with
>1 y followup in both
treatment
groups
Mean follow-up
1 y
Statin
No statin
Statin therapy
was associated
with a 9%
increased risk of
incident DM with
little
Aside from
DM risk, not
available
130
LDL levels <100

55% receiving
statin at
discharge
LDL levels >100
72% receiving
statin at
discharge
Statins: each 1%
Decrease in nonHDL-C decreased
4.5-y RR by 1%
(0.98-1.00)
3
ULN:
3.3% PROVEIT
N/A
N/A
Statin at
time of
discharge
associated
with MACE
reduction
0.76
(0.63,0.93)
Fibrate and
niacin
models also
had a 1:1
relation
between
non-HDLC
reduction
and risk
reduction
Pooled 2-y
HR
For intensive
statin
therapy MI
0.89
(0.60,1.33)
Ischemia
0.68 (0.500.92)
CV death
0.76
(0.66=0.87)
Lipophilic
Statins risk:
1.10
(0.99=1.22)
Hydrophilic
Statins risk:
Statin at time of
discharge
associated with 6mo total mortality
0.66 (0.51- 0.85)
6-mo statin use by pt selfreport
Fibrate trials vs.

statin trials no
different results
Bayes factor
K=0.49
Moderate
different effect on
non-HDLC
niacin vs. statin
Bayes factor
K=7.43
Rate of death and
CV events
reduction:
0.81 (0.77
0.87)
p<0.001
Lack of access to pt data
DM risk:
1.09 (1.02
1.17)
PC controlled
trials:
1.10 (1.01
Varied methods of dx of
DM. HRs not available in
all trials.In 2 trials Dx
based on physician
reporting rather than
biochemical analysis.
No info on statin types or

dosages
Unknown method of
endpoint adjudication. No
info on fibrates=statins.
Sig. statistical
heterogeneity.
Limited trials available.
Not a pooled analysis.
Adverse effects under
safety box.
heterogeneity
(11%) between
trials
Mostly AMI pts at
discharge 38%
received intensive
LLT and 62% less
intensive LLT
1.08 (0.981.20)
1.20)
Nonstandard criteria for Dx

of DM in some studies.
N/A
Factors
associated
with lack of
LLT
Female sex
Increased
age
Dialysis
(Multivariate
95%
CI<1.00)
Factors
associated with
intensive LLT:
LLT prior to
admission
PCI with stent
Known CAD on
admission
PVD
Prior MI
(Mltivariate 95%
CI>1.00)
MACE reduction
by intensive LLT
15% (11-18)
<0.0001
Major vascular
events
13% 97-19)
<0.0001
Total mortality
10%/1 mmol/L
LDLC
Reduction
0.90 (0.87
0.93)
Adjusted HR per
I-SD increase
non-HDLC :1.16
(1.12,1.19)
apo B 1.14 (1.11
1.18)
LDLC 1.13 (1.10
1.17)
Residual
increased risk:
HTN 1.38
(1.17,1.63)
DM 1.33
Discharge LLT dosing data

not available on 50% of
pts. Performance feedback
in GWTH hospitals may
influence pt care giving
higher rates of LLT than
general hospitals. Change
in LLT dosing after not
available.
Javed 2010
(291)
21146668
GWTG
Dischar
ge
intensiv
e LLT
in ACS
Retros
pective
data
base
analysi
s
65,396
Intensive LLT
regimen
likely to
cause >50%
LDL
reduction
25,036
Less intensive
LLT regimen
40,360
ACS related
hospitalizatio
n with LLT
Left against
medical advice
discontinued
care
Discharged to
nonparticipating
facility
Intensive
LLT regimen
Less
intensive
LLT regimen
Baigent 2010
(292)
21067804
CTT
Efficac
y and
safety
of
intensiv
e LDL
C
decrea
se
Metaanalysi
s 26
trials
165,13
8
More
intensive
19,829
5 trials
Less intensive
19,783
Main effect of
trial to lower
LDLC
1000+ pts >2
y follow-up
treatment
Lack of trial
eligibility criteria
Intensive
LLT regimen
Less
intensive
LLT regimen
MACE reduction
in 4.8 y by
intensive LLT
15%
No further
adverse
effects from
lowering
cholesterol
including
cancer risk
Reduction in
revasc
19% (15-24)
p<0.0001
Ischemic
stroke
16% (5-26]
p=0.005
Boekholdt 2012
(293)
22453571
RRs of
lipid
values
in
statin
treatme
nt
Metaanalysi
s
8 trials
38,153
Statin
therapy
Risk with 1
SD increase
in LDLC
non--HDLC
apoB
Lack of trial
eligibility criteria
LDLC
HDLC
Apo B during
statin Rx
RRs for
values
Adjusted HR for
major CV events
Per 1-SD
increase
1.16 non-HDLC
1.14 apoB
1.13 LDLC
N/A
HRs higher
for nonHDLC than
LDLC
p=0.002 and
apo B
p=0.02
Mora 2012
(294)
22461416
CV risk
in
statin
treated
pts
Retros
pective
evaluat
ion of a
multice
9251
High-dose
statin
80 mg
Atorvastatin
Approximatel
Low-dose
statin
10 mg
Atorvastatin
Approximately
Trials with
serial
evaluation of
TC, LDLC,
HDLC, TG
>2 y followup
1000+
participants
CAD
TG>600 mg/dL
Unstable CAD
High-dose
atorvastatin
Low-dose
atorvastatin
Multivariable
detection of
increased
residual risk
Older age
Decreased
residual risk:
High-dose
statin
Aspirin use
Known
baseline
variables
performed
moderately
Control
64,782
Statin
64,744
21 trials
131
Nonsignificant excess of
hemorrhagic stroke with
lowering cholesterol p=0.2
Fatal CV events occurring

