2014 AHA/ACC Guideline for the Management of Non–ST-Elevation Acute Coronary Syndromes

Are you studying for exams? Are you expected to be all over the latest guidelines and recommendations on common Emergency presentations? Then this is vital reading for you!



Since the last guideline update in 2012 (added to the 2007 guidelines), there have been a number of advances, including the expansion from NSTEMI to include unstable angina in the NSTEACS umbrella. If you already quite au fait with the previous version, this article provides a nice summary of the major changes in the new edition.

Some of the interesting updates are:

  • CK-MB adds nothing to modern troponin assays in diagnosis, but may help estimate infarct size (although a day 3-4 troponin will also suffice)
  • Inclusion of criteria for early invasive intervention:
    • 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
    • Early (within 24 hours): None of the immediate characteristics but new ST-segment depression, a GRACE risk score > 140, or temporal change in troponin
    • 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
  • Promotion of ticagrelor to first-line antiplatelet, next to clopidogrel
  • Management for suspected cocaine or methamphetamine intoxication are provided: if signs of acute intoxication, benzos alone or in combination with GTN is given a Class IIa recommendation while β-blockers are given a Class III recommendation due to potential harm and risk of coronary vasospasm. If no signs of acute intoxication are present, patients with a history of cocaine or meth use should be treated identically to other patients (Class I indication)

You can find the "Executive Summary" in all of its 227-page glory published online at Circulation, or load it up right here by clicking the link below.


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