2012 ACCF/AHA Focused Update Incorporated into the ACCF/AHA 2007 Guidelines for the Management of Patients with Unstable Angina/Non–ST-Elevation Myocardial Infarction

HomeCirculationVol. 127, No. 232012 ACCF/AHA Focused Update Incorporated Into the ACCF/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplementary MaterialsFree AccessResearch ArticlePDF/EPUB2012 ACCF/AHA Focused Update Incorporated Into the ACCF/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial InfarctionA Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines 2007 WRITING COMMITTEE MEMBERS Jeffrey L. Anderson, MD, FACC, FAHA, Cynthia D. Adams, RN, PhD, FAHA, Elliott M. Antman, MD, FACC, FAHA, Charles R. Bridges, MD, ScD, FACC, FAHA, Robert M. Califf, MD, MACC, Donald E. CaseyJr, MD, MPH, MBA, FACP, William E. ChaveyII, MD, MS, 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 K. Wenger, MD, MACC, FAHA and R. Scott Wright, MD, FACC, FAHA Presidents and Staff American College of Cardiology Foundation William A. Zoghbi, MD, FACC, Thomas E. ArendJr, Esq, CAE, William J. Oetgen, MD, MBA, FACC, Charlene May, American College of Cardiology Foundation/American Heart Association Lisa Bradfield, CAE, Sue Keller, BSN, MPH, Ezaldeen RamadhanIII, American Heart Association Gordon F. Tomaselli, MD, FAHA, Nancy Brown, Rose Marie Robertson, MD, FAHA, Gayle R. Whitman, PhD, RN, FAHA, FAAN, Judy L. Bezanson, DSN, RN, CNS-MS, FAHA and Jody Hundley 2007 WRITING COMMITTEE MEMBERS , Jeffrey L. AndersonJeffrey L. Anderson , Cynthia D. AdamsCynthia D. Adams , Elliott M. AntmanElliott M. Antman , Charles R. BridgesCharles R. Bridges , Robert M. CaliffRobert M. Califf , Donald E. CaseyJrDonald E. CaseyJr , William E. ChaveyIIWilliam E. ChaveyII , Francis M. FesmireFrancis M. Fesmire , Judith S. HochmanJudith S. Hochman , Thomas N. LevinThomas N. Levin , A. Michael LincoffA. Michael Lincoff , Eric D. PetersonEric D. Peterson , Pierre TherouxPierre Theroux , Nanette K. WengerNanette K. Wenger and R. Scott WrightR. Scott Wright Presidents and Staff , American College of Cardiology Foundation , William A. ZoghbiWilliam A. Zoghbi , Thomas E. ArendJrThomas E. ArendJr , William J. OetgenWilliam J. Oetgen , Charlene MayCharlene May , American College of Cardiology Foundation/American Heart Association , Lisa BradfieldLisa Bradfield , Sue KellerSue Keller , Ezaldeen RamadhanIIIEzaldeen RamadhanIII , American Heart Association , Gordon F. TomaselliGordon F. Tomaselli , Nancy BrownNancy Brown , Rose Marie RobertsonRose Marie Robertson , Gayle R. WhitmanGayle R. Whitman , Judy L. BezansonJudy L. Bezanson and Jody HundleyJody Hundley Originally published29 Apr 2013https://doi.org/10.1161/CIR.0b013e31828478acCirculation. 2013;127:e663–e828is corrected byCorrectionOther version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2013: Previous Version 1 Table of ContentsPreamble (UPDATED) e6661. Introduction (UPDATED) e6691.1. Organization of Committee and Evidence Review (UPDATED) e6691.2. Document Review and Approval (UPDATED) e6691.3. Purpose of These Guidelines e6691.4. Overview of the Acute Coronary Syndromes e6701.4.1. Definition of Terms e6701.4.2. Pathogenesis of UA/NSTEMI e6721.4.3. Presentations of UA and NSTEMI e6731.5. Management Before UA/NSTEMI and Onset of UA/NSTEMI e6731.5.1. Identification of Patients at Risk of UA/NSTEMI e6731.5.2. Interventions to Reduce Risk of UA/NSTEMI e6741.6. Onset of UA/NSTEMI e6751.6.1. Recognition of Symptoms by Patient e6751.6.2. Silent and Unrecognized Events e6752. Initial Evaluation and Management e6752.1. Clinical Assessment e6752.1.1. Emergency Department or Outpatient Facility Presentation e6792.1.2. Questions to Be Addressed at the Initial Evaluation e6812.2. Early Risk Stratification e6812.2.1. Estimation of the Level of Risk e6822.2.2. Rationale for Risk Stratification e6822.2.3. History e6822.2.4. Anginal Symptoms and Anginal Equivalents e6822.2.5. Demographics and History in Diagnosis and Risk Stratification e6832.2.6. Estimation of Early Risk at Presentation e6842.2.6.1. Electrocardiogram e6862.2.6.2. Physical Examination e6872.2.7. Noncardiac Causes of Symptoms and Secondary Causes of Myocardial Ischemia