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Ty J. Gluckman, MD; Molly Sachdev, MD, MPH; Steven P. Schulman, MD; Roger S. Blumenthal, MD

JAMA. 2005;293:349-357.

Context  While current practice guidelines provide an evidence-based approach to management of acute coronary syndromes (ACS), application of the evidence by individual physicians has been suboptimal.

Objective  To assess and synthesize the evidence regarding optimal management of non–ST-segment elevation ACS (NSTE-ACS).

Data Sources  Systematic searches of peer-reviewed publications were performed in MEDLINE and the Cochrane Database from January 1990 through November 2004, with consultation by content experts. Search terms included antiplatelet therapy, antithrombotic therapy, angiotensin-converting enzyme inhibition, angiotensin receptor blockade, -blockade, hypertension, hyperlipidemia, cigarette smoking, diet, diabetes mellitus, exercise, myocardial ischemia, and coronary artery disease.

Study Selection and Data Extraction  Criteria for selection of studies included controlled study design, English language, and clinical pertinence. Data quality was based on the publishing journal and relevance to clinical management of NSTE-ACS.

Data Synthesis  While outcomes of controlled studies support a comprehensive approach in the management of patients with NSTE-ACS, many physicians perceive existing guidelines as lengthy and complex. After risk stratification to identify those patients most likely to benefit from an early invasive vs early conservative strategy, a comprehensive management plan can be assembled through an "ABCDE" approach. The elements of this include "A" for antiplatelet therapy, anticoagulation, angiotensin-converting enzyme inhibition, and angiotensin receptor blockade; "B" for -blockade and blood pressure control; "C" for cholesterol treatment and cigarette smoking cessation; "D" for diabetes management and diet; and "E" for exercise.

Conclusion  An "ABCDE" approach for the management of NSTE-ACS provides a practical and systematic means to implement evidence-based medicine into clinical practice.

Author Affiliations: Division of Cardiology, the Johns Hopkins Hospital (Drs Gluckman, Sachdev, and Schulman) and Ciccarone Preventive Cardiology Center (Dr Blumenthal), Johns Hopkins University, Baltimore, Md.

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