in the 1st y of therapy not
accounted for. Participating
trials had different inclusion
criteria.
Excluded patients >130

mg/dL on Atorvastatin 10
mg, study was
observational, novel risk
factor data not available for
nter
trial
y 50%
(1.11,1.60)
the entire study group
Male 1.33
(1.07,1.65)
Age 1.13
(1.04,1.23)
Apo B 1.19
(1.11,1.28)
BUN 1.10
(1.03,1.17)
BMI 1.09
(1.02,1.17)
A to Z indicates Aggrastat to Zocor; ACS, acute coronary syndrome; ALT, alanine aminotransferase; AMI, acute myocardial infarction; Apo A, Apolipoprotein A; Apo B, Apolipoprotein B; AST, aspartate aminotransferase; BMI, body mass index; BUN, blood urea
nitrogen test; CAD, coronary artery disease; CV, cardiovascular; DM, diabetes mellitus; Dx, diagnosis; GP, glycoprotein; GWTG, Get With the Guidelines; HDLC, high density lipoprotein cholesterol; HR, hazard ratio; HTN, hypertension; LDLC, low-density lipoprotein
cholesterol; LLT, lipid lowering therapy; MACE, major adverse cardiovascular events; N/A, not available; PC, placebo; PCI, percutaneous coronary intervention; PROVE-IT, Pravastatin or Atorvastatin Evaluation and Infection Therapy; Pts, patients; PVD, peripheral
vascular disease; Revasc, revascularization; Rx, prescription; Sig, significant; TC, total cholesterol; TG, triglyceride; and ULN, upper limit of normal.
Data Supplement D. Blood Pressure Control
Study Name,
Aim of
Study
Study
Author, Year
study
Type
Size
(N)
Study
Intervention
Group (n)
50%
Study
Comparator
Group (n)
Increased BMI
Male sex
HTN
DM
Apo B
BUN
Patient Population
Inclusion
Criteria
Nissen 2004
(295)
15536108
CAMELOT
Antihypert
ensive
agents on
CV events
in CAD
and
normal BP
Multicente
r
prospectiv
e study
1991
274
IVUS
Amlodipine
663
Enalapril
673
IVUS
substudy:
Amlodipine
91
Enalapril
86
PC
655
IVUS substdy:
95
Angiog.Doc.
CAD
Age 30- 79
DBP<100
BB, a1
blockers,
Diuretics
permitted
Study
Intervention
Study
Comparat
or
Exclusion
Criteria
Left main CAD
LVEF<40%
Moderate or
severe CHF
>79 y
Amlodipine
10 mg or
Enalapril 20
mg
+ IVUS
Substudy
24-mo
follow-up
132
well in
discriminatin
g future
cases
Harrell c
index=0.679
Endpoints
Primary
Endpoint
(efficacy)
and Results
CV events in 24
mo/CV events in
fewer Amlodipine
vs. PC
Substdy: No
athero.
Px in amlodipine
Trend toward Px
in Enalapril,
progression in PC
p<0.001
PC
Apo A1
P Values,
OR: HR: RR &
95% CI:
Safety
Endpoint
and Results
Secondary
Endpoint
and Results
BP baseline
129/78
Decreased by
4.8/2.5 mm in
Amlodipine,
4.92.4 in
Enalapril
increased in
PC
p<0.001 vs.
Amlodipine
and Enalapril
Individual
components of
primary and 2
endpoints
showed trend
toward fewer
events with
enalapril
CV events:
Amlodipine:
16.6%
0.69 (0.54
0.88)=.003
Enalapril:20.2%
0.85 (0.67
1.07)=.16
NS diff between
Enalapril and
Amlodipine 0.81
(0.63
1.04)=.10
Study Limitations &

Adverse Events
Amlodipine D/ced for

edema in 5.0%.
Enalapril D/C for cough
in 3.9% HTN in 3.2%
PC, 2.2% amlodipine,
9.5% enalapril.
Limitations: extended
composite endpoint,
modest sample size,
CIs around point
estimates relatively
large.
Messerli 2006
(296)
16785477
Low
BP with
adverse
events in
CAD
Multictr
Ad hoc
analysis
22576
BP reduction
Sustained
Rel.
verapamil or
atenolol
Outcome
Stable pts
with CAD
and
hypertension
MI within 3 mo
and Class IV or
V CHF
Verapamil
Purpose was
to evaluate
BP with
outcomes,
not compare
agents
Atenolol
All-cause death
and total MI
2.7 y/pts
J-shaped curve
Nadir at 119/84
Lowest
outcome
120-140
systolic
70-90
diastolic
DBP
Nadir for
MI: 70-90
mmHg
Nadir for stroke
70-90 mmHg
Primary outcome
18% vs. 9%
SBP 110 vs. 120130
32% vs. 8%
DBP 60 vs. 80-90
No p values
provided
2 analysis, limited to
hypertensive pts with
stable CAD.
PROVE-IT TIMI
22
Bangalore 2010
(297)
21060068
BP control
and
adverse
events in
ACS
Multicente
r
prospectiv
e study
Ad hoc
analysis
4162
BP level
reached
Outcome
MACE
ACS within
10 d
Randomly
assigned to
Pravastatin
or
atorvastatin
Not stated
Pravastatin
40 mg
Purpose was
to evaluate
BP with
outcome, not
to compare
agents
Atorvastati
n
80 mg
Significant
increased risk
for outcomes
As SBP
decrease
below 110
systol.
or 70 diastolic
CAD
death,nonfatal
MI or revasc
Similar J- or Ushaped curve.
For SBP/DBP
X2=37,<0.0001
X2=47,<0.0001
respectively
Risk for 1
outcome
increased 4.9 fold
with SBP<100 vs.
130-140 mmHg
136 mmHg had
lowest event rate
by Cox model on
a continuous
scale
X2 =49, p<0.0001
Ad hoc analysis limited

