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{\u0022basePath\u0022:\u0022\\\/\u0022,\u0022pathPrefix\u0022:\u0022\u0022,\u0022highwire\u0022:{\u0022markup\u0022:[{\u0022requested\u0022:\u0022full-text\u0022,\u0022variant\u0022:\u0022full-text\u0022,\u0022view\u0022:\u0022full\u0022,\u0022pisa\u0022:\u0022spmdc;14\\\/46\\\/12-b\u0022},{\u0022requested\u0022:\u0022long\u0022,\u0022variant\u0022:\u0022full-text\u0022,\u0022view\u0022:\u0022full\u0022,\u0022pisa\u0022:\u0022spmdc;14\\\/46\\\/12-b\u0022}],\u0022ac\u0022:{\u0022spmdc;14\\\/46\\\/12-b\u0022:{\u0022access\u0022:{\u0022reprint\u0022:true,\u0022full\u0022:true},\u0022pisa_id\u0022:\u0022spmdc;14\\\/46\\\/12-b\u0022,\u0022atom_uri\u0022:\u0022\u0022,\u0022jcode\u0022:\u0022spmdc\u0022}}},\u0022googleanalytics\u0022:{\u0022trackOutbound\u0022:1,\u0022trackMailto\u0022:1,\u0022trackDownload\u0022:1,\u0022trackDownloadExtensions\u0022:\u00227z|aac|arc|arj|asf|asx|avi|bin|csv|doc(x|m)?|dot(x|m)?|exe|flv|gif|gz|gzip|hqx|jar|jpe?g|js|mp(2|3|4|e?g)|mov(ie)?|msi|msp|pdf|phps|png|ppt(x|m)?|pot(x|m)?|pps(x|m)?|ppam|sld(x|m)?|thmx|qtm?|ra(m|r)?|sea|sit|tar|tgz|torrent|txt|wav|wma|wmv|wpd|xls(x|m|b)?|xlt(x|m)|xlam|xml|z|zip\u0022,\u0022trackUrlFragments\u0022:1},\u0022ajaxPageState\u0022:{\u0022js\u0022:{\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/jquery.cluetip.js\u0022:1,\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/lib\\\/jquery.hoverIntent.js\u0022:1,\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/lib\\\/jquery.bgiframe.min.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/highwire\\\/highwire\\\/plugins\\\/highwire_markup_process\\\/js\\\/highwire_at_symbol.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/highwire\\\/highwire\\\/plugins\\\/highwire_markup_process\\\/js\\\/highwire_article_reference_popup.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/contrib\\\/google_analytics\\\/googleanalytics.js\u0022:1,\u00220\u0022:1}}});\n\/\/--\u003E\u003C!]]\u003E\n\u003C\/script\u003E\n\u003Clink type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EAcute coronary syndromes affect \u0026gt;780000 individuals in the United States each year, 70% of which cases will be NSTEMI. This article discusses updates in the treatment of NSTE-ACS based on the 2014 American Heart Association \/ American College of Cardiology guideline for the management of patients with NSTE-ACS\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ECritical Care\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EMyocardial Infarction\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ECritical Care\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EMyocardial Infarction\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EEmergency Medicine\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EAcute coronary syndromes (ACSs) affect \u0026gt; 780 000 individuals in the United States each year, 70% of which cases will be NSTEMI [Amsterdam EA et al. \u003Cem\u003ECirculation\u003C\/em\u003E. 2014]. Tarlan Hedayati, MD, Cook County Health and Hospitals System, Chicago, Illinois, USA, discussed updates in the treatment of NSTE-ACS based on the 2014 American Heart Association \/ American College of Cardiology guideline for the management of patients with NSTE-ACS [Amsterdam EA et al. \u003Cem\u003ECirculation\u003C\/em\u003E. 2014].\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003ENSTE-ACS includes NSTEMI and unstable angina (UA). The difference between the 2 is the myocardial necrosis that occurs in NSTEMI, which can be identified by an increase in biomarkers caused by myocyte death. However, troponin levels are elevated not only in patients with myocardial infarction (MI) but also in those with other conditions, such as tachycardia, trauma, heart failure, pulmonary embolism, burns, drug toxicity, respiratory failure, and neurologic diseases. Therefore, a history and clinical exam are important in the diagnosis of NSTEMI. Elevated troponin levels may be present for up to 2 weeks after the index event, but a \u0026gt; 20% increase over prior troponin levels may indicate reinfarction.