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2011年ACCF AHA不稳定性心绞痛和NSTEMI指南有奖翻译

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这个帖子发布于9年零289天前，其中的信息可能已发生改变或有所发展。

近几年，心血管领域取得诸多重大进展，为了及时反映最新心血管进展，2011年3月28日，ACC/AHA发布最新的不稳定型心绞痛和非ST段抬高心肌梗死治疗指南。

指南工作组的目的，是为了就心血管疾病患者的诊断与治疗做出建议。冠状动脉疾病（coronary artery disease，CAD）是美国的头号死亡原因。不稳定型心绞痛（unstable angina，UA）和与之密切相关的非ST段抬高心肌梗死（non-ST-elevation myocardial infarction，NSTEMI）则是本病非常常见的形式。委员会成员通过计算机检索英文文献，并且辅以手工检索，复习和编辑了所有公开发表的报告。对某一问题特殊研究的具体情况，予以必要叙述，并且列表展示具体数据。本指南中提出的建议，主要是依据这些已经发表的资料。若资料是来自多中心大规模临床随机试验，则证据的权重序位列为最高（A）到最低（C）。对UA/NSTEMI患者某一诊断性操作或具体治疗或介入治疗适应证的最终建议，总结了资料和专家们的意见。

因为全文翻译不现实，工作量也很大，所以我们这次翻译活动的主要目的就是将一些主要的Recommendations翻译出来，提高大家对指南的理解，希望能对临床工作有所帮助。欢迎各位同仁积极参与！

活动办法：将各章节的Recommendations分开，总共三十四部分，每人可至少认领一部分，要求认领后4天完成。指南原文附如下

指南建议全部翻译完毕，感谢各位战友的支持，尤其感谢谁是我的传说版主的校对！

版主shaolidaifu留言:
欢迎大家积极翻译，加分从宽！谢谢老版主。

2011ACCF AHA不稳定性心绞痛和NSTEMI指南更新(en).pdf(8271.08k)

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2011-04-11 22:53 浏览 : 13012 回复 : 95

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huangtm 编辑于 2011-04-20 12:49

• 【话题活动】#有没有患者的哪一句话，戳中了你的泪点？

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第一部分

1. Introduction

1.4.1. Identification of Patients at Risk of UA/NSTEMI
Class I
1. Primary care providers should evaluate the presence
and status of control of major risk factors for CHD for
all patients at regular intervals (approximately every 3
to 5 years). (Level of Evidence: C)
2. Ten-year risk (National Cholesterol Education Program
[NCEP] global risk) of developing symptomatic CHD
should be calculated for all patients who have 2 or more
major risk factors to assess the need for primary prevention
strategies.16,17 (Level of Evidence: B)
3. Patients with established CHD should be identified for
secondary prevention efforts, and patients with a CHD
risk equivalent (e.g., atherosclerosis in other vascular
beds, diabetes mellitus, chronic kidney disease, or
10-year risk greater than 20% as calculated by Framingham
equations) should receive equally intensive
risk factor intervention as those with clinically apparent
CHD. (Level of Evidence: A)

2011-04-11 23:01

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• 综合医院全科门诊中乏力患者特征及就诊原因分析

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第二部分

2. Initial Evaluation and Management

2.1. Clinical Assessment

Recommendations
Class I
1. Patients with symptoms that may represent ACS (Table
2) should not be evaluated solely over the telephone
but should be referred to a facility that allows evaluation
by a physician and the recording of a 12-lead
ECG and biomarker determination (e.g., an ED or
other acute care facility). (Level of Evidence: C)
2. Patients with symptoms of ACS (chest discomfort with
or without radiation to the arm[s], back, neck, jaw or
epigastrium; shortness of breath; weakness; diaphoresis;
nausea; lightheadedness) should be instructed to call 9-1-1 and should be transported to the hospital by
ambulance rather than by friends or relatives. (Level of
Evidence: B)
3. Health care providers should actively address the
following issues regarding ACS with patients with or at
risk for CHD and their families or other responsible
caregivers:
a. The patients heart attack risk; (Level of Evidence: C)
b. How to recognize symptoms of ACS; (Level of
Evidence: C)
c. The advisability of calling 9-1-1 if symptoms are
unimproved or worsening after 5 min, despite feelings
of uncertainty about the symptoms and fear of
potential embarrassment; (Level of Evidence: C)
d. A plan for appropriate recognition and response to
a potential acute cardiac event, including the phone
number to access EMS, generally 9-1-1.74 (Level of
Evidence: C)

