1. Unstable angina and NSTEMI
Implementing NICE guidance
ABOUT THIS PRESENTATION:
This presentation has been written to help you raise awareness of the NICE clinical guideline on unstable angina and NSTEMI. This guideline has been written for people providing care in secondary healthcare settings, including care from ambulance teams and other paramedical staff before admission to hospital.
The guideline is available in a number of formats, including a quick reference guide. You may want to hand out copies of the quick reference guide at your presentation so that your audience can refer to it. See the end of the presentation for ordering details.
You can add your own organisation’s logo alongside the NICE logo.
We have included notes for presenters, broken down into ‘key points to raise’, which you can highlight in your presentation, and ‘additional information’ that you may want to draw on, such as a rationale or an explanation of the evidence for a recommendation. Where necessary, the recommendation will be given in full in the notes.
DISCLAIMER
This slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself.
PROMOTING EQUALITY
Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.
March 2010
NICE clinical guideline 94

2. 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
NOTES FOR PRESENTERS:
This guideline updates and replaces recommendations for the early management of unstable angina and NSTEMI from NICE technology appraisal guidance 47 and 80
Related guidance:
This guidance also links to ‘Prasugrel for the treatment of acute coronary syndromes with percutaneous coronary intervention’ NICE technology appraisal guidance 182 (published 2009), and to ‘Myocardial infarction: secondary prevention’, NICE clinical guideline 48 (published 2007)

3. What this presentation covers
Background
Scope
Key priorities for implementation
Costs and savings
Discussion
Find out more
NOTES FOR PRESENTERS:
In this presentation we will start by providing some background to the guideline and why it is important.
We will then present the key priorities for implementation. The NICE guideline contains six key priorities for implementation which you can find on page 3 of your quick reference guide.
Next, we will summarise the costs and savings that are likely to be incurred in implementing the guideline.
Then we will open the meeting up with a list of questions to help prompt a discussion on local issues for incorporating the guidance into practice.
Finally, we will end the presentation with further information about the support provided by NICE.

4. 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
NOTES FOR PRESENTERS:
Additional information:
The development of cholesterol-rich plaques within the walls of coronary arteries (atherosclerosis) is the pathological process underlying ‘coronary artery disease’. When the atherosclerotic process advances insidiously the lumen of a coronary artery becomes progressively narrowed, blood supply to the myocardium is compromised (ischaemia) and a person will often develop predictable chest discomfort on exertion, or ‘stable’ angina. However, at any stage in the development of atherosclerosis, and often when the coronary artery lumen is narrowed only slightly or not at all, an unstable plaque may develop a tear of its inner lining cell layer (intima), exposing the underlying cholesterol-rich atheroma within the vessel wall to the blood flowing in the lumen. This exposure stimulates platelet aggregation and subsequent clot (thrombus) formation.
If the thrombus is large enough to block the lumen of the artery, and this is persistent, then acute ST- segment-elevation (an abnormality of the electrocardiogram) myocardial infarction or ‘STEMI’ ensues, with progressive death (necrosis) of heart muscle tissue. If the thrombus only partly or temporarily occludes the artery, then shortage of blood supply to the affected heart muscle (myocardium) is less severe or is intermittent. In these circumstances there is often some myocardial necrosis, as evidenced by a rise in cardiac-specific serum biomarkers such as troponin; this syndrome is described as ‘non-ST-segment-elevation myocardial infarction’ (NSTEMI). When myocardial ischaemia is present, but there is no evidence of actual myocardial necrosis (normal serum troponin level), the clinical syndrome is described as unstable angina.

5. 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
NOTES FOR PRESENTERS:
Additional information:
When the National Service Framework (NSF) for Coronary Heart Disease was published in it was estimated that every year in England 1.4 million people have angina, 300,000 have heart attacks, and more than 110,000 die as a result of heart problems. Much has improved since then. Mortality from myocardial infarction and other cardiovascular causes has declined and inequalities between socioeconomic groups have decreased. However, the number of people admitted with non-ST-segment-elevation acute coronary syndrome has shown less of a decline. And with worrying increases in the incidence of obesity and diabetes, and the tendency for people to take less exercise, the management of these conditions remains a high priority.
Over the past 10 years it has become clear that people with unstable angina and NSTEMI have quite widely varying outcomes, and much work has gone into defining the clinical components that individually predict this poor outcome (usually defined as mortality in hospital, or at varying periods of follow-up). Scoring systems have been established in an attempt to stratify patients according to risk. And more recent trials of drugs - and other interventions such as coronary angiography and revascularisation - have analysed the effect of an intervention according to patient risk group.
This guideline focuses on hospital care and defines patients likely to have net benefits from given interventions.

