Clinical Question: What is the optimal management of non-ST-segment elevation acute coronary syndrome?

Setting: Various (meta-analysis)

Study Design: Meta-analysis (randomized controlled trials)

Synopsis: Although practice guidelines abound on the best treatment of acute coronary syndromes, a simplified method for applying the best evidence would help many physicians. In this meta-analysis, the authors searched standard evidence-based sources, including the Cochrane database and MED-LINE, for controlled studies on the treatment of non-ST-segment elevation acute coronary syndromes. No information was given on the independent assessment of review and evaluation or the potential for publication bias, but the authors discussed the strength of evidence for their own recommendations. To simplify the recommendations, they summarized them with an ABCDE acronym, as follows:

A: Antiplatelet therapy, including aspirin for all patients indefinitely, initially with 162 mg to 325 mg, followed by 75 mg to 160 mg daily thereafter; clopidogrel for all patients unless physicians anticipate a need for urgent coronary artery bypass grafting surgery for up to one year; and Gp IIb/IIIa inhibitor therapy for all patients with continuing ischemia, an elevated troponin level, a Thrombolysis in Myocardial Infarction flow grade greater than 4, or anticipated percutaneous coronary intervention. Anticoagulation, including low-molecular-weight heparin or unfractionated heparin unless creatinine clearance is less than 60 mL per minute, or coronary artery bypass grafting surgery was performed within 24 hours. Angiotensin-converting enzyme inhibition or angiotensin receptor blockade for all patients with left ventricular dysfunction (i.e., ejection fraction of 40 percent or less), heart failure, or hypertension. [ corrected]

B: Beta blockade for all patients and blood pressure control, with a goal of 130/85 mm Hg or less.

C: Cholesterol treatment for all patients with a low-density lipoprotein goal of less than 70 mg per dL (1.80 mmol per L) and cigarette smoking cessation.

D: Diabetes management and diet (the Mediterranean diet, in particular).

E: Exercise, preferably with a cardiac rehabilitation program.

Bottom Line: The ABCDE approach can serve as a guide for applying the best evidence in the care of patients with non-ST-segment elevation acute coronary syndrome. ABCDE stands for Antiplatelet, Anticoagulation, and Angiotensin-converting enzyme inhibition; Beta blockade and Blood pressure control; Cholesterol treatment and Cigarette smoking cessation; Diabetes management and Diet; and Exercise. The acronym, although easy to remember, does not intend to rank the interventions in terms of their relative benefit. (Level of Evidence: 1a)