?4. Prehospital EMS providers should administer 162 to
325 mg of ASA (chewed) to chest pain patients sus-
pected of having ACS unless contraindicated or al-
ready taken by the patient. Although some trials have
used enteric-coated ASA for initial dosing, more rapid
buccal absorption occurs with non–enteric-coated for-
mulations. (Level of Evidence: C)
5. Health care providers should instruct patients with
suspected ACS for whom nitroglycerin [NTG] has
been prescribed previously to take not more than 1
dose of NTG sublingually in response to chest discom-
fort/pain. If chest discomfort/pain is unimproved or is
worsening 5 min after 1 NTG dose has been taken, it is
recommended that the patient or family member/
friend/caregiver call 9-1-1 immediately to access EMS
before taking additional NTG. In patients with chronic
stable angina, if symptoms are significantly improved
by 1 dose of NTG, it is appropriate to instruct the
patient or family member/friend/caregiver to repeat
NTG every 5 min for a maximum of 3 doses and call
9-1-1 if symptoms have not resolved completely. (Level
of Evidence: C)
6. Patients with a suspected ACS with chest discomfort or
other ischemic symptoms at rest for greater than 20
min, hemodynamic instability, or recent syncope or
presyncope should be referred immediately to an ED.
Other patients with suspected ACS who are experienc-
ing less severe symptoms and who have none of the
above high-risk features, including those who respond
to an NTG dose, may be seen initially in an ED or an
outpatient facility able to provide an acute evaluation.
(Level of Evidence: C)
Class IIa
1. It is reasonable for health care providers and 9-1-1
dispatchers to advise patients without a history of ASA
allergy who have symptoms of ACS to chew ASA (162
to 325 mg) while awaiting arrival of prehospital EMS
providers. Although some trials have used enteric-
coated ASA for initial dosing, more rapid buccal ?absorption occurs with non–enteric-coated formula-
tions. (Level of Evidence: B)
2. It is reasonable for health care providers and 9-1-1
dispatchers to advise patients who tolerate NTG to repeat
NTG every 5 min for a maximum of 3 doses while
awaiting ambulance arrival. (Level of Evidence: C)
3. It is reasonable that all prehospital EMS providers
perform and evaluate 12-lead ECGs in the field (if
available) on chest pain patients suspected of ACS to
assist in triage decisions. Electrocardiographs with vali-
dated computer-generated interpretation algorithms are
recommended for this purpose. (Level of Evidence: B)
4. If the 12-lead ECG shows evidence of acute injury or
ischemia, it is reasonable that prehospital ACLS provid-
ers relay the ECG to a predetermined medical control
facility and/or receiving hospital. (Level of Evidence: B)

Figure 2. Algorithm for Evaluation and Management of Patients Suspected of Having ACS. To facilitate interpretation of this algorithm and a more detailed discussion in the text, each box is assigned a letter code that reflects its level in the algorithm and a number that is allocated from left to right across the diagram on a given level. ACC/AHA American College of Cardiology/American Heart Association; ACS acute coronary syndrome; ECG electrocardiogram; LV left ventricular.

2011-04-11 23:07

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• 大家见过从患者体内取出过哪些异物？

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第三部分

?2.2. Early Risk Stratification
Recommendations for Early Risk Stratification
Class I
1. A rapid clinical determination of the likelihood risk of
obstructive CAD (i.e., high, intermediate, or low)
should be made in all patients with chest discomfort or
other symptoms suggestive of an ACS and considered
in patient management. (Level of Evidence: C)
2. Patients who present with chest discomfort or other
ischemic symptoms should undergo early risk stratifica-
tion for the risk of cardiovascular events (e.g., death or

