...episodes of drug-induced TdP usually start with a short-long-short pattern of R-R cycles consisting of a short-coupled premature ventricular complex (PVC) followed by a compensatory pause and then ...another PVC that typically falls close to the peak of the T wave (2). ...TdP episodes usually show a warm-up phenomenon, with the first few beats of ventricular tachycardia exhibiting longer cycle lengths than subsequent arrhythmia complexes.
Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine Jeffrey L. Anderson, MD, FACC, FAHA, Chair; Cynthia D. Adams, RN, ...PhD, FAHA; Elliott M. Antman, MD, FACC, FAHA; Charles R. Bridges, ScD, MD, FACC, FAHA*>; Robert M. Califf, MD, MACC; Donald E. Casey, Jr, MD, MPH, MBA, FACPdagger; William E. Chavey II, MD, MSdouble dagger; Francis M. Fesmire, MD, FACEP§; Judith S. Hochman, MD, FACC, FAHA; Thomas N. Levin, MD, FACC, FSCAI||; A. Michael Lincoff, MD, FACC; Eric D. Peterson, MD, MPH, FACC, FAHA; Pierre Theroux, MD, FACC, FAHA; Nanette Kass Wenger, MD, FACC, FAHA; R. Scott Wright, MD, FACC, FAHA ACCF/AHA Task Force Members Alice K. Jacobs, MD, FACC, FAHA, Chair; Jeffrey L. Anderson, MD, FACC, FAHA, Chair-Elect; Nancy Albert, PhD, CCNS, CCRN, FAHA; Judith S. Hochman, MD, FACC, FAHA; Mark A. Creager, MD, FACC, FAHA; Frederick G. Kushner, MD, FACC, FAHA; Steven M. Ettinger, MD, FACC; Erik Magnus Ohman, MD, FACC; Robert A. Guyton, MD, FACC; William G. Stevenson, MD, FACC, FAHA; Jonathan L. Halperin, MD, FACC, FAHA; Clyde W. Yancy, MD, FACC, FAHA Table of Contents Preamble (UPDATED)...e218 Introduction...e219 Organization of Committee and Evidence Review (UPDATED)...e219 Purpose of These Guidelines...e219 Overview of the Acute Coronary Syndromes...e219 Definition of Terms...e219 Pathogenesis of UA/NSTEMI...e223 Presentations of UA and NSTEMI...e223 Management Before UA/NSTEMI and Onset of UA/NSTEMI...e224 Identification of Patients at Risk of UA/NSTEMI...e224 Interventions to Reduce Risk of UA/NSTEMI...e224 Onset of UA/NSTEMI...e225 Recognition of Symptoms by Patient...e225 Silent and Unrecognized Events...e226 Initial Evaluation and Management...e226 Clinical Assessment...e226 Emergency Department or Outpatient Facility Presentation...e230 Questions to Be Addressed at the Initial Evaluation...e230 Early Risk Stratification...e230 Estimation of the Level of Risk...e231 Rationale for Risk Stratification...e232 History...e233 Anginal Symptoms and Anginal Equivalents...e233 Demographics and History in Diagnosis and Risk Stratification...e234 Estimation of Early Risk at Presentation...e234 Electrocardiogram...e235 Physical Examination...e238 Noncardiac Causes of Symptoms and Secondary Causes of Myocardial Ischemia...e238 Cardiac Biomarkers of Necrosis and the Redefinition of AMI...e238 Creatine Kinase-MB...e239 Cardiac Troponins...e239 Clinical Use...e239 Clinical Use of Marker Change Scores...e242 Bedside Testing for Cardiac Markers...e242 Myoglobin and CK-MB Subforms Compared With Troponins...e242 Summary Comparison of Biomarkers of Necrosis: Singly and In Combination...e242 Other Markers and Multimarker Approaches...e243 Ischemia...e244 Coagulation...e244 Platelets...e244 Inflammation...e244 B-Type Natriuretic Peptides...e244 Immediate Management...e244 Chest Pain Units...e245 Discharge From ED or Chest Pain Unit...e246 Early Hospital Care...e247 Anti-Ischemic and Analgesic Therapy...e248 General Care...e249 Use of Anti-Ischemic Therapies...e250 Nitrates...e250 Morphine Sulfate...e253 Beta-Adrenergic Blockers...e254 Calcium Channel Blockers...e256 Inhibitors of The Renin-Angiotensin-Aldosterone System...e257 Other Anti-Ischemic Therapies...e257 Intra-Aortic Balloon Pump Counterpulsation...e258 Analgesic Therapy...e258 Recommendations for Antiplatelet/Anticoagulant Therapy in Patients for Whom Diagnosis of UA/NSTEMI Is Likely or Definite...e258 Antiplatelet Therapy Recommendations (UPDATED)...e258 Anticoagulant Therapy Recommendations...e260 Additional Management Considerations