\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003EPatients with NSTEMI should receive initial treatment of 162 to 325 mg of aspirin or a loading dose of clopidogrel if they cannot tolerate aspirin. In addition, patients should receive nitrates and may require oxygen if their oxygen saturation is \u0026lt; 90%. Patients expected to undergo early invasive therapy should receive a P2Y\u003Csub\u003E12\u003C\/sub\u003E receptor inhibitor, such as clopidogrel or ticagrelor, in addition to aspirin [Amsterdam EA et al. \u003Cem\u003ECirculation\u003C\/em\u003E. 2014]. For patients with UA or NSTEMI who will receive conservative therapy, P2Y\u003Csub\u003E12\u003C\/sub\u003E receptor inhibition should be administered upon admission.\u003C\/p\u003E\u003Cp id=\u0022p-5\u0022\u003EClopidogrel is a prodrug that requires a 2-step process to produce the active metabolite that elicits antiplatelet activity. Some patients harbor a polymorphism in 1 of the metabolic enzymes required for this transformation, and in these patients, the benefit of clopidogrel therapy is attenuated. In contrast, ticagrelor is the active agent and does not require biotransformation.\u003C\/p\u003E\u003Cp id=\u0022p-6\u0022\u003EThe PLATO trial [Wallentin L et al. \u003Cem\u003EN Engl J Med.\u003C\/em\u003E 2009] evaluated ticagrelor in \u0026gt; 18 000 patients with ACS, with a primary end point of cardiovascular death, MI, and stroke at 12 months. Patients treated with ticagrelor experienced a lower rate of cardiovascular death, MI, and stroke, without an increase in major bleeding. However, patients with a body weight \u0026lt; 60 kg and normal biomarker levels did not experience a benefit from ticagrelor when compared with clopidogrel. Patients in North America who received ticagrelor also did not demonstrate an improvement regarding the primary end point when compared with clopidogrel; however, it is believed that the higher aspirin dose that is administered in North America may have negated the advantage of ticagrelor.\u003C\/p\u003E\u003Cp id=\u0022p-7\u0022\u003EIn addition to dual antiplatelet therapy (DAPT), patients with UA or NSTEMI who are expected to undergo invasive therapy should receive glycoprotein IIb\/IIIa inhibition with intravenous eptifibatide or tirofiban [Amsterdam EA et al. \u003Cem\u003ECirculation\u003C\/em\u003E. 2014]. Anticoagulation should also be initiated. In patients who are undergoing an invasive strategy, bivalirudin, unfractionated heparin (UFH), or enoxaparin should be administered, whereas in patients who are undergoing conservative therapy, enoxaparin or fondaparinux is preferred over UFH.\u003C\/p\u003E\u003Cp id=\u0022p-8\u0022\u003EAn early invasive strategy is typically performed in patients with UA or NSTEMI if they are high risk according to the TIMI criteria. In the TIMACS study [Mehta SR et al. \u003Cem\u003EN Engl J Med.\u003C\/em\u003E 2009], early vs delayed percutaneous coronary intervention (PCI) was evaluated in \u0026gt; 3000 patients with NSTEMI with a primary outcome of death, MI, and stroke. There was no significant difference in the primary outcome among the 2 arms of the study (\u003Cem\u003EP\u003C\/em\u003E = .15). However, early PCI was associated with a significant decrease in the secondary outcome of death, MI, and refractory ischemia (HR, 0.72; 95% CI, 0.58 to 0.89; \u003Cem\u003EP\u003C\/em\u003E = .003). In this study, high-risk patients experienced a benefit from early PCI, but medium- to low-risk patients did not.\u003C\/p\u003E\u003Cp id=\u0022p-9\u0022\u003EIn conclusion, once NSTEMI is diagnosed, all patients should be treated with DAPT and anticoagulation. Beyond that, risk stratification should be performed to determine if an early invasive therapy should be initiated.\u003C\/p\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2014 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/14\/46\/12.2.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzogxp\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}