e6872.2.8. Cardiac Biomarkers of Necrosis and the Redefinition of AMI e6882.2.8.1. Creatine Kinase-MB e6882.2.8.2. Cardiac Troponins e6892.2.8.2.1. Clinical Use e6892.2.8.2.1.1. Clinical Use of Marker Change Scores e6912.2.8.2.1.2. Bedside Testing for Cardiac Markers e6912.2.8.3. Myoglobin and CK-MB Subforms Compared With Troponins e6912.2.8.4. Summary Comparison of Biomarkers of Necrosis: Singly and in Combination e6922.2.9. Other Markers and Multimarker Approaches e6922.2.9.1. Ischemia e6932.2.9.2. Coagulation e6932.2.9.3. Platelets e6932.2.9.4. Inflammation e6932.2.9.5. B-Type Natriuretic Peptides e6932.3. Immediate Management e6932.3.1. Chest Pain Units e6942.3.2. Discharge From ED or Chest Pain Unit e6953. Early Hospital Care e6963.1. Anti-Ischemic and Analgesic Therapy e6973.1.1. General Care e6993.1.2. Use of Anti-Ischemic Therapies e6993.1.2.1. Nitrates e6993.1.2.2. Morphine Sulfate e7013.1.2.3. Beta-Adrenergic Blockers e7013.1.2.4. Calcium Channel Blockers e7033.1.2.5. Inhibitors of the Renin-Angiotensin-Aldosterone System e7043.1.2.6. Other Anti-Ischemic Therapies e7043.1.2.7. Intra-Aortic Balloon Pump Counterpulsation e7053.1.2.8. Analgesic Therapy e7053.2. Recommendations for Antiplatelet/Anticoagulant Therapy in Patients for Whom Diagnosis of UA/NSTEMI Is Likely or Definite (UPDATED) e7053.2.1. Antiplatelet Therapy: Recommendations (UPDATED) e7053.2.2. Anticoagulant Therapy: Recommendations e7073.2.3. Additional Management Considerations for Antiplatelet and Anticoagulant Therapy: Recommendations (UPDATED) e7073.2.3.1. Antiplatelet/Anticoagulant Therapy in Patients for Whom Diagnosis of UA/NSTEMI Is Likely or Definite (NEW SECTION) e7093.2.3.1.1. Newer P2Y12 Receptor Inhibitors e7093.2.3.1.2. Choice of P2Y12 Receptor Inhibitors for PCI in UA/NSTEMI e7113.2.3.1.2.1. Timing of Discontinuation of P2Y12 Receptor Inhibitor Therapy for Surgical Procedures e7113.2.3.1.3. Interindividual Variability in Responsiveness to Clopidogrel e7123.2.3.1.4. Optimal Loading and Maintenance Dosages of Clopidogrel e7133.2.3.1.5. Proton Pump Inhibitors and Dual Antiplatelet Therapy for ACS e7133.2.3.1.6. Glycoprotein IIb/IIIa Receptor Antagonists (Updated to Incorporate Newer Trials and Evidence) e7143.2.4. Older Antiplatelet Agents and Trials (Aspirin, Ticlopidine, Clopidogrel) e7153.2.4.1. Aspirin e7153.2.4.2. Adenosine Diphosphate Receptor Antagonists and Other Antiplatelet Agents e7173.2.5. Anticoagulant Agents and Trials e7203.2.5.1. Unfractionated Heparin e7213.2.5.2. Low-Molecular-Weight Heparin e7223.2.5.3. LMWH Versus UFH e7223.2.5.3.1. Extended Therapy with LMWHs e7253.2.5.4. Direct Thrombin Inhibitors e7263.2.5.5. Factor Xa Inhibitors e7283.2.5.6. Long-Term Anticoagulation e7293.2.6. Platelet GP IIb/IIIa Receptor Antagonists e7303.2.7. Fibrinolysis e7353.3. Initial Conservative Versus Initial Invasive Strategies (UPDATED) e7353.3.1. General Principles e7353.3.2. Rationale for the Initial Conservative Strategy e7363.3.3. Rationale for the Invasive Strategy e7363.3.3.1. Timing of Invasive Therapy (NEW SECTION) e7363.3.4. Immediate Angiography e7373.3.5. Deferred Angiography e7383.3.6. Comparison of Early Invasive and Initial Conservative Strategies e7383.3.7. Subgroups e7413.3.8. Care Objectives e7413.4. Risk Stratification Before Discharge e7433.4.1. Care Objectives e7443.4.2. Noninvasive Test Selection e7443.4.3. Selection for Coronary Angiography e7463.4.4. Patient Counseling e7464. Coronary Revascularization e7464.1. Recommendations for Revascularization With PCI and CABG in Patients With UA/NSTEMI (UPDATED) e7465. Late Hospital Care, Hospital Discharge, and Post-Hospital Discharge Care e7465.1. Medical Regimen and Use of Medications e7465.2. Long-Term Medical Therapy and Secondary Prevention e7485.2.1. Convalescent and Long-Term Antiplatelet Therapy (UPDATED) e7495.2.2. Beta Blockers e7495.2.3. Inhibition of the Renin-Angiotensin-Aldosterone System e7505.2.4. Nitroglycerin e7505.2.5. Calcium Channel Blockers e7505.2.6. Warfarin Therapy (UPDATED) e7505.2.7. Lipid Management e7515.2.8. Blood Pressure Control e7535.2.9. Diabetes Mellitus e7535.2.10. Smoking Cessation e7535.2.11. Weight Management e7545.2.12. Physical