1 The writing committee also emphasized
the importance of standardized quality-of-care data registries to track and measure outcomes, complications, and adherence to evidence-based processes of care for ACS and endorsed the participation in these registries as a reasonable strategy.1 The writing committee also advocated the use of an insulin-based regimen to achieve and maintain blood glucose levels <180 mg/dL while avoiding hypoglycemia for hospitalized UA/NSTEMI patients as a reasonable approach.18 An important addition to the 2012 ACCF/AHA guidelines update pertains to aspirin dosing. Inhibitors,research,lifescience,medical Previously, the 2007 UA/NSTEMI guidelines endorsed medium-to-high doses of aspirin selectively, with variability in dose and duration of Cediranib cell line therapy according to the type of stent utilized. Nevertheless, the saturability of the antiplatelet effect of aspirin at low doses, the lack Inhibitors,research,lifescience,medical of dose-response relationship in studies evaluating its clinical efficacy, and the dose-dependence response of its side effects all support the use of a low dose of aspirin (e.g., the 81-mg dosage form available in the United States).19, 20 Therefore, the 2012 ACCF/AHA guidelines update maintained that it is reasonable to Inhibitors,research,lifescience,medical use 81-mg daily aspirin in preference
to higher maintenance doses after PCI (irrespective of stent type), which is concordant with the recently released 2011 ACCF/AHA PCI guidelines.21 The 2012 ACCF/AHA UA/NSTEMI guideline update did not provide recommendations on the use of proton pump inhibitors (PPIs) in patients on dual antiplatelet therapy (DAPT). Despite experimental and registry data suggesting diminished effectiveness of clopidogrel with the use of a PPI, the COGENT trial showed no Inhibitors,research,lifescience,medical increase in adverse cardiovascular outcomes and decreased GI bleeding from the combination of clopidogrel and omeprazole.22 The 2012 ACCF/AHA Inhibitors,research,lifescience,medical PCI guidelines, on the other hand,
recommended the use of PPIs in patients with a history of prior GI bleeding who require dual antiplatelet therapy.21 In addition, the 2012 ACCF/AHA guideline update did address the use of anticoagulant therapies (such as the new oral factor Xa inhibitors, apixaban and rivaroxaban), Tryptophan synthase anti-ischemic therapies (such as ranolazine), or new diagnostic modalities and biomarkers in patients with ACS. Conclusions Overall, the ACCF and AHA are to be congratulated on their continuous efforts to update the guidelines in order to critically evaluate the evidence and produce useful recommendations to guide clinicians, influence practices, and improve outcomes. One should, however, remember that only 10% of the decline in CAD mortality observed since 1986 is attributable to immediate therapies after ACS.23 Nevertheless, acute therapies accounted for the majority of recommendations in the 2012 guideline update.