Diagnosis of myocardial infarction:

1. A class III recommendation: No benefit is given for CK-MB assay for diagnosis of MI
when using contemporary troponin assays and measurement should be reserved for
estimation of infarct size.
2. The diagnosis of myocardial infarction is made when the troponin rises or falls. If the
initial troponin is elevated (defined as greater than the 99th percentile of the upper value
of the reference range), the diagnosis is made if a 20% rise or fall in subsequent
troponins occurs.

3. Although no specific recommendation is made with respect to use of point-of-care

troponins, their lower specificity is acknowledged and central laboratory testing is
favored in addition to initial point-of-care testing.

4. A class IIb recommendation is made to remeasure troponin on day 3 or 4 to ascertain

infarct size.

5. A class IIb recommendation is made to add B-type natriuretic peptide (BNP) as an

additional prognostic tool.

Risk stratification:

6. A class IIa recommendation is given for coronary CT angiography in patients with

possible ACS, a normal 12-lead ECG, negative troponins, and no history of coronary
artery disease CAD.
7. The term ischemia-guided strategy replaces initial conservative management. An
ischemia-guided approach is recommended for patients with a low-risk score (TIMI 0 or
1, GRACE < 109).
8. The early invasive strategy recommendations are stratified by timing:
a. Immediate (within 2 hours): Patients with refractory or recurrent angina with
initial treatment, signs/symptoms of heart failure, new/worsening mitral
regurgitation, hemodynamic instability, sustained ventricular tachycardia, or
ventricular fibrillation
b. Early (within 24 hours): None of the immediate characteristics but new ST-
segment depression, a GRACE risk score > 140, or temporal change in troponin
c. Delayed invasive: None of the immediate or early characteristics but renal
insufficiency, left ventricular ejection fraction (LVEF) < 40%, early post-infarct
angina, history of percutaneous coronary intervention (PCI) within the past 6
months, prior coronary artery bypass surgery (CABG), GRACE risk score of 109-
140, or TIMI score of 2 or higher.

Medical Therapy:

9. Angiotensin-converting enzyme (ACE) inhibitors: a slight change in level of

recommendation was made. The guidelines clarify that an ACE inhibitor is a class I
recommendation for patients with stable chronic kidney disease (CKD) in addition to
 patients with LVEF < 40%, those with hypertension (HTN), heart failure, or diabetes
mellitus (DM). The recommendation for patients without a class I indication and NSTE
ACS (for example in patients with an LVEF > 40% without CKD, HTN or DM) was
downgraded from a class IIa recommendation in prior ACS guidelines to a IIb
recommendation in all other patients with cardiac or vascular disease. While data from
meta-analyses of ACE inhibitor trials reporting outcomes in the subgroup of patients
without heart failure or systolic dysfunction report a mortality benefit, 2 more recent data
from the observational REACH registry of patients with stable CAD did not find a
benefit for ACE inhibitors taken with other standard pharmacotherapy in reducing CV
events.3 There are no specific randomized trials that evaluated hard outcomes with ACE
inhibitors in NSTE ACS in patients without heart failure or low EF.
10. For early initial oral antiplatelet therapy, ticagrelor is given a class IIa recommendation
over clopidogrel. In the prior guidelines, either ticagrelor or clopidogrel was a Class I
recommendation with clopidogrel carrying a higher level of evidence rating. A recent
analysis of subgroup data from NSTE ACS patients enrolled in the PLATO trial found
that the benefit of ticagrelor was consistent with main study findings and independent of
primary management strategy. The rate of PLATO-defined major bleeding was similar
and non-CABG major bleeding increased with ticagrelor compared to clopidogrel. 4
11. Prior to PCI, both ticagrelor and prasugrel are given Class IIa recommendations over
clopidogrel, consistent with the findings of the PLATO and TRITON-TIMI 38 trials. This
is an added recommendation based upon the newer evidence classification adopted by the
ACC/AHA. In additional prasugrel, but not clopidogrel or ticagrelor, carries a caveat that
it should only be selected in patients who are not at high risk for bleeding complications
secondary to the increased risk of spontaneous, life-threatening, and fatal bleeding
compared to clopidogrel in TRITON-TIMI 38. While not described in the guidelines,
Wiviott et al reported post-hoc findings of enhanced efficacy and lower bleeding rates in
a core cohort patients less than 75 years of age, weighing 60 kg or more and with no
history of stroke or transient ischemic attack.5
12. The recommendation for dual antiplatelet therapy (DAPT) remains 12 months (Class I
recommendation) for both bare metal (BMS) and drug-eluting stents (DESs).
Consideration can be given (Class IIb recommendation) for a longer duration of DAPT
for patient receiving a DES. This is an area of intensive research. To date, there are no
results in randomized trials comparing the duration of DAPT specifically in patients with
ACS. Most trials suggesting the potential for shorter durations of therapy have been using
specific newer generation stents in all-comers undergoing PCI.6 More information in this
area, primarily from observational studies, is expected within the next two years.
13. If the patient has received a loading dose of clopidogrel 300 mg and is undergoing PCI, a
second 300-mg dose should be administered prior to PCI.
14. Bivalirudin is given a Class IIa recommendation over unfractionated heparin plus a
glycoprotein IIb/IIIa receptor antagonist for PCI in patients at high-risk of bleeding,
including older patients.
15. No formalized method of assessing bleeding risk in the hospital or post-hospitalization
period is suggested.
16. Clarified that in the setting of ACS, aspirin should be continued/administered prior to
CABG (and clopidogrel, ticagrelor be discontinued).
 17. No specific guidance is given for length of DAPT for patients receiving triple oral
antithrombotic therapy with warfarin other than to say that the duration should be
minimized as there are insufficient randomized trial data. The Class IIb
recommendation for an INR target of 2.0-2.5 in patients taking warfarin remains despite
no prospective trials on the practice. Practitioners interested in this topic may refer to the
recently released European Society of Cardiology guidelines for management of
antithrombotic therapy in patients with ACS undergoing PCI or valve procedures. 7
18. The use of a proton pump inhibitor (PPI) is recommended for patients receiving triple
oral antithrombotic therapy. Mention is made that the FDA recommends avoiding
esomeprazole and omeprazole specifically and that the data to suggest increased harm are
weak. A PPI is also recommended if an NSAID is used with DAPT.
19. Given the explosion of narcotic use within the U.S. and noted risks of NSAIDs in the
post-MI patient, the guideline writers addressed pain management for the patient with
ACS at the time of hospital discharge by recommending careful assessment of the
patients need for chronic therapy and a recommendation that a stepped approach be
taken with acetaminophen and nonacetylated salicylates (such as choline magnesium
trisalicylate, salsalate) or tramadol be prescribed before prescribing small doses of
narcotics. If small doses of narcotics are not effective, nonselective NSAIDs such as
naproxen are recommended. The use of COX-2 selective agents is reserved as last-line
pain management.
20. A Class III recommendation: No benefit, is given to the use of folic acid, vitamins E, C,
and beta carotene for secondary prevention. Despite reducing homocysteine levels, the
combination of folic acid and vitamin B12 taken following MI failed to reduce the risk of
recurrent CVD events, stroke, mortality, and cancer diagnoses compared to placebo in the
SEARCH trial.8 Given the potential for decreased medication adherence with numbers of
pills taken, we should encourage patients to discontinue taking these agents for
preventative care.