Activity e7545.2.13. Patient Education e7555.2.14. Influenza e7555.2.15. Depression e7555.2.16. Nonsteroidal Anti-Inflammatory Drugs e7555.2.17. Hormone Therapy e7555.2.18. Antioxidant Vitamins and Folic Acid e7565.3. Postdischarge Follow-Up e7565.4. Cardiac Rehabilitation e7575.5. Return to Work and Disability e7585.6. Other Activities e7595.7. Patient Records and Other Information Systems e7596. Special Groups e7606.1. Women e7606.1.1. Profile of UA/NSTEMI in Women e7616.1.2. Management e7616.1.2.1. Pharmacological Therapy e7616.1.2.2. Coronary Artery Revascularization e7616.1.2.3. Initial Invasive Versus Initial Conservative Strategy e7626.1.3. Stress Testing e7646.1.4. Conclusions e7646.2. Diabetes Mellitus (UPDATED) e7646.2.1. Profile and Initial Management of Diabetic and Hyperglycemic Patients With UA/NSTEMI e7646.2.1.1. Intensive Glucose Control (NEW SECTION) e7656.2.2. Coronary Revascularization e7666.2.3. Conclusions e7676.3. Post-CABG Patients e7676.3.1. Pathological Findings e7676.3.2. Clinical Findings and Approach e7686.3.3. Conclusions e7686.4. Older Adults e7686.4.1. Pharmacological Management e7696.4.2. Functional Studies e7696.4.3. Percutaneous Coronary Intervention in Older Patients e7696.4.4. Contemporary Revascularization Strategies in Older Patients e7706.4.5. Conclusions e7706.5. Chronic Kidney Disease (UPDATED) e7706.5.1. Angiography in Patients With CKD (NEW SECTION) e7716.6. Cocaine and Methamphetamine Users e7736.6.1. Coronary Artery Spasm With Cocaine Use e7736.6.2. Treatment e7736.6.3. Methamphetamine Use and UA/NSTEMI e7736.7. Variant (Prinzmetal's) Angina e7756.7.1. Clinical Picture e7756.7.2. Pathogenesis e7756.7.3. Diagnosis e7756.7.4. Treatment e7766.7.5. Prognosis e7766.8. Cardiovascular "Syndrome X" e7766.8.1. Definition and Clinical Picture e7776.8.2. Treatment e7786.9. Takotsubo Cardiomyopathy e7787. Conclusions and Future Directions e7787.1. Recommendations for Quality of Care and Outcomes for UA/NSTEMI (NEW SECTION) e7797.1.1. Quality Care and Outcomes (NEW SECTION) e780References e780Appendix 1. Author Relationships With Industry and Other Entities e806Appendix 2. Reviewer Relationships With Industry and Other Entities e811Appendix 3. Abbreviation List e816Appendix 4. 2012 Author Relationships With Industry and Other Entities (NEW) e819Appendix 5. 2012 Reviewer Relationships With Industry and Other Entities (NEW) e821Appendix 6. Selection of Initial Treatment Strategy: Invasive Versus Conservative Strategy (NEW) e824Appendix 7. Dosing Table for Antiplatelet and Anticoagulant Therapy to Support PCI in UA/NSTEMI (NEW) e825Appendix 8. Comparisons Among Orally Effective P2Y12 Inhibitors (NEW) e827Appendix 9. Flowchart for Class I and Class IIa Recommendations for Initial Management of UA/NSTEMI (NEW) e828Preamble (UPDATED)It is important that the medical profession play a significant role in critically evaluating the use of diagnostic procedures and therapies as they are introduced and tested in the detection, management, or prevention of disease states. Rigorous and expert analysis of the available data documenting absolute and relative benefits and risks of those procedures and therapies can produce helpful guidelines that improve the effectiveness of care, optimize patient outcomes, and favorably affect the overall cost of care by focusing resources on the most effective strategies.The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have jointly engaged in the production of such guidelines in the area of cardiovascular disease since 1980. The ACCF/AHA Task Force on Practice Guidelines (Task Force), whose charge is to develop, update, or revise practice guidelines for important cardiovascular diseases and procedures, directs this effort. Writing committees are charged with the task of performing an assessment of the evidence and acting as an independent group of authors to develop, update, or revise written recommendations for clinical practice.Experts in the subject under consideration have been selected from both organizations to examine subject-specific data and write guidelines. The process includes additional representatives from other medical practitioner