Journal of the American College of Cardiology
State-of-the-art paper
Integrating quality into the cycle of therapeutic development
Robert M Califf, Eric D Peterson, Raymond J Gibbons, Arthur Garson Jr, Ralph G Brindis, George A Beller and Sidney C Smith Jr
Table 3
Table 3
Class I, Level of Evidence A, Recommendations from Selected ACC/AHA Guidelines
| Guidelines | Recommendation |
|---|---|
| Acute coronary syndromes (ACS) (24) | • Assessment of patients with definite ACS and ST-segment elevation for immediate reperfusion therapy |
| • Immediate, continued antiplatelet therapy with aspirin; add clopidogrel as soon as possible, continue for ≥1 month (indefinitely if aspirin not tolerated) | |
| • Platelet glycoprotein IIb/IIIa inhibition (plus aspirin and heparin) if continued ischemia or other high-risk features | |
| • Subcutaneous LMWH or intravenous unfractionated heparin (plus aspirin and/or clopidogrel) | |
| • Platelet glycoprotein IIb/IIIa antagonist (plus aspirin and heparin) if catheterization and PCI planned | |
| • Early invasive strategy for: recurrent angina/ischemia: 1) at rest, 2) with low-level activities despite intensive anti-ischemic therapy, or 3) with HF symptoms, S3 gallop, pulmonary edema, worsening rales, or new/worse mitral regurgitation; elevated troponins; new ST-segment depression; high-risk findings on noninvasive stress testing; left ventricular systolic dysfunction (e.g., ejection fraction <40% on noninvasive test); hemodynamic instability; sustained ventricular tachycardia; PCI <6 months; prior bypass surgery | |
| • PCI for multivessel disease with suitable anatomy, normal LV function, and no diabetes | |
| • Bypass surgery for significant left main disease, three-vessel disease, or two-vessel disease with significant pLAD and either LV dysfunction or ischemia during noninvasive testing | |
| • Lipid-lowering drugs (HMG-CoA reductase inhibitor) and diet if LDL level >130 mg/dl | |
| • Hypertension control to <130/85 mm Hg | |
| • ACEI for patients with HF, ejection fraction <40%, hypertension, or diabetes | |
| • Diabetes is an independent risk factor | |
| Heart failure (HF) (29) | • Overall: revascularization if concurrent angina, anticoagulants if concurrent atrial fibrillation or thromboembolic event, control of ventricular response with beta-blocker (or amiodarone) if concurrent atrial fibrillation; beta-blocker in patients with HF to reduce risk of sudden death; implantable cardioverter-defibrillator (alone or with amiodarone) if prior cardiac arrest or severe ventricular arrhythmia |
| • Stage A patients: control of systolic and diastolic hypertension as per guidelines | |
| • Stage B patients: all class I Stage A recommendations, ACEI if prior myocardial infarction, beta-blocker if recent infarction | |
| • Stage C patients: all class I recommendations from prior stages; diuretics if fluid retention; ACEI, beta-blocker, digitalis in all patients unless contraindicated | |
| • Stage D patients: all class I recommendations from prior stages, referral to experienced HF program |
ACEI = angiotensin-converting enzyme inhibitor; ACC = American College of Cardiology; ACS = acute coronary syndromes; AHA = American Heart Association; HF = heart failure; LDL = low-density lipoprotein; LMWH = low-molecular-weight heparin; LV = left ventricular; PCI = percutaneous coronary intervention; pLAD = proximal left anterior descending artery.
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