The clinical effectiveness agency for England and Wales on March 24 issued new guidelines for early management of patients with acute coronary syndromes, covering the time period from the moment of a firm diagnosis to a patient’s discharge from the hospital.

For patients presenting with unstable angina or non-ST-segment-elevation myocardial infarction, the National Institute for Health and Clinical Effectiveness now demands that an established risk-scoring system to predict 6-month mortality be used immediately after diagnosis and administration of anti-blood-clotting drugs. Treatments can then be adjusted according to the patient’s risk profile and balanced against the risk of adverse advents, particularly bleeding.

Once aspirin and antithrombin therapy have been offered, physicians should assess the 6-month mortality risk using a tool such as the Global Registry of Acute Cardiac Events (GRACE) system, or a comparable system, NICE said.

For patients whose risk is above 3%, NICE recommends treatment with intravenous eptifibatide or tirofiban. NICE also recommends coronary angiography, with follow-on percutaneous coronary intervention if necessary, within 96 hours of hospital admission for the same high-risk patients if they do not have co-morbidities or active bleeding.

For lesser-risk patients who have not undergone angiography, the agency recommends ischemia testing, including echocardiography or magnetic resonance imaging, before discharge. Patients in either risk category should be involved in any discussions about revascularization strategy, as should an interventional cardiologist, cardiac surgeon, and other relevant healthcare professionals, the agency said.

In a separate but related guideline also published March 24, NICE officials described another two-pronged strategy, this time for the diagnosis and immediate care of patients presenting with chest pain. The first strategy applies to those patients suspected of having an acute coronary syndrome (ACS,) and the second to those with intermittent stable chest pain of suspected cardiac origin who may have stable angina.

For patients who may have an ACS, NICE recommends taking a resting 12-lead electrocardiogram (ECG) as soon as possible. If the patient is not yet at the hospital, the results should be sent in advance of the patient. “Recording and sending the ECG should not delay transfer to hospital,” the agency stated in a summary of the guidance.

An ACS should not be ruled out for patients with normal resting 12-lead ECGs, the agency said, and response to glyceryl trinitrate should not be used to make a diagnosis of ACS. Further, it said, ACS symptoms should not be assessed differently for different ethnic groups or for men vs. women. If ACS is suspected, immediate management should include aspirin and pain relief, but oxygen should not be routinely administered, the agency said. Oxygen saturation should be monitored using pulse oximetry to guide supplemental oxygen use.

If an ACS is determined, the pathway routes to the new ACS treatment guidelines.

For patients with intermittent stable chest pain who may have stable angina, the agency recommends clinical assessment plus diagnostic testing, including anatomical testing for CAD and functional testing for myocardial ischemia. If the likelihood of CAD is 90% or more, the patient should be managed for stable angina, and if it is between 10% and 90%, the patient should also be managed for stable angina while further testing proceeds. Exercise ECG should not be used to diagnose or exclude stable angina for people without known CAD, the agency said.

Also on March 24, NICE issued its first-ever guidance for the management of neuropathic pain by general practitioners, hoping to replace a trial-and-error approach with more standardized steps, including the off-label use of some medications. The agency recommends that healthcare providers prescribe amitriptyline or pregabalin as a first line treatment for patients with herpetic or other-cause neuralgia. For patients with painful diabetic neuropathy, NICE recommends a slightly different approach, beginning with oral duloxetine treatment.

For patients who continue to suffer pain at the maximum tolerated dose despite first-line treatment with amitriptyline, pregabalin, or duloxetine, NICE recommends switching to a different class of drug -- amitriptyline for patients previously prescribed pregabalin, for example. Combination therapies should be compared with monotherapies, NICE said.

If neuropathic pain persists, patients should be referred to pain specialists or specialists in the underlying disease (such as diabetes) that is the suspected cause of the patient’s pain. Opioids should only be prescribed if the patient has earlier been assessed by a specialist; other medications can also be prescribed if these were earlier started by a specialist, NICE said.

Copyright (c) 2009 Elsevier Global Medical News. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed.