and specialty groups when appropriate. Writing committees are specifically charged to perform a literature review, weigh the strength of evidence for or against a particular treatment or procedure, and include estimates of expected health outcomes where data exist. Patient-specific modifiers and comorbidities and issues of patient preference that may influence the choice of particular tests or therapies are considered, as well as frequency of follow-up and cost-effectiveness. When available, information from studies on cost will be considered; however, review of data on efficacy and clinical outcomes will constitute the primary basis for preparing recommendations in these guidelines.The guidelines will be reviewed annually by the Task Force and will be considered current unless they are updated, revised, or sunsetted and withdrawn from distribution. Keeping pace with the stream of new data and evolving evidence on which guideline recommendations are based is an ongoing challenge to timely development of clinical practice guidelines. In an effort to respond promptly to new evidence, the Task Force has created a "focused update" process to revise the existing guideline recommendations that are affected by evolving data or opinion. New evidence is reviewed in an ongoing fashion to more efficiently respond to important science and treatment trends that could have a major impact on patient outcomes and quality of care.For the 2012 focused update, the standing guideline writing committee along with the parent Task Force identified trials and other key data through October 2011 that may impact guideline recommendations, specifically in response to the approval of new oral antiplatelets, and to provide guidance on how to incorporate these agents into daily practice (Section 1.1, "Methodology and Evidence"). Now that multiple agents are available, a comparison of their use in various settings within clinical practice is provided. This iteration replaces the sections in the 2007 ACC/AHA Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction that were updated by the 2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction.1,2 The focused update is not intended to be based on a complete literature review from the date of the previous guideline publication but rather to include pivotal new evidence that may affect changes to current recommendations. See the 2012 focused update for the complete preamble and evidence review period.3In analyzing the data and developing recommendations and supporting text, the writing group uses evidence-based methodologies developed by the Task Force.4 The Class of Recommendation (COR) is an estimate of the size of the treatment effect, with consideration given to risks versus benefits, as well as evidence and/or agreement that a given treatment or procedure is or is not useful/effective and in some situations may cause harm. The Level of Evidence (LOE) is an estimate of the certainty or precision of the treatment effect. The writing group reviews and ranks evidence supporting each recommendation, with the weight of evidence ranked as LOE A, B, or C, according to specific definitions that are included in Table 1. Studies are identified as observational, retrospective, prospective, or randomized, as appropriate. For certain conditions for which inadequate data are available, recommendations are based on expert consensus and clinical experience and are ranked as LOE C. When recommendations at LOE C are supported by historical clinical data, appropriate references (including clinical reviews) are cited if available. For issues for which sparse data are available, a survey of current practice among the clinicians on the writing group is the basis for LOE C recommendations, and no references are cited. The schema for COR and LOE is summarized in Table 1, which also provides suggested phrases for writing recommendations within each COR. A new addition to this methodology for the 2012 focused update is separation of the Class III recommendations to delineate whether the recommendation is determined to be of "no benefit" or is associated with "harm" to the patient. In addition, in view of