to pts studies for lipid
evaluation. Not
adjusted for many
confounders nor
dosages of
antihypertensive
agents received.
Cannot determine
whether SBP, DBP, or
mean BP is main risk
Cooper-DeHoff
2010
(298)
20606150
INVEST
Effect of
tight BP
control in
CAD and
diabetes
Observati
onal
substudy
of
multicente
r clinical
trial
6400
Tight BP
control
BP 130/85
Usual BP
control
Stable CAD
and
hypertension
with diabetes
Not stated
Tight BP
control
Verapami/tra
ndolapril
16,893
patient/y of
follow-up
Usual BP
control
Composite MACE
SBP followed a Jor U-shaped
curve
Risk Nadir:
136 mmHg
systolic
85 mmHg
diastolic
HR 49% vs. 13%
SBP<100 vs. 130140
HR 46% vs. 15%
DBP<60 vs. 8090
Composite MACE
Usual control
vs. uncontrolled
12.8% vs. 19.8%
Tight vs. usual
Control :
NS diff.
12.6% vs. 12.7%
Study
Size
(N)
Study
Intervention
Group (n)
Mortality:
Tight vs. usual
Post hoc analysis. No
11.0% vs.
control
randomization for
10.2%
MACE
different BP groups.
Tight vs. Usual
Usual control:
Data only applied to
1.20 (0.99-1.45) 1.11(0.93-1.32)=
CAD pts with diabetes.
p=0.06
24
Extended
follow-up
1.15 (1.01-1.32)
p=0.04
1 indicated primary; 2, secondary; ACS, acute coronary syndrome; BP, blood pressure; CAD, coronary artery disease; CHF, congestive heart failure; CV, cardiovascular; DBP, diastolic blood pressure; IVUS, intravascular ultrasound; LVEF, left ventricular ejection
fraction; MACE, major adverse cardiovascular events; PC, placebo; Pts, patients; Px, prognosis; and SBP, systolic blood pressure.
Data Supplement E. Diabetes Mellitus
Study Name,
Aim of Study
Author, Year
study
Type
Study
Comparator
Group (n)
Patient Population
Study
Intervention
Study
Comparator
133
Extended
analysis
follow-up
indicated
increased risk
with tight BP
control
Endpoints
P Values,
OR: HR: RR &
95% CI:
Study Limitations &

Adverse Events
Inclusion
Criteria
Exclusion
Criteria
Primary
Endpoint
(efficacy) and
Results
Mortality
33% died in
intensive group,
44% in regular
group
Safety
Endpoint
and Results
Secondary
Endpoint
and Results
Admission
body weight,
HbA1c,
pulmonary
rates, heart
rate were all
independently
linked to
hyperglycemi
a
p<0.001 0.00
01
Hospitalizatio
ns and deaths
NS different
among groups
GI sx
p<0.0167
metformin vs.
PC
Admission
blood
glucose
HbA1c were
independent
predictors of
mortality
Long-term
mortality
reduction
Intensive vs.
regular 28% (845%)p=0.011
No prior insulin
and low CV risk:
reduction
51%(1970)=0.004
No indication whether
increased use of insulin or
decreased use of
sulfonylureas decreased
risk.
Average
weight loss
PC 0.1 kg
Metformin
2.1 kg
Life 5.6 kg
p<0.001 v.
Metformin
and PC
Reduced
incidence vs. PC
Lifestyle: 58% (48
66)
Metformin 31 (17
43)
Lifestyle vs.
metformin
39%[24-51%]
GI Sx highest in metformin
group and musculoskeletal
highest in lifestyle GP
Incidence of DM in PC
group higher than
anticipated
30-d mortality by
tertile vs. normal
FBS
1st: 4.6 (1.7
12.7)
P=0.003
2nd: 6.4 (2.5
16.6)
P<0.0001
3rd: 11.5 (4.7
20.0)
P<0.0001
6 mo-mortality:
FBS 126 199
mg/dL
1.71 (1.25
Did not attempt to evaluate

