AHA/ACC Non–ST Elevation Acute Coronary Syndrome Guidelines

Guideline Watch |
November 4, 2014

AHA/ACC Non–ST Elevation Acute Coronary Syndrome Guidelines

  1. Joel M. Gore, MD

Updated guidelines from the American Heart Association and American College of Cardiology

  1. Joel M. Gore, MD

Sponsoring Organizations: American Heart Association, American College of Cardiology

Target Population: Primary care providers, cardiologists

Background and Objective

These are updated guidelines, following the 2007 fully revised guidelines (NEJM JW Cardiol Sep 12 2007) on the management of patients with unstable angina (UA) or non–ST segment elevation (NSTE) myocardial infarction (NSTEMI) and the 2012 focused update of those guidelines (NEJM JW Cardiol August 8 2012).

Key Points

  • Patients with suspected acute coronary syndrome (ACS) should be risk-stratified for the likelihood of ACS and adverse outcomes, to guide hospitalization and treatment decisions.

  • Patients with chest pain or other ACS symptoms should undergo electrocardiography to identify ischemic changes within 10 minutes after emergency department arrival.

  • Serial troponin levels should be obtained at presentation and 3 to 6 hours after symptom onset in patients with suspected ACS to identify rising, falling, or fluctuating values. Additional troponin testing should be done beyond 6 hours if the index of suspicion for ACS is high despite normal earlier values.

  • High-intensity statin therapy should be initiated or continued in all patients with NSTE-ACS who have no contraindications.

  • Oral beta–blockers should be initiated within the first 24 hours in patients without contraindications (e.g., signs of heart failure, evidence of low output state, increased risk for cardiogenic shock).

  • Non–enteric-coated aspirin, a P2Y12 inhibitor (clopidogrel or ticagrelor), and anticoagulation should be given to all patients with NSTE-ACS without contraindications, regardless of in-hospital treatment strategy.

  • An urgent/immediate invasive strategy (diagnostic angiography with revascularization, if appropriate based on coronary anatomy) is recommended for patients with NSTE-ACS who have refractory angina, hemodynamic or electrical instability, or elevated risk for clinical events. Early invasive treatment is not recommended for patients with extensive comorbidities (e.g., hepatic, renal, pulmonary failure, cancer) or for those with low likelihood of ACS who are troponin-negative.

  • All eligible patients with NSTE-ACS should be referred to a comprehensive cardiovascular rehabilitation program before hospital discharge.

  • Patients should receive an evidence-based plan of care to prevent hospital readmissions that promotes medication adherence, timely follow-up with the healthcare team, and appropriate diet and physical activity.

What's Changed

These guidelines newly emphasize the continuum between UA and NSTEMI. At presentation, these patients can be indistinguishable. Special populations addressed for the first time are women and elders. The use of risk-stratification tools is emphasized, with a new focus on low-risk patients. Newer, more-potent antiplatelet agents are indicated.


These guidelines provide an evidence-based approach to patients with the spectrum of NSTE-ACS. However, this guidance should not replace the good sound judgment of the clinician when caring for an individual patient.

Editor Disclosures at Time of Publication

  • Disclosures for Joel M. Gore, MD at time of publication Grant / Research support NIH-NHLBI


Reader Comments (3)

Anahita Sadeghi

In this guideline, ACE or ARB in NST ACS was not mentioned.

CAROL SANDERS Other, Hypoparathyroidism Association, Inc.

Special populations addressed for the first time are women - and why were women not addressed earlier, at the same time as men, perhaps? The answer would be interesting to hear.

argaw hussien Resident, Black lion hospital, Ethiopia

nice to see ur guidelines and really will love it!

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