the increasing number of comparative effectiveness studies, comparator verbs and suggested phrases for writing recommendations for the comparative effectiveness of one treatment or strategy versus another have been added for COR I and IIa, LOE A or B only.Table 1. Applying Classification of Recommendations and Level of EvidenceTable 1. Applying Classification of Recommendations and Level of EvidenceTable 2. Guidelines for the Identification of ACS Patients by ED Registration Clerks or Triage NursesRegistration/clerical staff Patients with the following chief complaints require immediate assessment by the triage nurse and should be referred for further evaluation: Chest pain, pressure, tightness, or heaviness; pain that radiates to neck, jaw, shoulders, back, or 1 or both armsIndigestion or "heartburn"; nausea and/or vomiting associated with chest discomfortPersistent shortness of breathWeakness, dizziness, lightheadedness, loss of consciousnessTriage nursePatients with the following symptoms and signs require immediate assessment by the triage nurse for the initiation of the ACS protocol: Chest pain or severe epigastric pain, nontraumatic in origin, with components typical of myocardial ischemia or MI: Central/substernal compression or crushing chest painPressure, tightness, heaviness, cramping, burning, aching sensationUnexplained indigestion, belching, epigastric painRadiating pain in neck, jaw, shoulders, back, or 1 or both armsAssociated dyspneaAssociated nausea and/or vomitingAssociated diaphoresisIf these symptoms are present, obtain stat ECG.Medical historyThe triage nurse should take a brief, targeted, initial history with an assessment of current or past history of: CABG, PCI, CAD, angina on effort, or MINTG use to relieve chest discomfortRisk factors, including smoking, hyperlipidemia, hypertension, diabetes mellitus, family history, and cocaine or methamphetamine useRegular and recent medication useThe brief history must not delay entry into the ACS protocol.Special considerationsWomen may present more frequently than men with atypical chest pain and symptoms.Diabetic patients may have atypical presentations due to autonomic dysfunction.Elderly patients may have atypical symptoms such as generalized weakness, stroke, syncope, or a change in mental status.Adapted from National Heart Attack Alert Program. Emergency Department: rapid identification and treatment of patients with acute myocardial infarction. Bethesda, MD: US Department of Health and Human Services. US Public Health Service. National Institutes of Health. National Heart, Lung and Blood Institute, September 1993. NIH Publication No. 93-3278.6ACS = acute coronary syndrome; CABG = coronary artery bypass graft surgery; CAD = coronary artery disease; ECG = electrocardiogram; ED = emergency department; MI = myocardial infarction; NTG = nitroglycerin; PCI = percutaneous coronary intervention.Table 3. Causes of UA/NSTEMI*Thrombus or thromboembolism, usually arising on disrupted or eroded plaque Occlusive thrombus, usually with collateral vessels†Subtotally occlusive thrombus on pre-existing plaqueDistal microvascular thromboembolism from plaque-associated thrombusThromboembolism from plaque erosion Non–plaque-associated coronary thromboembolismDynamic obstruction (coronary spasm‡ or vasoconstriction) of epicardial and/or microvascular vesselsProgressive mechanical obstruction to coronary flowCoronary arterial inflammationSecondary UACoronary artery dissection§*These causes are not mutually exclusive; some patients have 2 or more causes. †DeWood MA, Stifter WF, Simpson CS, et al. Coronary arteriographic findings soon after non–Q-wave myocardial infarction. N Engl J Med 1986;315:417–23.13‡May occur on top of an atherosclerotic plaque, producing missed-etiology angina or UA/NSTEMI. §Rare. Modified with permission from Braunwald E. Unstable angina: an etiologic approach to management. Circulation 1998;98:2219–22.12UA = unstable angina; UA/NSTEMI = unstable angina/non–ST-elevation myocardial infarction.Table 4. Three Principal Presentations of UAClassPresentationRest angina*Angina occurring at rest and prolonged, usuallygreater than 20 minNew-onset