for undiagnosed DM
Significant overlap in
HbA1c levels in AMI in
known or newly diagnosed
DM and no DM
DIGAMI
Malmberg 1999
(299)
10338454
Glycometabo
lic state
in DM
in ACS
and
mortalit
y risk
Multice
nter
prospe
ctive
study
620
Intensive
Insulin
306
314
Routine
diabetic
therapy
DM with AMI
<24 h
Not stated
Intensive
insulinglucose
infusion,
then sc
insulin 3.4-y
follow-up
Regular DM
coverage
Diabetes Prevention
Program Research
Group Knowler 2002
(300)
11832527
Effects
of
treating
elevate
d
glucos
e on
develo
pment
of DM
Fasting
glucos
e and
30-d
mortalit
y in
AMI
Multice
nter
prospe
ctive
study
3234
Metformin
1,073
Or lifestyle
modification
1,079
PC
1,082
25 y or older
BMI 24
FBS 95-125
Or 140-199
2-h global
thrombosis
test
Glucose
tolerance affects
medications
Short life
expentancy
Metformin
850 mg bid
Or lifestyle
Int. to reduce
weight and
inc exercise
PC or lack of
lifestyle
intervention
Incidence of DM
2.8-y follow-up
Cases/100 pat-y
PC 11.0
Metformin 7.8
Lifestyle 4.8
Prospe
ctive
cohort
observ
ational
study
735
Fasting
glucose
Admission
glucose
Non-DM AMI
<24 h
>24 h from Sx
onset,
inflammatory
disease, surgery
or trauma
preceding mo
Fasting
blood
glucose
Admission
blood
glucose
30-d mortality
compared with
FBG
<110, adjusted 30
d-mortality
increased with
increasing tertile
of FBG
30-d death
and heart
failure vs.
normal FBG:
Impaired FBS:
2.6 (1.35.0)=0.004
FBS 126:
5.8 (2.2
10.3)
<0.0001
30 dmortality co
mpared with
normal AG
and FG
Elevated FG
and AG: 9.6
Elevated AG
and Normal
FG 3.4
Elevate
d FBS
in ACS
and
Multice
nter
retrosp
ective
13,526
Range of
FBS
In-hospital
and 6-mo
mortality
ACS
Noncardiac
chest pain
Admission
and FBS 6mo follow-up
Mortality inhospital 6
mo
Higher FBS
associated with
graded in-hospital
and 6-mo
Major
bleeding
complications
increased with
6-mo death:
FBS <100
vs.
100- 125
Suleiman 2005
(301)
15699267
Sinnaeve 2009
(302)
19237725
GRACE
134
Retrospective analysis,
unmeasured variables not
accounted for, hospital
glucose levels may not
mortalit
y
study
mortality.
6 mo sig higher
with FBS above
125
mg/dL vs. <100
mg/sL
higher FBS.
Stroke level
unrelated to
glucose level.
NSTEMI:
4.66 vs.
7.14I%
UA:
2.56 vs.2.28
2.34)
FBS300:
2.93 (1.33
6.33)
But not 200
299:
1.08 (0.60
1.95)
reflect true glucose

levels. Because of glucose
infusions, some FBS levels
might not have been truly
fasting levels.
ACS indicates acute coronary syndrome; AG, admission glucose; AMI, acute myocardial infarction; bid, twice daily; CV, cardiovascular; DM, diabetes mellitus; FBG, fasting blood glucose; FBS, fasting blood sugar; FG, fasting glucose; GI, gastrointestinal; GP,
glycoprotein; HbA1c, Hemoglobin A1c; NS, nonsignificant; NSTEMI, non-ST-elevation myocardial infarction; PC, placebo; Sig, significant; Sx, symptom; and UA, unstable angina.
Data Supplement F. Smoking Cessation
Study Name,
Aim of
Study
Author, Year
study
Type
Study
Size
(N)
Study
Intervention
Group (n)
Study
Comparator
Group (n)
Patient Population
Inclusion
Criteria
Study
Intervention
Study
Comparator
Exclusion
Criteria
Daly 1983
(303)
6409291
Persistence
of smoking
cessation
after ACS
Prospe
ctive
cohort
study
498
Smoking
cessation
217
Nonsmokers
at entry and
follow-up
147
Continued
smoking
157
Survived 1st
attack of
ACS by at
least 28 d
Nonsmokers at
entry who
started to
smoke died
within 2 y of
entry.
Follow up by
life tables for
13 y beyond
2 y survival
stopped
smoking
Continued
smoking
Jorenby 2006
(304)
16820547
Efficacy and
safety of
varencline
Multice
nter
Prospe
ctive
Study
1,027
Varencline
344
Bupropion
342
PC
341
18-75 y.
10+
cigarettes/d
during
previous y
No
abstinence
longer than 3
mo
Previous use of
bupropion.
Contraindication
s to
medications.
Sig CV disease;
HTN; pulmonary
disease;
depression
Varencline 1
mg bid
Bupropion
SR
150 mg bid
12 wk + brief
counseling
12 wk with
40-wk follow-
PC+brief
smoking
cessation
counseling
135
Endpoints
Primary
Endpoint
(efficacy) and
Results
Mortality 13-y life
tables beyond 1st
2 y from ACS
Stopped smoking
vs. continued
smoking was 2.8
lower
Safety
Endpoint and
Results
Secondary
Endpoint
and Results
Vascular
causes of
death: 68%
24% MI
35% sudden
death
NS diff among
3 groups
Continuous
abstinence: wk 912
Varecline vs. PC:
43.9% vs. 17.6%
Bupropion vs. PC:
29.8% vs. 17.6%
>10% side
effects:
Bupropion
Insomnia 21%
Varencline
Nausea 29%
Abnormal
dreams
13.1%
Mortality of
previous
nonsmoker
62.1%
n=124
Average
annual RR
of death:
2.4 for
smokers vs.
stopped
p<0.01
Wk 9-52
Abstinence
Varecline vs.
PC
23% vs.
10.3%
2.66
(1.72,4.11)
p<0.001
P Values,
OR: HR: RR &
95% CI:
Study Limitations &