6. 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
NOTES FOR PRESENTERS:
Additional information:
Adults are defined as people who are at least 18 years old.
This guideline does not cover
People with ST-segment-elevation myocardial infarction
b) The management of specific complications of unstable angina and NSTEMI such as cardiac arrest or acute heart failure
People with unstable angina or NSTEMI who have been discharged from hospital.
Clinical management addressed
a) Risk stratification for triage and management purposes.
b) Percutaneous coronary intervention (PCI) or early coronary artery bypass grafting (CABG)
c) Pharmacological therapies, for example antiplatelet and antithrombin therapy
d) Provision of information and communication in the early stage of treatment.
Note that guideline recommendations normally fall within licensed indications; exceptionally, and only if clearly supported by evidence, use outside a licensed indication has been recommended. The guideline assumes that prescribers will use a drug’s summary of product characteristics to inform their decisions for individual patients.

7. 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
NOTES FOR PRESENTERS:
The NICE guideline contains lots of recommendations about how care can be improved, but the experts who wrote the guideline have chosen key recommendations that they think will have the greatest impact on care and are the most important priorities for implementation. The six key priorities are summarised in the slide. We will consider each in turn.

8. 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]).
NOTES FOR PRESENTERS:
Key point to raise:
Any risk scoring system capable of predicting with comparable predictive accuracy to GRACE could be used.
Recommendation in full: shown on slide (recommendation 1.2.1)
Related recommendations:
Include in the formal risk assessment:
a full clinical history (including age, previous myocardial infarction [MI] and previous percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG])
a physical examination (including measurement of blood pressure and heart rate)
resting 12-lead electrocardiography (ECG) (looking particularly for dynamic or unstable patterns that indicate myocardial ischaemia)
blood tests (such as troponin I or T, creatinine, glucose and haemoglobin).
(recommendation 1.2.2)
Record the results of the risk assessment in the patient's care record
(recommendation 1.2.3)
Use risk assessment to guide clinical management, and balance the benefit of a treatment against any risk of related adverse events in the light of this assessment
(recommendation 1.2.4)

9. Risk assessment 2 Predicted 6-month mortality
Risk of future adverse cardiovascular events
1.5% or below
Lowest
> 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
NOTES FOR PRESENTERS:
Use predicted 6-month mortality to categorise the risk of future adverse cardiovascular events as in the table shown: (recommendation 1.2.5)
Categories of risk are derived from the Myocardial Ischaemia National Audit Project (MINAP) database.
Offer patients clear information about the risks and benefits of the treatments offered so that they can make informed choices about management strategies. Information should be appropriate to the patient's underlying risk of a future adverse cardiovascular event and any comorbidities. (recommendation 1.1.1)

10. Antiplatelet therapy
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 a 300 mg loading dose to patients with a predicted 6-month mortality of more than 1.5% and no contraindications
NOTES FOR PRESENTERS:
These are not key priorities for implementation, but are included as key components in the holistic care of patients
Recommendations in full:
Offer aspirin as soon as possible to all patients and continue indefinitely unless contraindicated by bleeding risk or aspirin hypersensitivity. (recommendation 1.3.1)
Offer patients a single loading dose of 300 mg aspirin as soon as possible unless there is clear evidence that they are allergic to it. (recommendation 1.3.2)
For patients with aspirin hypersensitivity, clopidogrel monotherapy should be considered as an alternative treatment. (This recommendation is from ‘MI: secondary prevention’, NICE clinical guideline 48.) (recommendation 1.3.3)
As soon as the risk of adverse cardiovascular events has been assessed, offer a loading dose of 300 mg clopidogrel in addition to aspirin to patients with a predicted 6-month mortality of more than 1.5% and no contraindications (for example, an excessive bleeding risk). (recommendation 1.3.4)
Offer a 300-mg loading dose of clopidogrel to all patients with no contraindications who may undergo PCI within 24 hours of admission to hospital. (recommendation 1.3.5)
It is recommended that treatment with clopidogrel in combination with low-dose aspirin should be continued for 12 months after the most recent acute episode of non-ST-segment-elevation ACS. Thereafter, standard care, including treatment with low-dose aspirin alone, is recommended. (This recommendation has been incorporated from TA80.) (recommendation 1.3.6)
Consider discontinuing clopidogrel treatment 5 days before CABG in patients who have a low risk of adverse cardiovascular events. (recommendation 1.3.7)
For patients at intermediate or higher risk of adverse cardiovascular events, discuss the continuation of clopidogrel before CABG with the cardiac surgeon and base the decision on the balance of ischaemic and bleeding risk (recommendation 1.3.8)
Note: In line with 'Prasugrel for the treatment of acute coronary syndromes with percutaneous coronary intervention' (NICE technology appraisal guidance 182), prasugrel in combination with aspirin is an option for patients undergoing PCI who have diabetes or have had stent thrombosis with clopidogrel treatment.