anginaNew-onset angina of at least CCS class III severityIncreasing anginaPreviously diagnosed angina that has becomedistinctly more frequent, longer in duration, or lower in threshold (ie, increased by 1 or more CCS class to at least CCS class III severity)*Patients with non–ST-elevated myocardial infarction usually present with angina at rest. Adapted with permission from Braunwald E. Unstable angina: a classification. Circulation 1989;80:410–4.14CCS = Canadian Cardiovascular Society classification; UA = unstable angina.Table 5. Grading of Angina Pectoris According to CCS ClassificationClassDescription of StageI"Ordinary physical activity does not cause… angina," such aswalking or climbing stairs. Angina occurs with strenuous, rapid, or prolonged exertion at work or recreation.II"Slight limitation of ordinary activity." Angina occurs on walking orclimbing stairs rapidly; walking uphill; walking or stair climbing after meals; in cold, in wind, or under emotional stress; or only during the few hours after awakening. Angina occurs on walking more than 2 blocks on the level and climbing more than 1 flight of ordinary stairs at a normal pace and under normal conditions.III"Marked limitations of ordinary physical activity." Angina occurson walking 1 to 2 blocks on the level and climbing 1 flight of stairs under normal conditions and at a normal pace.IV"Inability to carry on any physical activity without discomfort— anginal symptoms may be present at rest."Adapted with permission from Campeau L. Grading of angina pectoris (letter). Circulation 1976;54:522–3.15CCS = Canadian Cardiovascular Society.Table 6. Likelihood That Signs and Symptoms Represent an ACS Secondary to CADFeatureHigh Likelihood Any of the following:Intermediate Likelihood Absence of high-likelihood features andpresence of any of the following:Low Likelihood Absence of high- or intermediate-likelihood features but may have:HistoryChest or left arm pain or discomfort as chief symptom reproducing prior documented anginaKnown history of CAD, including MIChest or left arm pain or discomfort as chief symptom Age greater than 70 yearsMale sexDiabetes mellitusProbable ischemic symptoms in absenceof any of the intermediate likelihood characteristicsRecent cocaine useExaminationTransient MR murmur, hypotension,diaphoresis, pulmonary edema, or ralesExtracardiac vascular diseaseChest discomfort reproduced by palpationECGNew, or presumably new, transient ST-segmentdeviation (1 mm or greater) or T-wave inversion in multiple precordial leadsFixed wavesST depression 0.5 to 1 mm or T-wave inversiongreater than 1 mmT-wave flattening or inversion less than1 mm in leads with dominant wavesNormal ECGCardiac markersElevated cardiac TnI, TnT, or CK-MBNormalNormalModified with permission from Braunwald E, Mark DB, Jones RH, et al. Unstable angina: diagnosis and management. Rockville, MD: Agency for Health Care Policy and Research and the National Heart, Lung, and Blood Institute, U.S. Public Health Service, U.S. Department of Health and Human Service, 1994. AHCPR publication no. 94-0602.124ACS = acute coronary syndrome; CAD = coronary artery disease; CK-MB = MB fraction of creatine kinase; ECG = electrocardiogram; MI = myocardial infarction; MR = mitral regurgitation; TnI = troponin I; TnT = troponin T.In view of the advances in medical therapy across the spectrum of cardiovascular diseases, the Task Force has designated the term guideline-directed medical therapy (GDMT) to represent optimal medical therapy as defined by ACCF/AHA guideline (primarily Class I)–recommended therapies. This new term, GDMT, is incorporated into the 2012 focused update and will be used throughout all future guidelines.Because the ACCF/AHA practice guidelines address patient populations (and healthcare providers) residing in North America, drugs that are not currently available in North America are discussed in the text without a specific COR. For studies performed in large numbers of subjects outside North America, each writing group reviews the potential impact of different practice patterns and patient populations on the treatment effect and relevance to the ACCF/AHA target population to