Table 11

Summary of Recommendations for Special Patient Groups

NSTE-ACS in older patients
Treat older patients (≥75 y of age) with GDMT, early invasive strategy, and revascularization as appropriateIA(515–519)
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 sensitivityIA(515,520–522)
Undertake patient-centered management for older patients, considering patient preferences/goals, comorbidities, functional and cognitive status, and life expectancyIB(515,523–525)
Bivalirudin rather than GP IIb/IIIa inhibitor plus UFH is reasonable for older patients (≥75 y of age), given similar efficacy but less bleeding riskIIaB(396,526–528)
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 eventsIIaB(529–534)
Treat patients with a history of HF according to the same risk stratification guidelines and recommendations for patients without HFIB(14,42–44,75–81)
Select a revascularization strategy based on the extent of CAD, associated cardiac lesions, LV dysfunction, and prior revascularizationIB(14,138,141,333,334,337,341,560,561)
Cardiogenic shock
Recommend early revascularization for cardiogenic shock due to cardiac pump failureIB(560,588,589)
Recommend medical treatment and decisions for testing and revascularization similar to those for patients without DMIA(138,339,601)
Recommend GDMT antiplatelet and anticoagulant therapy and early invasive strategy because of increased risk with prior CABGIB(67,68,141,340–342)
Perioperative NSTE-ACS
Administer GDMT to perioperative patients with limitations imposed by noncardiac surgeryIC(626,627)
Direct management at underlying cause of perioperative NSTE-ACSIC(21,626–634)
Estimate CrCl and adjust doses of renally cleared medications according to pharmacokinetic dataIB(649,650)
Administer adequate hydration to patients undergoing coronary and LV angiographyICN/A
Invasive strategy is reasonable in patients with mild (stage 2) and moderate (stage 3) CKDIIaB(649–652)
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 riskIB(669–673)
Early invasive strategy is recommended in women with NSTE-ACS and high-risk features (troponin positive)IA(141,345,346,561)
Myocardial revascularization is reasonable for pregnant women if ischemia-guided strategy is ineffective for management of life-threatening complicationsIIaC(674)
Women with low-risk features (Section 3.3.1) should not undergo early invasive treatment because of lack of benefit and the possibility of harmIII: No BenefitB(141,345,346)
Anemia, bleeding, and transfusion
Evaluate all patients for risk of bleedingICN/A
Recommend that anticoagulant and antiplatelet therapy be weight-based where appropriate and adjusted for CKD to decrease the risk of bleedingIB(522,697,698)
There is no benefit of routine blood transfusion in hemodynamically stable patients with hemoglobin levels >8 g/dLIII: No BenefitB(699–703)
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 (e.g., euphoria, tachycardia, and hypertension) and beta-blocker use unless patients are receiving coronary vasodilator therapyICN/A
It is reasonable to use benzodiazepines alone or in combination with NTG to manage hypertension and tachycardia and signs of acute cocaine or methamphetamine intoxicationIIaC(741–744)
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 spasmIII: HarmCN/A
Vasospastic (Prinzmetal) angina
Recommend CCBs alone or in combination with nitratesIB(753–758)
Recommend HMG-CoA reductase inhibitor, cessation of tobacco use, and atherosclerosis risk factor modificationIB(759–763)
Recommend coronary angiography (invasive or noninvasive) for episodic chest pain with transient ST-elevation to detect severe CADICN/A
Provocative testing during invasive coronary angiography may be considered for suspected vasospastic angina when clinical criteria and noninvasive assessment fail to determine diagnosisIIbB(764–767)
ACS with angiographically normal coronary arteries
Invasive physiological assessment (coronary flow reserve measurement) may be considered with normal coronary arteries if endothelial dysfunction is suspectedIIbB(629,773–776)
Stress (Takotsubo) cardiomyopathy
Consider stress-induced cardiomyopathy in patients with apparent ACS and nonobstructive CADICN/A
Perform ventriculography, echocardiography, or MRI to confirm or exclude diagnosisIB(795–798)
Treat with conventional agents (ACE inhibitors, beta blockers, aspirin, and diuretics) if hemodynamically stableICN/A
Administer anticoagulant therapy for LV thrombiICN/A
It is reasonable to administer catecholamines for symptomatic hypotension in the absence of LV outflow tract obstructionIIaCN/A
It is reasonable to use IABP for refractory shockIIaCN/A
It is reasonable to use beta blockers and alpha-adrenergic agents for LV outflow tract obstructionIIaCN/A
Prophylactic anticoagulation may be considered to prevent LV thrombiIIbCN/A

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, non–ST-elevation acute coronary syndrome; NTG, nitroglycerin; PCI, percutaneous coronary intervention; and UFH, unfractionated heparin.

  • Provocative testing during invasive coronary angiography (e.g., 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.