?2.2. Early Risk Stratification
Recommendations for Early Risk Stratification
Class I
1. A rapid clinical determination of the likelihood risk of
obstructive CAD (i.e., high, intermediate, or low)
should be made in all patients with chest discomfort or
other symptoms suggestive of an ACS and considered
in patient management. (Level of Evidence: C)
2. Patients who present with chest discomfort or other
ischemic symptoms should undergo early risk stratifica-
tion for the risk of cardiovascular events (e.g., death or
?[re]MI) that focuses on history, including anginal symp-
toms, physical findings, ECG findings, and biomarkers of
cardiac injury, and results should be considered in pa-
tient management. (Level of Evidence: C)
3. A 12-lead ECG should be performed and shown to an
experienced emergency physician as soon as possible
after ED arrival, with a goal of within 10 min of ED
arrival for all patients with chest discomfort (or anginal
equivalent) or other symptoms suggestive of ACS. (Level
of Evidence: B)
4. If the initial ECG is not diagnostic but the patient
remains symptomatic and there is high clinical suspicion
for ACS, serial ECGs, initially at 15-to 30-min intervals,
should be performed to detect the potential for develop-
ment of ST-segment elevation or depression. (Level of
Evidence: B)
5. Cardiac biomarkers should be measured in all patients
who present with chest discomfort consistent with
ACS. (Level of Evidence: B)
6. A cardiac-specific troponin is the preferred marker,
and if available, it should be measured in all patients
who present with chest discomfort consistent with
ACS. (Level of Evidence: B)

?7. Patients with negative cardiac biomarkers within 6 h
of the onset of symptoms consistent with ACS should
have biomarkers remeasured in the time frame of 8 to
12 h after symptom onset. (The exact timing of serum
marker measurement should take into account the
uncertainties often present with the exact timing of
onset of pain and the sensitivity, precision, and insti-
tutional norms of the assay being utilized as well as the
release kinetics of the marker being measured.) (Level
of Evidence: B)
8. The initial evaluation of the patient with suspected
with ACS should include the consideration of noncoro-
nary causes for the development of unexplained symp-
toms. (Level of Evidence: C)
Class IIa
1. Use of risk-stratification models, such as the Throm-
bolysis In Myocardial Infarction (TIMI) or Global
Registry of Acute Coronary Events (GRACE) risk
score or the Platelet Glycoprotein IIb/IIIa in Unstable
Angina: Receptor Suppression Using Integrilin Ther-
apy (PURSUIT) risk model, can be useful to assist in
decision making with regard to treatment options in
patients with suspected ACS. (Level of Evidence: B)
2. It is reasonable to remeasure positive biomarkers at 6-
to 8-h intervals 2 to 3 times or until levels have peaked,
as an index of infarct size and dynamics of necrosis.
(Level of Evidence: B)
3. It is reasonable to obtain supplemental ECG leads V7
through V9 in patients whose initial ECG is nondiagnostic
to rule out MI due to left circumflex occlusion. (Level of
Evidence: B)
4. Continuous 12-lead ECG monitoring is a reasonable
alternative to serial 12-lead recordings in patients whose
initial ECG is nondiagnostic. (Level of Evidence: B)
Class IIb
1. For patients who present within6hofthe onset of
symptoms consistent with ACS, assessment of an early
marker of cardiac injury (e.g., myoglobin) in conjunc-
tion with a late marker (e.g., troponin) may be consid-
ered. (Level of Evidence: B)
2. For patients who present within 6 h of symptoms suggestive
of ACS, a 2-h delta CK-MB mass in conjunction with 2-h
delta troponin may be considered. (Level of Evidence: B)
3. For patients who present within6hof symptoms
suggestive of ACS, myoglobin in conjunction with
CK-MB mass or troponin when measured at baseline
and 90 min may be considered. (Level of Evidence: B)
4. Measurement of B-type natriuretic peptide (BNP) or
NT-pro-BNP may be considered to supplement assess-
ment of global risk in patients with suspected ACS.
(Level of Evidence: B)
Class III
Total CK (without MB), aspartate aminotransferase
(AST, SGOT), alanine transaminase, beta-
hydroxybutyric dehydrogenase, and/or lactate dehydro-
genase should not be utilized as primary tests for the
?detection of myocardial injury in patients with chest
discomfort suggestive of ACS. (Level of Evidence: C)

2011-04-11 23:15

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