What are the AHA/ACC treatment guidelines for NSTE-ACS?

Updated: Sep 30, 2020
  • Author: David L Coven, MD, PhD; Chief Editor: Eric H Yang, MD  more...
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The 2014 AHA/ACC revision of their 2007 guidelines for the management of NSTE-ACS includes the following recommendations for evaluation of patients with suspected ACS, as summarized below. [112]

Class I

  • Risk stratify patients with suspected ACS based on the likelihood of ACS and adverse outcome(s) to decide on the need for hospitalization and to assist in the selection of treatment options. (Level of evidence: B)
  • Immediately refer patients with suspected ACS and high-risk features (eg, continuing chest pain, severe dyspnea, syncope/presyncope, or palpitations) to the emergency department (ED) and transport by emergency medical services when available. (Level of evidence: C)
  • In patients with chest pain or other symptoms suggestive of ACS, perform a 12-lead ECG and evaluate for ischemic changes within 10 minutes of the patient’s arrival at an emergency facility when possible. (Level of evidence: C)
  • Perform serial ECGs (eg, 15- to 30-minute intervals during the first hour) to detect ischemic changes if the initial ECG is not diagnostic but the patient remains symptomatic. (Level of evidence: C)
  • Obtain serial cardiac troponin I or T levels (when a contemporary assay is used) at presentation and 3 to 6 hours after symptom onset in all patients who present with symptoms consistent with ACS (to identify a rising and/or falling pattern of values). If the time of symptom onset is ambiguous, the time of presentation should be considered the time of onset for assessing troponin values. (Level of evidence: A)
  • Obtain additional troponin levels beyond 6 hours after symptom onset in patients with normal troponin levels on serial examination when changes on ECG and/or clinical presentation confer an intermediate or high index of suspicion for ACS. (Level of evidence: A)

Class IIa

  • It is reasonable to give low-risk patients who are referred for outpatient testing daily aspirin, short-acting nitroglycerin, and other medications if appropriate (eg, beta blockers), with instructions about activity level and clinician follow-up. (Level of evidence: C)
  • Observe patients with symptoms consistent with ACS but without objective evidence of myocardial ischemia (nonischemic initial ECG and normal cardiac troponin) in a chest pain unit or telemetry unit with serial ECGs and cardiac troponin at 3- to 6-hour intervals. (Level of evidence: B)
  • For patients with suspected ACS who have normal serial ECGs and cardiac troponin levels, it is reasonable to have obtain a treadmill ECG (Level of evidence: A), stress myocardial perfusion imaging, or stress echocardiography before discharge or within 72 hours after discharge. (Level of evidence: B)
  • In patients with suspected ACS but a normal ECG, normal cardiac troponin levels, and no history of coronary artery disease (CAD), it is reasonable to initially perform (without serial ECGs and troponins) coronary computed tomography angiography to assess the coronary artery anatomy (Level of evidence: A) or rest myocardial perfusion imaging with a technetium-99m radiopharmaceutical to exclude myocardial ischemia. (Level of evidence: B)

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