Special Populations:

Women:

21. A class III recommendation: No benefit, is given for an early invasive strategy in women
presenting with low-risk features. This recommendation is based upon the AHRQ report
stating that there were limited data in UA and NSTE MI comparing an invasive versus
ischemia-driven revascularization strategy in women with ACS to confirm benefit and
one meta-analysis reporting an increase in death or MI in biomarker-negative women
undergoing an early invasive strategy.9,10

Older Persons:

22. CABG is given a Class IIa recommendation over PCI in patients 75 years of age and
older who are appropriate candidates (particularly those with DM, SYNTAX score of 22
or higher), with or without LAD involvement.
Suspected Cocaine or Methamphetamine Intoxication:
 23. Management strategies for patients with suspected cocaine or methamphetamine
intoxication are provided. Signs of acute intoxication such as euphoria, tachycardia,
and/or HTN) should be identified and, if present, benzodiazepines alone or in
combination with nitroglycerin is given a Class IIa recommendation while beta-blockers
are given a Class III recommendation: Harm and should be avoided due to risk of
coronary vasospasm. If no signs of acute intoxication are present, patients with a history
of cocaine or methamphetamine use should be treated identically to other patients (Class
I indication).

Stress Cardiomyopathy:

24. In patients presenting with stress (Takotsubo) cardiomyopathy, conventional secondary

prevention medications of ACE inhibitors, beta-blockers, and aspirin, as well as
symptomatic relief using diuretics, are recommended (Class I recommendation). Oral
anticoagulation is recommended for patients with LV thrombi (Class I recommendation)
and as stroke prophylaxis (duration not specified) (Class IIb recommendation).

Patients with Asymptomatic Anemia:

25. The risks of routine blood transfusion are addressed. A Class III recommendation: No
benefit, is given for routine blood transfusion for hemodynamically stable patients with
hemoglobin level of 8 g/dL or higher. While most observational data suggest no mortality
benefit associated with transfusion in patients with higher hemoglobin values, this
recommendation does not endorse transfusion for patients with lower hemoglobin values
as no prospective randomized data exist in patients with MI. A recent study of transfusion
practices across 57 hospitals in almost 35,000 patients presenting with MI used
propensity modeling for 45 patient characteristics and found lower adjusted mortality in
transfused patients who had a nadir hemoglobin of 7-8.9 g/dL but no excess mortality in
those transfused patients with higher nadir hemoglobin values who were transfused. 11

References