1. ACS Critical Pathways 2007 Teleconferences August 15, 2007 This activity is co-provided by the Network for Continuing Medical Education and EduPro Resources LLC. This activity is supported by an educational grant from the Bristol-Myers Squibb/Sanofi Pharmaceuticals Partnership.

2. Faculty Christopher P. Cannon, MD Associate Professor of Medicine Harvard Medical School Senior Investigator, TIMI Study Group Associate Physician, Cardiovascular Division Brigham and Women’s Hospital Boston, Massachusetts

3. The Network for Continuing Medical Education and EduPro Resources LLC require that CME/CNE faculty disclose, during the planning of an activity, the existence of any personal financial or other relationships they or their spouses/partners have with the commercial supporter of the activity or with the manufacturer of any commercial product or service discussed in the activity. Disclosure Statement

4. Christopher P. Cannon, MD , has received research support from Accumetrics, AstraZeneca Pharmaceuticals LP, GlaxoSmithKline, Merck & Co., Inc., Merck/Schering-Plough Pharmaceuticals, sanofi-aventis, and Schering-Plough Corporation. The team from Doylestown Hospital reports it has no relationships to disclose. The NCME staff reports it has no relationships to disclose. Faculty Disclosure Statement

5. Update of the ACC/AHA ACS Guidelines: UA/NSTEMI Christopher P. Cannon, MD

13. Algorithm for Patients With UA/NSTEMI Managed by an Initial Invasive Strategy Proceed to Diagnostic Angiography ASA (Class I, A) Clopidogrel if ASA intolerant (Class I, A) Diagnosis of UA/NSTEMI Is Likely or Definite Invasive Strategy Initiate A/C Rx (Class I, A) Acceptable options: enoxaparin or UFH (Class I, A) bivalirudin or fondaparinux (Class I, B) Select Management Strategy Proceed With an Initial Conservative Strategy Prior to Angiography Initiate at least one (Class I, A) or both (Class IIa, B) of the following: Clopidogrel IV GP IIb/IIIa inhibitor Factors favoring administration of both clopidogrel and GP IIb/IIIa inhibitor include: Delay to angiography High risk features Early recurrent ischemic discomfort Reprinted with permission from Anderson JL, et al. J Am Coll Cardiol . 2007;50:652-726. 2007 ACC/AHA UA/NSTEMI Guideline Revision

14. Initiate clopidogrel (Class I, A) Consider adding IV eptifibatide or tirofiban (Class IIb, B) Conservative Strategy Initiate A/C Rx (Class I, A): Acceptable options: enoxaparin or UFH (Class I, A) or fondaparinux (Class I, B), but enoxaparin or fondaparinux are preferable (Class IIA, B) Select Management Strategy ASA (Class I, A) Clopidogrel if ASA intolerant (Class I, A) Diagnosis of UA/NSTEMI Is Likely or Definite Algorithm for Patients With UA/NSTEMI Managed by an Initial Conservative Strategy Proceed With Invasive Strategy (Continued on slide 18) Reprinted with permission from Anderson JL, et al. J Am Coll Cardiol . 2007;50:652-726. 2007 ACC/AHA UA/NSTEMI Guideline Revision

18. Any subsequent events necessitating angiography? EF >0.40 Evaluate LVEF Low Risk Continue ASA indefinitely (Class I, A) Continue clopidogrel for at least 1 month (Class I, A) and ideally up to 1 y (Class I, B) Discontinue IV GP IIb/IIIa if started previously (Class I, A) Discontinue A/C Rx (Class I, A) (Class I, B) Proceed to Dx Angiography Yes EF ≤ 0.40 Stress Test (Class I, A) No Not Low Risk (Class IIa, B) Algorithm for Patients With UA/NSTEMI Managed by an Initial Conservative Strategy (Continued from slide 14) (Class I, A) (Class IIa, B) (Class I, B) Reprinted with permission from Anderson JL, et al. J Am Coll Cardiol . 2007;50:652-726. 2007 ACC/AHA UA/NSTEMI Guideline Revision

21. Long-term Antithrombotic Therapy at Hospital Discharge After UA/NSTEMI Medical Tx Without Stent Bare Metal Stent Drug-Eluting Stent ASA 162-325 mg/d for at least 1 mo, then 75-162 mg/d indefinitely (Class I, A) and Clopidogrel 75 mg/d for at least 1 mo (Class 1, A) and ideally up to 1 y (Class I, B) Add: Warfarin (INR 2.0- 2.5) (Class IIb, B) Continue with dual antiplatelet tx as above Indication for Anticoagulation? ASA 75-162 mg/d indefinitely (Class I, A) and Clopidogrel 75 mg/d for at least 1 mo (Class I, A) and up to 1 y (Class I, B) ASA 162-325 mg/d for at least 3-6 months, then 75-162 mg/d indefinitely (Class I, A) and Clopidogrel 75 mg/d for at least 1 y (Class I, B) UA/NSTEMI Patient Groups at Discharge Reprinted with permission from Anderson JL, et al. J Am Coll Cardiol . 2007;50:652-726. 2007 ACC/AHA UA/NSTEMI Guideline Revision

29. Featured Institution Doylestown Hospital Doylestown, Pennsylvania

31. Progress Checklist: Immediate Goals Circulate discharge plan and other tools to all cardiology, ED, and CV nursing staff for comments  Circulate pathways to all cardiology, ED, and CV nursing staff for comments  Develop draft pathways  Assemble team and set up meeting of working group 

32. Progress Checklist: Short-term Goals/Activities Grand rounds/conference: Cardiology/IM  Grand rounds/conference: Emergency Dept.  Grand rounds/conference: Nursing  Circulate memo  Launch critical pathways  Finalize critical pathways 

33. Progress Checklist: Long-term Goals/Activities  NRMI  AHA Get With The Guidelines  ACC National Cardiovascular Data Registry  CRUSADE  GRACE  REACH  Other Monitor data: which registry? 

34. Question-and-Answer Session

35. Concluding Remarks Christopher P. Cannon, MD Next Program Gregg C. Fonarow, MD Wednesday, September 12, 2007 12:00 Noon Eastern Time (9:00 AM Pacific Time) Report From the European Society of Cardiology (ESC) Congress 2007