Adverse Events
Mortality 2-15 y
beyond ACS:
stopped vs.
continued
36.9% vs. 82.1%
p<0.01
Average annual mortality:

stopped vs. continued
smoking
Initial ACS St Cont
RR
UA 1.9 10.0 5.4; p<0.01
MI uncomp 3.9 8.6 2.2
p<0.05
MI comp 4.7 12.4 2.7
p<0.01
Abstinence 9-12
vs. PC
3.85 (2.69,5.50)
p<0.001
9-12 Bupropion
vs. PC:
1.90 (1.38- 2.62)
p<0.001
Volunteers. Minimal
counseling may confound
results. Exclusion of
depression.
35% did not complete
follow-up period.
Dropout rate for adverse
events higher in PC group.
up
Headache
12.8%
Tonstad 2006
(305)
16820548
Effect of
varenicline
on smoking
cessation
Multice
nter
Prospe
ctive
Study
1,210
Varencline
603
PC
607
18-75 y.
10 cigarettes/
d + smoking
cessation
Ation after 12
wk of
varenicline
Unstable
disease,
depression,
COPD, CV
disease within 6
mo,
uncontrolled
HTN, smoking
cessation aid
12-wk open
label vs. if
stopped
smoking
Randomized
for 40 wk
PC
Continued
abstinence
Wk 13-24
Varenicline vs.
PC
70.5% vs. 49.6%
Wk 13- 52
43.6% vs. 36.9%
Rigoitti 2006
(306)
17145253
Bupropion in
smokers with
ACS
Multice
nter
Prospe
ctive
Study
248
Bupropion
124
PC
124
Smoked >1
Cigarette in
previous mo
CAD
admissions
Not willing to
stop
Smoking. Risk
of seizure, sig.
HTN, heavy
alcohol use,
depression, liver
or renal
disease, illegal
drug use
Smoking
counseling
to 12-wk
postdischarg
e Bupropion
SR
1-y follow-up
Same
smoking
counseling
PC
Abstinence and
CV events 3 m
and 1 y
Borderline Sig
abstinence at 3
mo only.
NS diff in
outcome
events
PREMIER
Registry
Dawood 2008
(307)
18852396
Predictors of
smoking
cessation
after AMI
Retros
pective
from
registry
639
342 smokers
at 6 m
297
Nonsmokers
at 6 mo
AMI
Smoker >18
y age
Transfer to
hospital >24 h
from AMI
Did not speak
English or
Spanish. Could
not consent
Smoking
behavior by
self-report
During
hospital and
6 mo in pt
smoking
cessation
program
Continued
smoking
Same but
stopped
smoking at 6
mo
6-mo post MI:

46% had stopped
Odds greater for
those receiving
discharge
recommendations
for cardiac rehab
or smoking
cessation facility
136
Major adverse
Effects:
Varenclin
Nasopharyngi
tis
4.8%
Headache
2.8%
Psych
disorders
6.4%
Noncardiac
serious
adverse
events: NS
3 mo: 1.31
(0.62,2.77)
1 y: 1.34
(0.64,2.84)
Not evaluated
Bupropion
vs. PC
1.77
(1.19,2.63)
p=0.004
N/A
Abstinence vs.
PC
Wk 13-24
2.48 (1.953.16)<0.001
Wk 13-52
1.34
(1.06,1.69)=0.02
Generally healthy group.

No depression. CO may
not evaluate complete
check on self-report of
nonsmoking. Those lost to
follow-up differed between
groups.
CV mortality
1y
Bupropion
vs. PC
0% vs. 2%
CV events 1
y:
26% vs.
18%
1.56
(0.91,2.69)
NS
Abstinence vs.
PC
3 mo: 37.1% vs.
26.8%
1.61
(0.94,2.76)=0.08
1 y: 25.0% vs.
21.3%
1.23 (0.68,2.23)
NS
1/3 lost at 1 y. Study not

powered to detect less
than a 1.8-fold increase in
cessation rates with
bupropion.
Many eligible declined to
enroll.
Reluctance to be
randomized to PC.
Hospital
smoking
cessation
counseling
did not
predict
cessation:
0.80
(0.51,1.25)
Depressive
pts during MI
less likely to
quit:
Smoking
cessation with
rehab:
1.80 (1.17-2.75)
Treated at
smoking
cessation facility:
1.71 (1.03=2,83)
Limited insights on
smoking cessation
programs available at
different hospitals.
Loss to follow-up.
Self-reporting assessment
without biochemical
evaluation.
Unmeasured confounding.
Mohuiddin
2007
(308)
17296646
Intensive
smoking
cessation
intervention
in acute CV
disease
Prospe
ctive
random
ized
cohort
209
Smith 2009
(309)
19546455
Hospital
smoking
cessation in
CAD with
long-term
effects
Multiinstitut
e
Prospe
ctive
Study
Rigotti 2008
(310)
18852395
Hospital
smoking
cessation
intervention
with 6-mo
follow-up
Metaanalysi
s of 33
trials
Smoking
relapse rate
after quitting
following
ACS
Prospe
ctive
cohort
study
Colivicchi
2011
(311)
21741609
Intensive
intervention
109
2 y follow-up
Usual care
100
275
Intensive
smoking
cessation
intervention
136
6,252
(using
number
s
in
Figure
1 and
2)
813
0.57 (0.360.90)
p<0.05
2-y all-cause
mortality:
2.8%
intensive vs.
12.0% UC
RR
reduction:
77% (27,
93%)
p=0.014
30-75 y
Daily
smokers
>5 y in CCU
with AMI or
heart failure
Alcohol or illicit
drug use
Unfamiliar with
English
30-min
counseling
before
discharge.
Intensive
counseling
for 3 mo +
pharmacothe
rapy in 75%
Same
counseling
before
discharge
only.
At each follow-up
interval, point
prevalence and
continued
abstinence
greater in the
intensive
treatment group
Over 2-y
period more in
UC group
Hospitalized
RR
reduction:44%
(16,63)=0.007
Minimal
intervention
139
18 or older
Smoked in
previous mo
AMI or
CABG
admission
Pregnant
Medically
unstable
Lived in an
institution
No English
Psychiatric
disorder
Substance
abuse
Minimal
intervention
+ 45-60 min
bedside
counseling
7 telephone
counseling
sessions
after
discharge
Minimal
intervention
2 pamphlets
No smoking
message by
physician
1-y abstinence
self-reported
62% intensive GP
vs. 46% minimal
GP
Confirmed: 54%
intensive GP vs.
35% minimal
group
Not evaluated
Abstinence
lower in
those using
pharmacoth
erapy
p<0.01
Abstinence
higher in
CABG vs. MI
pts
p<0.05
1-y abstinence
self-reported:
2.0 (95% CI: 1.23.1)
Confirmed:
2.0 (CI: 1.3-3.6)
Intensive
intervention
counseling
2,673
Usual care or
control
counseling
2,935
Hospitalized
and current
smokers
Smoking
cessation rates 612 mo decreased
with smoking
counseling.
No benefit with
less
postdischarge
contact.
Not evaluated
No
pharmacother
apy
312
Intensive
intervention
with or
without
pharmacothe
rapy
Usual care
with minimal
smoking
counseling
Pharmacothe
rapy
332
Trials not
recruiting on
basis of
smoking, Hx,
Hospitalization
with psychiatric
disorder, or
substance
abuse
Adding NRT
produced a
trend toward
efficacy vs.
counseling
alone:
1.47 (CI:
0.92- 2.35)
Smoking
cessation 6-12
mo with
counseling:
1.65 (CI: 1.441.90)
12-mo
relapse
813
(of 1,294 not
relapsing)
Predictors of
relapse
Previous
smokers who
stopped after
ACS
following
hospital
Major
concurrent
illness,
depression,
alcohol and
drug abuse,
Several inhospital
counseling
sessions.
12-mo
follow-up
Predictors of
relapse
Age and female