11. Antiplatelet therapy
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
NOTES FOR PRESENTERS:
Recommendation in full:
Consider intravenous eptifibatide or tirofiban as part of the early management for patients who have an intermediate or higher risk of adverse cardiovascular events (predicted 6-month mortality above 3.0%), and who are scheduled to undergo angiography within 96 hours of hospital admission (recommendation 1.3.9)
Note: Eptifibatide and tirofiban are licensed for use with aspirin and unfractionated heparin. They do not have UK marketing authorisation for use with clopidogrel. This recommendation is therefore for an off-label use of these drugs. Informed consent should be obtained and documented before they are used in combination with clopidogrel.
Related recommendations:
Consider abciximab as an adjunct to PCI for patients at intermediate or higher risk of adverse cardiovascular events who are not already receiving a GPI. (recommendation )
Balance the potential reduction in a patient's ischaemic risk with any increased risk of bleeding, when determining whether a GPI should be offered. (recommendation )

12. 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
NOTES FOR PRESENTERS:
These are not key priorities for implementation, but are included as key components in the holistic care of patients
Offer fondaparinux to patients who do not have a high bleeding risk, unless coronary angiography is planned within 24 hours of admission. (recommendation 1.4.1)
Offer unfractionated heparin as an alternative to fondaparinux to patients who are likely to undergo coronary angiography within 24 hours of admission. (recommendation 1.4.2)
Offer systemic unfractionated heparin (50–100 units/kg) in the cardiac catheter laboratory to patients receiving fondaparinux who are undergoing PCI. (recommendation 1.4.5)
Note - Unfractionated heparin is not licensed for use during angiography and PCI. Such use is an off-label use. Informed consent should be obtained and documented before it is used during angiography and PCI.

13. 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
NOTES FOR PRESENTERS:
These are not key priorities for implementation, but are included as key components in the holistic care of patients
Carefully consider the choice and dose of antithrombin in patients who have a high risk of bleeding associated with any of the following:
advancing age
known bleeding complications
renal impairment
low body weight (recommendation 1.4.3)
Consider unfractionated heparin, with dose adjustment guided by monitoring of clotting function, as an alternative to fondaparinux for patients with significant renal impairment (creatinine above 265 micromoles per litre). (recommendation 1.4.4)
Once risk of adverse cardiovascular events is known, as an alternative to the combination of a heparin plus a GPI, consider bivalirudin for patients who:
are at intermediate or higher risk of adverse cardiovascular events (predicted 6-month mortality above 3%), and
are not already receiving a GPI or fondaparinux, and
are scheduled to undergo angiography (with follow-on PCI if indicated) within 24 hours of admission (recommendation 1.4.6).
As an alternative to the combination of a heparin plus a GPI, consider bivalirudin for patients undergoing PCI who:
are at intermediate or higher risk of adverse cardiovascular events, and
are not already receiving a GPI or fondaparinux. (recommendation 1.4.7)
Note - Unfractionated heparin is not licensed for use during angiography and PCI. Such use is an off- label use. Informed consent should be obtained and documented before it is used during angiography and PCI.

14. 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
NOTES FOR PRESENTERS:
Recommendation in full: Offer coronary angiography (with follow-on PCI if indicated) within 96 hours of first admission to hospital to patients who have an intermediate or higher risk of adverse cardiovascular events (predicted 6-month mortality above 3.0%) if they have no contraindications to angiography (such as active bleeding or comorbidity). Perform angiography as soon as possible for patients who are clinically unstable or at high ischaemic risk. (recommendation 1.5.1)
Related recommendations:
Offer conservative management without early coronary angiography to patients with a low risk of adverse cardiovascular events (predicted 6-month mortality 3.0% or less) (recommendation 1.5.2)
Offer coronary angiography (with follow-on PCI if indicated) to patients initially assessed to be at  low risk of adverse cardiovascular events (predicted 6-month mortality 3.0% or less) if ischaemia is subsequently experienced or is demonstrated by ischaemia testing (recommendation 1.5.3)

15. 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
NOTES FOR PRESENTERS:
Recommendation in full: When the role of revascularisation or the revascularisation strategy is unclear, resolve this by discussion involving an interventional cardiologist, cardiac surgeon and other healthcare professionals relevant to the needs of the patient. Discuss the choice of revascularisation strategy with the patient (recommendation 1.5.5)
Related recommendation:
When advising patients about the choice of revascularisation strategy (PCI or CABG), take account of coronary angiographic findings, comorbidities, and the benefits and risks of each intervention (recommendation 1.5.4)

16. 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
NOTES FOR PRESENTERS:
Recommendation in full: shown on slide (recommendation 1.5.6)
Other management strategy recommendations:
‘Assessment of left ventricular function is recommended in all patients who have had an MI. (This recommendation is from ‘MI: secondary prevention’, NICE clinical guideline 48.)‘
Consider assessing left ventricular function in all patients with unstable angina (recommendation 1.5.8)
Record measures of left ventricular function in the patient’s care record and in correspondence with the primary healthcare team and the patient
(recommendation 1.5.9)