for Antiplatelet and Anticoagulant Therapy (UPDATED)...e261 Antiplatelet Agents and Trials (Aspirin, Ticlopidine, Clopidogrel)...e262 Aspirin...e262 Adenosine Diphosphate Receptor Antagonists and Other Antiplatelet Agents...e264 Anticoagulant Agents and Trials...e268 Unfractionated Heparin...e269 Low-Molecular-Weight Heparin...e270 LMWH Versus UFH...e270 Extended Therapy With LMWHS...e273 Direct Thrombin Inhibitors...e274 Factor XA Inhibitors...e276 Long-Term Anticoagulation...e277 Platelet GP IIb/IIIa Receptor Antagonists...e278 Fibrinolysis...e283 Initial Conservative Versus Initial Invasive Strategies (UPDATED)...e283 General Principles...e283 Rationale for the Initial Conservative Strategy...e284 Rationale for the Invasive Strategy...e284 Immediate Angiography...e284 Deferred Angiography...e285 Comparison of Early Invasive and Initial Conservative Strategies...e285 Subgroups...e288 Care Objectives...e288 Risk Stratification Before Discharge...e290 Care Objectives...e291 Noninvasive Test Selection...e292 Selection for Coronary Angiography...e293 Patient Counseling...e293 Coronary Revascularization...e293 Recommendations for Revascularization With PCI and CABG in Patients With UA/NSTEMI...e293 Recommendations for PCI...e293 Recommendations for CABG...e295 General Principles...e295 Percutaneous Coronary Intervention...e296 Platelet Inhibitors and Percutaneous Revascularization...e297 Surgical Revascularization...e298 Conclusions...e300 Late Hospital Care, Hospital Discharge, and Post-Hospital Discharge Care...e300 Medical Regimen and Use of Medications...e300 Long-Term Medical Therapy and Secondary Prevention...e301 Convalescent and Long-Term Antiplatelet Therapy (UPDATED)...e301 Beta Blockers...e302 Inhibition of the Renin-Angiotensin-Aldosterone System...e302 Nitroglycerin...e303 Calcium Channel Blockers...e303 Warfarin Therapy (UPDATED)...e303 Lipid Management...e303 Blood Pressure Control...e305 Diabetes Mellitus...e305 Smoking Cessation...e305 Weight Management...e306 Physical Activity...e306 Patient Education...e307 Influenza...e307 Depression...e307 Nonsteroidal Anti-Inflammatory Drugs...e307 Hormone Therapy...e308 Antioxidant Vitamins and Folic Acid...e308 Postdischarge Follow-Up...e308 Cardiac Rehabilitation...e309 Return to Work and Disability...e310 Other Activities...e311 Patient Records and Other Information Systems...e311 Special Groups...e312 Women...e312 Profile of UA/NSTEMI in Women...e313 Management...e313 PHARMACOLOGICAL THERAPY...e313 CORONARY ARTERY REVASCULARIZATION...e314 INITIAL INVASIVE VERSUS INITIAL CONSERVATIVE STRATEGY...e314 Stress Testing...e316 Conclusions...e316 Diabetes Mellitus (UPDATED)...e316 Profile and Initial Management of Diabetic and Hyperglycemic Patients With UA/NSTEMI...e317 Coronary Revascularization...e318 Conclusions...e319 Post-CABG Patients...e319 Pathological Findings...e319 Clinical Findings and Approach...e319 Conclusions...e320 Older Adults...e320 Pharmacological Management...e321 Functional Studies...e321 Percutaneous Coronary Intervention in Older Patients...e321 Contemporary Revascularization Strategies in Older Patients...e321 Conclusions...e322 Chronic Kidney Disease (UPDATED)...e322 Cocaine and Methamphetamine Users...e323 Coronary Artery Spasm With Cocaine Use...e324 Treatment...e324 Methamphetamine Use and UA/NSTEMI...e325 Variant (Prinzmetal's) Angina...e325 Clinical Picture...e325 Pathogenesis...e326 Diagnosis...e326 Treatment...e326 Prognosis...e327 Cardiovascular "Syndrome X"...e327 Definition and Clinical Picture...e327 Treatment...e328 Takotsubo Cardiomyopathy...e328 Conclusions and Future Directions...e328 Recommendations for Quality of Care and Outcomes for Acute Coronary Syndromes (NEW SECTION)...e330 Appendix 1...e331 Appendix 2...e336 Appendix 3(UPDATED)...e341 Appendixes 4-8 (NEW SECTION)...e343 References...e344 Preamble (UPDATED) For new or updated text, view the2011 Focused Update.
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