sex were
predictors of
relapse.
Pts in cardiac
rehab and pts
Resumption
of smoking
predicted 1-y
mortality:
3.1 (CI: 1.35.7) p=0.004
Age and
resumption:
1.034
(1.03,1.04)
p=0.001
Female:
Cardiac rehab
and abstinence:
0.74 (CI: 0.510.91)=0.02
DM and
abstinence:
2-y follow-up
137
2-y abstinence:
33% intensive vs.
9% UC
p<0.0001
Small sample size-lacking

multivariate analysis to
adjust for other factors on
outcome.
Pharmacotherapy at no
cost.
Question of whether
results would have been
achieved if smokers
purchased their own
medications.
Pharmacotherapy used by
34% of pts in both groups.
Slightly less than
smokers did not want to
quit or refused to
participate.
Exclusion of pts with
substance abuse or
psychiatric comorbidities,
many of whom are
smokers, limits
generalizability of results.
Benefit of adding
bupropion limited to 1
study. Counseling
intervention not delivered
by staff responsible for
patient care. Only
1/2studies used sustained
abstinence to assess
outcome, the rest point
prevalence
Sig diff in age and CV risk
factors in cohort.
Questions about sens of
troponin assay for Dx of
AMI
discharge
Planer 2011
(303)
21403011
Efficacy of
bupropion in
smoking
cessation
after AMI
2
center
prospe
ctive
study
Bupropion
74
Study
Size
(N)
Study
Intervention
Group (n)
PC
75
Study
Comparator
Group (n)
Smokers
hospitalized
for ACS
Smoking >10
cigarettes/d
Intention to
quit smoking
Patient Population
Inclusion
Criteria
Nordmann 2006
(312)
16476868
Lowcarb
vs. lowfat
diets
on
weight
loss
and CV
risk
Metaanalysi
s
447
5 trials
Low carb
222
Low fat
225
Randomized
controlled
low carb vs.
low fat,
BMI25,
Follow-up 6
mo + Age
16+
Bupropion
150 mg bid
for 2 mo
1-y
abstinence
evaluation
PC Same
abstinence
evaluation
Study
Intervention
Study
Comparator
with DM more
likely to remain
abstinent
Abstinence rates
at 3 mo, 6 mo and
1 y were not
increased by
bupropion
1.23
(1.09,1.42)
0.79 (CI: 0.680.94)=0.03
Adverse
3-mo abstinence: Recruitment stopped early
effects
Bupropion vs.
after interim analysis
attributed to
PC:
limiting sample size.
treatment
45% b 44%
Self-reports of quitting, no
was a
p=0.99
biochemical confirmation.
negative
6 mo. Abstinence: High self-reports of quitting
predictor of
Bupopion vs. PC: in PC group.
smoking
37% vs. 42%
Dizziness more common
cessation:
p=0.61
than PC 14% vs. 1.4%
0.23 (95%
1-y abstinence:
p=0.005
CI: 0.0731% vs. 33%
0.78)
p=0.86
ACS indicates acute coronary syndrome; AMI, acute myocardial infarction; bid, twice daily; CAD, coronary artery disease; CABG, coronary artery bypass graft; CCU, coronary care unit; CO, COPD, chronic obstructive pulmonary disease; CV, cardiovascular; Diff,
difference(s); DM, diabetes mellitus; GP, glycoprotein; HTN, hypertension; Hx, history; MI, myocardial infarction; N/A, not available; NRT, nicotine replacement therapy; NS, nonsignificant; PC, placebo; Pt, patient; RR, relative risk; Sens, sensitivity; Sig, significance;
SR, sustained release; UA, unstable angina; and UC, usual care.
Data Supplement G. Weight Management
Study Name,
Aim of Study
Author, Year
study
Type
149
renal, lung, liver