17. 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
NOTES FOR PRESENTERS:
Recommendation in full: Before discharge offer patients advice and information about:
their diagnosis and arrangements for follow-up (in line with 'MI: secondary prevention', NICE clinical guideline 48)
cardiac rehabilitation (in line with 'MI: secondary prevention', NICE clinical guideline 48)
management of cardiovascular risk factors and drug therapy for secondary prevention (in line with 'MI: secondary prevention', NICE clinical guideline 48, and 'Lipid modification', NICE clinical guideline 67)
lifestyle changes (in line with 'MI: secondary prevention', NICE clinical guideline 48)
(recommendation )
Related recommendations:
Cardiac rehabilitation should be equally accessible and relevant to all patients after an MI, particularly people from groups that are less likely to access this service. (This recommendation is from ‘MI: secondary prevention’, NICE clinical guideline 48.) (recommendation )
All patients who smoke should be advised to quit and be offered support and advice, and referral to an intensive support service (for example, the NHS Stop Smoking Services) in line with 'Brief interventions and referral for smoking cessation in primary care and other settings' (NICE public health guidance 1). (This recommendation is adapted from ‘MI: secondary prevention’, NICE clinical guideline 48.) (recommendation )
Additional information
NICE clinical guideline 48 includes detailed information about cardiac rehabilitation, including contact arrangements and issues of concern to patients, such as sexual activity.

18. 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
NOTES FOR PRESENTERS:
NICE has found that implementing this guideline is unlikely to result in any significant changes in resource use, based on national assumptions. However, different areas may vary from the national average and it is important to look at the recommendations most likely to have a resource impact to make sure that local practice matches the national average.
These recommendations are:
Consider intravenous eptifibatide or tirofiban as part of the early management for patients who have an intermediate or higher risk of adverse cardiovascular events (predicted 6-month mortality above 3.0%), and who are scheduled to undergo angiography within 96 hours of hospital admission (recommendation 1.3.9)
Note: Eptifibatide and tirofiban are licensed for use with aspirin and unfractionated heparin. They do not have UK marketing authorisation for use with clopidogrel. This recommendation is therefore for an off-label use of these drugs. Informed consent should be obtained and documented before they are used in combination with clopidogrel.
It is expected that the time to angiography for intermediate and higher risk patients will reduce slightly so that any increase in the number of angiographies and the use of GPI’s may be offset by savings from reduced hospital stay and admissions.
Offer fondaparinux to patients who do not have a high bleeding risk, unless coronary angiography is planned within 24 hours of admission (recommendation 1.4.1)
This recommendation is expected to lead to some savings across the NHS, but these savings are not expected to be significant. Fondaparinux costs around £5 per patient per day less than enoxaparin.
To detect and quantify inducible ischaemia, consider offering ischaemia testing before discharge for patients whose condition has been managed conservatively and who have not had coronary angiography (recommendation 1.5.6)
Many of these patients will already receive ischaemia testing (although some may currently receive this post-discharge) and therefore the overall cost impact of implementing this recommendation is not expected to be significant.

19. 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?
NOTES FOR PRESENTERS:
These questions are suggestions that have been developed to help provide a prompt for a discussion at the end of your presentation – please edit and adapt these to suit your local situation.
Additional questions:
What ischaemia testing facilities are available for suitable patients?

20. NHS Evidence NOTES FOR PRESENTERS:
NHS Evidence - cardiovascular is a specialist collection that aims to provide access to the best available evidence on all aspects of cardiovascular diseases, including Unstable angina and NSTEMI, to NHS healthcare professionals.
Find out more at

21. Find out more Visit www.nice.org.uk/guidance/CG94 for: the guideline
the quick reference guide
‘Understanding NICE guidance’
Costing statement
audit support, including patient questionnaire
NOTES FOR PRESENTERS:
You can download the guidance documents from the NICE website.
The NICE guideline – all the recommendations.
A quick reference guide – a summary of the recommendations for healthcare professionals.
‘Understanding NICE guidance’ – information for patients and carers.
The full guideline – all the recommendations, details of how they were developed, and reviews of the evidence they were based on.
For printed copies of the quick reference guide or ‘Understanding NICE guidance’, phone NICE publications on or and quote reference numbers N2111 (quick reference guide) and/or N2112 (‘Understanding NICE guidance’).
NICE has developed tools to help organisations implement this guideline, which can be found on the NICE website.
Costing tools – a costing report gives the background to the national savings and costs associated with implementation, and a costing template allows you to estimate the local costs and savings involved.
Costing statement – details of the likely costs and savings when the cost impact of the guideline is not considered to be significant.
Audit support – for monitoring local practice.