Support for implementing NICE guidance: Unstable angina and NSTEMI Unstable angina and NSTEMI, CG94, rd Edition March 2014

Implementing NICE guidance Updated guidance This guideline updates and replaces recommendations for the early management of unstable angina and NSTEMI from NICE technology appraisal guidance 47 and 80. Recommendation has been replaced by recommendation in MI – secondary prevention: Secondary prevention in primary and secondary care for patients following a myocardial infarction.MI – secondary prevention: Secondary prevention in primary and secondary care for patients following a myocardial infarction Recommendation has been updated to take into account people with a learning disability.

Implementing NICE guidance What this presentation covers Background Scope Key priorities for implementation Costs and savings Discussion NHS Evidence Hyperglycaemia in ACS Find out more

Implementing NICE guidance Background:1 Cholesterol-rich plaques form on coronary artery walls narrowing the lumen. Blood supply to myocarduim is compromised causing pain on exertion An unstable plaque may tear and expose underlying athermoma. This stimulates clot (thrombus) formation The thrombus partly blocks the artery, interrupting blood supply to heart muscle (myocardial ischaemia) Unstable angina – myocardial ischaemia with no evidence of heart muscle death (myocardial necrosis) NSTEMI – myocardial ischaemia with evidence of myocardial necrosis

Implementing NICE guidance Background:2 Outcomes vary widely among patients with NSTEMI and unstable angina Scoring systems attempt to stratify risk of future adverse cardiovascular events Guideline defines patients likely to benefit from interventions

Implementing NICE guidance Scope This guideline covers: Adults with a diagnosis of unstable angina or NSTEMI This guideline does not cover: ST-segment-elevation myocardial infarction (STEMI) Specific complications of unstable angina and NSTEMI such as cardiac arrest or acute heart failure Management after discharge from hospital

Implementing NICE guidance Key priorities for implementation Assess risk of adverse cardiovascular events Consider glycoprotein inhibitors for patients at intermediate or higher risk Offer angiography within 96 hours to patients at intermediate or higher risk Discuss revascularisation with other healthcare professionals and choice of strategy with patient Consider ischaemia testing before discharge Rehabilitation and discharge planning

Implementing NICE guidance Risk assessment: 1 As soon as the diagnosis of unstable angina or NSTEMI is made, and aspirin and antithrombin therapy have been offered, formally assess individual risk of future adverse cardiovascular events using an established risk scoring system that predicts 6-month mortality (for example, Global Registry of Acute Cardiac Events [GRACE]).

Implementing NICE guidance Risk assessment: 2 Predicted 6-month mortality Risk of future adverse cardiovascular events 1.5% or belowLowest > 1.5 to 3.0%Low > 3.0 to 6.0%Intermediate > 6.0 to 9.0%High over 9.0%Highest Risk categories derived from Myocardial Ischaemia National Audit Project (MINAP) database

Implementing NICE guidance Antiplatelet therapy: 1 Aspirin – offer a 300 mg loading dose as soon as possible unless there is clear evidence that a patient is allergic to it Clopidogrel – offer as a treatment option for up to 12 months to people who have had an NSTEMI, regardless of treatment.

Implementing NICE guidance Antiplatelet therapy: 2 Consider intravenous eptifibatide or tirofiban as part of the early management for patients who: −have intermediate or higher risk (  3.0%) and −are scheduled to undergo angiography within 96 hours of admission

Implementing NICE guidance Antithrombin therapy Fondaparinux – for patients without high bleeding risk who are not undergoing coronary angiography within 24 hours of admission Unfractionated heparin – for patients likely to undergo coronary angiography within 24 hours of admission Offer systemic unfractionated heparin in the cardiac catheter laboratory to patients receiving fondaparinux who are undergoing PCI

Implementing NICE guidance Antithrombin considerations Carefully consider choice and dose of antithrombin for patients with high bleeding risk associated with: advancing age known bleeding complications renal impairment low body weight As an alternative to the combination of a heparin plus a GPI, consider bivalirudin for patients at intermediate or higher risk of adverse cardiovascular events (predicted 6-month mortality above 3%), who: have angiography scheduled within 24 hours and are not on fondaparinux or a GPI

Implementing NICE guidance Management strategies: 1 Offer coronary angiography (with PCI if indicated) within 96 hours of first admission to patients with: −intermediate or higher risk (  3.0%) and −no contraindications (such as comorbidity or active bleeding) Perform angiography as soon as possible for patients who are: −clinically unstable or −at high ischaemic risk

Implementing NICE guidance Management strategies: 2 When the role of revascularisation or the strategy is unclear, discuss with: −interventional cardiologist −cardiac surgeon −other healthcare professionals relevant to the needs of the patient Discuss choice of strategy with the patient

Implementing NICE guidance Testing for ischaemia To detect and quantify inducible ischaemia, consider ischaemia testing before discharge for patients whose condition has been managed conservatively and who have not had coronary angiography

Implementing NICE guidance Rehabilitation and discharge planning Before discharge offer patients advice and information about: diagnosis arrangements for follow-up cardiac rehabilitation management of cardiovascular risk factors drugs for secondary prevention lifestyle changes

Implementing NICE guidance Costs and savings The guideline on unstable angina and NSTEMI is unlikely to result in a significant change in resource use in the NHS. However, recommendations in the following areas may result in additional costs/savings depending on local circumstances: Considering intravenous eptifibatide or tirofiban as part of the early management for patients Offering fondaparinux to patients who do not have a high bleeding risk Offering ischaemia testing before discharge

Implementing NICE guidance Discussion Which risk-scoring system should we be using to formally assess risk of future adverse cardiovascular events after diagnosis? Do we have a robust mechanism for the timely and appropriate identification and risk assessment of patients? How do we use eptifibatide and tirofiban and will this need to change? Do we need to think about wider discussion across the team when considering revascularisation? How do we need to update our discharge information for patients?

Implementing NICE guidance NHS Evidence Click here to go to the NHS Evidence website

Implementing NICE guidance Hyperglycaemia in ACS Hyperglycaemia in ACS is a powerful predictor of poorer survival and increased risk of complications while in hospital. In October 2011 NICE published clinical guideline 130 and a NICE pathway on Hyperglycaemia in ACS. The guideline and pathway cover the management of hyperglycaemia within the first 48 hours in all patients admitted to hospital for acute coronary syndromes (ACS).

Implementing NICE guidance Find out more Visit for: the guideline the quick reference guide ‘Understanding NICE guidance’ costing statement audit support, including patient questionnaire chest pain algorithm, including clinical case scenarios online educational tool

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