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Online Appendix for the following October 18 JACC article
TITLE: Evolution in Cardiovascular Care for Elderly Patients With Non–ST-Segment Elevation
Acute Coronary Syndromes: Results From the CRUSADE National Quality Improvement
Initiative
AUTHORS: Karen P. Alexander, MD, Duke Clinical Research Institute and Division of
Cardiology, Duke University Medical Center, Durham, North Carolina, Matthew T. Roe, MD,
Duke Clinical Research Institute and Division of Cardiology, Duke University Medical Center,
Durham, North Carolina, Anita Y. Chen, MS, Duke Clinical Research Institute and Division of
Cardiology, Duke University Medical Center, Durham, North Carolina, Barbara L. Lytle, MS,
Duke Clinical Research Institute and Division of Cardiology, Duke University Medical Center,
Durham, North Carolina, Charles V. Pollack, Jr., MD, MA, Pennsylvania Hospital, Philadelphia,
Pennsylvania, Joanne M. Foody, MD, Section of Cardiovascular Medicine, Department of
Medicine, Yale School of Medicine, New Haven, Connecticut, William E. Boden, MD, Division
of Cardiology, Hartford Hospital, Hartford, Connecticut, Sidney C. Smith, Jr., MD, Department
of Cardiology, University of North Carolina, Chapel Hill, North Carolina, W. Brian Gibler, MD,
Department of Emergency Medicine, University of Cincinnati School of Medicine, Cincinnati,
Ohio, E. Magnus Ohman, MD, Department of Cardiology, University of North Carolina, Chapel
Hill, North Carolina, Eric D. Peterson, MD, MPH, Duke Clinical Research Institute and Division
of Cardiology, Duke University Medical Center, Durham, North Carolina, for the CRUSDADE
Investigators
APPENDIX
Hospital Care
Anti-Ischemic Therapy
IB: Beta-blocker, with the first dose intravenously if ongoing chest pain, in the absence of
contraindications.
IB: Non-dihydropyridine calcium antagonist (e.g., verapamil or diltiazem), in patients with
continuing or recurring ischemia when beta-blockers are contraindicated, in the absence of severe
left ventricular dysfunction.
IB: Angiotensin-converting enzyme inhibitor when hypertension persists despite treatment with
nitroglycerine and a beta-blocker in patients with left ventricular systolic dysfunction or
congestive heart failure and in acute coronary syndrome patients with diabetes.
Antiplatelet and Anticoagulation Therapy
IA: Antiplatelet therapy should be initiated promptly. Aspirin should be administered as soon as
possible after presentation and continued indefinitely. Clopidogrel should be administered to
patients unable to take aspirin.
IA: In patients in whom an early conservative approach is planned, clopidogrel should be added
to aspirin as soon as possible on admission and administered for at least one month, and for up to
nine months.
IA: In patients for whom a percutaneous coronary intervention is planned and who are not at high
risk for bleeding, clopidogrel should be started and continued for at least one month and for up to
nine months.
IA: Glycoprotein IIb/IIIa antagonist should be administered, in addition to aspirin and heparin, to
patients in whom catheterization and percutaneous coronary intervention are planned. The
glycoprotein IIb/IIIa antagonist may be
administered prior to percutaneous coronary
intervention.
IA: Anticoagulation with subcutaneous low-molecular-weight heparin or intravenous
unfractionated heparin should be added to antiplatelet therapy with aspirin and/or clopidogrel.
Early Conservative Versus Invasive Strategies
IA: An early invasive strategy in patients with unstable angina/non–ST-segment myocardial
infarction without serious comorbidity with high-risk indicators: (a) recurrent angina/ischemia at
rest or with low-level activities despite intensive anti-ischemic therapy; (b) elevated TnT or TnI;
(c) new or presumably new ST-segment depression; (d) recurrent angina/ischemia with
congestive heart failure symptoms, an S3 gallop, pulmonary edema, worsening rales, or new or
worsening mitral regurgitation; (e) high-risk findings on noninvasive stress testing; (f) depressed
left ventricular systolic function (e.g., ejection fraction <0.40 on noninvasive study); (g)
hemodynamic instability; (h) sustained ventricular tachycardia; (i) percutaneous coronary
intervention within six months; (j) or prior coronary artery bypass grafting.
IB: In the absence these findings, either early conservative or early invasive strategy may be
considered.
Discharge and Post-Hospital Care
IA: Aspirin 75 to 325 mg/day in the absence of contraindications.
IA: Angiotensin-converting enzyme inhibitors for patients with congestive heart failure, left
ventricular dysfunction (ejection fraction <0.40), hypertension, or diabetes.
IA: Lipid-lowering agents and diet in post-acute coronary syndromes patients including patients
who are post revascularization with low-density lipoprotein cholesterol of >125 mg/dl, including
after revascularization. A fibrate or niacin if high-density lipoprotein cholesterol is <40 mg/dl,
occurring as an isolated finding or in combination with other lipid abnormalities.
IB: Clopidogrel 75 mg/day in patients with a contraindication to aspirin.
IB: Beta-blockers in the absence of contraindications.