disease, stroke,
malignancy
Prior use of
bupropion in
past y or NRT in
past 6 mo
Prior head
trauma,
depression,
bulimia liver or
kidney disease,
pregnancy
Exclusion
Criteria
Trials with
cross-over or
sequential
design
Low-carb
weight loss
at 6 and 12
mo
Endpoints
Primary
Endpoint
(efficacy)
and Results
Weight loss to 6
and 12 mo.
6 mo: low
carb>weight loss.
12 mo: NS
difference
Low fat
same
138
Bupropion
safe. NS diff
vs. PC in:
death, any
hospitalization
s, MI, ACS,
Chest pain
P Values,
OR: HR: RR &
95% CI:
Safety
Endpoint
and Results
Secondary
Endpoint
and Results
Trend toward
lower BP in
low carb
group at 6 mo
only.
TG and HDL
changed more
favorably in
high-carb
diets, LDL-C
in low-fat diets
In diabetics,
HbA1cdec.
In low carb
gp. vs. low
fat: 12 mo
-0.7% vs.0.1%
p=0.02
Weighted mean
difference 6 mo
Low carb vs. low
fat
-3.3 kg (-5.3,-1,4)
12 mo.
-1.0 kg (-3.5,1.5)
Study Limitations &

Adverse Events
Substantial losses to
follow-up.
No blinded outcome
assessment.
Had to use ITT analysis
because of dropouts.
Heterogeneity concerning
main outcome.
Chow 2010
(313)
20124123
Adhere
nce to
behavi
oral
recom
mendat
ion in
CV risk
Multice
nter
Observ
ational
substu
dy
18,809
Adherence to
diet,
exercise,
smoking
cessation
Nonadeheren
ce to
individual
components
UA, NSTEMI
Age 60+ y
Contraindication
to LMW heparib,
recent
hemorrhagic
stroke
AC for other
than ACS, high
creatinine
Survey at 30,
90, 180 d on
3 lifestyle
values
adherence
No diet,
exercise,
No smoking
cessation
CV events at 6
mo decreased
with exercise
onlyand diet +
exercise and exsmoker vs.
persistent smoker
Side effects
not addressed
Decreased
independent
risk of
stroke/MI/de
ath
All 3 with
diet/exercise
Death with
ex-smoker
vs.
continued
smoker
Gadde 2011
(314)
21481449
Efficac
y and
safety
of
Qnexa
Multice
nter
prospe
ctive
trial
Phase
3
2,448
Phenteramin
e/Topiramate
7.5mg/46mg
488
P/T 15/92mg
981
PC
979
Age: 18-70
BMI: 27-45
Or diabetes
2 or more CV
risk factors
BP >160/100
FBS >13.32
mmol/L
TG >4.52
mmol/L
Type 1 diabetes
or Type 2
managed with
antidiabetic
drugs except for
metformin
Phenteramin
e/
Topiramate
1 of 2
dosages for
56 wk
PC for same
period
Proportion of pts
achieving at least
5% weight loss:
Low-dose Qnexa:
62%
High-dose
Qnexa:70%
PC: 21%
>10% weight
loss
Low-dose
Qnexa
37%
p<0.0001
High-dose
Qnexa
48%
p<0.0001
PC
7%
Garvey 2012
(315)
22158731
Longterm
efficacy
and
safety
of
Qnexa
Multice
nter
prospe
ctive
trial
Extensi
on of
previou
s trial
(4)
676
Out of
original
2,448
Phenteramin
e/Topiramate
7.5mg/46mg
173
P/T15/92mg
295
PC
227
See above
agreed to
extension
See above
See above
52-wk
extension
PC for same
period
Percentages
achieving >5%,
>10%, >15% and
>20% weight loss
in 108-wk period,
in all 4 categories,
Qnexa low and
high dose >PC
Adverse
effects vs. PC
10% or more
with sig dif:
Dry mouth
21%
Paresthesia
21%
Constipation
17%
Dysgeusia
10%
Headache
10%
Cognitive (sig
Attention dist
4%
Change in
percentages
Adverse
effects were
0-56 vs. 56108
High-dose Q
constipation
21% to 4%
Paresthesia
21% to 2.4%
Dry mouth
139
Percentage
changes in
BP, lipid, DM
meds:
High-dose Q
BP: -9.8%
Lipid: +4.7%
DM: 0%
Low-dose Q
BP: -3.9%
Risk of CV events
Exercise vs. no
0.69
(0.54,0.89)]=.003
7
Exercise/diet vs.
no
0.46 (0.38- 0.57)
<0001
Ex-smoker vs.
smoker
0.68 (0.51.90).0067
5% weight loss:
Low-dose Qnexa
OR: 6.3 (4.9-8.0)
p<0.0001
High-dose Qnexa
OR: 9.0 (7.311.1)
p<0.0001
No active study
intervention program. Selfreport of outcomes.
No details of actual diet
and exercise quantification.
Adherers/nonadherers
categorized only at 30-d
follow-up.
>5% weight loss

Low dose: 79.3%
High dose: 75.2%
PC: 30.0%
p<0.0001
>10% weight loss
Low dose: 53.9
High dose: 50.3%
PC: 11.5%
p<0.0001
>15% weight loss
Low dose: 31.9%
Discontinuation rates
similar to 1st 56-wk period
above. Higher rate lost to
follow-up in the 15/92 arm.
Impact of Rx of
dyslipidemia and HTN on
secondary cardiometabolic
variables. Type of adverse
events similar to 1st 56-wk
period but incidence rates
lower.
Endpoint assessment not