3月24日，英格兰和威尔士的临床疗效评价机构针对急性冠脉综合征(ACS)患者的早期治疗发布了新的指南，指南涵盖了从确诊到患者出院的全过程。

 

对于表现为不稳定性心绞痛或非ST段抬高心肌梗死的患者，英国国家卫生与临床优化研究所(NICE)现要求在确诊后立即采用已确立的风险评分系统预测患者的6个月病死率，并予以抗凝血药物治疗。然后根据患者的风险评分结果对治疗进行调整，并权衡以出血为主的不良事件风险。

 

NICE建议，一旦予以了阿司匹林和抗凝血酶治疗，医生就应采用诸如全球急性心脏事件注册(GRACE)系统或其他类似系统等工具对患者的6个月病死风险进行评价。

 

对于风险大于3%的患者，NICE建议经静脉给予依替巴肽(eptifibatide)或替罗非班(tirofiban)。NICE还建议，对于这样的高危患者，只要没有合并症或活动性出血，应在入院后96h内施行冠脉造影术，如有必要还应继续开展经皮冠脉介入术。

 

对于风险相对较低且没有接受冠脉造影术的患者，NICE建议在患者出院前开展缺血检查，包括超声心动图或磁共振成像。NICE指出，无论患者属于哪个风险类别，都应与心脏介入医生、心脏外科医生以及其他相关的医务人员共同讨论血运重建的策略。

 

也是在3月24日，NICE还发布了另外一份与之相关的指南，针对胸痛患者的诊断和即时治疗提出了另一种双向策略。第1种策略适用于ACS疑似患者，第2种策略则适用于疑似心源性间歇性稳定胸痛、可能患有稳定性心绞痛的患者。

 

对于可能患有ACS的患者，NICE建议尽快行静态12导联心电图(ECG)检查。如果患者尚未送达医院，应将检查结果先于患者送交给医院。NICE在指南小结中说：“应尽快完成ECG检查并立即将检查结果传送至医院。”

 

NICE提醒道，静态12导联ECG正常并不能排除ACS，也不能根据患者对硝酸甘油的应答情况来诊断ACS。NICE还指出，对于不同种族的患者，无论男性或女性，都应采用相同的方法来评价ACS症状。NICE建议，如果疑似ACS，那么即时治疗应包括阿司匹林和镇痛，但不应常规吸氧。应采用脉搏血氧监测仪对血氧饱和度进行监测，以此指导补充供氧的使用。

 

一旦确诊是ACS，临床路径则参照新发布的ACS治疗指南。

 

对于可能患有稳定性心绞痛的间歇性稳定胸痛患者，NICE建议将临床评价与诊断性检查相结合，后者包括针对冠心病(CAD)的解剖学检查以及针对心肌缺血的功能性检查。如果CAD的可能性达到90%以上，则按照稳定性心绞痛进行治疗；如果CAD的可能性介于10%~90%之间，则在开展进一步检查的同时也按照稳定性心绞痛进行治疗。NICE建议，对于并非已知患有CAD的患者，不应采用动态ECG来诊断或排除稳定性心绞痛。

 

仍然是在3月24日，NICE还针对全科医生首次发布了神经性疼痛的治疗指南，希望以此取代包含更多格式化步骤的试误法(试验-失败-再试验)，其中包括超出某些药物的适应证范围而用药。NICE建议医务人员选用阿米替林(amitriptyline)或普瑞巴林(pregabalin)作为疱疹性或其他原因所致神经痛的一线治疗药物。对于出现了糖尿病痛性神经病变的患者，NICE所建议的策略稍有不同，最初应选用口服度洛西汀(duloxetine)治疗。

 

对于经最大耐受剂量的阿米替林、普瑞巴林或度洛西汀等一线药物治疗后仍无法控制疼痛的患者，NICE建议换用另一类药物，例如，之前使用普瑞巴林的患者改用阿米替林。NICE还指出，应将联合用药的效果与单药治疗进行比较。

 

如果神经性疼痛仍持续存在，则应转诊至疼痛科专科医生或怀疑导致了这种疼痛的潜在疾病(如糖尿病)的专科医生。NICE指出，除非患者之前已经接受过专科医生的评估，才可以使用阿片类药物；对于其他药物，如果之前专科医生已经使用过，也可以考虑采用。

 

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