determine whether the findings should inform a specific recommendation.The ACCF/AHA practice guidelines are intended to assist healthcare providers in clinical decision making by describing a range of generally acceptable approaches to the diagnosis, management, and prevention of specific diseases or conditions. The guidelines attempt to define practices that meet the needs of most patients in most circumstances. The ultimate judgment about care of a particular patient must be made by the healthcare provider and patient in light of all the circumstances presented by that patient. As a result, situations may arise in which deviations from these guidelines may be appropriate. Clinical decision making should consider the quality and availability of expertise in the area where care is provided. When these guidelines are used as the basis for regulatory or payer decisions, the goal should be improvement in quality of care. The Task Force recognizes that situations arise in which additional data are needed to inform patient care more effectively; these areas will be identified within each respective guideline when appropriate.Prescribed courses of treatment in accordance with these recommendations are effective only if they are followed. Because lack of patient understanding and adherence may adversely affect outcomes, physicians and other healthcare providers should make every effort to engage the patient's active participation in prescribed medical regimens and lifestyles. In addition, patients should be informed of the risks, benefits, and alternatives to a particular treatment and should be involved in shared decision making whenever feasible, particularly for COR IIa and IIb, for which the benefit-to-risk ratio may be lower.The Task Force makes every effort to avoid actual, potential, or perceived conflicts of interest that may arise as a result of industry relationships or personal interests among the members of the writing group. All writing group members and peer reviewers of the guideline are required to disclose all current healthcare–related relationships, including those existing 12 months before initiation of the writing effort.For the 2007 guidelines, all members of the writing committee, as well as peer reviewers of the document, were asked to provide disclosure statements of all such relationships that may be perceived as real or potential conflicts of interest. Writing committee members are also strongly encouraged to declare a previous relationship with industry that may be perceived as relevant to guideline development.In December 2009, the ACCF and AHA implemented a new policy for relationships with industry and other entities (RWI) that requires the writing group chair plus a minimum of 50% of the writing group to have no relevant RWI (Appendix 4 includes the ACCF/AHA definition of relevance). These statements are reviewed by the Task Force and all members during each conference call and/or meeting of the writing group and are updated as changes occur. All guideline recommendations require a confidential vote by the writing group and must be approved by a consensus of the voting members. Members are not permitted to draft or vote on any text or recommendations pertaining to their RWI. The 2012 members who recused themselves from voting are indicated in the list of writing group members, and specific section recusals are noted in Appendix 4. 2007 and 2012 authors' and peer reviewers' RWI pertinent to this guideline are disclosed in Appendixes 1, 2, 4, and 5, respectively. Additionally, to ensure complete transparency, writing group members' comprehensive disclosure informationincluding RWI not pertinent to this documentis available as an online supplement. Comprehensive disclosure information for the Task Force is also available online at www.cardiosource.org/ACC/About-ACC/Leadership/Guidelines-and-Documents-Task-Forces.aspx. The work of the 2012 writing group is supported exclusively by the ACCF, and AHA, without commercial support. Writing group members volunteered their time for this activity.In April 2011, the Institute of Medicine released 2 reports: Finding What Works in Health Care: Standards