available for 31% of
sample.
Restriction of upper limit to
BMI: 45. Lack of ethnic
diversity (86% white), few
men (30%). No active
comparator group such as
orlistat or lorcaserin
20% to 1.4%
Lipid:+5.2%
High dose: 24.2%
upper
DM: +1.9%
PC: 6.6%
respitory
p<0.0001
infection
PC
>20% weight loss
18.6% to
BP: +3.5%
Low dose 9.2%
15.3%
Lipid:+17.2% High dose: 15.3%
Nasopharyngi DM: +7.1%
PC: 2.2%
tis
p=.0072 for low
13.2% to
dose <0.0001 for
8.8%
high dose.
Depression
NS
From PC
AC indicates anticoagulant; ACS, acute coronary syndrome; BMI, body mass index; BP, blood pressure; CV, cardiovascular; DM, diabetes mellitus; FBS, fasting blood sugar (glucose); HbA1c, Hemoglobin A1C; HDLC, high-density lipoprotein cholesterol; HF, heart
failure; HTN, hypertension; ITT, intention-to-treat; LDL-C, low-density lipoprotein cholesterol; LMW, low molecular weight; MI, myocardial infarction; NS, no(n) significance; NSTEMI, non-ST-elevation myocardial infarction; PC, placebo; Pt, patient; Rx, prescription; TG,
triglycerides; and UA, unstable agina.
Data Supplement H. Cardiac Rehabilitation
Study Name,
Study Aim
Study Type/
Author, Year
Size (N)
Intervention vs.
Comparator (n)
Patient Population
Inclusion
Criteria
Exclusion
Criteria
Study
Intervention
Endpoints
Primary
Endpoint &
Results
All-cause
mortality HR
Safety
Endpoint &
Results
Subsequent MI,
PCI-NS
P Values,
OR: HR: RR: &
95 CI:
Secondary
Endpoint &
Results
Death, PCI, MI,
CABG p=0.28
Adverse Events
Study Limitations
Goel, K et al
Assess CR
2,395
CR (1431) vs. non- PCI
No prior pt
At least 1 CR
HR 0.54 (0.41Events in CR=83; in Observational,
Circulation. 2011;
participation
CR (964)
registry,
authorization
outpatient
0.71)
non-CR=139
Cohort
123: 2344-2352
and impact on
participants
Olmstead
session
p<0.001
(316)
mortality
County
21576654
Hammil,
Characterize
30,161 (6,181
Internal:
Medicare
None identified
At least 1 CR
Death
Subsequent
MI
Death HR 0.86
Subsequent
Observational,
Circulation.
dose-response with AMI as
cumulative
5% sample
outpatient
hospitalization
(0.76-0.97) for
hospitalization
sample of Medicare
2010;121:63-70
for # CR
qualifying
comparison with #
2001-2005
session billed to
those attending
claims
(317)
sessions
reason for CR)
of CR sessions
Medicare
>6 sessions
20026778
(dose)
AMI indicates acute myocardial infarction; CABG, coronary artery bypass graft; CR, cardiac rehabilitation; HR, hazard ratio; MI, myocardial infarction; NS, not significant; PCI, percutaneous coronary intervention; Pt, patient; and RR, relative risk.
140
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2014 AHA-ACC Guideline For The Management of Patients With Non-ST-Elevation Acute Coronary Syndromes

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AHA/ACC Guideline

2014 AHA/ACC Guideline for the Management of Patients

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ACC/AHA TASK FORCE MEMBERS

3.5. Immediate Management . . . . . . . . . . . . . . . . . . e359

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4.4.3.Rationale for Ischemia-Guided

7. Special Patient Groups . . . . . . . . . . . . . . . . . . . . . . . . e382

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Amsterdam et al 2014 AHA/ACC NSTE-ACS Guideline e347

Relationships With Industry and Other EntitiesThe

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e348CirculationDecember 23/30, 2014

unstable angina, and weight management. Additionally, the

1.2. Organization of the GWC

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1.3. Document Review and Approval

1.4. Scope of the CPG

2.2. Epidemiology and Pathogenesis

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e350CirculationDecember 23/30, 2014

Assessment of cardiovascular risk

Lifestyle management to reduce cardiovascular risk

ST-elevation myocardial infarction

Treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults

Coronary artery bypass graft surgery

Effectiveness-based guidelines for the prevention of cardiovascular disease in women

Assessment of cardiovascular risk in asymptomatic adults

Unstable angina and nonST-elevation myocardial infarction

Guidelines for cardiopulmonary resuscitation and emergency cardiovascular carepart 9:

Practical clinical considerations in the interpretation of troponin elevations

Management of overweight and obesity in adults

Acute myocardial infarction in patients presenting with ST-segment elevation

Percutaneous coronary intervention

Primary prevention of cardiovascular diseases in people with diabetes mellitus

injury (eg, myocarditis, cardiac contusion, cardiotoxic drugs);

3. Initial Evaluation and Management

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e352CirculationDecember 23/30, 2014

Patients with suspected ACS and high-risk features should be

3.2. Diagnosis of NSTE-ACS

cardiovascular causes of chest pain (eg,

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Amsterdam et al 2014 AHA/ACC NSTE-ACS Guideline e353

tamponade physiology and may also be useful to detect

3.3. PrognosisEarly Risk Stratification:

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e354CirculationDecember 23/30, 2014

Pleuritic pain (sharp or knifelike pain provoked by respiration or cough);

Primary or sole location of discomfort in the middle or

Pain localized by the tip of 1 finger, particularly at the

LV apex or costochondral junction;

Evaluation should include the clinicians impression of

Table 3. TIMI Risk Score* for NSTE-ACS

4.4.3.Rationale for Ischemia-Guided

P 2Y12 inhibitor, in addition to aspirin, for up to 12 mo for patients

P 2Y12 inhibitor therapy (clopidogrel, prasugrel, or ticagrelor)

T icagrelor in preference to clopidogrel for patients treated

1 mg/kg SC every 12 h (reduce dose